Computerized clinical decision support systems (CDSSs) have emerged as an approach to improve compliance of clinicians with clinical practice guidelines (CPGs). Research utilizing CDSS has primarily been conducted in clinical contexts with clear diagnostic criteria such as diabetes and cardiovascular diseases. In contrast, research on CDSS for pain management and more specifically neuropathic pain has been limited. A CDSS for neuropathic pain has the potential to enhance patient care as the challenge of diagnosing and treating neuropathic pain often leads to tension in clinician-patient relationships.The aim of this study was to design and evaluate a CDSS aimed at improving the adherence of interprofessional primary care clinicians to CPG for managing neuropathic pain.Recommendations from the Canadian CPGs informed the decision pathways. The development of the CDSS format and function involved participation of multiple stakeholders and end users in needs assessment and usability testing. Clinicians, including family medicine physicians, residents, and nurse practitioners, in three academic teaching clinics were trained in the use of the CDSS. Evaluation over one year included the measurement of utilization of the CDSS; change in reported awareness, agreement, and adoption of CPG recommendations; and change in the observed adherence to CPG recommendations.P=.01 for mean awareness scores at 6 and 12 months compared with baseline, for mean adoption scores at 6 months compared with baseline, and for mean adoption scores at 12 months). Documenting significant findings related to diagnosis of neuropathic pain increased significantly. Clinicians accessed CPG information more frequently than they utilized data entry functions. Nurse practitioners and first year family medicine trainees had higher utilization than physicians.The usability testing of the CDSS was highly successful in the prototype environment. Deployment in the clinical setting was partially complete by the time of the study, with some limitations in the planned functionality. The study population had a high level of awareness, agreement, and adoption of guideline recommendations before implementation of CDSS. Nevertheless, there was a small and statistically significant improvement in the mean awareness and adoption scores over the year of observation (We observed a small increase in the adherence to CPG recommendations for managing neuropathic pain. Clinicians utilized the CDSS more as a source of knowledge and as a training tool than as an ongoing dynamic decision support. Computerized clinical decision support systems (CDSSs) can be defined as the information and communication systems that provide clinicians or patients with timely, accurate, and appropriate knowledge to enhance patient care . They haEvidence describing the effectiveness of CDSSs in improving knowledge translation comes from a number of systematic reviews, including studies carried out in a variety of contexts -5. The mThe effectiveness of CDSSs in these settings is supported through improvements in process adherence, including medication ordering, vaccinations, test ordering, and diagnosis and disease management -5. HowevPain management, on the other hand, has less clarity for many diagnostic criteria and less consensus on effective treatment and monitoring. Thus, the knowledge base is more difficult to translate. Little research has been conducted on the effect of CDSS on pain management generally, and neuropathic pain more specifically. The available literature, including 1 systematic review, is primarily focused on cancer pain management -11. To aFactors that limit and facilitate the effectiveness of CDSS have been reported. Most studies are able to demonstrate improvements in clinical process, but very little data provide information about improved patient outcomes . Many paThe Veterans Affairs (VA) in the United States developed a CDSS for neuropathic pain in their national electronic medical record (EMR) that involved significant clinician engagement in prototype development to improve use . AlthougNeuropathic pain is a unique subset of pain conditions that often becomes chronic, decreasing function and quality of life ,19. It cOverall, the challenge of diagnosing and treating patients with neuropathic pain often leads to tension in clinician-patient relationships, frequent and prolonged visits with high emotional intensity, poor patient compliance, poor clinical outcomes, and sometimes refusal of access to care for those who identify as having chronic pain. It is clear that support is needed to facilitate optimal care for patients with chronic pain in primary care .Our aim was to improve the adherence to CPG recommendations in primary care for the diagnosis and treatment of neuropathic pain through CDSS. The CDSS development has been reported previously . Our hypThe CDSS and the evaluation study were both developed through engagement of an advisory board made up of clinician researchers, software developers, end users, CPG developers, and information systems experts. The project was based at the Department of Family Medicine at McMaster University in Hamilton, Canada. The CDSS was designed for the Open Source Clinical Application Resource (OSCAR) EMR . At the Overall, 3 academic family medicine clinics, all involved in delivering McMaster’s family medicine residency training program, were the sites where development, testing, implementation, and evaluation took place. Together, these clinics serve 40,000 patients, with 169 clinicians, including family physicians, family medicine residents, and nurse practitioners.The study was approved by the Hamilton Integrated Research Ethics Board, reference number 13-136.We began with a broad consultation with the varied stakeholders on the advisory board, as described above. This was followed with focus group discussions with interprofessional end users to determine the requirements for the CDSS content, appearance, function, and workflow. Practice recommendations were drawn from the Canadian guidelines for management of neuropathic pain . The conThe final version of the CDSS was created and integrated into the OSCAR EMR code. Its functionality was designed to be optimal with a new user interface that was scheduled to be in use by the time of the study. However, this did not occur and the CDSS was deployed within the older user interface environment. Although all functions were available on the older user interface, gaining access to and the appearance of the CDSS were not as clear or easy to follow as the prototype design.We conducted a quasi-experimental study comparing clinicians at the preintervention phase (baseline) with 6 months and 12 months after the introduction of the CDSS. A questionnaire was used to assess the degree to which a clinician was aware of, agreed with, and felt they had adopted key CPG recommendations for managing neuropathic pain.Our recruitment goal was 120 clinicians, with 50 family physicians, 50 family medicine residents (postgraduate physicians in training), and 20 nurse practitioners (advanced practice nurses). Participants were recruited to the study through presentations about the CDSS at clinician rounds and other prescheduled educational events.Participants were asked to attend 1 training session of 1-hour duration, use the CDSS during clinical encounters, and complete questionnaires about awareness, agreement, and adoption of guideline recommendations. They were also invited to a focus group discussion about the experience of using the CDSS. Training videos about the use of the CDSS were created and posted on the Web to be widely available. Each clinic recruited a study champion on site to promote the CDSS and address any issues about its use. A total of 12 training sessions were completed over the duration of the project.Evaluation of Utilization below). We defined study participants as the subset of clinicians who completed questionnaires about neuropathic pain recommendations and CDSS use.All clinicians (both participants and nonparticipants in the study) were welcome to attend the training sessions, to use the CDSS, and to access the clinic champions. The utilization of the CDSS was also measured for all clinicians  making a diagnosis of neuropathic pain and (2) prescribing first-line medications specific to neuropathic pain.t test to compare the means of these 3 constructs at time 0 and at 6 and 12 months following CDSS introduction.To evaluate change in awareness, agreement, and adoption over time, we used the dependent Adherence is defined as objective, observed practice of the key guideline recommendations. This was measured through a visual review of the EMR records. As neuropathic pain is a relatively rare condition in primary care, and our goal was to audit a large number of clinical encounters that involved pain management, we elected to select records based on a query for clinical encounters involving pain, rather than based on the clinicians who were providing care. As the introduction of the CDSS could have an impact on all clinicians, not only those who were enrolled in the study, all patients in the clinic and their encounters with all clinicians were deemed eligible to be sampled.We selected a sample of 100 patients for chart review before CDSS introduction and an independent sample of another 100 patients for chart review at 12 months following CDSS introduction. We used the following selection procedure. All patients in the clinic aged over 17 years with a clinic visit in the past 12 months were deemed eligible. Queries were developed to identify patients with new acute neuropathic pain or an acute exacerbation of neuropathic pain. From the list generated from the EMR, 100 patients were randomly selected for review. This same procedure was conducted at 12 months following CDSS introduction, with the removal of any patients who had been assessed already in the first selection and appearing again in the second selection.The review of records was conducted by an independent medical doctor who was not an investigator. The reviewer used a data template to extract pertinent measures. For the first 10 patients, records were independently reviewed by one of the investigators (DG) to determine that interrater reliability reached a kappa of 0.95. All clinical encounters experienced by any clinician were reviewed.We defined CDSS utilization as the entering and saving of data in any of the fields of any of the forms of the CDSS. Opening the form, viewing it, or entering data that were not saved was not captured in our utilization query. A query of the data saved in the CDSS was run at the 6- and 12-month time points. Provider names were recoded with study identifiers, as well as provider type. Descriptive statistics were used to analyze the patterns of utilization.A total of 5 focus groups were conducted with 2 at each of the 2 clinics and 1 at the third. All clinicians who had enrolled in the study were eligible to participate in a focus group, with the purpose of assessing satisfaction with, and overall experience of, using the CDSS. Clinicians were welcome to participate in the focus group discussion if they felt familiar enough with the CDSS to comment on their own experience. There were at least 2 research team members attending each group, and all were led by an experienced facilitator (KN). Group discussions were digitally recorded and transcribed verbatim. Overall, 2 team members (MA and KN) completed the coding and analysis of the data.The consultation process resulted in the following overarching principles to guide the CDSS development:The pain experience comprises a variety of symptoms and issues and requires strategies and providers from various disciplines. The CDSS should include tools that address the scope and depth of the pain experience.The CDSS should allow assessment, monitoring, and graphing of trends for symptoms over time.The CDSS should decrease the burden of finding relevant historical patient data in the EMR, such as previous and current medications, diagnostic tests and consultations, and trends in symptoms over time.The CDSS should offer the opportunity to access as much or as little decision support as the clinician prefers.Clinical parameters collected in the management of other chronic conditions in primary care that may also be relevant to pain management (such as vitamin B12 level in neuropathic pain) should be imported for reference during the pain assessment. Flow sheets for multiple chronic conditions should be visible at the same time.The CDSS should support patients in their own self-management plans.modules were created. The encounter guide offers clinicians an approach for assessment, diagnosis, and treatment of neuropathic pain. An encounter guide was also created for LBP and for opioid management as these were deemed common and often accompanied neuropathic pain. Each of these offered practice recommendations from the relevant guideline, fields to input clinical data, and options to read or to view a brief video of the supporting evidence for the recommendation. In addition, validated questionnaires were coded as tools for monitoring more general parameters about chronic pain, including pain/function levels measured by Brief Pain Inventory, sleep measured by Pain and Sleep Questionnaire three-item index, the four-item Patient Health Questionnaire for depression and anxiety, and the Primary Care PTSD Screen for trauma. Finally, a questionnaire was developed to assess goal and planning.Various components of the CDSS may be viewed online . Separathealth tracker flow sheet summary, which also graphed trends. All modules could be printed for distribution, attached to referral or insurance letters, sent to personal health record, and used on mobile devices.Clinical parameters that may have been collected as part of the clinical care unrelated to the pain assessment encounter were imported automatically into the neuropathic pain encounter form for ease of viewing . Values entered that required calculation to become summary values had formulas coded . Values entered or calculated that were deemed important to follow over time then populated a in the moment video was created to provide the main teaching points to both clinicians and patients about the key recommendations. For neuropathic pain, this included a video about the importance of making a diagnosis of neuropathic pain and a video about the unique medications used for neuropathic pain.Each module had embedded links to materials that could support self-management, including videos, documents, and websites. These could be accessed during the visit or by the patient at another time. In addition, a 2-minute Participants are described in Of the 118 clinicians who consented to participate in the study, 100 (84.7%) completed the baseline and 66 (55.9%) completed the 6-month questionnaires. There were fewer eligible participants for the 12-month time point owing to 1 clinic being delayed in starting and the second-year residents graduating before study completion. This allowed only 2 time points to be collected for those participants. Thus, there were 86 eligible participants and 35 (40%) completed questionnaires at 12 months.Clinician awareness, agreement, and adoption of guideline recommendations was high at baseline in this study population, with mean scores in the top quartile for all parameters. Scores at 6 and 12 months when compared with baseline were, however, significantly higher for both awareness and adoption.P=.001) described features of neuropathic pain as being either present or absent. Similarly, there was a significantly higher number of visits for which sensation testing was carried out and recorded during the post-CDSS period .Finally, the use of first-line medication was higher than the use of second-line medication, even at baseline. There was no significant change in the initiation of either first-line or second-line medications from pre-CDSS to post-CDSS periods.P=.06.When analyzing by patient, rather than the encounters, we found that 56 of the 100 patients in the pre-CDSS sample and 69 of the 100 patients in the post-CDSS sample were either newly prescribed or already taking a first-line neuropathic pain medication. Although this suggests an increase in appropriate prescribing over the study year, the difference did not reach statistical significance, at At the 12-month time point, 18 of 169 possible clinicians (10.7%) had saved data in the CDSS neuropathic pain forms. A total of 1352 fields were saved on 40 neuropathic pain forms. Utilization was highest among nurse practitioners, with an average of 61 forms saved per nurse, 12 forms per resident, and 5.4 forms per physician.Among study participants, both those who used any of the CDSS forms and those who did not, showed significant increases in awareness and adoption of guideline recommendations. Users and nonusers had similar awareness and adoption at baseline.Among the 5 focus groups at 3 sites, there were 23 participants, including 10 physicians, 10 residents, and 3 nurse practitioners. Participants had all been introduced to the CDSS either through in-person or online training or through contact with colleague champions. Several key themes were evident.Access and workflow were commented on most frequently. Owing to the combination of the newer format of CDSS and the older format of user interface, people had difficulty finding the CDSS link. In addition, its integration with other chronic disease management tools was an unfamiliar feature, and they did not completely trust its function. As one participant reported, “...I thought it was a great idea and I was enthusiastic...if it takes more than 3 seconds or something like that, it quickly falls off your priority list to do.”The format and function of the CDSS itself was appealing once they had this open. However, some found that there were more information and data fields available than what they wished to make use of. Some felt that the number of patients they managed with pain was too low to develop ease with using the CDSS. A participant reported, “I remember going in there and clicking around and finding all the different things that were in there and I think if I had spent more time in there and used it, it probably would have been valuable.”Most had opened and referred to the CDSS for the guideline recommendations 1 or more times, even if they had not entered data or used the dynamic functions. Reference information related to guideline recommendations was generally valuable and well accessed. Many participants had opened the CDSS to view the material there, often to confirm that their practice was fitting with guidelines. This was particularly common for first year residents and for nurse practitioners. As one resident said, “...when I have read it through enough times it gave me that practice and just, just asking those questions. So, I use it more as a reference tool I think.”Our priority was to create a CDSS that was appealing to clinicians and therefore would be used in a way that would translate knowledge into practice. We also discovered that clinician knowledge concerning guideline recommendations for neuropathic pain was higher in our study participants at baseline than anticipated, leaving less room for improvement. In spite of this, there were several significant findings that will help to inform future CDSS development.Utilization of the CDSS for data entry, and thus the dynamic decision support functions, was low, although the utilization for reference information was higher. In addition, utilization was much higher among nurses and first year family medicine trainees. All of this suggests that, for this type of clinical scenario at least, the value of a CDSS is highest for its reference material and for its influence on developing new practice patterns and behaviors. Once those patterns and behaviors are developed, the CDSS is less appealing, likely in part as its recommendations do not change.Our study aimed to improve our understanding of the impact of a CDSS on patient outcomes. Improvements in knowledge translation were observed from several perspectives. Self-reports of awareness and adoption of recommendations showed statistically significant improvement. Behaviors observed through chart audit showed that the assessment of pain specifically for neuropathic pain had a statistically significant increase as well. These outcomes are valuable as they are indicators of the quality of care. Ultimately, we would also hope to see an increase in the appropriate use of medication. We discovered that a majority of these patients were using first-line medications already at baseline, and that although there was a shift to even higher use of first-line medication in the year of observation, this was not statistically significant. As the utilization of the data fields in the CDSS was low, it seems unlikely that we can attribute any improved practice to the data collection aspect of the CDSS. Some combination of the training activities and the passive reference material included in the CDSS are more likely to have influenced practice.We created a CDSS taking into account factors that have been shown to lead to the success of a CDSS, such as being created by study authors rather than by an external vendor, providing decision support at the time and location of decision making, and integration into practice workflow ,13-15. OIn addition, our CDSS is only minimally responsive to specific features of individual patients. Most features of this system would be typical of a recommendation system, rather than a decision support system. It may be most useful therefore as a training tool rather than for ongoing decision support. Neuropathic pain is a relatively rare entity in primary care, making it difficult to study . FinallyOur study demonstrated that aligning all necessary dimensions of information systems development to meet research timelines, while achieving measurable impact on quality of care, is challenging. We were able to demonstrate improvement in clinical practice that may have resulted from clinicians developing practice patterns learned from recommendations included in the CDSS. Ongoing use of the CDSS was not common.


Assessment of mangrove ecosystem services (ES) is essential to understand and manage the contribution of these ecosystems to the well-being of local communities. They are the primary beneficiaries but their experience, knowledge, and information are frequently ignored in ES assessment and mapping. In this study, a participatory resource mapping (PRM) approach was applied using local knowledge and experience to analyze geo-referenced information on mangrove ecosystem services. Local communities were involved from the beginning in method selection, application, evaluation, and verification. This “inclusive participatory ES mapping” was conducted in two villages  from 2014 to 2015. Participants representing different community elements were involved in the mapping process. They first created a historical map of the situation in their villages roughly between 1980 and 1999 (before rehabilitation) and then described the subsequent environmental changes. The mapping exercise also documented different mangrove resources that are utilized by communities and identified key areas, such as harvesting zones, biodiversity hotspots, erosion zones, different fishing grounds, and newly rehabilitated areas. The maps reveal that integrating PRM and indigenous geo-referenced information can elicit past and contemporary information on (changes in) ecosystem service availability and use. The results show that by involving local communities from the beginning, the participatory ES mapping can facilitate social learning, provide the foundation for the creation of social capital, and equip the community with sufficient spatial information to improve local mangrove management. The participatory ES mapping approach presented in this paper can be used as a model to support local and regional decision-making processes and to enhance community-based mangrove management in other coastal regions in Indonesia and beyond. The importance of mangroves to support local livelihoods by providing ecosystem services  has been widely recognized Chong . Recent In the past three decades, increasing understanding of the environmental and livelihood importance of mangroves has stimulated various rehabilitation initiatives in Java. The earliest rehabilitation effort started in the 1960s by the State Forest Cooperation (Perhutani) Kusmana . HoweverIn spite of these efforts to rehabilitate the mangroves in Java, only a few studies have mapped the rehabilitated mangrove areas in this region, including Ardli and Wolff , Kamal eA wide range of participatory mapping approaches for ecosystem services assessments has been applied in different countries  How has the overall mangrove landscape and locally important mangrove ecosystem services changed since the 1980s? (2) What are the factors influencing the changes of the ecosystem services? (3) How can the mapping processes and results contribute to enhance local mangrove management?The Participatory ES mapping was carried out in two coastal villages, Bedono, and Timbulsloko, in Sayung sub-district, Central Java, Indonesia see Fig. . These vDemak district is located adjacent to the Java sea, approximately 26 km from Semarang, the capital city of Central Java. The district’s coastal areas stretch along 13 villages including Bedono and Timbulsloko in Sayung Sub-District see Fig. . The coaNumerous mangrove rehabilitation projects have been implemented in these villages since the late 1990s. These projects involved different actors, including local communities, government, NGOs, and private organizations. Some of the projects were successful in restoring the mangroves while engaging the communities in the management, whereas the rest failed due to high natural disturbance and lack of monitoring and maintenance. After more than 10 years of continuous planting activities, mangroves can now be seen occupying the seaside ponds and settlements with a total area of more than 160 ha. The return of mangroves in these villages provides a valuable source of livelihood that can be observed from the increase in economic activities within and around the rehabilitated areas.We used PRM approach in combination with GIS to build spatial information of both the historical and present state of the mangrove ecosystems and their utilization. We combined different tools  and techniques  to gain consensual qualitative information of ESs based on local collective memories and perception. We applied an inclusive participatory approach in which the communities were involved from the beginning in method selection, application, evaluation, and verification. The overall mapping process was carried out from November 2014 to January 2015, involving 25 participants in each village.The preparation covered two main activities including building good relations with the villagers and local authorities through both personal and institutional communication and preparing technical details for the mapping exercise. We lived with local families during the whole research period and used local language in our daily conversation. This enabled us to observe and participate in communities’ life and communicate our project formally and informally. We developed cooperation with the village officers and some villagers to prepare the technical details for the mapping activities, including setting up the meetings, determine the participants, and prepare the venue and equipment. We applied purposive sampling to select the participants. The number of participants involved in the mapping process was determined based on two criteria: the number of sub-villages and the number of community associations involved in mangrove rehabilitation and management. We then applied additional criteria, i.e., gender, age, and occupation to achieve a balanced representation of different elements in the community. We also added information retrieved from our observations and informal communication with villagers in the selection process to avoid the exclusion of relevant actors due to personal political interest. Regarding the mapping material, we prepared the satellite imagery of the villages retrieved from Google Earth in 2014 to be used by the participants during the mapping process.In this study, the participants were involved in the discussion and selection of the mapping process and methods to ensure they were suitable for them. We used the six common stages and methods applied in participatory mapping summarized in Corbett  to guideIn this step, we discussed the village condition, the mangrove ecosystems, the rehabilitation activities, and the importance of maps to manage the village and mangrove rehabilitated areas. We also provided an overview of the mapping process and different mapping tools and techniques including ephemeral, sketch, and scale mapping. Ephemeral mapping refers to drawing a map on the ground using raw materials like soil, pebbles stick, and leaves. Sketch mapping means drawing a map on large sheets of paper. Scale mapping involves marking and drawing the features on a geo-coded and scaled map. The participants were then given the freedom to determine the method that will be used to map their village. The participants in Timbulsloko chose to do sketch mapping first and continued with scale mapping. The participants in Bedono preferred to do scale mapping directly.This step began with a discussion on the attributes that will be mapped and determine the legends for these attributes. The participants in Bedono preferred to use the example of legends provided during the meeting, whereas the participants in Timbulsloko preferred to create their legends. The participants were then split into small groups based on their sub-villages. Each small group mapped the past and present condition of their sub-villages using a scale map in Bedono and both a sketch map and scale map in Timbulsloko. The participants marked the attributes on the satellite image using colored polygons. Additional information was added using points and sticky notes. The maps from each sub-village were then combined, evaluated, and corrected by all participants.The participants were trained to use the Global Positioning System (GPS) tool and record the coordinate from the GPS for backup data. They also discussed the technical preparation needed for the next step (ground truthing), including the strategic time to start the activity, the vehicle needed and the person responsible for conducting the activity. Some areas in the villages, especially the mangroves, can only be reached by boat. Therefore the participants had to do the activities during the high tide.The ground truthing step was arranged by sub-village. Each sub-village created a small group consisting of three participants selected based on consensus among all participants. Each participant involved in this activity was given different tasks, i.e., marking, recording the coordinates, and preparing the boat and logistics needed for mapping. Each group of participants was accompanied by two facilitators who ensured that all attributes discussed in the previous meeting are marked and recorded by participants.The data collected from the previous steps were combined and processed into geo-referenced maps. All recorded coordinates were digitized using ArcGIS 10.2. The maps were created in 1:6000 scale and printed on A0 (841 × 1189 mm) paper for verification by all participants and other stakeholders, i.e., district and sub-district government and NGOs. The maps were then revised based on their evaluation. The fifth and sixth steps were conducted iteratively to ensure that all information and input as discussed in the previous steps are included in the map.After two (in Bedono) to three (in Timbulsloko) verification and revision rounds, the final version of the maps was then given back to the communities through a multi-stakeholder meeting. Aside from socializing the map, this final meeting was also used to disseminate the maps to all stakeholders and discuss the possibility to improve mangrove management in these villages based on the final maps. We closed the session with a discussion and interview on the benefits of the mapping process and results for mangrove management in the two villages. After the project ended, we sent the digital version of the maps to different stakeholders involved in mangrove management in these villages .The mapping process facilitates the exchange of collective memories of villagers on the village condition between the 1980s and 1990s. This process also facilitates the consensus on the present (2014) condition of the village, mangrove resources, and their utilization. The spatial and narrative construction of these collective memories and consensus showed significant landscape changes in the two villages, and the factors influenced these changes.During the mapping process, the participants confirmed that their village had lost the mangroves that used to occupy the seashore and river banks before 1980s. The main drivers for the loss were conversion to aquaculture and excessive use of mangroves for firewood. As shown in Fig. Various efforts to protect the village from erosion, tidal floods, and inundation had been implemented by different government institutions. These efforts included construction of breakwaters with bamboo, concrete, and stone, construction of concrete sea belt, and mangrove rehabilitation see Fig. , right. gemah ripah loh jinawi”: peaceful, prosperous, and very fertile. In the 1980s and 1990s, the villagers were mostly rice and/or aquaculture farmers. Different from Bedono, some participants in Timbulsloko witnessed the presence of mangroves on the seashore in the 1980s. This testimony was connected to their childhood experience when they spent their time around the seaside  led by Wetlands International. In 2014, OISCA also began to set up mangrove planting projects in this village. Aside from the conservation objective, rehabilitation also aimed to protect the village from erosion, flooding, and inundation. Other coastal protection measures were also mentioned during the mapping process, including construction of tire, concrete, and hybrid-breakwater and sea-belt as shown in Fig. The rehabilitation executed in the two villages has been able to restore the lost or degrading mangrove ecosystem services, i.e., provisioning, regulating, habitat, and cultural and amenity services. Our finding shows increasing communities’ dependency on these services through the increasing number of services used or perceived as important by the participants Fig. .Fig. 4MaAvicennia marina or locally called brayo. Local communities used to harvest brayo for food, either as complementary or substitute of staple food. Another type of utilization mentioned was firewood extraction. In the past, firewood was the most important source of energy beside kerosene. Therefore, extracting firewood from mangroves reduced expenditures needed for energy used in cooking activities. Additionally, the participants also identified mangrove utilization for pond construction notably to regulate the water in the canal around the ponds. This information showed a relatively low communities’ dependence on mangrove ES. Therefore mangrove conversion to aquaculture ponds for higher economic benefits was more favorable for most of the villagers rather than conservation to sustain mangrove ES. This attitude, according to the participants, was caused by a lack of knowledge on the benefits provided by these ecosystems which only became apparent after the mangroves were lost.During the mapping process, the participants in both villages recalled three primary mangrove ecosystem services utilized by communities, especially before the 1980s. These services include food, firewood, and construction material. Before the mangroves disappeared, the dominant species recognized by the participants in both villages was Avicennia marina’s seed again, mainly for cultural and seasonal complementary foods. The participants in both villages also mentioned the use of mangroves for firewood. In Bedono, the firewood was extracted from the mangroves on the seaside, whereas in Timbulsloko, this resource was mainly extracted from the mangroves around the ponds which are only accessible for the pond owners. Likewise, construction material, particularly mentioned in Timbulsloko, was only extracted from privately owned pond areas.The return of mangroves in the two villages changed the communities’ attitude toward these ecosystems. This is shown among others by the increasing variety of resource utilization mentioned by participants. They can now harvest Rhizophora’s roots. Activities using this gear are usually conducted within the mangrove areas. The crab traps are commonly placed in the creek around the mangrove areas. One fisher often used dozens of mud-crab traps when fishing. Lastly, crab lines and crab nets are used to catch the crabs in different locations around the mangrove areas.In the past, mud-crab had a very low economic value. Therefore, the communities only caught this species for household consumption. Since the late 1990s, mud-crabs became a valuable export commodity and the price in the local market has increased substantially, up until recently. The participants recognized that the mud-crab abundance increased after the rehabilitation. This phenomenon has raised the number of fishers specialized in catching this species. Many of these fishers used mud-crabs as their primary source of income. According to the participants, the mud-crabs fishing activities were conducted using different tools  that can be associated with the fishing ground. The crab finder is a long iron rod with a hooked tip that is mainly used to catch the crabs burrowing underneath Rhizophora sp harvested from mangrove areas on the seaside.Two other types of resource utilization that was not historically used are the extraction of fishing gear and seedling nursery. As mentioned in “Mangrove regulating services, particularly coastal protection from storms and damaging waves, was strongly addressed when constructing the present map. All participants in Bedono and Timbulsloko had experienced the impact of various coastal hazards before and after the presence of mangroves in their villages. The participants confirmed the decreasing impact of wave and storm damage since the mangroves grew around their houses. This experience increased their knowledge on the importance of mangroves to protect their villages. They are currently worried about the constant erosion that threatens the sustainability of the rehabilitated mangrove ecosystems. Therefore, they marked the mangrove areas that are prone to erosion as guidance for further management discussion.Scylla sp.), white shrimp (Penaeus merguensis), and the return of mangroves in their villages. They stated that the larger the mangrove area, the higher the abundance of these species. This statement shows an increasing understanding of mangrove importance to fisheries based on their experience or observation. Additionally, to improve fisheries, the participants also recognized that the increasing size of the rehabilitated areas also increased the number of bird species in their villages. Therefore during the mapping process, they also marked the areas with high bird diversity as biodiversity hotspots.While constructing the map of present conditions in both villages, the participants recognized the correlation between some commercially important fish species, i.e., mud-crabs . Several villagers stated that the spatial data provided valuable information to understand the landscape changes, enhance current mangrove management programs and develop villager’s potential to formulate mitigation and adaptation plans to deal with the environmental degradation that threatens these villages.Among the most important phenomena observed during the mapping process was the increasing confidence of the participants in communicating their ideas, opinions, and management planning to the government and NGO representatives. They confidently express their knowledge of the features shown on the map and asked for the support from the government and NGO to provide them with necessary assistance to improve mangrove and village development. Such a bottom-up communication process had never happened before and the government and NGO representatives responded positively by setting up follow-up discussions and stimulated the participants to use the maps as one of their communication tools.Participatory mapping is increasingly applied in ES assessment , an International NGO currently works in the studied area. The remote sensing images show mangrove conversion to aquacultures during the period 1988–1989. The mangroves in the two villages continuously decreased and most of the agricultural land had been converted into ponds by the end of the 1990s. The earliest erosion was identified in Bedono village in 1996, and the size of mangrove areas in the two villages continuously increased since 2005. The comparison suggests that the remote sensing images provide an accurate picture of the historic land cover change  and after rehabilitation. By applying PRM combined with GIS, we were able to collect spatial information on different mangrove resources and ecosystem services utilized by communities and identify key areas including harvesting zones, biodiversity hotspots, erosion zones, fishing grounds for the different type of fishers, and newly rehabilitated areas. The results also show that the return of mangroves has changed communities’ attitude toward these ecosystems. The types of mangrove resources utilized by the communities are currently more diverse compared to pre-rehabilitation times. Due to their participation in the mapping exercise, the communities are more aware of the importance of the rehabilitated ecosystems to protect their villages from coastal hazards. This information can be used as valuable baseline information for management and (economic) valuation. However, application of workshop-based PRM can also lead to conflicts among participants, especially when it reveals sensitive information related to activities that potentially violate local rules or norms. Furthermore, PRM can potentially disempower communities when the potential ethical implications of this method are neglected. Meticulous planning, good facilitation, and ownership sharing of the results are therefore essential when conducting PRM. Despite these constraints, our results show that by involving local communities from the beginning, participatory ES mapping can facilitate social learning, provide the foundation for the creation of social capital and equip the community with sufficient spatial information to improve local mangrove management. We believe that our “inclusive participatory ES mapping approach” can be used as a model to support local and regional decision-making processes and to enhance community-based mangrove management in other coastal regions in Indonesia and beyond.


Republic Act 10121 does not work in the regional and local disaster management networks in Region 10, particularly during Typhoon Washi in 2010. At the regional level, such structure does not build interdependencies among agencies, while at the local level, disaster response operations are constrained by bureaucratic protocols making disaster management networks ineffective. At the regional level, where many agencies and organisations are involved, the existing less centralised structure of decision-making should be transformed into a highly centralised structure, while disaster operations should be improved through coordination at all levels of disaster operations and intensified collaboration with non-government agencies.Disasters are the litmus test of governance. The inherent complexity of disasters places government agencies and societies in vulnerable situations. This study uses the mixed-method approach to social network analysis in evaluating the network structure of the Philippine disaster management and its implications for disaster governance. A survey was conducted among the target 56 identified disaster response-related agencies and organisations from the disaster management networks of the most susceptible areas in the Philippines – Cities of Cagayan de Oro and Iligan, Province of Misamis Oriental and the overall Region 10 disaster response network, aimed at measuring the existing relationships among member agencies. Forty-four agencies and organisations were able to participate in the survey. Also, key informant interviews were conducted among the representatives of the lead agencies, non-government organisations and survivors of Typhoon Washi. The findings revealed that the mandated tall structure and the lead organisation form of network governance as stipulated in  Disasters naturally require decentralised decision-making and intensive human interactions Aside from the fact that collaboration often occurs among proximal and like agencies  in examining how the Philippine disaster management structure affects the disaster governance in the region. Disaster network characteristics and network centrality are particularly generated to analyse the network structure and its implications for disaster governance.In studying public sector organisations, the whole network approach is widely utilised as the framework of analysis as it examines the connections that are both present and absent among a defined set of organisations, indicating the extent to which the organisations are working with one another to achieve a common goal In the same vein, Raab, Manna and Cambre  exploredEnsuring that public value is fostered, as it is the ultimate goal of collaborative engagements, re-assessments and evaluation are made. Bardach  posited Broadly, networks are O’Toole :structures of interdependence with many or multiple organisations made up many parts wherein one unit is not merely the formal subordinate of the others in some larger hierarchical arrangement. (p. 45)The network structure is the most noticeable acreage of a network Anklam . JatmikoBryson, Crosby and Stone  postulatOn the contrary, Dalton and Upchurch  explaineGenerally, this article utilises the whole network theory as its framework of analysis in examining the structure of the network based on its characteristics and centrality scores. For this research, the terms DRRM Council is used interchangeably with DRRM network or disaster management network. Also, network or governance structure refers to the structural configuration and characteristics of the networks, while network leadership and management pertains to network governance. Lastly, the term ‘dominance’ in the network refers to the agencies and organisations that may not be part of the mandated and authorised agencies to lead the disaster operations but are able to exercise leadership in the network.Republic Act 10121 in 2010, all government units adapted the National DRRM Plan with specific modifications on its operations according to what is appropriate and applicable in the context and capacity of every community. Based on the level of implementation to disaster response, the Barangay DRRM Council will respond if a barangay is affected; if two or more barangays are affected, the City or Municipal DRRM Council will manage the operations, while the Provincial DRRM Council will respond if two or more cities or municipalities are affected. In cases where two or more provinces are affected, the Regional DRRM Council will direct the response operations, and if two or more regions are affected, the National DRRM Council (NDRRMC) will lead the disaster operations.Upon the enactment of the The NDRRMC structure, as well as its composition, is parallel among Local Government Units (LGUs): provinces, cities and municipalities. At the national level, the Department of National Defense (DND) heads the NDRRMC, and the Office of the Civil Defense (OCD) is the DND’s counterpart at the regional level, while among LGUs, their respective Local Chief Executives (LCEs) (Governor or Mayor) head the Council. DRRM Offices are established to assist the implementation of disaster-related activities agreed upon and approved by the DRRM Council composed of different agencies and non-government organisations. Generally, the DRRM Council is divided into four clusters or pillars of disaster management with lead agencies who serve as vice-chairs in the Council: the Department of Science and Technology (DOST) leads the Prevention and Mitigation Cluster; the Department of Interior and Local Government (DILG) leads the Preparedness Cluster; the Department of Social Welfare and Development (DSWD) heads the Response Cluster and the National Economic Development Authority (NEDA) heads the Rehabilitation and Recovery Cluster.Moreover, to facilitate the response operations, the cluster approach was adopted. The response clusters are part of the NDRRMC’s strategic action in providing humanitarian assistance and disaster response services. These are organised groups of government agencies that are designated to undertake coordination functions at the strategic level to provide resource support for the tactical response. The response cluster is composed of nine clusters led by the DSWD, being the vice-chair on disaster response to the DRRM Council. The response clusters, led by different government agencies, are composed of education, health and psychosocial support, logistics support, emergency livelihood, management of the dead and missing, camp coordination and management, search and rescue, emergency telecommunications support and humanitarian services clusters see .Generally, these disaster response procedures in the Philippines reflect a centralised approach to disaster management. The hierarchical relationships and the efficiency of clear network direction and management among organisations in the local and national government suggest that the Philippine disaster management has a large structure with a lead organisation form of governance This study uses the mixed-method approach to SNA in evaluating the network structure of Philippine disaster management and its implications for disaster governance. Social network analysis that provided the overview of the network’s topology in terms of its density, diameter and average distance metrics, and of the network’s centrality in terms of degree, betweenness and closeness centrality metrics, determined which organisation or agency held the central role within a network.A survey was conducted among the target 56 identified disaster response-related agencies and organisations from the disaster management networks of the most susceptible areas in the Philippines – Cities of Cagayan de Oro and Iligan, Province of Misamis Oriental and the overall Region 10 disaster response network, aimed at measuring the existing relationships among member agencies. Forty-four agencies and organisations were able to participate in the survey: Region 10 – 7, Misamis Oriental – 11, Cagayan de Oro City – 14 and Iligan City – 11. Also, key informant interviews were conducted among the following sector: (1) representatives of the lead agencies see , (2) nonTotal Possible Edges: # Nodes* (# Nodes-1)/2; Density: Actual Edges/Possible Edges. The result of the formula determines if the generated density of the network is considered low or high. Moreover, network diameter is the shortest distance between the two most distant nodes in the network. In other words, once the shortest path length from every node to all other nodes is calculated, the diameter is the longest of all the calculated path lengths. Meanwhile, average distance refers to the shortest path between nodes.The network’s topology and centrality measures are the main foundation for understanding the network and governance structure of Philippine disaster management. NodeXL software was used to process and analyse the data. Primarily, the topology of the network – density, diameter and average distance – was generated. The network’s density describes the portion of the potential connections with a network that are actual connections. A ‘potential connection’ is a connection that could potentially exist between two ‘nodes’ – regardless of whether or not it actually does. By contrast, an ‘actual connection’ is one that actually exists. To assess the density of the network, the following formula is applied: Centrality analysis gives a rough indication of the social power of a node based on how well they ‘connect’ to the network. A highly centralised network is dominated by one person who controls information flow. A less centralised network has no single point of failure. People can still pass on information even if some communication channels are blocked. The centrality of an entity is analysed using the network’s degree, betweenness and closeness measures. Degree centrality measures how connected an entity is by counting the number of direct links each entity has to others in the network; betweenness centrality measures the number of paths that pass through each entity, whereas closeness centrality measured the proximity of an entity to the other entities in the social network.Republic Act 10121.This study measured the characteristics of the disaster management networks in terms of high or low density, diameter and average distance. Also, the influence of each agency in their respective disaster management networks was assessed based on the centrality measures – degree, betweenness and closeness. Nodes, as referred to in this study, pertain to the disaster response-related agencies and organisations. Specifically, in The data showed interesting findings among the characteristics of the governance networks in the LGUs and at the regional level. ‘the Regional DRRM Council gathers at least 4 times in a year as it is required by Republic Act 10121 and during these regular meetings, some members are not able to attend due to their respective meetings and appointments while other agencies send their staff to represent them.’ The comparison of the diameter metric scores reveals that the Misamis Oriental DRRM Council has a diameter of 2 nodes with an average distance of 1.76 nodes. On the contrary, Iligan, Cagayan de Oro, Region 10 and the overall network have a diameter of 4, 5, 4 and 5 nodes, with an average distance of 2.003, 2.371, 2.508 and 2.401 nodes, respectively. These data suggest that the local disaster management networks, primarily the Misamis Oriental DRRM network, have more connections than the rest of the disaster networks. Generally, the networks’ high-density scores, lower diameter and lower average distance are products of a smaller number of network members, which suggest easier familiarity between and among agencies. On the contrary, the regional and overall disaster management networks’ low density and higher average distance suggest a less connected relationship between member agencies. However, the characteristics of the local disaster management networks show that there is high density and higher diameter and the average distance is almost the same as the rest of the networks.Therefore, member agencies in the regional and local disaster management networks are sparsely connected as revealed in the diameter and average distance scores. However, in the local disaster networks, more connections are established among member agencies as implied by the higher density scores. This situation is validated in the statement of the Iligan City Social Welfare and Development focal person, Ms. P. Mantos. When interviewed on 25 November 2016, she stated that:‘I can say that I am already familiar with the focal person of the different agencies in the City DRRM Council, except for the new ones. We have been seeing each other in the different activities of the City. However, our only real interaction is only during the regular meeting/s of the Council, disaster management planning or response. Some of these focal persons are replaced by their agencies and are assigned to another unit. It was quite challenging to request any information or data with them during disaster planning, especially during disaster response operations.’ Furthermore, these findings suggest that there are processes in the network that generate minimal information sharing which causes ineffective coordination and inefficient disaster response operations in Region 10.The centralisation scores of the four networks revealed that in terms of degree centrality, the Region 10 DRRM Council has the least degree centrality, while the DRRM Council of the LGUs of Misamis Oriental, Cagayan de Oro and Iligan has high degree centrality. The degree centrality score of the overall DRRM network in the Region is 9.091 degree relationship, which is lower considering the number of its member agencies. Hence, the networks with the smaller number of member agencies and organisations are relatively highly centralised. Members who are mandated by the law to take part in the disaster management activities have higher degree centrality scores than those members whose membership is on a voluntary basis. Thus, the disaster management network at the regional level is less centralised, while the local management networks are highly centralised in terms of degree centralisation, particularly the Misamis Oriental disaster management network. The less centralised character of the regional network is confirmed by the statement of the Region 10 DILG focal person, Ms H. Ocena. When interviewed on 11 December 2016, she stated that:‘in the Regional level, each cluster in disaster response is led by a certain agency. For example, the Department of Education leads the Education Cluster, Department of Health for the Health Cluster. The OCD oversees these operations. However, I cannot say that the OCD or a certain agency in Region 10 is most influential or more dominant in the network.’ Meanwhile, in terms of betweenness, the overall network and the Region 10 DRRM network have high betweenness centralisation scores with 54.442 and 88.517 degree relationships, respectively see , while t‘disaster management in the region is clustered to properly address the specific needs and concern during disaster response. Each cluster has its own lead agency. As we take over the disaster operations from the LGUs, we always make sure that we provide the needs of the affected communities by facilitating the processes involved particularly by coordinating with other agencies and organisations across the Region.’ ‘our organisation was not ready for disaster response, but we were receiving donations from our partners from all over the Philippines, so we attempted to coordinate with the LGU, but there was no focal person in charge to receive the donations. Worst, at that time, the City Mayor of Cagayan de Oro was not around, and the impact of Washi overwhelmed the DSWD, DRRM Office and other agencies in the City. So, we capacitated ourselves, mobilised our members and distributed the goods to the victims of the typhoon in coordination with Xavier University and Catholic Church of Cagayan de Oro.’ The absence of bureaucratic protocols in the operations of the mentioned non-government agencies is one of the factors that enable them to respond faster and effectively. Noteworthy, the characteristics of the disaster management networks described above – highly dense with sparsely connected member agencies and less centralised in terms of degree – imply that the existing structure of the disaster management networks is not suitable in Region 10 as manifested by its ineffective disaster response operations. When interviewed on 13 November 2016, most of the interviewed survivors of Typhoon Washi shared:‘we were not rescued in our homes. We brought ourselves to the evacuation centers near us, bringing nothing but ourselves and family members. We had nothing, and we were not able to contact our relatives because there was no electricity and no signal on cellular phones. We relied on the relief goods distributed by NGOs and private agencies. Relief goods from the government were delivered weeks after the typhoon.’The Iligan City former DRRM Officer, Mr A. Bendijo, expounded that bureaucratic protocols did not work in their favour. When interviewed on 28 November 2016, Mr A. Bendijo said that:‘the government has funds for disaster response but prior to its utilisation, the Local DRRM Council has to convene first and declared that the City is in the State of Calamity, and it took weeks for both DRRM Councils to convene. Also, the funds are subjected to the regular procurement processes of the government. So, it took a while for the City Government to utilise the fund and fully address the needs of the Typhoon survivors.’ Significant findings are observed from the chosen DRRM networks in the Philippines. Primarily, in terms of the topographic characteristics of the networks, the density scores are high among the LGUs of Misamis Oriental, Cagayan de Oro and Iligan City, while there is a low density in the Region 10 DRRM Council. These data suggest that the smaller the number of network members, the higher the connections between and among member agencies and organisations are established. Similarly, in networks with more members, such as Region 10, connections are hardly established because agencies and organisations are divided among clusters.Networks with low density imply fewer connections among member agencies. Fewer connections further imply that there are fewer cases or opportunities for face-to-face encounters or similar activities that enhance the quality of the relationship between and among agencies, which lead to fewer interdependences and low trust in the network (Ansell & Gash Republic Act 10121 to lead the disaster response operations in the region according to their respective clusters. Thus, in terms of centralisation scores, the entire disaster management network in Region 10 mirrors the mandated structure in the Republic Act 10121. According to the Republic Act 10121, the disaster management network is structured with a lead agency governing the activities in every cluster and is facilitated by the OCD. In terms of Region 10’s network characteristics, there are only 52 connections out of the 152 mentioned agencies. Hence, network density at the regional level is low. This implies that there is weak collaboration in the regional network, which resulted in the minimal information sharing and less effective and less efficient operations. Consequently, trust and interdependencies were low because of the lack of opportunities to have face-to-face encounters among member agencies at the regional level. These findings confirm the finding of Bharosa et al. (Meanwhile, the presence of the cluster-based lead agency in the region is shown in the centralisation scores of the network see . Table 2a et al.  that mosMany scholars believe that disaster management networks should be decentralised. However, Kapucu  argued tOn the contrary, the disaster management networks in LGUs revealed distinctive findings. The LGUs of Misamis Oriental, Cagayan de Oro and Iligan City have high-density scores with relatively higher average distance and diameter. With a smaller number of member agencies, more connections within local disaster management networks are established.Republic Act 10121 (see Moreover, 0121 see . Accordi0121 see , there iFurthermore, the tall structure and the lead organisation form of network governance (Provan & Kenis Republic Act 10121. Hence, emergency managers should fully grasp the value of collaboration by capacitating the members of the network and the community (Kapucu, Arslan & Collins This study further corroborates the findings of Seng  that theTherefore, this study suggests that a highly centralised disaster network with a shared governance and a flat structure should be considered to enhance the competence of the local agencies through an inclusive collaborative process in order to attain agreements, foster interdependencies and sustain reliable partnerships in the region’s disaster management networks. The strong presence of non-government agencies  suggestsOne of the major limitations of this study is its scope. Disaster governance processes, as well as the degree of social capital among the affected communities using a stakeholder analysis, could be explored.Generally, the Philippine disaster management networks in Region 10 failed to respond effectively during Typhoon Washi in 2010 because of significant reasons. Primarily, the overall disaster management network in Region 10 has a low density, which means that trust and interdependencies were low because of the lack of opportunities to have face-to-face encounters among member agencies at the regional level. Moreover, decision-making in the regional disaster management network is less centralised, as revealed by the lack of a dominant or lead agency in the entire regional disaster management. This implies that there is weak collaboration in the regional network, which resulted in minimal information sharing and ineffective disaster response.On the contrary, the disaster management networks in LGUs have high-density scores with relatively lower average distance and diameter because of the smaller number of member agencies. Hence, the smaller the network, the higher the connection. Despite the relative cohesiveness in the local management networks, the presence and dominance of non-government agencies imply lack of capacities in terms of decision-making and resources among the mandated agencies. With this limitations, the local network structures nurtures the existing bureaucratic protocols which make it more difficult for the local government units to operate effectively. These network characteristics reduce the capacities of the local disaster management networks, which leads to weak disaster operations.Therefore, the tall structure and the lead organisation form of network governance (Provan & Kenis


To review studies that evaluate the correspondence between the estimate height via segmental measures and the actual height of children with cerebral palsy.Systematic literature review between 1995–2018, guided by the PRISMA criteria , in PubMed, BVS, MEDLINE and Lilacs databases. The descriptors, connected by the AND Boolean Operators, were: anthropometry, cerebral palsy, child and body height. The research comprised papers in Portuguese, English and Spanish, with Qualis-CAPES equal or superior to B3 that addressed the question: “Is there any correlation between estimate height by equations and direct height measures in children with cerebral palsy?” 152 studies were recovered and seven were selected. Their methodological quality was assessed by the scale of the Agency for Healthcare Research and Quality (AHRQ).Most studies showed no correspondence between estimated and real height. Studies that showed coincidence of the measures contain limitations that could jeopardize the results . Japanese researchers developed an equation which harmoniously aligns the statures; the study comprised only Japanese patients, though.Given the importance of accuracy in height measures to evaluate infant health, it is crucial to carry out more researches in order to safely establish an association between both estimate and real statures. The development of anthropometric protocols, emerged from such researches, would benefit the follow-up of children with severe psychomotor disabilities. However, it is necessary to know if the measurements estimated by methods such as this reflect actual height.In children with motor limitations, as in the case of cerebral palsy (CP), height measurement is currently performed by segmental measurements, as proposed by Stevenson in 1995.Thus, this article performs a systematic review of the literature, with the goal of verifying if there is evidence, in the published works on the subject, of the correspondence between height measured by segmental measurements and the real height of children with CP.Biblioteca Virtual em Saúde – BVS), the Medical Literature Analysis and Retrieval System Online (MEDLINE) and Latin American and Caribbean Health Sciences Literature (LILACS). The descriptors and expressions used in the searches were: “anthropometry”, “cerebral palsy”, “child” and “body height”. These are part of the list of Health Sciences Descriptors (Descritores em Ciências da Saúde - DeCs) and Medical Subject Headings (MeSH) and were combined through the Boolean operator AND.For the development of this systematic review study, scientific literature searches were performed from the US National Library of Medicine databases – the National Institutes of Health (PubMed), the Virtual Health Library .The search for bibliographic references was performed according to the following steps:First step: 159 papers were identified in the databases searched.Second step: Two articles in the German language were excluded . After using the language filter , 157 references remained eligible.7 Applying this filter resulted in the exclusion of 41 articles.Third stage: The period of interest was selected: between January 1995 and April 2018. The lower limit of this interval was chosen according to the year of publication of the equation proposed by Stevenson, which is often used in clinical practice to estimate height in children with CP.Fourth stage: of the 116 remaining references, 29 were excluded because they were repeated in multiple databases, which left 87 references. From this point on, the articles were selected based on their content compatibility, considering the guiding question, as described in the following steps.9 The use of the PICO criteria allowed for the creation of a research question that made the database search more effective, since it focused on the objective of the study and avoided unnecessary analyses. Therefore, when considering the guiding question “Is there a correlation between estimated height from equations and direct measurements of height in children with CP?”, the PICO criteria were: participants - children with cerebral palsy; intervention - estimation of height from equations; control - nonintervention; and results (outcomes) - correspondence between direct height measurements and height estimated by equations. The analysis, directed by the guiding question, was performed by reading the abstracts of the 87 works that remained after the exclusion of 29 repeated references in the databases.Fifth step: PICO eligibility criteria  were followed, as proposed by the Preferred Reporting Items for Systematic Reviews and Meta -Analyses - PRISMA, 2015 in order to create a question that would guide the search according to the objectives of the research.Sixth step: this step explained the reason for excluding each article analyzed in light of the guiding question. We found articles in several thematic axes that differed from the purpose of this study: 21 articles specifically dealt with BMI analysis, body composition and growth charts in individuals with motor disorders. Another 21 articles addressed nutrition, eating dysphagia, consequences of gastrostomy, eating difficulties and/or the nutritional status of patients with motor impairment. Eight articles addressed CP, but with regard to bone involvement, bone density and the presence of scoliosis in patients. Another eight articles dealt with neural impairment in premature infants, or those with low or very low birth weights. Seven articles referred to motor changes, motor function classification and functional performance in patients with neural impairment. Six articles spoke to physical activity, physical inactivity and energy expenditure in patients with CP. One paper addressed the theme of CP in book chapter format, not fitting, therefore, the selection of articles proposed by the guiding question. The remaining nine studies that were excluded dealt with very specific themes, such as hypopituitarism, vitamin D deficiency, the effects of hippotherapy on gait in CP children, growth analysis of children after dorsal rhizotomy, antibody analysis in CP children, growth hormone treatment, prostaglandin levels and short height in cases of hydrocephaly. In addition, in order to be included in this review, selected articles had to be published in journals with a Qualis-CAPES score equal to or greater than B3.Seventh step: Finally, after excluding the 80 references that did not answer the guiding question, seven articles that met the established criteria were selected. These, in turn, were read in full and the most relevant information from each of them was extracted. With this information, tables were made in order to better see and interpret the results.Eighth stage: two tables were produced  and 2, wNinth step: A flowchart was prepared according to the PRISMA recommendation model, consisting of four steps , to synthesize the technique of the systematic review performed . Figure Tenth stage: after the selection of the articles, a secondary search was made in the bibliographic references of each of the selected articles. However, the articles that answered the guiding question were the same as those found in the primary search. Thus, the discussion of the results was limited to the seven articles located in the initial screening.10 This instrument evaluates studies according to nine criteria , generating a final score from zero to one hundred. Studies with a score below 50 were considered to be low quality. Those of moderate quality received a score between 50 and 66 and those with a score above 66 were classified as having high quality methods. Any disagreements among the evaluators regarding the scores given to the articles were resolved by consensus.Determining the quality of the methods used in each article during this systematic review was independently performed by two reviewers using the modified quality criteria evaluation scale for observational studies by the Agency for Health Care Research and Quality (AHRQ).9The scope of the work was guided by the checklist of items to be included in the systematic review report proposed in PRISMAThe steps followed for the selection of the seven articles analyzed in this study are described as a flowchart in 19 The most widely utilized technique to overcome these problems was to use the equations proposed by researchers to estimate height based on the measurement of body segments. However, as the analyzed studies suggest, this is a reference standard that is subject to many variations. 16Limiting factors - such as the presence of scoliosis, muscle atrophy, the inability to stay upright, spasticity and joint muscle contracture - present in CP patients precluded the application of the technique and the use of normal instruments to measure height. These difficulties are mentioned in most of the articles evaluated in this systematic review. 14Bell and Davies, for example, in 2006 compared children with CP and healthy children using the equations described by Chumlea et al. in 1994 and Stevenson in 1995. There were variations of the order of 9 to 10% between the estimated height and the height obtained through direct measurement. In this study, the Stevenson equation was suitable only for children with mild CP, in whom pronounced body contractures do not occur. 15 This Japanese study also pointed to the fact that children with CP are shorter than children with typical development and they observed significant differences between the height estimated by the Stevenson technique for each measured segment . One hypothesis to justify the variability of these measures is highlighted by Haapala et al. According to these authors, there are differences in the growth of body segments, according to the severity of paralysis, which may cause errors in estimating height through segmental measurements.16Kihara et al. conducted a comparative study in Japan between CP patients (with severe contractures and/or scoliosis) and healthy individuals, estimating height from T. The actual height measured could be considered quite accurate, since the researchers made the measurements by dividing the body length into contiguous linear segments that, when added, represented the actual height. Thus, these authors developed regression equations for the calculation of estimated height (from T), which were suitable for both healthy children and those with neural impairment.17 However, in 40% of the sample, it was difficult to perform direct measurements of height in an orthostatic position. This fact represents an important limitation of this study, since these 40% coincide precisely with individuals with moderate to severe paralysis. Thus, an analysis of the equation correspondence only included patients with mild paralysis.Amezquita and Bunster, on the other hand, agreed on the direct measurement of height and the height values estimated by the KH and T segments, using the Stevenson equations.16 Corroborating these findings, García Iñiguez et al. observed that estimated height from equations was significantly higher in individuals with spastic paralysis compared to individuals with other types of CP. 13Haapala et al. also investigated the validity of the Stevenson equations, among others, proposed by Chumlea in 1994 and Gauld in 2004. This work demonstrated the validity of equations for estimating height. However, for individuals with a high degree of musculoskeletal and orthopedic impairment, there was poor agreement between actual measurements and height calculations, leading the authors to recommend caution in applying these equations to these individuals.It is also important to highlight the lack of age group stratification in some studies. The separation of measurements for each age is important since, for each phase of child development, there are differences in the limb size proportions. Therefore, the incorporation of adults and children in the same sample, as in the study by Hogan and Haapala et al., may generate bias.10 However, they all had some degree of limitation with respect to the domains evaluated. Certain items contributed to the loss of points in most articles, such as: the lack of information regarding the treatment of confounders,19 the lack of a sample calculation or adequate justification for the size of the sample17 and the lack of consideration of study limitations in the discussion of results.18 In addition, the lack of statistical analyses also contributed to reducing the score of the examined articles. Calculating statistical power, for example, was mentioned in only one of the articles.17 Most studies did not use modeling or multivariate techniques 19 and they did not evaluate confounders. 19 With regard to the criteria for presenting the results, only two of the articles evaluated failed to have appropriate effect or precision measurements.19 None of the studies were blindly quantifying intervention outcomes. Regarding the use of concurrent controls, only two studies presented this investigation model. With regard to the measurement techniques employed, only one of the studies did not use a suitable instrument .19 It is also important to point out that, in the investigated articles, due to the specificity of their objectives, no dose-response effects were evaluated. Moreover, because these were all cross-sectional studies, there was no follow-up of the populations’ studied. Only one study received funding or sponsorship.14With regard to methodological quality, the articles included in this systematic review were examined according to the criteria of the AHRQ scale, modified by West et al., and obtained scores that rated them as being of moderate (43%) to high (57%) quality.Finally, as a limitation of this systematic review, we highlight the scarce number of articles on the topic addressed here. In addition, the samples evaluated in these studies were mostly small. Another restriction factor that deserves to be mentioned is the time interval used in the selection of articles (1995 to 2018), which may have contributed to this small number of selected studies, since some of them mention similar works published before 1995. Furthermore, the inclusion of other languages and searches in other databases could increase the number of selected studies, providing new information.It can be concluded, therefore, that anthropometry provides important information for the monitoring of healthy children with CP, contributing to the tracking of their development. Knowing that there may be differences between actual height and height calculated from equations, it is possible, therefore, that significant discrepancies in the calculation of BMI may occur, since it is based on the ratio between the mass and the squared height of the individual. Thus, slight variations in the estimation of height can generate exponential errors in the calculation of BMI, leading to misdiagnosis and misleading approaches regarding the nutritional status of patients.This systematic review proposed the objective of verifying, in the literature, studies that showed correspondence between estimated height from segmental measures and the actual height of children with CP. As suggested by most of the studies analyzed, the equations used in clinical practice to estimate the height of children with CP, such as Stevenson’s (proposed in 1995), are more closely matched to real height when applied to individuals with mild paralysis. For children with severe paralysis , whose measurement of height in the standing position is difficult to measure, the use of methods such as those proposed by Kihara et al. in 2014, which uses equations based on direct measurements of height (obtained by dividing body length into contiguous linear segments) is indicated.Thus, given the importance of the accuracy of height measurements to assess child health, further research is needed to establish, more safely, the association between estimated and actual height. The development of anthropometric protocols resulting from these studies would benefit the monitoring of children with severe psychomotor sequelae.


Obstetric violence refers to the mistreatment of women in pregnancy and childbirth care by their health providers. It is linked to poor quality of care, lack of trust in health systems, and adverse maternal and neonatal outcomes. Evidence of interventions to reduce and prevent obstetric violence is limited. We developed a training intervention using a participatory theatre technique called Forum Play inspired by the Theatre of the Oppressed for health providers in Sri Lanka. This paper assesses the potential of the training method to increase staff awareness of obstetric violence and promote taking action to reduce or prevent it. We conducted four workshops with 20 physicians and 30 nurses working in three hospitals in Colombo, Sri Lanka. Participants completed a questionnaire before and three-to-four months after the intervention. At follow-up, participants more often reported that they had been involved in situations of obstetric violence, indicating new knowledge of the phenomenon and/or an increase in their ability to conceptualise it. The intervention appears promising for improving the abilities of health care providers to recognise obstetric violence, the first step in counteracting it. The study demonstrates the value of developing further studies to assess the longitudinal impacts of theatre-based training interventions to reduce obstetric violence and, ultimately, improve patient care. Abusive and disrespectful treatment of patients in health care has been increasingly documented over the past decades. Qualitative and quantitative studies indicate the wide reach of the phenomenon and the long-lasting suffering it can create for patients ,2,3,4. TThe use of abusive behaviours against women during childbirth in delivery facilities has been the subject of numerous studies, predominately in developing countries ,13,14,15This paper responds to a global call to action for respectful maternity care . In prioWe invited physicians and nurses working in obstetrics and gynaecology units at three public hospitals in Colombo district to participate in half-day FP training workshops. One of our Sri Lankan co-authors distributed written information about the study on the hospital wards in advance of the workshops. The hospital directors followed up with verbal information about the study, gave formal permission and arranged transportation for all off-duty staff to attend the workshops on the days. We had previously developed the workshops for Swedish health care settings ,23. The An experienced drama pedagogue led the FP workshops, which we held over the course of four consecutive days in November 2017. The workshops began with warm-up exercises to build comfort and rapport amongst and between the participants and research team. Thereafter, the core activities started with sharing personal experiences of situations of AHC. These were collected on paper . The groThe first two workshops were conducted in English, with a total of 20 participating physicians. The remaining two workshops were conducted in English and Sinhala, with 30 nurses in total. One of our Sri Lankan authors provided language interpretation. We did not mix physicians and nurses in the workshops in an effort to avoid potential dominance and subordination related to the rigid professional hierarchies in Sri Lankan working environments. Each workshop was held in the same location, a research institute unrelated to the participants’ workplaces. Before and three-to-four months after the workshops, the participants completed a questionnaire developed by the research team. This included background information  and four questions assessing their views on AHC . ValidatAll participants gave their informed written consent for inclusion in the study before the workshops and were told that their participation could be withdrawn at any time without explanation or consequence. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Review Committee (ERC), Faculty of Medical Sciences, University of Sri Jayewardenepura (project ID: 55/17).The workshop participants were mainly female, between the ages of 35–50, Singhalese, and had more than three years of work experience. We found no statistically significant differences in the background characteristics of the participants at follow-up, except regarding occupation; only five physicians and 25 nurses answered the questionnaire a second time . A totalp = 0.035)  .We found no statistically significant results for the remaining three questions. For the question about regret, we asked participants who reported that they had not been in a situation of AHC to continue to the next question. Due to these skip instructions, there were too few observations to draw conclusions, but the skip pattern dropped from 56% before to 33.3% after the workshop. Some other trends are notable. Namely, when asked about earlier responses in AHC situations, 44% reported that they had not been in such a situation before the intervention compared to 30% at follow-up, and 43% reported acting in support of the patients’ position compared to 35% before the workshop .It is no simple task to challenge the entrenched and often mechanical or unconscious norms and patterns of behaviour that perpetuate AHC, particularly in under-resourced health systems where the availability of options to act differently may also be limited . Creative efforts have to be built from the ground up to address these challenges . We brouFirst, the workshops reconfirmed that FP can be an effective strategy for increasing the capacity of health care providers to recognise obstetric violence. All participants recalled situations when a patient had been abused by a health care provider. Moreover, as each workshop progressed, the participants shared more personal stories of enacting and witnessing AHC. A recurring topic in the situations they described was the normalised way that staff respond to ‘uncooperative’ patients in childbirth  by scolding them, yelling at them, insulting them, and using physical force to punish, restrain and/or examine them. Women who were pregnant at a young age or outside of marriage, even if the result of rape, and women with sexually transmitted infections, were also identified as being particularly targeted with staff contempt, expressed openly through verbal abuse.Following the FP intervention, participants more often reported that they had been personally involved in situations of AHC compared to before the workshop. We also witnessed promising trends in the data in terms of increased recognition of the importance of considering patient perspectives in medical care. This indicates an increase in participants’ awareness of AHC, or in their abilities to conceptualise the phenomenon of AHC, or possibly both. To clarify this distinction, participants may have lacked the professional vocabulary and practice for identifying and conceptualising AHC before the workshop. Alternatively, they may not have identified with the term because of an assumption that it implied the actions were intentional. Participants may have also had some awareness of the range of dilemmas that AHC created in their daily work but may not have reflected on its frequency, impact on patients, or alternative ways of acting or behaving in these situations.Recognising AHC is an important step towards improving readiness to take action against it in real-world situations. Our results also suggest that the FP method, which combines collaborative social interaction with practical or ‘hands-on’ learning, can encourage new ways of thinking and behaving in health care practice. In the workshops, the scenes that were played out were altered by the audiences’ interventions; that is, the workshop participants rehearsed realistic solutions and new paths to responding to the scenes of AHC. In these rehearsals, instead of being tolerated, accepted or even reinforced, the abuse was rejected and the patient’s dignity protected. Notably, protecting dignity was also considered necessary to restore confidence in health care. Thus, the FP method reinforced that it is not only the situation of abuse, but also its prevention, that can be undertaken collaboratively.The results from this pilot study are persuasive regarding the feasibility and value of the training method. The workshop participants expressed their appreciation for the training and requested more training, for themselves and their colleagues who were not present, as well as staff at other hospitals. However, the conclusions that can be drawn from this study are limited by a variety of factors. Namely, the study is small, with only a few participants, and only one workshop for each participant. The involvement of a control group would have allowed us to assess the amount of change before and after the intervention for each group separately, in turn strengthening our results. Also, a variety of types of interventions are needed to tackle the complex structural drivers of AHC that cannot be addressed at the individual level, nor even the level of singular hospitals. AHC can result from the individual behaviours and attitudes of health providers, but our studies in Sweden and Sri Lanka suggest that contextual factors are more critical for the occurrence of AHC than are individuals and their actions or non-actions ,41. ThisThis study also identified numerous questions to address and approaches to refine in related future training interventions, which may be of relevance in other low-resource contexts and/or regional settings. For example, is a training intervention a potentially effective strategy to change the norms and standards of care that allow for the existence of such types of AHC, such as attitudes that discriminate and devalue women in society at large? Can we ethically justify workshops on counteracting AHC if staff risk being abused for stepping up to counter AHC when they witness it, or in environments lacking policies and structures to effectively ensure both patient and employee rights? What are the long-term effects of such an intervention? How can we ensure that changes in attitudes and behaviours from such an intervention are enduring and sustainable? Will training health providers lead to improved maternal and neonatal health outcomes and patient assessments of quality of care? More experimental evidence is required to answer these and related questions. A brief training intervention using improvisational and participatory theatre techniques may be an efficient ‘eye-opener’ and safe forum for discussing the individual behaviours, cultures and structures in the health system that allow for disrespect and abuse of patients. Our results also suggest that FP has the potential to encourage new ways of thinking to prevent and reduce AHC. This observation indicates possibilities for further developing strategies to counteract AHC, even in very hierarchical health care systems, as in Sri Lanka.