In Israel, approximately one-third of the country’s nurses work in community settings – primarily as salaried employees in Israel’s four non-profit health plans. Many health system leaders believe that the roles of health plan nurses have changed significantly in recent years due to a mix of universal developments (such as population aging and academization of the profession) and Israel-specific changes .The main objectives of the study were to identify recent changes in the roles of health plan nurses and their current areas of activity. It also explored the experience of front-line nurses with regard to autonomy, work satisfaction, and barriers to further role development.The study integrated interviews and surveys of nurses and other professionals conducted across 4 years. Data generated from earlier study components were used to guide questions and focus for later components.In 2013, in-depth interviews were held with 55 senior nursing and medical professionals supplemented by interviews in mid-2017 with the head nurses in the four health plans. In addition, a national survey was conducted in 2014–5 among a representative sample of 1019 community nurses who work for the health plans and who are engaged in direct patient care. Six hundred ninety-two nurses responded to the survey, yielding a response rate of 69%. The survey sample consisted of an equal number of nurses from each health plan, and the observations were weighted accordingly.Senior professionals identified general themes associated with a shift in nursing roles, including a transition from reactive to initiated work, increased specialization, and a shifting of tasks from hospitals to community settings. They identified the current main areas of activity in the health plans as being: routine care, chronic care, health promotion, quality monitoring and improvement, specialized care (such as wound care), and home care.In the survey of front-line nurses, 38% of the nurses identified “caring for chronically ill patients” as their main area of activity aside from routine care; 30% did so regarding “health promotion”, and 26% did so regarding “a specific area of specialization” e.g., diabetes, wound care or women’s health). In response to a separate question, 77% reported “great” or “very great” involvement in quality measurement programs.Four out of five front-line nurses were satisfied with their work to a great or very great extent, and approximately three out of four of them (73%) felt that they had autonomy at work to a great or very great extent. About half of the nurses take into account, to a great or very great extent, the financial concerns of the health plans that employ them.A large majority of the nurses (85%) indicated that the nature of their work had changed substantially in recent years, with an increase in autonomy noted as one of the key changes. Perceived barriers to further role development include attitudes on the part of some physicians and nurses, an insufficient number of dedicated nursing positions, and insufficiently attractive wage levels.The findings, gathered over 4 years, indicate alignment between universal and Israel-specific trends in health care and the evolving roles of nurses in Israel’s health plans.The findings provide support for ongoing efforts in the health plans to give nurses more authority and responsibility in the management of chronically ill patients, a more central role in health promotion efforts, more advanced training - both inter-professional and nurse-specific, and more opportunity to focus on the roles and tasks that require nursing professionals. The nursing profession is an important component of the provision of community healthcare world-wide. Nearly a third of the nurses in Israel are employed in the community,Traditionally, the main roles of community-based nurses (particularly in urban clinics) were to prepare patients for their meetings with a physician  and implementing specific physician directives in the immediate wake of the patients’ encounters with the physicians. However, for over a decade, nursing and other leaders in Israeli health care have been talking about significant changes taking place in the roles of the community nurses. They have been attributing these role changes to a variety of contextual changes, which are described below. Interestingly, some of these contextual changes are happening in health care systems around the world, while others are Israel-specific. Some relate to changes in the population, other to changes in the health care system and still others to changes in the nursing profession itself.aging of the population, there is a growing recognition among health care leaders of the need to better address chronic health problems [With the problems , 22. Theproblems , 5 CAN, problems  and playNational Quality Monitoring Program that has galvanized the plans to seek ways to improve the quality of care, particularly in the areas of chronic care and screening and prevention. Nurses are playing a central role in the health plans’ efforts to improve those measures [The increased attention being given by Israeli health plans to chronic care stems not only from population aging. Another motivator has been Israel’s measures .Community nursing can play a major role in effecting life-style changes in chronically ill patients, in guiding direct caregivers in elder and childcare and in long-term care, and in identifying and preventing abuse , 18, 20.health promotion [Israeli health plans are also gradually recognizing the need to do more in the area of romotion , well beromotion , 21. Hearomotion .mental health services from the government to the health plans has catalyzed health plan managers to also consider how various staffing models could help them address mental health needs in an efficient and effective manner , and opposition on the part of the Israel Medical Association to some of the changes being advocated by the nursing profession.At the same time, there are several nursing shortage facing Israel [Interestingly, the major g Israel , 23, 24 In several countries, major studies have been carried out to explore how such factors as the increasing importance of chronic, mental and preventive care are changing the roles of nurses in community settings , 17, 35.♦ To document the main changes in the roles of health plan nurses in Israel in recent years♦ To document the main areas of health plan nursing work today and the extent of their occupation in these areas.In addition, the study was designed to:♦ Examine the extent of autonomy felt by nurses in their work♦ Examine the extent of satisfaction felt by nurses with various aspects of their work♦ Examine how nurses perceive their contribution to the quality measurement program and how the program affects them♦ Identify the barriers to the continued development of the role of community nurses.The study had two main goals:Apart from these issues, the study was designed to examine the varying perceptions of nurses based on the following variables: age, country of birth, level of education, professional status, and position of management or otherwise. Further, it compared the situation in Israel with that in the US and England regarding both how roles of community nurses have changed in recent years and the current nature of their roles.The study focuses on nurses employed by Israel’s four non-profit health plans. Background information on the status of nurses in each of the four plans can be found in Appendix This paper is based on a broad study conducted in 2014 .In-depth interviews with approximately 50 leading professionals in the field of nursing and related fields.A survey of more than 1000 community nurses who engage in direct patient careThe study had two main components:The two main components are complementary; the leading professionals are uniquely situated to identify the role changes that have taken place over time and to provide a broader system perspective, while the front-line nurses are uniquely situated to provide detail and quantification regarding the current nature and content of the work. Moreover, the in-depth, open-ended interviews with the leaders contributed to the development of the largely closed-ended questionnaire for the front-line nurses, . For example, the in-depth interviews generated a list of current areas of activity and then the survey was used to quantify the centrality of each area of activity and then explore it in greater detail.These two main components are described further below; the study team also explored how the Israeli situation compares with the situations in the US and the UK, as described in Appendix Fifty-five semi-structured, in-depth interviews were held with leading figures from the field of nursing and related fields. Interviewees were suggested by the members of the members of the Community Nursing Study Group . The interviewees included past and present heads of nursing at the MOH, the health plans, and the hospitals; leading academics in the field; managers at various levels of the health system , the Israel Medical Association, the National Association of Nurses in Israel, hospitals, and various professional societies. The interviewees included both nurse managers and managers from other professions. The mix of interviewees made it possible to obtain a variety of perspectives on the processes affecting the nursing profession.The interviews were conducted between January and August 2013. A semi-structured interview guide was used including questions on: the main current areas of activity of health plan nurses, how their work has changed in recent years, the challenges they face at work, their view of the future of the profession and of the barriers to changes to the profession.The in-depth interviews were analyzed by first extracting the main themes and then exploring how these themes were addressed in the various interviews. Each interview was summarized in writing. An initial content analysis was carried out shortly after the interview, and significant issues were identified. In cases where a gap was discovered or a question arose, we returned to the interviewees and asked for clarifications.In the analysis of the interviews, we compiled a detailed list of all the roles performed by the nurses and categorized them according to relevant groups. We made comparisons among health plans, different levels of management and regions. We focused on topics that were mentioned by many interviewees, but we also addressed noted significant issues raised by one or two interviewees. In addition, we analyzed reports and documents submitted to us by the interviewees.In mid-2017, supplementary interviews were held with the head nurses in the four plans, focusing on changes in the most recent years, against the background of the findings from the survey.The study population consisted of all health-plan nurses in the four health plans spending most of their time in non-management work, regardless of whether their positions were full- or part-time. Registered nurses, Licensed practical nurses, and RNs with advanced certification were included. Nurses whose main occupation was managerial were not included in the survey to ensure that the focus was on nurses involved primarily in direct patient care. According to the data of the health plans, in 2014 this amounted to more than 4600 nurses.Despite the differences in size between the four health plans in the number of employees and persons insured, approximately 250 nurses were sampled at random from each health plan to permit a reliable analysis for each plan.The research questionnaires were computerized and emailed to all the nurses using the addresses supplied by the health plans. The survey was conducted between August 2014 and February 2015. The appeal to the nurses invited them to respond by email through the link provided or by telephone.In each health plan, 250 nurses were sampled randomly. This random sampling is relied upon to provide a representative mix of full v. part time, etc. within each health plan.The sample numbered 1019 nurses. Of these, 6.6% chose not to cooperate and 1.4% did not meet sampling criteria. In total, 692 or 69% of the nurses responded to the questionnaire.The survey was composed of 70 questions, of which 15 were open-ended.The topics covered included the following: the main areas of the nurses’ work; their main activities within those areas; perceptions of autonomy; perceptions of the quality measurement program; job satisfaction; perceptions of the professional future of health plan nurses; and background characteristics.The categories for the question about usual work activities were derived from the leadership interviews.The research questionnaires were computerized and emailed to all the nurses using the addresses supplied by the health plans. The survey was conducted between August 2014 and February 2015. The appeal to the nurses invited them to respond by email through the link provided or by telephone or regular mail. 65% of the responses were by e-mail, 25% by phone and 10% by regular mail. Comparison of key response variables  found very similar patterns of response across data collection modalities.The questionnaire made it clear to the respondents that their responses would remain anonymous and the st.udy team abided by that commitment, sharing with the health plans only aggregate results.A key distinction in the survey was between routine work and “professional work”. Routine work was defined in the questionnaire as "work that is carried out routinely in the nurses' room, e.g., blood tests, ECG, blood pressure, vaccinations, inhalations, etc." Professional work was defined as "work in a specific professional field, such as treatment of complex wounds, stomas, follow-up in diabetes clinic, heart failure, giving instructions for genetic survey testing, geriatrics, women's health, mental health, day hospital, minor surgical procedures, etc.".The data were weighted to reflect differences among health plans in the sampling proportions and the response rate. After the weighting, the data presented unbiased national estimates of the parameters examined. The analysis focused on the findings for the full sample. Comparisons were also carried among population sub-groups defined in terms of age, educational level, and other background variables.The data were analyzed using SPSS version 21, and its complex samples utility. The open questions were analyzed using Naralyzer, a program that makes it possible to consider the entire set of responses to any given question. The responses were coded by category and a codebook was built for the questionnaire, after which the respondents’ responses were transferred to SPSS.A transition from reactive to initiated workIncreased specialization of nurses in various areas of care, including diabetes and wound careThe integration of nursing work into various circles of care-giving and support .A transfer of activities from the hospital to the community.Senior professionals identified 4 key trends influencing the evolution of the work and functions of community and health plan nurses , 27:A trThe general picture arising from the interviews is that the work of community nurses has broadened in recent years, and this trend is expected to continue.♦ Routine work (as defined above)♦ Care of chronic patients♦ Health promotion ♦ Quality measurement and improvement .♦ Home visits ♦ Specialized care in various areas including diabetes, stoma, treating wounds, and geriatrics♦ Participation in unique health-plan initiatives such as “conversation maps for diabetes” and a “personal physician”.The interviews identified the following as the main areas of current work of health plan nursesThe in-depth interviews also surfaced similarities and differences among the health plans; these are depicted in Appendix With the support of top management, technical tasks are increasingly being delegated by nurses to support staffNurses are increasingly being appointed to general management positions such as regional directors and program directorsInter-professional education, involving training of the full primary care team, is on the riseNurses are increasingly being given patient management roles in chronic careand lead roles in health promotion and hospital-community transitionsInterviews in mid-2017 of the health plans’ nursing directors highlighted the following recent developments:The main findings emerging from the survey are that the nurses feel that their role has broadened, that they enjoy substantial autonomy and, in general, they are satisfied with their work. They believe that the profession will continue to develop in the future, but at the same time, they point to significant problems and barriers.As indicated in Table The study team compared the characteristics of the respondents and the study population for Israel’s two largest health plan, which account for more than half of the nurse population (similar data were unavailable from the other two plans). In one of the large plans, the characteristics were found to be very similar with regard to sex and education level, but with the sample having a slightly higher proportion of nurses who had done Diploma courses 54% v. 43%). In the other large plan, the population and sample were very similar with regard to sex, the proportion of the nurses who had done Diploma courses was slightly lower in the sample (33% v. 40%), and the sample also had a lower percentage of LPNs (8% v. 18%).  continue to engage in routine activities (as defined in this study) to a great or very great extent. In addition, approximately one quarter to a third of the respondents indicated that their major area of care, besides routine work, was chronic illness care (38%), health promotion (30%), specialized care (26%) and home care (6%).Those nurses who indicated that caring for the chronically ill was their main area of non-routine activity were presented with a list of relevant activities and asked to indicate in which of them they are involved to a great or very great extent. As indicated in Table The same group of nurses was also presented with a list of tasks associated with caring for individuals with chronic illness Table  and askeThose nurses who indicated that health promotion was their main area of non-routine activity were similarly asked about the extent of their involvement in a list of relevant activities. As indicated in Table Eighty-five percent of the nurses felt that concerning their main area of activity, in the past 5 years there have been significant changes in the way that they work. Among other things, the changes cited included: more planned work than in the past, focused activity on specific areas (such as the those noted above), and expansion of medical knowledge. Furthermore, 61% of the nurses noted that the working environment in this period had changed to a great or very great extent, and another 26% indicated that it had changed to a moderate extent.Almost all of the nurses (90%) take into account the family and economic situation of the patient to a great or very great extent while only 2% of them take it into account to a small or very small extent or not at all. Moreover, almost half (47%) of the nurses take into account financial considerations of the health plan to a great or very great extent while 18% of them take it into account to a small, very small extent or not at all. (The remainder takes these factors into account to a moderate extent.)Approximately three-quarters of the nurses (77%) reported involvement to a great or very great extent in quality measurement programs; only 10% felt that they were not involved or were involved to a very small extent. Similarly, 75% of the nurses felt that the program had impacted their work to a great or very great extent, and 73% of them felt that their workload had increased to a great or very great extent as a result of the program.Approximately three-quarters of the nurses (73%) felt that they had autonomy at work to a great or very great extent. Similarly, 75% of the nurses felt that their professional autonomy had broadened in the preceding 5 years in contrast to 9% who reported a sense of curtailed autonomy in this period, and 16% who noted that they had felt no change. 70% indicated that, to a great or very great extent, they had the authority needed to do their jobs.Four out of every five nurses (80%) were satisfied to a great or very great extent with their work overall, and only 3% felt little or very little satisfaction; the rest were moderately satisfied. In keeping with these feelings, 80% said that they would recommend to others to enter the profession.As indicated in Chart 1, the aspects of work with which the most nurses were satisfied to a great or very great extent were: the impact of their work with patients (84%), the extent of responsibility given to them (81%), and their co-workers (82%). The aspects of work with which the lowest proportion of nurses were satisfied were: the salary (39%), physical conditions .Physicians’ perceptions. Some nurses believe that physicians fear the profession’s development, being interested in keeping the nurses in the position of following physicians’ directives.♦ Nurses. Some nurses believe that they and/or some of their colleagues slow down the profession’s development, having no interest in broadening their authority for fear of a greater workload.♦ Lack of resources and positions. Many nurses regard the lack of resources as a barrier to the profession’s development: the large workforce shortage, and the fact that there are no established positions♦ Compensation. Subsequent to the relative wage dissatisfaction, some nurses regard low levels of compensation as a barrier to the profession’s development. Low compensation attracts fewer young people to the profession and increases the workload.♦ Asked about barriers to the development of the profession, the front-line nurses who participated in the survey and the managerial nurses who participated in the in-depth interviews cited similar barriers. These included:Note that the barriers identified in the survey were largely similar to those that came up in the in-depth interviews.The nurses’ perceptions were examined according to the following variables: age, country of birth, level of education, professional status and managerial position. As a rule, very few large or statistically significant differences were found among the groups . Surprisingly, however, the nurse-managers were less likely than the others to report that take into account the economic interests of their health plans (22% vs. 36%). The reasons for this difference might be a good subject of a future study.Another key finding is that a significant proportion of the nurses (38%) indicated that care of the chronically ill patient is their main area of activity beyond routine care. With the population continuing to age, work in this area is likely to expand. It will be important to develop patient-centered projections of the amount and nature of the work that will be needed to care effectively for the chronically ill, and then think strategically about how health plan leaders, and physicians, nurses, and other professionals on the front-line can best work together to address this important challenge. This will clearly have important implications for the number of professionals required and continuing education, and this could be an important area for inter-professional continuing education. Serious consideration should be given to continuing the trend of giving nurses a greater role in care coordination and management of the chronically ill.Health promotion is the main area of non-routine activity for another large group (30%) of health plan nurses. In the future, it will be important to explore in greater detail in which health promotion challenges they are most involved, the nature of their involvement in those challenges, and the degree of their success in those areas. This could have important implications for ensuring that nurses have the opportunity to engage in relevant continuing education opportunities regarding health promotion strategies, concepts and techniques. The major role that nurses are playing in patient-level health promotion should also be give greater recognition.The study also confirms the extensive involvement of nurses in quality monitoring and improvement efforts, hence another area where inter-professional education should be given greater emphasis. A related finding is that almost all the nurses are quite attuned to the family and economic situation of the patient. This attention to context can be vitally important in efforts to improve a health plan’s quality performance, particularly with regard to those dimensions of quality, which require patient compliance and/or behavioral change. They will be even more important in the future if/when quality measures are developed that assess quality in such areas as depression care and community-based long-term care.As indicated earlier, this study found that nurses perceive quality monitoring and improvement to be an important part of their work, but that this comes with various costs – more managerial pressure, more competition and a higher workload. A previous study by Nissanholtz et al. adds valuable context to these findings. In a national representative survey of health plan primary care physicians, most respondents (74%) agreed that nurses contribute to practice quality and share responsibility for improving quality measures. Physicians who felt that quality monitoring improved the quality of care and those who supported the program were more likely to consider that nurses shared responsibility for the quality of care , 27. ThaThe findings also indicated that a very high proportion of the health plan nurses are very satisfied with their work overall (80%). However, the study also highlighted pervasive concerns with the shortage of nursing positions, wage levels and the attitudes of some physicians and nurses that constrains the professional development of health plan nurses. Expanding nurses' role is one of the factors that improve satisfaction of nurses . DealingA related finding is that the vast majority of the health plan nurses are significantly involved in both routine work (in which they function largely as supports for primary care physicians) and more specialized work . In theory, a mix of this sort could be either a source of frustration (related to time constraints and/or the complexity of role identity) or a source of satisfaction (related to task diversity). Unfortunately, we do not have information on how this mix of roles is affecting nurse satisfaction. What we do know is that the vast majority of health plan nurses are satisfied with their work and that, at present, for most of them work entails a mix of routine tasks and specialized work.In general, there is a good fit between the study’s findings about the evolving content of the work of health plan nurses and the contextual changes highlighted at the beginning of this article. One important exception is that, despite the ongoing reform of Israel’s mental health care system, the nurses did not indicate that mental health care is an important component of their workload. This may be because the in-depth interviews were carried out in 2013 and the survey of front-line nurses took place in 2014; while these were subsequent to the 2012 government decision to transfer responsibility for mental health care to the health plans, the transfer itself did not go into effect until 2015. Interestingly, in 2017 presentations to the Mental Health Reform Administration, the health plans spoke about significant strides in involving nurses in mental health care and in the future it will be important to study systematically the extent and nature of this evolution.The changes in the roles of community nurses has apparently been a gradual evolution spread over many years. Interestingly, the main changes emphasized by nursing leaders in the 2013 in-depth interviews were largely similar to those emphasized in the 2017 follow-up interviews. At the same time, several new points were made in the 2017 interviews, suggesting that this evolution continues; these include the appointment of several nurses to regional director positions, greater expose of the nurses to patient clinical data, and more inter—professional educational.Recruiting more people to the nursing profession, especially to community nursing. The data can enable recruiters to provide a clearer picture of the current content of the work (including its diversity), how that content is changing in exciting directions, and how satisfied community nurses are with their work.♦ Intra-organizational thinking within the health plans and other relevant organizations Key topics including the place of nursing resources in the budgeting of community-based services, the provision of appropriate levels of compensation, the definition of nursing tasks, the division of labor between the various staff members and mechanisms for increased cooperation.♦ Sharing information with the public on the changed role of health plan nurses. This could contribute significantly to the empowerment of both nurses and their patients and to cooperation between these two groups.♦ Overall, the data presented in this study can contribute to Israeli efforts in the following areas:The main study limitation is that the interviews were carried out at only one point in time. Thus, the findings about changes in the nurses’ roles are based, in part, on the nurses’ ability to recall the substance of their roles several years prior to the interviews and their assessments of how those roles had changed. This limited the extent to which the changes in the roles could be detailed and quantified.Another limitation is that no formal assessment was made of the reliability and validity of the questionnaire used in the survey of front-line nurses. However, it was carefully derived from the in-depth interviews of the 55 nursing and other leaders and also reviewed for face validity.Finally, as indicated in the methods section, there may be small-moderate under-representation of some sub-groups of nurses. However, the impact of these on the overall study findings is apparently quite limited, as the study found few substantial differences in key study variables among these sub-groups.While the current study focused on Israel, it highlights developments, trends and issues, which may be relevant to other countries as well. For example, in the U.S. a 2017 report by the Macy Foundation called for using RNs as significant contributors to health promotion efforts in primary care settings . That reThe study team plans to be in touch with researchers in other countries to identify similar studies, compare findings, and reflect together on similarities and differences. One of the issues of particular interest is whether the predominance of health plans in Israel has resulted in a unique mix of roles for its community nurses and whether Israel might be a harbinger for other countries in the process of adopting more organized systems of community care.An exploration of how the nature of the interactions between health plan nurses and physicians are changing and how both professional groups feel about itQualitative research to further understand how front-line nurses experience the mix of traditional/routine and newer/proactive rolesMore detailed analysis of the survey data regarding such topics as nurse involvement in the quality monitoring program, change barriers and facilitators, similarities and differences across age groups, etc.An analysis of how nurses answer the challenge of caring for the mentally ill and persons with mental health problemsThe evaluation of new nursing roles as nurse practitioners and nurse consultants and their impact upon patients’ and families’ quality of care and quality of lifeAn analysis of the current roles of the nurses in preventive mother and child health centers, and how these have changed over timeAn exploration of of Israeli models of physician-nurse teamwork, which were recently praised by the OECD , and areDirections for further research within Israel include:


Populations in resource dependent economies gain well-being from the natural environment, in highly spatially and temporally variable patterns. To collect information on this, we designed and implemented a 1586-household quantitative survey in the southwest coastal zone of Bangladesh. Data were collected on material, subjective and health dimensions of well-being in the context of natural resource use, particularly agriculture, aquaculture, mangroves and fisheries. The questionnaire included questions on factors that mediate poverty outcomes: mobility and remittances; loans and micro-credit; environmental perceptions; shocks; and women’s empowerment. The data are stratified by social-ecological system to take into account spatial dynamics and the survey was repeated with the same respondents three times within a year to incorporate seasonal dynamics. The dataset includes blood pressure measurements and height and weight of men, women and children. In addition, the household listing includes basic data on livelihoods and income for approximately 10,000 households. The dataset facilitates interdisciplinary research on spatial and temporal dynamics of well-being in the context of natural resource dependence in low income countries. The relationship between productivity of natural resources and human well-being is complex, influenced by issues of access and ownership, and dynamic across time and space2–8. Hence there is a significant need to integrate analysis of ecosystem quality, the services ecosystems provide and the multiple dimensions of well-being that are concurrent with, or derived from, these ecosystems.The well-being of populations living in geographically and socially marginalised regions across the globe are dominated by natural resource extraction, and use, and are heavily dependent on ecosystems and their services9–13. Much work on ecosystem services focuses on mapping ecosystem services and their joint production in bundles; on modelling the underlying ecosystem processes; and development of payment and market mechanisms15. The dataset reported here is one of the first large scale quantitative investigations that allows the nature and strength of relationships between ecosystem services and well-being to be tested, with generalisable results, and to include diverse indicators of well-being.A diversity of studies to date have developed conceptual frameworks and collected data on specific elements of well-being and ecosystem servicesAssessing Health, Livelihoods, Ecosystem Services and Poverty Alleviation in Populous Deltas (www.espadeltas.net) funded under the Ecosystem Services for Poverty Alleviation programme (www.espa.ac.uk) from 2012 to 2016. The project provides policy-relevant information on managing natural resources for well-being in Bangladesh, by developing systems models, scenarios and detailed analysis of poverty-ecosystem services linkages. The data reported have formed an integral part of these outputs and have been coupled with bio-physical models and scenarios of future climate and social change in an integrated systems model16 and directly analysed to determine the social and ecological conditions under which use of ecosystem services lead to positive well-being outcomes.The dataset described in this paper was developed, designed and collected to represent multiple dimensions of well-being, ecosystem service use, social mechanisms, spatial variation and seasonality, in a context of social-ecological systems. The International Centre for Diarrhoeal Disease Research, Bangladesh , the University of Exeter and the University of Southampton co-designed and implemented the survey as part of the project The quantitative household questionnaire survey was administered to 1586 households three times to capture temporal dynamics of well-being from ecosystem services. The sample was stratified by social-ecological systems in order to capture spatial dynamics of well-being from ecosystem services. Information on assets, income, expenditure, food consumption, satisfaction with life, blood pressure and anthropometric measurements of height and weight (in order to estimate the Body Mass Index) was collected to ensure representation of diverse forms of well-being. Detailed sections on fisheries and forest collection ensured that open access resources were fully represented. Multi-stage random sampling ensured that results were representative of the area and generalizable. Some data were collected about individuals to provide insights into intra-household dynamics.17. The population of the non-urban delta region is dense with more than 800 people per square kilometre and with high incidence (>50%) of landlessness18. This area exemplifies many of the stresses associated with coastal and delta regions around the world: land use conflicts, large salinity fluxes with background increases in salinity, coastal hazards such as cyclones, prioritisation of monoculture to the detriment of open access resources, lack of government support and high population density19.The study area covered by the dataset is Khulna and Barisal Divisions on the southwest and south-central coast of Bangladesh, representing one of the most vulnerable parts of the Ganges-Meghna-Bhramaputra delta. Bangladesh scores low on international comparisons of human development and income, with low per capita income, although its average literacy and health outcomes  score higher than expected for such low income levels21.The diversity of variables, rarely collected together in the same survey instrument, create a high potential for reuse of this dataset. Furthermore, certain variables are comparable with the standard Household Income Expenditure Surveys of Bangladesh and the national census offering the possibility of analysing the data over multiple years or decades. The dataset can be used to test key associations between environmental processes and social and health outcomes that are critical for environmental policy and development strategies for Bangladesh, the delta region, and deltas more generally. For example, there are a range of variables that will allow researchers to examine the social relationships that affect livelihoods in rural areas such as money lending, casual labour, in-kind payments and share-cropping. Comprehensive data on yields, income and livelihood choices could be used to undertake simulation modelling of interventions, ranging from improvements in agronomy, through to social interventions in availability of credit, or supporting mobility and migration. The dataset here can be disaggregated by social-ecological system, and crucially includes information on seasonal variation in environmental conditions and livelihoods, a critical issue in the variation of well-being and povertyThe following sections describe the sampling strategy used to randomly select households and individuals for the survey and survey implementation. The first level of sampling was by social-ecological system. We assigned administrative units to social-ecological systems (SES) so that we could create a sampling frame. We did this by obtaining a land cover map (digitized from satellite imagery) of the field site and overlaying with a map of administrative units (Unions) in a geographic information system (ArcGIS) see  and 3. A22. Here, the concept is operationalized by integrating land cover with the social and livelihood systems that influence, and are influenced by, the way the land is used. The social-ecological systems of the field area were defined by a literature review and expert elicitation with scholars in Bangladesh, then verified through seventy-five semi-structured interviews carried out across the field site from September 2012 to April 2013 (Data citation 1). Seven systems were identified as having distinct ecological characteristics and access regimes: rainfed agriculture, irrigated agriculture, freshwater prawn, saltwater shrimp, riverine (including eroding islands), Sundarban mangrove dependence and offshore fisheries. A social-ecological system is a set of ecosystems, human populations and institutions with close functional interactionsSome social-ecological systems directly correspond to land use type, for example, shrimp aquaculture. However, in the case of coastal and offshore fishing, for example, fishermen live in villages among agricultural land and travel to the ocean to work. Therefore, two different methods were used in sequence to assign social-ecological systems to administrative units: land cover (agriculture or aquaculture) or proximity to land feature .Each Union could belong to only one SES in this analysis, and the proximity to features was decided to be used as the more important factor if a Union could belong to multiple SES. If a Union did not have one dominant land cover type it was excluded from the analysis  and agriculture (irrigated and non-irrigated). Non-productive land cover uses were subtracted from total area  before calculations took place. Urban areas were not included in the sample because of the nature of the research questions relating to direct natural resource dependence.A sensitivity analysis was carried out to find out how many Unions fell within the sampling frame for each of the four SES if the percentage land cover threshold is changed. We investigated changes in the number of eligible Unions for 70, 80, 90 and 99 percent coverage of each of the four classes of land use. While 70 percent coverage may not allow the land use to be described as dominant, a threshold of 90 percent excluded too many Unions from the sampling frame. Thus, 80 percent coverage represents a balance and was applied in this research. The original land cover data is included in the Reshare database allowing other possible categorisations to be made .ArcGIS was used to manually select Unions adjacent to the Sundarbans, the southern coast or that contained a char (and thus create the riverine zone). Unions assigned to these categories were then excluded from the list of Unions belonging to land cover-SES. For example, once a Union was identified as a coastal Union, it was removed from the rainfed agriculture category. Or once a Union was identified as Sundarban dependent it was removed from the saltwater shrimp category.Sundarban dependant zone included all the Unions adjacent to the Sundarbans directly or separated by the Baleshwar-Haringhata Rivers on the eastern edge of the forest. The Union on the south eastern corner of the forest that could be classified as either Sundarban dependent or coastal periphery, was categorized as a coastal Union based on expert knowledge. Unions on the Bay of Bengal from the western border of Bangladesh to Shahbazpur Channel were included in the sampling frame as marine periphery Unions. Four Unions were excluded from the sampling frame (in Char Manpura Upazilla and Char Khukrimukri) because of known security issues.23 to classify riverine char Unions. A char is a low lying area within a river that may be seasonally flooded, be attached to the riverbank or exist as an island. The chars were mapped as point features in a GIS and classified as attached to mainland, riverine, and marine or estuarine. We were interested only in the dynamics of riverine chars so we excluded the marine and estuarine chars from the analysis. The presence of chars was verified using an up-to-date land cover map.We used a pre-existing database of charsbeels) are also present in the northern part of the field area, however, their geographical spread was small, their importance within the region limited, and there was no way of isolating them in the GIS for systematic random sampling so they were omitted. Some land cover types such as waterlogging, were not associated with separate hypotheses regarding the relationship between ecosystem services and well-being based on the initial qualitative work.The list of social-ecological systems is not exhaustive. The systems chosen represent a compromise between the sample size (and thus possible number of strata), the ability to define the systems in a GIS (to create a robust sampling frame), and systems that were hypothesized to influence the poverty-ecosystem service dependence relationship. For example, while inland capture fisheries are an important system, they are ubiquitous across the study area and so were not included as a separate category. Wetlands  and clusters. The total sample size was spread evenly between social-ecological systems to ensure that all systems have equal representation in the analysis despite uneven geographical extent. Therefore, certain social-ecological systems are over-sampled and others under-sampled.24 for Barisal and Khulna Division. Here nine districts  were considered as one study area and the mean was weighted accordingly. Weighted mean of prevalence of poverty below the lower poverty line is 22.1 percent for the project area. A further 10 percent was added to the sample size to take into account non-responses, 6.5 percent for precision and additional 10 percent more was added to maintain sample size between the different rounds of the survey once migration was taken into account. The formula used to determine the sample size is:The sample size required was calculated using prevalence of poverty according to a Head Count Ratio. Prevalence of poverty according to Head Count Ratio below lower poverty line (constructed on the basis of cost of basic food needed) is 26.7 percent and 15.4 percent respectivelyp=estimated proportion (from a survey);z=z value associated with the degree of confidence selected;d=allowable errorUnions belonging to each of the seven SES were labelled from 1 to n (west to east). The.dbf files from the GIS were converted to Microsoft Excel files and filter was used to arrange the Unions from one to n by SES. 25, was removed. Then the remaining Mouzas were assigned number from 1 to n. R programme was used to randomly selected three Mouzas from each of the selected three Unions. Each Mouza was divided into segments, where number of segments=total no. of households in the selected Mouza/150. Due to time and money constraints a segment was considered, not an entire village. A segment of 150 households was decided based on previous studies in Bangladesh26. R programme was used to randomly select a segment. The count of the households began from the north corner of the Mouza and moved southwards. Full details of the villages in which the survey took place, can be found in the ReShare repository .To select Mouzas from each Union, first any Mouza with fewer than 150 households identified using the Mouza list from the Bangladesh Population Census 2011 TablesThus 63 segments, randomly selected from the 63 Mouzas, were mapped and then listed by trained enumerators. The listing form included information on name of main earner and household head, age, marital status, primary, secondary and tertiary occupation of main earner, monthly total household income, and household construction material information. The full household listing data is available from the ReShare repository . The household listing facilitated systematic random sampling of households. No further stratification took place.Households were selected where there was the presence of both a male aged 18 to 54 and a female respondent aged 15–49. The target respondent for the survey was the main earner, not necessarily the household head, although the two categories often overlap. The main earner  completed the structured questionnaire. Information on global satisfaction of life, anthropometry (height and weight) and blood pressure was collected from both a male and female member of the selected household.If the main earner was not available at the time of interview then the enumerator made an additional two attempts to catch him or her at home. However, if the main earner was not likely to return to the household during the time enumerator was in the area, then the spouse of the main earner, second earner or spouse of the second earner of that household was interviewed (in that order of preference), as long as he or she was between the ages of 18–54 years for men and 15–49 for women. If no-one fitting this description was in the household we excluded that household and moved to the next selected household.Prior to implementation the research protocol was subject to review and approval by the Research Review Committee (RRC) and the Ethical Review Committee (ERC) at icddr,b. In addition, in order for the research to be approved by the ERC, all named researchers on the research protocol completed National Institutes of Health online training and individual ethical approval was obtained from the University of Southampton (as the lead institution in the ESPA Deltas consortium in the UK) and the Ecosystem Services for Poverty Alleviation Directorate.The ERC, an independent body to safeguard the physical, mental and social well-being of the participants, is guided by the relevant international regulations and is responsible to the Board of Trustees of icddr,b. The committee reviews each protocol involving human participants and accords approval, and the decision of the ERC in this matter is final. The icddr,b ERC is internationally recognized ethics review committee and pioneer in Bangladesh. The icddr,b ERC is a registered Institutional Review Board with Federal Wide Assurance (#FWA0001468), Human Welfare Assurance (#IRB00001822) since November 2001.The ESPA Deltas social survey was implemented in the south west and south central coastal zone of Bangladesh and included rural areas of Satkhira, Khulna and Bagerhat districts of Khulna Division and all districts in Barisal Division except Jhalokati. The survey was implemented with the assistance of Associates for Community and Population Research (ACPR), a highly experienced data collection firm in Bangladesh.ACPR together with icddr,b provided intensive training on survey tools, data collection methodology and ethical grounds of social data collection. Several days of field testing of the survey tools were carried out before each round of survey as there were minor modifications of questionnaire in each round of survey (e.g. the gender empowerment and response to oil spill sections were added in third round of survey). A field guide was distributed to teams carrying out water sample collection and measuring blood pressure in Bengali and English. The questionnaire was pretested in the field in a pilot phase, before data collection.Thirty skilled field staff were recruited along with ten experienced supervisors for the study and retrained on standard methods of obtaining physical measurements. Seven teams were assigned to seven zones, each team consisted of one supervisor, three interviewers and one porter to carry height scale and other equipment. To ensure the quality of the data, a monitoring team from icddr,b checked one percent of the data and held periodic meetings to provide necessary feedback to the field work. Prior to data collection from individual household members, written consent was taken in presence of a witness. In the second and third round surveys enumerators tried to reach the same household and interview the same household members as in the first round. Three to five percent of households were absent in the second and third round for reasons such as permanent or temporary migration, or unwillingness to give the interview.All study participants were interviewed only after giving informed consent according the Belmont principles of respect for persons and using consent forms approved by the Ethical Review Committee of icddr,b. In addition, where applicable, assent as also taken. Efforts were made to ensure that all respondents were appropriately informed about the study and thoroughly understood their participation in the study. Participation was voluntary and interviewers ensured that participants knew that refusal to participate would not lead to any adverse consequences. According to ERC requirement, one copy of the signed informed consent form was handed over to all potential study participants.Height and weight were collected from respondent and his or her counterpart. These measurements were also taken from eldest under five children if available. If the eldest child under five was less than a year old, then length was measured instead. While measuring height, the Frankfort position was confirmed and reading was noted accurately. Standard tools were used to measure for height (stadiometer) and weight .The three rounds of survey were implemented between June 2014 and March 2015 see . icddr,bThis study did not use any computer codes to generate the dataset. The IBM SPSS Statistics (version 22) software was used to store and quality check the collected data.Three different datasets are available in association with this research. The first contains the data required to sample by social-ecological system . The second data record contains the results of the household listing . While it provides only limited data, the large sample size may facilitate analysis. The final data records provide the survey results , Data Citation 2). The Survey data is provided in IBM SPSS and comma-separated values format. All 3086 variables are named according to their number in the questionnaire, and fully described in the variable labels. The household listing and three survey instruments can be downloaded in English and act as the code book for the datasets.The quality of the dataset is ensured by: a) thorough pre-testing of the questionnaire; b) translating the questionnaire into Bengali, including local terminology, and reverse translating to check quality of translations; c) recruitment of experienced enumerators and comprehensive training in survey implementation; d) quality control questionnaires being carried out alongside the main data collection and high levels of supervision in the field; e) double data entry and numerous quality checks on the final digital dataset, including cross-referencing original paper surveys. These are detailed in the following paragraphs.The survey questions were designed based on the research questions of the project, using questions from other surveys already implemented in Bangladesh where appropriate, and drawing on the qualitative data collection and expert judgement to create new questions. To ensure that the questions are relevant and meaningful, extensive pre-testing of the quantitative questionnaire was conducted in the study area prior to finalisation of the survey questions.Training of the enumerators is essential for effective implementation of a survey. A deep understanding of the questions and philosophy of the survey ensures that enumerators are able to help the surveyed households in answering the questions properly. To achieve this, the enumerator team was selected for its long track record in doing similar surveys and was trained over a period of a month by the ESPA Deltas research team. Role play and field practice was carried out for every section of the questionnaire. Specialists were brought in as required, for example doctors for the blood pressure measurement and experts in using global positioning systems for the location data. Rigorous training on anthropometry was carried out.A quality control team was assigned in the field to monitor data collection. Spot checking, direct observation and re-interviewing of five percent were carried out. A senior level supervision team also frequently visited the data collection activities in the field. During the survey the field supervisor checked all completed questionnaires. The interviewer cross-checked each questionnaire for internal consistency at end of the day. Section 3 of the survey provides general information on the range of incomes which subsequent sections investigate in more depth. As such, Section 3 was used (with other key indicators) to check that all appropriate income and expenditure questions had been completed. If not, the respondent returned to the household. Analysis of these variables reveals a highly detailed data set that has captured household differences For example, attributes such as monthly income and food expenditure show high variance between households despite a four month recall period.Completed questionnaires were checked before data entry by an office editor. In the process of data entry all possible logical checks were built into the program (CSPro). Dual entry and comparison between datasets ensured correct data entry. Data management experts from icddr,b thoroughly checked all possible inconsistencies  of the datasets in an ORACLE platform. The survey used paper for recording the data. The original paper version is kept to allow the team to check individual records in the digital dataset if necessary.Finally, the dataset was thoroughly analysed for outlier and extreme values to ensure that typing errors are eliminated from the final dataset. To identify such typing errors, individual and composite variables were calculated and summarised as minimum, median, mean, maximum and compared with other data sources and reports or, if similar data was not available for Bangladesh or the study area, these were evaluated by expert judgement.https://www.ukdataservice.ac.uk/get-data/how-to-access/conditions#/tab-end-user-licence). For commercial use, please contact the UK Data Service at help@ukdataservice.ac.uk.A benefit of the data is their spatial nature that allows social factors to be analysed in the context of environmental conditions and resources. Therefore, the location of the villages is included in the dataset. However, this increases the sensitivity of the data as it creates the potential for households within each village to be identified from the survey data. As such, the data has been made available as safeguarded on the UK Data Archive’s data repository ReShare. In order to download safeguarded data the user must register with the UKDA and agree to the conditions of their End User Licence .Due to attrition of households between survey rounds, not all cases are present in all three rounds. Data should be filtered before proceeding before carrying out longitudinal analysis on any of the variables. An additional 10 percent was added to the initial sample in order to account for expected attrition. Actual attrition rates were much lower: 4.4 percent between the first and second rounds, and 3.5 percent between the first and third rounds.There are three rounds of data for all sections except a section added specifically to capture the impact of an oil spill that occurred in the Sundarban mangrove forest between the second and third rounds; and the gender empowerment section that was only carried out once, in the final round. There were some additional data collected in round three to try and better capture variables of interest that were not well captured in previous rounds. Whereas in Round 1 and 2 information was only captured on economic migrants (i.e. migrants who were remitting to the household), in Round 3 households were asked to list all family members who had left the household and were now living away.Since the number of people using the mangrove forest seemed improbably low in the first two rounds, additional prompts were added in the final round. In Round 1 and 2, questions regarding Sundarban forest collection (in Section 4) were asked only to those who had mentioned that they use the forest in the previous section . However, in Round 3 all households in the Sundarban dependent zone Unions were asked the questions in Section 4, regardless of whether they had mentioned using forest resources in the previous section.How to cite this article: Adams, H. et al. Spatial and temporal dynamics of well-being, livelihoods and ecosystem services in coastal Bangladesh. Sci. Data 3:160094 doi: 10.1038/sdata.2016.94 (2016).Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


Schistosomiasis, one of the 17 neglected tropical diseases listed by the World Health Organization, presents a substantial public health and economic burden. Of the 261 million people requiring preventive chemotherapy for schistosomiasis in 2013, 92% of them lived in sub-Saharan Africa and only 12.7% received preventive chemotherapy. Moreover, in 2010, the WHO reported that schistosomiasis mortality could be as high as 280 000 per year in Africa alone.In May 2012 delegates to the sixty-fifth World Health Assembly adopted resolution WHA65.21 that called for the elimination of schistosomiasis, and foresees the regular treatment of at least 75% of school age children in at-risk areas. The resolution urged member states to intensify schistosomiasis control programmes and to initiate elimination campaigns where possible.Despite this, in June 2015, schistosomiasis was indicated to have the lowest level of preventive chemotherapy implementation in the spectrum of neglected tropical diseases. It was also highlighted as the disease most lacking in progress. This is perhaps unsurprising, given that it was also the only NTD with access to drug donations but without a coalition of stakeholders that collaborates to boost commitment and implementation.As a consequence, and to ensure that the WHO NTDs Roadmap Targets of 2012 and World Health Assembly Resolution WHA65.21 are met, the Global Schistosomiasis Alliance (GSA) has been set up. Diverse and representative, the GSA aims to be a partnership of endemic countries, academic and research institutions, international development agencies and foundations, international organizations, non-governmental development organizations, private sector companies and advocacy and resource mobilisation partners. Ultimately, the GSA calls for a partnership to work for the benefit of endemic countries by addressing health inequity and rural poverty.The online version of this article (doi:10.1186/s40249-017-0280-8) contains supplementary material, which is available to authorized users. Please see Additional file Schistosoma haematobium infection increases from 1.5% for households with an income greater than US $1 600, to 70% for households with an income of less than US $600 [Schistosomiasis is one of 17 diseases that are listed by the World Health Organization (WHO) as the group of neglected tropical diseases (NTDs). Of these, schistosomiasis presents a substantial public health and economic burden. In 2010, the WHO reported that schistosomiasis mortality could be as high as 280 000 per year in Africa alone [ US $600 . Specifi US $600 . IndividPraziquantel (PZQ) is the drug of choice for effective treatment of schistosomiasis . DevelopThere has been progress since, with 20.7% of those requiring treatment receiving it in 2014  and a further increase to 28%  in 2015 . FurtherIn many cases, however, a lack of both political will and committed resources remains. For example, only a few countries in Africa, despite recent increases in GDP  have comWith the understanding of the cost-effectiveness of PC interventions to control or, if associated with other interventions, support the elimination of schistosomiasis and other NTDs came the commitments of major pharmaceutical manufacturers to provide the necessary medicines free of charge. In 2012 a number of large pharmaceutical manufacturers have pledged to continue or extend large medicinal donations under the London Declaration on NTDs. The cumulative value of these donations of US $17.8 bn from 2014–2020, represents the greatest growing public health donation and additionally targets the most vulnerable afflicted populations in the world .Yet, in addition to improved supply of the drug, there is a need for research and development into, amongst others, combination therapies , and bioConsidering this potential for real impact thanks to the growing interest in and commitments to schistosomiasis and at the same time the many unmet needs and open questions, the purpose of this review is to highlight the need of having an alliance that addresses the global elimination of schistosomiasis by aligning these two sides of the coin.In May 2012 delegates to the sixty-fifth World Health Assembly adopted resolution WHA65.21 that called for the elimination of schistosomiasis . The eliA central problem for the achievement of the above resolution, however, is the fact that, until now, the schistosomiasis community has been built mainly around separate research-driven activities. These include, but are not limited to, the EU funded CONTRAST programme, the Bill & Melinda Gates Foundation funded Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) programme as well as The Schistosomiasis Control Initiative (SCI), based at Imperial College London, which has been the major body dealing with implementation in Africa. Most recently, the Research and Evidence Division of DFID has invested in COUNTDOWN, a multidisciplinary implementation research consortium engaged in identifying best ways to foster scale-up of preventive chemotherapy approaches in sub-Saharan Africa.rd annual progress report published by Uniting to Combat NTDs. [While each organisation and its efforts are very valuable, coordination and communication amongst the stakeholders involved has so far been limited. According to the authors, this lack of a coordinated approach to the control and elimination of schistosomiasis as a public health problem was reflected in the poor performance of the disease vis-a-vis other NTDs in the scorecard of the 3at NTDs. . SchistoThe experience of previous NTD alliances shows that they provide a necessary platform for keeping a committed community together, whilst being able to highlight operational research needs and freely advocate for stronger political commitment. A significant change in the organisation of efforts is hence considered necessary to ensure that the increased donation from Merck is used effectively in endemic country settings in Africa if the WHO NTDs Roadmap Targets of 2012, and World Health Assembly Resolution WHA65.21, are to be met. Maintaining or expanding efforts in the rest of the world will need sustainable political and financial commitment by countries where transmission has reached the critical point towards elimination. Meeting these targets will require building a robust coalition of a multitude of stakeholders and securing stronger political commitment in endemic countries especially, but not exclusively, in Africa.Such a coalition has now been established in the form of the Global Schistosomiasis Alliance (GSA) in response to the challenge afforded by WHA65.21 and in a manner similar to other NTD coalitions .The major aim of the GSA is to be a partnership of endemic countries, academic and research institutions, international development agencies and foundations, international organizations, non-governmental development organizations, private sector companies and advocacy and resource mobilisation partners. Thereby, the GSA can communicate with and between all different stakeholders working on and engaged with schistosomiasis. While a number of key stakeholders have already become member of the GSA, the GSA’s aim is to capitalise upon the growing momentum for control and elimination of schistosomiasis and unite a growing number of members who all work towards the objectives outlined in WHA65.21. In particular, the GSA would welcome if an increasing number of African based organisations and institutions, as well as African governments were to join the alliance.The GSA is conceptualised as an independent organisation allowing for transparency, as well as allowing all members to speak openly and independently. Furthermore, this organisational set-up respects the autonomy of each partner and promotes efficient and effective governance. Thereby the GSA is hoping to create a space that increases engagement and alignment among partners and optimises the contribution of alliance members for the greatest possible impact.With elimination as the overarching objective, the work of the GSA focuses on five interconnected themes, presented below in Fig. The immediate focus lies on priority number one, implementation. This refers to the provision of support to the scale-up of preventive chemotherapy interventions and other operational components for the control and elimination of schistosomiasis based on successes already achieved and lessons learned in several countries all over the world. The communication of best practices between countries and stakeholders and capacity building are considered central tasks of the GSA.http://sitw.eliminateschisto.org/int/) is one such campaign, that reached viewers globally and won six awards in 2016 for its creative approach. Finally, as the GSA becomes more established, it will use its influence to continue to push its mission to eliminate schistosomiasis as a public health problem. The goal is to do so via a number of different actions, such as arriving at one common and shared definition of elimination and the required actions to achieve it, coordinating and commissioning global research efforts, as well as close collaboration with WHO to ensure optimal allocation of resources that support schistosomiasis elimination.Secondly, research is an important part of the GSA’s strategy towards elimination. Specific research areas to be addressed, as well as research activities the GSA has engaged in so far through its research working group are outlined below in more detail. A third priority of the GSA is advocacy work, both in endemic and non-endemic countries, which will be coordinated with key regional stakeholders. The aim is to raise awareness of the importance to address schistosomiasis and to mobilise resources together with GSA stakeholders. This links directly to the fourth priority, which concerns communications. In order to deliver its key messages, the GSA employs a variety of communication channels and tools, such as newsletters and campaigns, to reach and target stakeholders. The “Something in the Water” website  and member states of the WHO, that collaborate with non-governmental development organizations (NGDOs), co-operate with non-endemic member states through bilateral agreements and are responsible for distribution of medicines in the country. Furthermore, most donations, including that of PZQ, are based upon a memorandum of understanding between the WHO and the specific pharmaceutical company. The GSA supports this set-up since it facilitates coordination, forecasting and procurement by member states of the WHO.Ultimately the GSA is working for the benefit of endemic countries and providing support on the way to schistosomiasis elimination. In turn, the growing economies of Africa will need to invest in schistosomiasis elimination programmes in sustained ways. This will demonstrate their commitment to reaching the sustainable development goals by 2030, to develop their rural communities in an equitable way and to reduce the burden of poverty in their countries. By uniting highly committed stakeholders the GSA aims to support these African countries by facilitating partnerships, which address health inequities, reduce rural poverty, and work towards the elimination of schistosomiasis for the benefit of the world’s most vulnerable communities with the ultimate objective to assure equitable human, agricultural and economic development.


Congenital anomalies are prevalent in Nicaragua, and disability is estimated to be 10% in the general population. We studied children with congenital upper limb differences, as they are vulnerable to disability. This case study documents a collaborative effort between American and Nicaraguan orthopedic surgeons to determine unmet health needs of children with congenital upper limb differences at Hospital Manuel de Jesus Rivera  in Nicaragua, with the goal of developing programs that successfully address these needs within the context of the priorities of the community. Participants were recruited during one of the biannual pediatric hand specialty clinics held by a partnership of pediatric hand surgeons and occupational therapists under the auspices of Health Volunteers Overseas  and Nicaraguan orthopedic surgeons. Structured interviews were performed with 34 parents or caregivers of patients with the diagnosis of a congenital upper limb difference. Parents were asked to rank the social, economic, environmental, and biological factors that determine health according to priority. Using the Hanlon Method for prioritizing health problems, in consultation with local providers and the program director of La Brigada, five needs were identified: (1) improvements in access to specialized care from hand surgeons and (2) rehabilitation specialists; (3) improvements in upper extremity function; (4) access to transportation; and (5) improvement in physical activity and sports participation. Based on the results of this needs assessment, we learned that some of the needs were already part of the ongoing work of the partnership, but in addition, more needs became evident; for that reason, local health care providers and members of La Brigada identified potential solutions to these needs and are currently working to translate these in future interventions. Partnerships between local health-care professionals with international allies can improve health in developing countries, especially when they are based on equal participation, knowledge contribution, and focus on important community health issues . The chaAccording to the World Health Organization (WHO), “Health is a state of complete physical, psychological, and social wellbeing and not simply the absence of disease or infirmity” . Based oDisability is a current public health concern in national and international agendas, which arises from the disturbance of anatomical structure or function and is highly influenced by social environment . As a reAccording to WHO, congenital anomalies are prevalent in Nicaragua , and ratUnder the auspices Health Volunteers Overseas (HVO), a non-profit organization dedicated to improving the availability and quality of health care through the education, training, and professional development of the health workforce in resource-scarce countries , a partnThe needs assessment was conducted in Hospital Infantil Manuel de Jesus Rivera “La Mascota” located in Bo. Ariel Darce, Distrito V, Managua, Nicaragua. This pediatric hospital was established in 1982 in Nicaragua’s capital as a teaching governmental hospital that offers services free of charge and is administered by the Ministry of Health . The hospital not only offers services to the city but also receives referrals from the entire country making this institution the main referral center for children and adolescents less than 15 years of age. The Department of Orthopedic Surgery, where the need assessment took place, was recently transferred to “La Mascota” as above, and currently includes six staff surgeons, one of whom is dedicated to the treatment of upper limb conditions as above.This needs assessment evaluation employed structured interviews to obtain insight from families of children from 0 to 15 years of age with the diagnosis of a congenital upper limb difference, who sought care in La Mascota Hospital during the La Brigada visit in October 2016. Parents were questioned using a non-validated interview created for the purpose of this needs assessment. The interview was structured in five sections related to (1) demographic variables; (2) environmental factors such as water sanitation, housing, transportation, security, and access to health care services; (3) socioeconomic factors including education, employment, and income; (4) individual behavioral factors as nutrition, physical activity, and habits; and (5) biological factors such as the presence of a medical condition or history of genetic diseases. These sections were developed to have three possible responses: a positive outcome, a neutral outcome, and a negative outcome. For example, when asking about family monthly income, the possible responses included positive incomes , neutral , or negative (expenses surpassed income). At the end of the interview, parents were asked to enumerate the most important needs for their family, and when more than one need was designated, they were asked to rank the need according to priority in the context of their life.In addition to the interview, Spanish translations of Patient Reported Outcome Measurement Information System (PROMIS) questionnaire Pediatric Item Bank short form of upper extremity function were used for this assessment . Parent Demographic characteristics, determinants of health, and PROMIS scores were summarized for all patients and parents using descriptive statistics. The sections from the interview, related to both environmental and socioeconomic factors as well as individual behaviors and biological determinants of health were ranked according to the percentage of negative outcomes. If the average for PROMIS scores was less than 50 for peer upper extremity function domains, they were considered areas of need. A list of needs was created based on responses from interviews and questionnaires. In order to select the most important need, a Hanlon’s priority matrix method was used similar to previous program planning strategies . This prThirty-four patients with a diagnosis of an upper limb difference were screened for this study, . Patient median age was 30 months (IQR 18–63). The right side was most commonly affected, and unilateral conditions accounted for 68%. According to the Oberg–Manske–Tonkin classification for congenital differences, malformations in the hand were the most numerous group (41%) with radial polydactyly as the most common condition screened (15%). Parents of six patients did not complete the interview due to lack of time availability, and one parent did not want to provide socioeconomic information. Parents of 27 patients consented to participate and provided information centered about needs, including environmental, socioeconomic, behavioral, and biological factors determining health.Access to sources of water was limited; three (11%) families had to walk a considerable distance to obtain water from wells. While more families reported they had access to electricity, there was still one family (4%) without this service and instead used coal, biofuels, or candles to light their house. All respondents used public transportation, but seven (26%) of the parents reported having difficulties traveling to La Mascota Hospital. Finally, none of the families had insurance coverage, and all received medical attention in public institutions funded by the Nicaraguan government. The provision of basic health-care services was considered by the majority to be accessible and efficient; however, half of the respondents complained that prescribed drugs were only partially covered by the public health system. In addition, 22 (82%) parents reported difficulty accessing specialized care; in particular, this group was concerned that it was difficult to obtain access to a pediatric hand surgeon between La Brigada visits.A total of 19 (70%) of the respondents reported that the father economically supported the family; of those, 13 (68%) were full-time employees. Parents complained that monthly income varied under several circumstances, and nine (33%) respondents reported an unstable income. Regarding the highest level of education in the household, 19 (70%) of parents had completed primary education and started high school, and in one household, none of the parents (4%) had finished primary education.According to five (19%) of the parents, nutrition in the family was not balanced and included a low proportion of fruit and vegetables. Similarly, 15 (56%) families mentioned that at least 1 member of the household had over or underweight. When asked about physical activity in children, seven (25%) of parents stated that their child performed moderate physical activity for less than 3 h per week.History of genetic diseases was reported in four families, two of them similar to the child’s pathology. Relatives of three subjects were diagnosed with radial polydactyly and one with arthrogryposis. Finally, 10 (37%) of the parents mentioned that at least 1 member of the household suffers of chronic conditions . Table Parents were asked to prioritize the following needs: access to specialized orthopedic care and hand surgeons, improvement of basic health services, family income, employment opportunities, and improvement of child’s upper extremity function. In addition to what parents considered important, the process of prioritization included the input of other stakeholders, in this case health-care providers from La Brigada and local physicians from La Mascota Hospital. They rated the needs considering the internal capacity to develop potential interventions, in such a way that needs were relevant for the community and attainable by La Brigada. Table La Brigada, under the auspices of HVO, established continuity in volunteering efforts for children with hand problems in Managua, Nicaragua, in 2009. Through 16 biannual trips, La Brigada has not only provided specialized health-care services to patients with upper limb pathology but also has formed a partnership with Nicaraguan colleagues which has proven to be effective strengthening local health-care efforts of delivering surgical care to children with hand pathologies. By training a local surgeon, the partnership aims to cover a gap in the shortage of specialists in Nicaragua, addressing one of the major problems in low- and middle-income countries.Due to this collaborative alliance, La Brigada has gained the confidence of La Mascota Hospital administration to extend efforts beyond volunteering and training, by exploring health promotion opportunities through research endeavors that improve other aspects of health. In order to promote health, however, the first step is to gain a deeper understanding of what the patient needs and to determine if health-care professionals have the capacity to make the improvements the patient and the family request. In addition, this analysis also made clear the role of social determinants of health in relationship with access to health-care services. Children with congenital upper limb differences are more susceptible to long-term disability due to physical impairments , but in Respondents uniformly expressed that the most important health need is related to their child’s condition, ranking first the need for hand surgeons who specialize in the treatment of congenital upper limb differences. Parents favorably viewed visiting surgeons from La Brigada and were very appreciative of their services; however, the priority of this need reinforces the importance of training local surgeon(s) who can serve these patients throughout the year. To that end, La Brigada has prioritized training a local orthopedic surgeon the necessary skills to perform pediatric hand surgical procedures independently. This training strategy to date has proved to be successful, as this physician has carried out hand surgeries in children with congenital pathologies such as polydactyly and syndactyly when La Brigada is not present with favorable results. Although this training will make specialized care more available at La Mascota Hospital, it does not meet the needs of communities that are distant to Managua.The second need derived from the analysis is that patients perceived the need to increase in the capacity of rehabilitation services, especially the ability to fabricate splints with thermoplastic materials. Since La Brigada started recurrent trips to La Mascota, the fabrication of splints has relied on donations of splint material from volunteers and requires the guidance of U.S. therapists. Through continuous skills training, a pool of local therapists has been able to gain proficiency in splint fabrication to cover the basic needs of patients in La Mascota Hospital. While this method has proven effective for training purposes, donated materials do not meet the local demand of the locally trained hand surgeon and therapists. This area of need requires more institutional compromise to extend the partnership to areas beyond training of local therapists; with institutional negotiations an agreement could be reached with industry that can provide materials at low cost. There is the need to establish a local institutional mechanism that guarantees the provision of resources instead of relying in donations.As result of the examination of PROMIS questionnaires, patients and parents acting as their proxy expressed the importance of improving child’s upper extremity function. It is not surprising that upper extremity function is affected in this patient’s population. Prior research has shown a wide spectrum of outcomes depending on the type of congenital difference and the level of involvement. For example, patients with unilateral below-the-elbow deficiency exhibit deficits in upper extremity function when compared with controls , 15, 16.Parents frequently complained of the difficulty accessing surgical services due to several factors related to distance, poor roads, lack of suitable transport, and cost related to accessing the hospital. The first inconvenience is the distance they have to travel from their communities, as on average, families traveled 57 km to get to La Mascota Hospital. Second is the cost, because public transportation is infrequent in rural areas, a round trip to the hospital is lengthy, and some families have to travel 1 day in advance and stay overnight in a hotel in order to arrive in time for their child’s appointment, which increases the cost of the trip. Parents may also have to take unpaid time off to travel with their child to the appointment.Overall, parents expressed that their children were active; however, 25% of them are not getting the necessary physical activity recommended by WHO of 3 h of moderate to intense physical activity per week. In addition, parents expressed that patients were not involved in many sports that required upper limb involvement due to the perceived physical limitation. There were several reasons for this, but the most important were their fear of rejection by other children, and they felt unable to practice certain sports because of their physical impairment.After analyzing the needs of families and considering the capacities of La Brigada, the next steps this partnership between American and Nicaraguan health providers became apparent. Based on the findings, possible interventions were outlined to improve health of patients with congenital upper limb differences. La Brigada is already addressing the most important need by providing pediatric hand surgery training to a local orthopedic surgeon who will care for patients with congenital differences between la Brigada visits, increasing access to specialists. This surgeon, in turn, works with Nicaraguan orthopedic surgery residents from three local training programs. Similar “train the trainer” strategies have proved effective in orthopedic surgery. One example of the initiatives on non-surgical care has been physician education in the Ponseti method to treat clubfeet in developing countries . SimilarIn a similar effort, the need for physical therapists has also been addressed as part of the ongoing efforts of La Brigada. Physical therapists in La Mascota hospital are being trained in the fabrication of splints due to the high demand of services for patients with congenital differences and neuromuscular problems. However, the need to make splint materials more available to local therapists in La Mascota persists. Local therapists currently rely on donated material, but this is not sustainable in the long term. In response to results from this needs assessment, La Brigada’s therapy director will work to engage the hospital’s administration and local institutions to develop purchase mechanisms that will allow the acquisition of a steady supply of thermoplastic materials, thus making splints more available for the community.In response to the need for increased access to orthopedic services in remote locations, La Brigada plans to initiate an outreach clinic in Leon, a large population center 75 km from Managua, so that only patients who need surgical care (20–25% of those seen in the La Brigada clinics) will have to travel to La Mascota Hospital. Similar strategies to deliver care in rural areas have been implemented in other areas of medicine with promising results, as is the case of mobile clinics dedicated to cancer screening , and matFinally, in an effort to improve upper extremity function, physical activity, and sports participation, La Brigada will work to develop an intervention for skills training focused in promoting function enhancement and activity performance that will lead to increased physical capacities of patients with congenital upper limb differences. Several young adults with congenital hand differences have recently joined La Brigada as volunteers; the development of skills training programs may be a possible role for them on future trips as they have shown to be successful in people with disabilities , 24.The purpose of this health needs assessment was to discover the most important health needs of children with congenital upper limb differences and to propose interventions to address their needs, considering the opinions of the community. An approach that takes into account social determinants of health and considers the opinion of families is important to develop effective and long-lasting interventions that suit the social and economic environment of the family. In addition, the case study highlighted the importance of having organized partnerships that have built a long-standing relationship of trust with local authorities and community members and have committed resources to the improvement of health of this vulnerable population. An assessment of health needs should be considered one of the first activities of global health partnerships, because this process guides the efficient allocation of resources and maximizes results, taking in account what the community needs. As result of this case study, we learned that the most important need for patients and families is improving access to specialized care for their child’s condition, including hand surgeons and rehabilitation services that will improve child’s upper extremity function. In addition, parents expressed difficulty accessing the hospital from distant places and they will benefit from strategies that address this problem. Finally, there was the need to improve physical activity and sport participation as means to increase social inclusion and acceptance in their community. Health-care providers from La Brigada and Nicaraguan partners in response to this assessment have identified potential solutions to these needs and are currently working in future interventions.This study was carried out in accordance with the recommendations of the Human Research Protection Office with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the University of Massachusetts—Amherst Institutional Review Board and La Mascota Hospital Director.MC: lead author, study conception and design, compiled/collected data, data analysis, manuscript writing, critical revision of the manuscript, and final approval of the version being published. JR-R and GR-Z: co-authors, study conception, interpretation of data for the work, critical revision of the manuscript, final approval of the version being published. MJ: senior author, study conception and design, interpretation of data for the work, critical revision of the manuscript, final approval of the version being published, critical revision of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Objective: After adoption of the National Competency-based Learning Objectives Catalogue in Medicine , the German medical faculties are asked to test the learning obejctives recorded in it and evaluate them critically. The faculties require curricular transparency for competence-oriented transition of present curricula, which is best achieved by systematic curriculum mapping in comparison to the NKLM. Based on this inventory, curricula can be further developed target-oriented.Considerable resistance has to be expected when a complex existing curriculum is to be mapped for the first time and a faculty must be convinced of its usefulness. Headed by Tübingen, the faculties of Freiburg, Heidelberg, Mannheim and Tübingen rose to this task. This two-part article analyses and summarises how NKLM curriculum mapping was successful at the locations despite resistance. Part I presented the resources and structures that supported implementation. Part II focuses on factors that motivate individuals and groups of persons to cooperate in the faculties.Method: Both parts used the same method. In short, the joint project was systematically planned following the steps of project and change management and adjusted in the course of the process. From the beginning of the project, a Grounded-Theory approach was used to systematically collect detailed information on measures and developments at the faculties, to continually analyse them and to draw final conclusions. Results: At all sites, faculties, teachers, students and administrative staff were not per se willing to deal with the NKLM and its contents, and even less to map their present curricula. Analysis of the development reflected a number of factors that had either a negative effect on the willingness to cooperate when missing, or a positive one when present. These were: clear top-down and bottom-up management; continuous information of the faculty; user-oriented support in the mapping process by reduction of the mapping categories, portioning and condensation of the NKLM via student pre-mapping (blueprint) and visibility of growing consent. Apart from that, there were a series of frequent questions, objections and concerns that could be countered strategically and by argumentation. They particularly referred to relevance, benefit, feasibility and effort of curriculum mapping.Conclusion: An overview of beneficial framework conditions, strategies and results from different points of view is achieved and interrelations are made visible. Based on literature results, the motivating factors as well as their implementation and effects in the faculties involved are critically reflected on. Recommendations can be derived that can support other faculties in practice. NKLM, retrieved on 22.03.2016] was adopted in Germany by the Medical Faculties Conference (oMFT [Ordentlicher Medizinischer Fakultätentag]) in June of 2015 .Most faculties educated for some years with reformed study plans in which present NKLM content, like promotion of practical skills and communication abilities was already integrated . In currLIN database  ha haVisibiRepeated analyses of strengths and weaknesses during the process made it possible for the project staff to find location-specific strategies and to argue depending on the location. Questions about relevance, benefit, feasibility and required effort were of major interest. It was crucial to have convincing arguments and examples ready at the right time. Understanding the profit clearly reduced the resistance.Relevance. According to recorded notes, particularly at management levels, the clear political will was seen as an important argument against opposing subject-related and individual interests. The approval of the NKLM once again clearly increased the significance of the mapping. The fact that the learning objective catalogue is a recommendation until 2020 and not mandatory, temporarily provoked a wait-and-see attitude in many departments and faculty managements or minimal engagement (“Sit it out?”). In committee discussions, it was seen as an advantage to use the coming five years as a competitive edge for the location to position itself on the basis of its local experiences and to participate in shaping the prospective NKLM evidence-based.Benefits. Convincing responses to the frequently posed question of sense were supplied by the MERLIN database , e, e10], eWithout a differentiated overview of the existing overall curriculum, the risk when integrating so-called core curricula increases significantly, that decentralized curricula evolve resp. are reinforced . AlthougThe measures and derived recommendations agree well with the groundbreaking publication of Bland and colleagues . Based oThe mapping results show, where in the comparison to the NKLM standards (further) curricular optimisations are possible or perhaps even necessary. They are already used as fundamental data source for strategic planning. Decisions can therefore be made based on evidence. Co-determination and participation in the project will be enabled at the faculties.To ensure that curricular restructuring, as conclusive, integrated overall concept directed on competence orientation will succeed, curriculum mapping and strategic, evidence-based curriculum planning is not sufficient. In the end, it also depends on the didactical implementation and the didactical abilities of the lecturers . MedicalLIN group for the stimulating discussions. We also wish to express our thanks to Dr Wolfgang Öchsner and Mrs Claudia Grab (both of Ulm University) for their contributions during pilot mapping, as well as to the deans of study and teaching, the staff of the deans’ offices of student affairs, lecturers and students, who supported the mapping project with full engagement. Particularly, we wish to thank all teaching coordinators and those responsible for modules for their energetic participation in the mapping process and the discussions. They contributed important information and gave impulses for optimising the instruments and the process.We are grateful to the entire MERLIN  of the medical faculties of the universities of Freiburg, Heidelberg, Mannheim and Tübingen, led by Tübingen, reference number: 01Pl12011A.The project is funded by the Federal Ministry of Education and Research (BMBF [Bundesministerium für Bildung und Forschung]) within the framework of the promotional programme “Quality Pact for Teaching” ; the joint project MERThe authors declare that they have no competing interests.