In recent years there have been many cases of violence against healthcare professionals (HCPs) in China leading to the death of some doctors as well as nurses by patient’s relatives. Our objective was to identify the causative factors for these violent acts and address these isssues which is vital to ensure patient safety.A multidisciplinary research task force was formed to do a root cause analysis of the violent acts against the healthcare professionals. A flowchart was developed to identify the steps in the process and discover the potential links.There are complex reasons behind the violence against HCPs. However, the main reasons were found to be poor quality of medical services and increased awareness of patients’ rights and their willingness to knock at the doors of courts to seek justice. The feasible counter measures includes stimulating hospital directors to improve patient safety, aligning incentives with quality of service provided in healthcare facilities, monitoring educational quality of HCPs, making necessary changes in medical education programmes besides setting up a reasonable academic promotion mechanism for health professionals based on merit and competence. Poor quality of medical services, increased awareness among patients about their rights has resulted in increase in medical disputes and at times violence against healthcare professionals. A number of effective measures can be undertaken by the government, hospitals, and medical schools ensuring patient safety. However, it is essential to sensitize the hospital directors to elevate their quality of medical services. One study reported that there are more than one million cases of violence against HCPs every year in China.1 One wonder whether these violent acts are inevitable. In China, the incidence of violence against healthcare professionals has significantly increased in recent years. For example, in April 2010, in Shiyan of Hubei Province, 50 relatives of a deceased patient attacked hospital staff, beating and pouring boiling water on the staff.6 poor government investment in the healthcare system,7 negative media reports about hospitals and doctors,8 catastrophic out-of-pocket medical expenses for families,9 and lack of trust in doctors and hospitals.10 However, one cannot say with surety whether these are the only factors leading to increasing acts of violence against the HCPs. Our objective in this study was to identify the reasons behind these violent acts and address the causative factors, which is vital to ensure and improve patient safety in China. Some studies have analyzed the causes of increased violence against HCPs in China, such commercialization of the medical services system,In order to analyze the causative factors for this increasing incidents of violence against HCPs, a multidisciplinary research task force involving hospital managers, hospital clinical department directors, health officials, researchers, lawyers, pharmacists, doctors, and nurses was formed in July 2014. The team did a root cause analysis of the acts of violence. A flowchart was developed to identify the steps in the process and discover the potential links . Two mai1Other causes included commercialization of the healthcare system, China embarked on reforms in the early 1980s. The subsequent government funding in the health system was low, at 5% of GDP from 1985 to 2000, but there were few cases of violence against HCPs. From 2009 to 2011, the Chinese government allocated huge financial resources for the healthcare system, with an annual increase of RMB 283.3 billion ($41.42 billion). However, instead of reduction in incidence of violence against healthcare professionals, it has increased. For example, medical malpractice claims in courts increased by 7.6% from 2009 to 2010.Negative media reports do not directly lead to acts of violence. Once such violent acts have occurred, some individuals do not want to resolve these disputes through legal means but resort to violence or protests because they are encouraged by mass media. This result is the rising number of illegal actions. However, it is difficult to say with certainty that the volume of litigations has actually increased. Other factors, such as catastrophic out-of-pocket expenditures on health, lack of trust in doctors and hospitals, inadequacy of legal systems and the absence of any other effective way of addressing the patient’s grievances can also give rise to increase in acts of violence against HCPs. The most important reasons for the increasing acts of violence against the healthcare professionals were increased awareness of patient’s rights, and legal consciousness as well as poor quality of medical services. Patients and their relatives no longer remain silent regarding medical malpractice or medical negligence on the part of doctors or nurses. On the contrary, they want to identify why unexpected results happened and wish to receive adequate explanations besides demanding compensation from hospitals. This has given rise to increasing disputes between the patients and healthcare professionals and healthcare facilities. Lack of quality care and competition among hospitals: Public hospitals are dominant because the scope of private medical facilities is extremely low.11 Until 2012, the proportion of beds in private hospitals was below 10%.12 At the same time, there is also a lack of quality competition among public hospitals. On one hand, there are municipal, district, and community hospitals, and it is impossible for the low-level hospitals to compete with state of the art healthcare facilities; large hospitals compete with small medical facilities for individual patients, which is a negative competition. On the other hand, even though there is competition among some tertiary hospitals, it is based on the hospitals’ scale rather than the quality of medical services because patients are attracted to the hospitals’ keeping in view their equipment, beds, and buildings rather than quality of service.Hospital directors have little incentive to improve quality: Because the vast majority of public hospitals in China are state owned, multiple government sectors control the hospitals. For example, the financial sector controls hospital inputs, the development and reform commission controls basic construction projects and equipment, and the bureau of price monitors the cost of medical services, medicines and diagnostics. Since all the administrative sectors want to control the hospitals, none of the sectors are able to effectively supervise the hospitals, hence the monitoring of services being provided is not effective. Public hospital directors are appointed by the regional government. The health authorities do not have influence over these appointments, and the directors are not answerable to the health department. The regional governments are unfamiliar with the healthcare industry, making it difficult for them to regulate the directors and the hospitals. At the same time, the directors are more concerned with profits and the hospitals’ popularity in the medical market; therefore, the hospitals’ internal management is focused on productive efficiency rather than on the quality of medical services. As a result, directors often use economic indicators to assess doctors’ job performance, such as inpatient admissions, surgery visits, and outpatient visits, but the directors ignore quality management and medical staff training. Furthermore, the staff do not invest in continuing medical education; at the same time, the medical association has little power to supervise the continuing medical education programme. These factors taken together make it difficult to embark on continuous professional development of the healthcare professionals.Health authorities do not efficiently supervise quality: The local health bureau is responsible for routine medical administration, including the management of medical professional and institution assessments, blood management, and hospital infection control. Because the health bureaus do not use efficient supervision measures or quality assessment mechanisms, the effect of this regulation is doubtful. For example, the bureaus usually conduct the hospital accreditation programme; however, there are a number of reasons why this programme cannot ensure to improve the quality of hospital services. First, the accreditation standards focus on the hospitals’ scale and productive efficiency rather than the quality of services. Second, many hospitals falsify medical records and statistics to receive higher scores.13 Third, the hospitals are not immune to the pitfalls of bureaucracy in the accreditation process. Medical insurance agencies have little influence on quality: There are several health insurance programmes in China, including the Urban Employee Basic Medical Insurance, the Urban Resident Basic Medical Insurance, New Rural Cooperative Scheme, and the Government Insurance System.14 Because these insurance programmes are managed by several different sectors, including the health bureau, the personnel bureau, and large state-owned enterprises, respectively, it is impossible for all these institutions to use a uniform management system. Meanwhile, because their administrative capacity is low, medical insurance agencies have unequal bargaining power and cannot exert influence over hospitals and doctors. In addition, the main payment methods are fee-for-service and capitation payment systems, which are unreasonable and have led to poor quality in the form of over-provision and over-utilization of services and medicines. Moreover, patients prefer to seek care in better hospitals in other regions, which makes it more difficult for insurance agencies to supervise the quality of medical services. Problems in the medical education system resulting in decreased quality: Some research have highlighted problems in the medical education system in China, which include unreasonable curriculum setting, absence of humanities education, and traditional “teacher-centered” teaching methods.15 Nevertheless, the two main problems resulting in poor quality of medical services are as follows. 16 However, government sectors have not increased financial inputs, resulting in a shortage of teaching resources,17 which has decreased the quality of education. The total number of medical school in China at present are 644. It includes 146 institutions of higher education for medicine and 498 secondary medical vocational schools. . The medical schools have experienced unprecedented growth in admisisons since 1998. Yearly enrolment into these schools increased six-fold from 75,000 in 1998 to almost 450,000 in 2008.18 Meanwhile, most graduates do not want to work in rural or remote areas; as a result, many graduates have joined other industries, such as drug distribution. As noted in the literature, the number of newly employed health staff accounted for only 20%–40% of medical graduates in 2004–2008.16Second, since 2002, graduates have been faced with many difficulties in finding employment.As such due to poor quality, the incidence of medical errors has increased, the length of hospital stays is prolonged, and medical expenses are increased meanwhile, patients’ legal consciousness is also rising. When treatment results in adverse effects, patients or their relatives want to receive compensation from hospitals, causing medical disputes leading to even violent acts.7 However; hospital directors can manage their hospitals well if they are given powers to appoint and remove the staff based on their performance. They should be able to review the staff performance and give input in development of services and planning. The directors act as the most important persons in hospital development. Therefore, we believe that designing an effective incentive and constraint mechanism to monitor hospital directors would strengthen hospitals’ quality management, train professionals, and improve clinical services. As a result, patient safety would be improved resulting in reduction in medical disputes and acts of violence. How do we encourage the hospital directors to improve the quality of medical services needs to be looked into. It is critical to implement effective and reliable performance assessment tools to evaluate the performance of hospital directors. Since the causative factors leading to increased violence and medical disputes have been identified, we can therefore focus on improving the quality of services to reduce the incidence of such disputes. One study has reported that public hospital directors in China do not have the authority to discipline their employees.Medical insurance sectors aligning incentives with hospital quality: The Chinese government is integrating its health insurance systems, which means the above-mentioned insurance programmes will be managed by one sector. This reform will not only improve the efficiency of fund utilization but will also encourage hospital directors to improve the quality of medical services because of the increased bargaining power of insurance bodies. In addition, by reforming provider payments, these agencies can indirectly influence the quality of hospital services. For example, the agencies could encourage the director to implement clinical pathways under the combined methods of the global budgeting and DRGs (Diagnosis Related Groups). Because of declines in the use of unnecessary technologies and medicines, patient safety could be improved and medical disputes reduced. Furthermore, medical insurance agencies have more strength than the health authorities to publicly disclose clinical quality indicators, which has the potential to increase medical quality.Reforms in medical education system: In the short term, it will not be easy for the government to increase its inputs into the medical education system in China. Therefore, the priority should be to conduct a series of strict accreditations for medical schools and eliminate schools with poor quality and standards. To ensure that accreditation is objective and impartial, it is necessary to set up scientific accreditation standards and invite foreign experts to evaluate the performance of all these medical schools. Those institutions which are denied accreditation after inspection should be closed after giving them some time to improve and make up the deficiencies pointed out by the inspection team. The number of enrollments in the medical schools should be based on the number, quality of teachers and other teaching facilities.With the societal and economic developments in China, medical disputes could still increase because of increased awareness among patients about their rights. A small proportion of these medical disputes are inevitable, but the majority can be prevented. There are many factors responsible for the increase of medical disputes, including the government, patients, and the media. However, the important causes are the poor quality of medical services and the rise in patients’ legal consciousness. Patients claim compensation for losses, and few people resort to violence against healthcare professionals to voice their grievances. It is important to decrease medical disputes to protect the legal interests of both doctors and patients by reinforcing hospital security and protecting the safety and dignity of medical staff, as well as settling medical disputes under the law. However, reforming the legal and judicial system in China would be costly and could take years to complete. Hence to reduce medical disputes, the key measure is to gradually improve the quality of medical services and prevent avoidable disputes. There are many actions which can be taken by the government, hospitals, and medical schools, but the most critical is to encourage public hospital directors to enhance and improve the quality of medical services.


Translational genomics is changing, not only in the technology used but also in the sharing of data. The enormous potential for genomics technologies to improve patient care has been recognized, but it will not be reached unless powerful but secure data-sharing technologies are developed. A recent study demonstrates the power of federated queries, in which sequence variants can be searched simultaneously in files distributed over multiple centers. The past few years have witnessed several shifts in the practice of exome and genome sequencing. Thanks to the dramatic drop in cost and to the increasing penetration of bioinformatics into clinical medicine and translational research, numerous groups around the world have adopted these technologies and used them to identify hundreds of novel Mendelian disease genes, and next-generation sequencing (NGS) is making its way into routine clinical diagnostics. Hand in hand with these technological advances, new challenges are emerging for bioinformatics in translational genomics. Read mapping and variant calling are by no means simple, routine procedures, as recent reports on the low concordance of different variant calling pipelines  suggest.The enormous potential for genomics technologies to improve patient care has been recognized in fields as diverse as rare diseases, cancer, immunology, infectious diseases, prediction of medication side effects, and therapy stratification for patients with common diseases. Progress in these fields will depend on data sharing. In 2009, about a decade after the introduction of genome-wide association studies (GWASs), the term 'missing heritability' was introduced to describe the fact that only a small proportion of variance in a population attributable to additive genetic factors had been discovered by GWASs . More reThere are substantial barriers to data sharing at the scale that is needed to enable progress in genomic medicine. These include: technical issues surrounding storing terabytes, petabytes, and soon exabytes of data, and transporting at least part of the data across public and private networks; ethical and privacy issues to protect the rights of sequenced individuals; and statistical and algorithmic issues about the best ways of combining disparate datasets to address biomedical research questions. We cannot provide a comprehensive review of genomic data-sharing initiatives here, but even in the field of rare diseases, a wide variety of approaches can be discerned. For example, ClinVar intends to provide a catalog of genetic variants together with their clinical consequences, with over 120,000 variants at the time of writing . DECIPHESeveral ambitious new genomic initiatives are forming with the goal of enabling data sharing by fostering agreement about data standards and technical interfaces. Several such initiatives have been shown to be particularly valuable. These include the Human Genome Variation Society (HGVS), with its widely accepted guidelines for mutation nomenclature, and the Human Variome Project (HVP), which spearheads the collection, curation, interpretation, and sharing of information on variation in the human genome. Newer projects have also shown promise, including the International Rare Disease Research Consortium (IRDiRC), initially founded by the National Institutes of Health and the European Commission, which aims to promote diagnostics for all rare diseases and accelerate the development of new treatments for them; it promotes standards for data and samples and also for other areas, including ethical and regulatory procedures. IRDiRC members are funding bodies and other organizations that will promote the use of these standards by funded researchers. Another newer project is the Global Alliance for Genomics and Health (GAGH), which promotes similar goals for all areas of genomic medicine, including rare disease. One of the projects that is emerging from the GAGH is the Beacon Project, a technical interface for implementing a web service that allows limited sharing of genetic data. A genomic variant query can be conducted at a participating 'beacon' and will answer the question of whether the institution has one or more human genomes with a certain allele at a certain position (the answer is a simple 'yes' or 'no'). Thus, if a research group has identified an interesting rare variant at a certain position of the genome, it can easily find out whether other centers have additional genomes with the variant in question. At the time of writing, seven such beacons were listed at the GAGH website.Current paradigms of sharing raw genomic data (such as FASTQ or BAM files) will not scale well for certain research goals, especially those that require a large amount of data to be integrated. For instance, the European Genome-phenome Archive (EGA) of the European Bioinformatics Institute (EBI) and the database of Genotypes and Phenotypes (dbGaP) of the National Center for Biotechnology Information (NCBI) are large archives for various types of genomic data. However, data access decisions are made for individual datasets, and thus it would not be easy for a user to obtain access and download 10 sets of 100 genomes each from 10 unrelated centers to perform an integrated computational analysis on all of the data.Genome Medicine, Ardeshirdavani and coworkers describe software, NGS-Logistics [RPCG1, but the statistical evidence provided by the analysis of the first group is not sufficient for publication. There are currently several options available to our imaginary consortium for making progress. It could decide to put all 1,000 genomes into a central repository, but this would require additional IT resources, and also the willingness of all 10 groups to share their data before publication. Alternatively, the first group could ask each of the other nine groups to share data on the RPCG1 gene in each of the 100 genomes. But even if nine postdocs in the nine groups found the time to search out and copy the data, it still might be difficult for the first group to complete the analysis because of different formats or variant-calling settings being used in the other nine groups.In this issue of ogistics , which pRPCG1 gene at all 100 BAM files of all 10 centers. The variant calling is performed locally at each of the centers, and the results are collected and returned to the first center, a procedure that is known as a federated search. If the researcher at the first center thinks the results are of potential interest, NGS-Logistics can be used to request more data access. Importantly, the researcher at the first center is not allowed to download the genomes from the other centers, thus preserving privacy and respecting the intellectual property of collaborating groups. NGS-Logistics instead allows researchers to ask hypothesis-driven questions about specific variants or specific genes, such as RPCG1 above, which can lead to targeted follow-up studies within collaborative networks. NGS-Logistics therefore may be useful to research consortia that are acquiring too much data to move from one partner to another and that for one of many reasons choose not to store their data in a central archive.NGS-Logistics provides a different solution for this, in which each of the 10 centers installs the NGS-Logistics software and lets the software know where to find the 100 BAM files. This now allows each of the centers to ask a hypothesis-driven question about a gene or a variant. In the example above, the first center could use NGS-Logistics to run variant calling using its own preferred GATK parameters in the


Indeed, public-health interventions that have focused on policies, systems, and environmental changes in the community have become popular in recent years and have been used extensively by a number of health authorities in developed countries (Zandian and colleagues’ article on the control of body weight by eating behavior in children draws upon the experience of several disciplines. They reviewed the evidence for the impact of brain physiology, genetics, diet and exercise, and pharmacological interventions in counteracting the worldwide increase in pediatric body weight . The autountries . In the ountries . In mostountries  or “exteountries , 4. Althountries . In shorThe author confirms being the sole contributor of this work and approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


There is overwhelming evidence that autism spectrum disorder (ASD) is related to altered brain connectivity. While these alterations are starting to be well characterized in subjects where the clinical picture is fully expressed, less is known on their earlier developmental course. In the present study we systematically reviewed current knowledge on structural connectivity in ASD infants and toddlers. We searched PubMed and Medline databases for all English language papers, published from year 2000, exploring structural connectivity in populations of infants and toddlers whose mean age was below 30 months. Of the 264 papers extracted, four were found to be eligible and were reviewed. Three of the four selected studies reported higher fractional anisotropy values in subjects with ASD compared to controls within commissural fibers, projections fibers, and association fibers, suggesting brain hyper-connectivity in the earliest phases of the disorder. Similar conclusions emerged from the other diffusion parameters assessed. These findings are reversed to what is generally found in studies exploring older patient groups and suggest a developmental course characterized by a shift toward hypo-connectivity starting at a time between two and four years of age. Autism spectrum disorders (ASD) are a heterogeneous group of neurodevelopmental diseases affecting 1 in 68 children in the USA , charactAn overwhelming number of studies have been performed in the last decade addressing the possible brain abnormalities associated with ASD. Increasing evidence suggests that in the phase when symptoms of ASD are fully expressed, i.e., in school-aged children or older, their neurobiological underpinnings consist of a disruption in structural and functional connectivity  AND (Infant∗ OR Toddler∗) AND . Criteria for inclusion in the study were established prior to the literature search. Inclusion was limited to papers published between January, 2000 and February, 2015, and was restricted to peer-reviewed English language articles. Reviews were not included in the selection, but were used to collect original studies. We screened all the selected papers in order to include studies in which mean age of the ASD sample was below 30 months. Studies focussing only on ASD subjects with known etiology  were not included.To review the literature, we queried PubMed and Medline using the following search terms:  and conflicting judgements were solved by consensus. During the review process 223 papers were excluded based on clear failure to meet the inclusion criteria. Forty-one papers were evaluated in full-text, of which 18 were review papers. Of the remaining 23, only four met the inclusion criteria and were included in this review . All fouTable 1). In the remaining three studies  FA, which is currently the most common index explored in diffusion studies, and (ii) all other diffusion indexes.Figure 1).Three of the four studies measured FA values. Findings are discussed according to the identified connections as grouped into commissural fibers, projection fibers, , and association fibers (long and short range) . As FA iCommissural fibers . In three . In two of the four selected papers association fibers were explored . In two of the four selected papers projection fibers were explored (explored . In bothexplored . Signifiexplored  and the explored .Three of the four papers explored diffusion indexes different from FA. The most innovative approach was the one by Evidence from the reviewed studies suggests that white matter atypical diffusion properties are a consistent finding in the early phases of ASD, and can precede the full-blown expression of the clinical picture. All three studies exploring brain FA, the most commonly investigated diffusion measure , extensiWhile these latter reports have been considered by most as supporting the underconnectivity theory of ASD, firstly formulated from functional MRI studies , recent The relationship between structural and functional connectivity is not fully understood in subjects with ASD, and particularly so in infants and toddlers, since no study to date has specifically addressed this issue . InitialThe few functional connectivity studies performed in infants and toddlers with ASD do not clarify this issue. In the only EEG study assessing connectivity in infants with ASD, Irrespective of its connotations, the issue remains about the time of development at which, as compared to control subjects, white matter properties begin to shift from increased FA to decreased FA. Overall, studies in this review suggest a time between 2 and 4 years of age as the phase when this shift is most likely starting to occur. The first structures showing an inversion of FA distribution are the thalamocortical projections, which were found to have significantly lower FA values in ASD toddlers already at 24 months of age . Around While interpreting the findings of the papers included in this review, the heterogeneity in the quality of the studies needs to be mentioned. For instance, number of diffusion directions used ranged from 6 in one study to 25 or 30 in the other three. Also, movement artifacts are likely to have affected differentially the findings, as only two of the four studies  used sedOverall, the results of this review describe a developmental trajectory of white matter diffusion properties in ASD infants compatible with the early signs of enlarged head circumference and macrocephaly extensively reported in the literature . ConvergDespite the growing interest in the literature in understanding the neuro-structural underpinnings of ASD at the onset of clinical symptoms, or before, available data are still not exhaustive. To date, studies are still scarce and are highly heterogeneous in terms of sample size, control groups and MRI analysis. A possible strategy to face this limitation would be the partaking of large, longitudinal ASD data repositories within the scientific community, which would provide priceless information about the early neurostructural markers of the disorder. The increasing application of this and other methodological strategies, including the use of higher-order diffusion imaging such as HARDI, is likely to rapidly and exponentially widen in the near future our knowledge on the developmental trajectory of early brain connectivity in ASD.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.


This paper illustrates the results of a study carried out in four Regional Parks of Sicily , concerning traditional knowledge on food use of wild plant species. The main aims of the paper were: (i) to verify which wild plant species are used for food purpose in the local culture based on information provided by elderly inhabitants (ii) to verify the presence of wild plant species which have not been cited for food use in previous studies in the Mediterranean area (iii) to determine how many of the most frequently cited wild plant species are cultivated by the local population in the four Sicilian Parks.Semi-structured interviews were carried out in the local communities of the four Regional Parks between 2007 and 2010. A total of 802 people over the age of 60 were interviewed. Cultural Importance Index was used to evaluate the level of importance given to any wild plant species as a food in the local culture. The level of appreciation of the wild plant species and the possible effects of wild plants on human health were also investigated.Cichorium intybus L. and Foeniculum vulgare Mill. obtained the highest Cultural Importance Index values. Sixty-four species were indicated as also having medicinal properties. Leaves and other aerial plant parts were the parts most-used for the preparation of traditional recipes.Local communities currently use a total number of 119 wild species for food purposes. Asteraceae and Brassicaceae were the most represented botanical families. In each of the four Sicilian Parks, The research shows that the level of traditional knowledge on the food uses of wild plant species in the study area is poor. The food uses of plants which are most likely to survive over time are those at the interface of food and medicine. Further agronomic studies are needed for a number of species with a view to introducing them as a crop into non-intensive agricultural systems. Wild plant species have always played a fundamental role in the diet of man. Although plants once represented a good source of food in rural areas, there has been a gradual change in lifestyle over the centuries; people have moved away from the countryside and there has been huge progress in farming methods. Wild plants became a progressively less important source of food over time, as it was replaced by food products from intensive farming crops and industrialized processing. Food habits and tastes have undergone intense change, with the introduction of increasingly more refined and highly-processed industrial food products. In more recent times, the consumption of food products of animal origin has increased sharply, giving rise to a series of health problems, exacerbated by a fall in the consumption of plant foods rich in fiber, vitamins and trace elements , 2. FurtThe study area covered four mountainous, hinterland areas in Sicily : the Madonie Regional Park , Nebrodi Regional Park (North-Eastern Sicily), Etna Regional Park (Eastern Sicily) and Sicani Regional Park  Fig. . Based o2 . Cereal and fodder crops are grown in the area, together with a substantial number of olive, fruit and horticultural crops. The animal farming sector is also fairly consistent, a factor which affords environmental and economic protection.The Nebrodi Regional Park  covers an area of 856 kmea level . Althoug2 and encloses 20 towns. The Park’s most important resident is without doubt Mount Etna, the highest and most active volcano in Europe, declared a World Heritage Site by UNESCO in June 2013. The land in the park is highly varied. There are large areas of fertile soils with dense woodland or shrubby, meadow areas, and, in stark contrast, vast areas where fresh lava gathers and where no vegetation grows. The most abundant forest species, found at most altitudes on Etna, are Quercus ilex, and the deciduous oaks belonging to the Quercus robur L. group : Quercus cerris L., Castanea sativa Miller, Fagus sylvatica L., Betula pendula Roth and Pinus nigra subsp. laricio Maire [Etna Regional Park was the first national Park to be established by the Region of Sicily. It is 590 kmio Maire . Agricul2 and includes 32 small towns [Quercus ilex, Quercus suber, Quercus gussonei and Quercus pubescens Willd. s.l.) Forests border on traditional olive groves, fruit orchards and crop fields growing cereals, fodder, and vegetables. are also common.The Monti Sicani Regional Park  covers a surface area of about 230 kmll towns . The altWhich plants have you used in your lifetime and which do you continue to use today for food purposes? Which of these plants used for food purposes have you also used for other reasons? How do you use the plants? Where do you gather these plants? How useful do you consider these plants to be for food purposes? Do you know the cultivation techniques required for these plants Do you use any wild food plants also for medicinal purposes, etc. The number of wild plant species which are/could be cultivated by the local populations, the level of appreciation of wild plants compared to cultivated plants and the possible effects on human health were also investigated. The plants collected were used to prepare exsiccata in the laboratories of the Department of Agricultural and Forest Sciences at the University of Palermo. The plants were identified using the Italian Flora [The research was carried out by conducting interviews in the 90 towns of the 4 Sicilian Parks. The interviewers selected elderly people who had spent their entire lives in the area and who were/had been traditional farmers (agriculture and livestock farming). The interview protocol is described in –39. Intean Flora . Plant nan Flora  and tropan Flora . Voucheri varies from only one use to the total number of uses, NU) obtained for any given species, divided by the number of informants in the interviews (N).In order to verify the existence or not of previous citations of a given plant species for food use in the Mediterranean area, and to compare food uses with other studies, literature from other regions in Italy and other Mediterranean countries was consulted. From the information gained, we were able to determine a series of data, such as the most cited species, the most cited food uses, the most used parts of the plants and the most common culinary uses. By applying the Cultural Importance Index (C.I.) , we wereA total of 658 men (82 %) and 144 women (18 %) were interviewed. The informants were aged between 60 and 90, giving and the average informant age was 73.9 years. The informants aged 70-80 years were able to supply the greatest information on the plants in terms of numbers of plants cited; less information was obtained by the younger and older age brackets. Regarding the lack of information provided by the older informants, this was in large part due to communication difficulties which arose during interviews. A far greater number of men than women were interviewed in the 4 Sicilian Parks and, therefore, the female contribution to the acquisition of information was low. This male prevalence was not intentional and was mainly due to the fact that the elderly men were more available/willing to participate. The significant lack of women in the survey we did not consider to be of decisive importance regarding information on the number of wild food plants as the men had spent most of their lives in the countryside and forests and had expert knowledge of the plants. The under-representation of women, however, may have contributed to a smaller amount of detailed information on the processing and cooking methods of wild food plants. Confirmation of this may come from Hardy’s theory  which mause of wild food species between the investigated area and those reported in studies in Sicily, in other Italian regions and some Mediterranean countries are also shown. The most represented families are Asteraceae (33 species), Brassicaceae (14 species), Lamiaceae (10 species), Asparagaceae (8 species) and Leguminosae (6 species). Only 4 species with food properties from the study were identified as being endemic to Sicily, according to [Asperula rupestris Tineo, Brassica rupestris Raf., Carlina sicula Ten. and Urtica rupestris Guss. The predominance of Asteraceae in food use and food/medicinal use confirmed results from a number of studies carried out in Mediterranean countries [Mentha spp., are collected from natural habitats , while others, such as Rosmarinus officinalis L. are often cultivated for food and/or medicinal purposes  .Cichorium intybus L. (C.I. 0.37), Foeniculum vulgare Miller (C.I. 0.31), Borago officinalis L. (C.I. 0.23) and Asparagus acutifolius L. (C.I. 0.21) are the most important species to the local populations in terms of food use  L. are eaten boiled and pan fried in omelettes. Lentini and Venza [Laurus nobilis L. (C.I. 0.09) was found to have the lowest Cultural Importance Index. Most of the species had a very low Cultural Importance Index, this would seem to demonstrate that little cultural importance is given to these species as a food. This may be an indication of a fall in TPK  regarding food uses of plants. However, it would be a mistake to consider those species with a low C.I. index as uninteresting from a culinary point of view in that we would need to take other factors into consideration, such as the lesser or greater availability of the species in the natural habitat, or the greater or lesser use of the plants to cure the most widespread disorders in that same area. When considering the 90 towns in the study area individually, the cultural importance of these species was found to differ between towns, and this highlights the fact that, in quantitative analysis terms, the species is used by the local populations to differing degrees. In this study a total of 119 wild plant species were collected, 109 of which were found to be used for food purposes also in other Italian regions and 75 in the Mediterranean countries taken into consideration. Most previous studies, however, were carried out using different methodologies or in areas which differed in terms of size and floral diversity. When a comparison was made of the wild plant species in this study and those previously cited by Lentini and Venza [Apium nodiflorum (L.) Lag., for example, is eaten in Sicily, Tuscany, Spain and Tunisia. It is worth noting that some culinary uses are typically found in only one Sicilian Park or another, and this would seem to be proof of a slight variation in diet between populations of the same region. The greatest range of culinary uses was found in the Etna (28) and Nebrodi Regional Parks (27). Regarding current use of the species cited in the study, 28.57 % of the species are still used today whilst the remaining part can be considered to have fallen out of use. Concerning the perceived degree of usefulness of the species for food purposes, and referring only to those species currently used by the local populations, Concerning the perceived degree of usefulness of the species for food purposes, and referring to those species currently used by the local populations, 59.66 % of the culinary uses were highly appreciated by the informants whilst only 54.62 % of the culinary uses were little appreciated. Some wild plants were recorded by the informants as being both highly and little appreciated.s Latium , Tuscanys Latium  and Sards Latium . In Sicis Latium . In the in Italy , 12, 74 in Italy . The aerountries –81. The nd Venza  reportednd Venza  in Sicilnd Venza , in otheSilene vulgaris (Moench) Garcke were used in quite the same way: eaten raw in salads or cooked in omelettes, and the aerials parts and flowers of Asphodeline lutea (L.) Rchb. were eaten indifferently, boiled and then fried with eggs. Further on the topic of preparation methods, the wild food species are consumed in a number of different ways: some are cooked whilst others are eaten raw and require only washing. The methods of consumptions are reported in Fig. Foeniculum vulgare, Borago officinalis and Asparagus acutifolius. Some wild plant species are consumed fried, especially in the preparation of omelettes. In the Monti Sicani Regional Park, the aerial parts of Diplotaxis erucoides (L.) Dc. are typically fried with eggs and lemon in omelettes, and in the Nebrodi Regional Park the bulbs of Leopoldia comosa (L.) Parl. are sautéed with eggs to prepare traditional dishes as confirmed by [Portulaca oleracea L., the young shoots of Clematis vitalba L., the leaves of Nasturtium officinale R. Br. are usually served with a little olive oil, salt and vinegar. Other species like Allium spp. and Foeniculum vulgare are used fresh with tomato and bread. Some wild plant species are consumed fried, especially in the preparation of omelettes. In the Monti Sicani Regional Park, the aerial parts of Diplotaxis erucoides (L.) Dc. are typically fried with eggs and lemon in omelettes, and in the Nebrodi Regional Park the bulbs of Leopoldia comosa (L.) Parl. are sautéed with eggs to prepare traditional dishes as confirmed by [Portulaca oleracea L., the young shoots of Clematis vitalba L., the leaves of Nasturtium officinale R. Br. are usually served with a little olive oil, salt and vinegar. Other species like Allium spp. and Foeniculum vulgare are used fresh with tomato and bread. Some plants are consumed as fresh fruit: Fragaria vesca L. in Etna Regional Park and Opuntia ficus-indica (L.) Miller in the Madonie Regional Park. Fruits are also used to make cakes and preserves. Twelve plant species are used to prepare sauces for traditional Sicilian pasta recipes. The most representative are Foeniculum vulgare, Asparagus spp., Sonchus spp., Borago officinalis and Capparis spinosa L. Some aromatic plants are gathered in the wild and consumed steadily throughout during the year. The highly aromatic species Origanum vulgare L., Rosmarinus officinalis and Thymbra capitata (L.) Cav. are examples of such, commonly used to flavour traditional Sicilian dishes. Only two plants species are used for alcoholic beverages: in the Etna and Nebrodi Regional Parks, Mentha pulegium L. and Mentha spicata L. are traditionally used to make liqueurs.The aerial parts of the plants are the parts most widely used, followed by leaves, flowers and shoots Fig. ; internairmed by . A high irmed by . A high Of the 119 wild plant species in this study, 64 were recorded as having therapeutic effects . AccordiClinopodium nepeta (L.) Kuntze was the species most cited by the populations of both the Etna and Nebrodi Regional Parks. The broth obtained from the aerial parts of the species is used to cure internal haemorrhoids. Singh et al. [Clinopodium nepeta contains 64 pharmacologically active compounds which give the species antibacterial, antioxidant and anti-inflammatory properties.h et al.  note thaCichorium intybus was the most-cited species by the populations of the Madonie and Monti Sicani Regional Parks. The aerial parts of this plant species are commonly boiled and eaten for their good flavour, but also as a bland diuretic, particularly highly appreciated by the local people. The same use was reported by [Cichorium intybus is well known in other Italian regions [orted by . The pla regions , 76, 82, regions , in Tuni regions  and in S regions .Origanum vulgare is an example of such; used in many traditional Sicilian recipes as flavouring in salads, or roast/fried fish and meats, it is also considered to be an important medicinal plant by the local populations, helping to fight colds, flu and stomachache [Rosmarinus officinalis and Thymbra capitata; the leaves of both of these species are used to flavor vegetables, roast meats etc. A decoction of the aerial parts of rosemary is considered to be particularly effective in the treatment of asthma and gastric disorders; an observation commonly made in both Italian and world literature [Several aromatic plants belonging to the Lamiaceae family were particularly highly-appreciated for their therapeutic effects by the informants. machache . Severalmachache –88. Otheterature –92. An iterature –95.Laurus nobilis is extremely common throughout the study area. The fresh and dried leaves of the species are used for their distinctive flavor and fragrance. However, the species is also considered medicinal: laurel leaf infusions are used to help digestion, as noted in literature from Sicily [, noted that there seems to be a relationship between the pharmacological effectiveness of these species and its antiradical activity.The culinary use of m Sicily , Italianm Sicily , 91, 96.m Sicily , in a stThe local populations have very good knowledge of the cultivation techniques of small number of wild plant species and have wide experience with many agronomic practices such as soil preparation, crop rotation, sowing, fertilization, irrigation, diseases and pests and harvesting. Organic farming practices are also highy appreciated by the informants. In many towns of the Madonie Regional Park, common chicory and starflower are commonly grown in kitchen gardens and the most used cultivation techniques for these crops are similar to that of spinach and salad rocket. The increasing importance of fennel in the Mediterranean diet has encouraged many aromatic plant producers to breed and commercialize the species in pots. The cultivation of cactus pear is especially widespread in the Etna Regional Park and, on a European level, cactus pear processing is only found in Sicily. The success of this Sicilian production sector is the result of excellent quality fruit, but also in part due to the recent adoption of low-impact cultivation techniques, such as fertilisation, irrigation and thinning, which traditionally were not practiced on this species. In recent years, in the most productive agricultural areas of Sicily, cactus pear crops have been cultivated with irrigation, greatly improving fruit quality.wild plant species were beneficial to human health because they were not contaminated by fertilizers and pesticides, and that they contained large amounts of nutrients and active principles. Vice versa informants stated that the domesticated plants were not grown naturally and could possibly contain substances harmful to health as a result of human intervention. Most of the informants perceived that plants cultivated in own-kitchen gardens were better than those produced in intensive farming. However, from an agronomic point of view, the domestication of wild plant species, using low impact cultivation techniques, represents a point of interest for sustainable agriculture in order to obtain a high quality foods for human consumption. Nowadays, many consumers want to know more about the food they eat and look for high quality. Agriculture needs to ensure organoleptic stability of a wild plant species when cultivated on a large scale. The first step is to protect the plant genetic resources through ex situ conservation, and the second is to establish cultivation protocols for the wild plant species. In this way, it is possible to select wild plant species with agronomic interest for food/medicinal uses.Laurel is grown in kitchen gardens and farms for the production of aromatic plants. Regarding all the 119 wild plant species, it is important to note that the majority are not cultivated and only a small number are cultivated or could be cultivated in kitchen gardens and crop fields. Another point worth highlighting is the fact that agronomic practices often affect organoleptic and nutritional properties of the plant parts. This may depend on how extensive cultivation is: the more intensive production, the greater the probability of a change occurring in the nutritional properties of the food. Many informants commented on the fact that as a source of food are those at the interface of food and medicine, and not those used solely as a food. Comparative analysis with other Mediterranean regions indicates that 6 wild food species have not been mentioned previously in the literature of the references countries and would seem to be novel in culinary terms. In terms of agriculture, it is important to highlight that given the fact that only very few of the wild plants mentioned can/could be cultivated in kitchen gardens and/or crop fields, further agronomic research on these few species is essential in order to improve knowledge on their main cultivation techniques. An important result of the research is the fact that most of the wild plants are perceived as highly useful for food/medicinal purposes and this is due to the health effects of the wild plants as reported by the informants. The protection of the native genetic resources and the culinary traditions linked to them is essential if we are to preserve the cultural heritage of the Sicilian Parks concerning the food use of wild plant species and in order to cultivate a number of species of agricultural interest. Our contribution should be not considered as exhaustive and future research is necessary in order to extend investigation to the younger generations and comment on the transmission of knowledge from the old to the new generation.This study carried out in 4 Regional Parks in Sicily shows that the culinary use of wild shrub and herbaceous plants is not a predominant part of the food culture of the local populations. Most of the species were not found in all of the Sicilian Parks and the number of total citations per species was, in general, very low: sign of an on-going process of the cultural erosion. The lack of homogeneity in the number of women and men in the interview group may have affected some results of the study; in particular, the under-representation of women in the sample of informants is most likely to have contributed to lower quantities of detailed information, for example on the methods of consumption of wild plants. The study found that only very few wild plants are widely used for food use by the elderly populations of the study area and, on many occasions, their consumption is due to the fact that wild plants are used both for food and medicinal purposes. This confirms the fact that, in Sicily, some foods are believed to have a natural, therapeutic effect and the food use of one species or another is considered curative of various disorders. Quantitative analysis shows that the plants that have the greatest probability of survival over time


This paper uses original survey data of the Great East Japan earthquake disaster victims to examine their decision to apply for the temporary housing as well as the timing of application. We assess the effects of victims’ attachment to their locality as well as variation in victims’ information seeking behavior. We additionally consider various factors such as income, age, employment and family structure that are generally considered to affect the decision to choose temporary housing as victims’ solution for their displacement. Empirical results indicate that, ceteris paribus, as the degree of attachment increases, victims are more likely to apply for the temporary housing but attachment does not affect the timing of application. On the other hand, the victims who actively seek information and are able to collect higher quality information are less likely to apply for the temporary housing and if they do apply then they apply relatively later. A large-scale natural disaster is physically destructive, and the recovery process is emotionally and financially costly. Survivors need to transition from victims to citizens, and decision makers are often held accountable for a speedy recovery . TherefoThe provision of temporary public housing has become a standard procedure to resolve the displacement caused by disasters. Public discussion focuses on the government’s reaction to the damage, including whether the government has allocated sufficient resources to build and manage temporary housing. The media covers the quality of temporary housing, the costs paid by residents for it, and the timing of the discontinuation of temporary housing, but it rarely covers the decision making of victims to actually choose temporary housing as a displacement solution when other options are available. Previous studies have identified the effective factors that cause discrepancies in the overall progress of recovery at the individual and regional levels, and the implications are important to efforts to improve the recovery process. However, understanding the details of how survivors react to address displacement can shed some light to how decision makers should proceed when they face particular stages of the recovery process.We contribute to the literature on disaster response and management by disaggregating the effects of various components of victims’ decisions to move into temporary housing as well as the timing of victims’ application for temporary housing. Our main objective is to empirically analyze the effectiveness and measure the impacts of the locality attachment and information-seeking behavior of disaster victims on the decision to apply for temporary housing and the timing of the application while controlling for the effects of other generally emphasized factors such as age, income and family circumstances. For our analysis, we use original survey data from the Great East Japan Earthquake disaster victims that were collected in March 2012, approximately one year after the earthquake.The paper is structured as follows: Section 2 provides the background on disaster displacement and temporary housing, with a particular focus on the case of the Great East Japan Earthquake. Section 3 discusses the related literature and the expected effects of locality attachment and informational factors regarding disaster victims’ choice of a solution for displacement and the timing of their decisions. Section 4 and Section 5 provide details on the data and the statistical analyses, respectively. Section 6 discusses the results of the empirical analysis, and Section 7 concludes the study.tsunami with wave heights of up to 9.3 meters that inflicted enormous damage, particularly in the Tohoku region’s coastal area. According to official reported statistics, the earthquake resulted in 15,884 deaths, 2,633 missing persons and 6,148 injured victims. Furthermore, 127,302 structures collapsed and 272,849 structures were left in semi-collapsed conditions. The estimated total damage was 16.9 trillion yen (approximately 169 billion dollars), of which 10.4 trillion yen (approximately 104 billion dollars) of financial damage resulted from the destruction of physical property, including both residential and non-residential buildings and other land property damage.One of the consequences of a natural disaster is the displacement of victims. The earthquake and tsunami that occurred in Japan on March 11, 2011 was the largest earthquake ever recorded in Japan. Registering a maximum seismic intensity of 7 and a moment magnitude of 9.0, the earthquake triggered a powerful The disaster led to the displacement of 470,000 people who were forced to stay in emergency shelters. The number of people in emergency shelters rapidly decreased over the six months following the disaster, at which time only 27,000 victims remained in the shelters, as the majority of the disaster victims had either found housing on their own or had moved to temporary housing. One year after the earthquake, approximately 320,000 disaster victims remained in temporary housing, and approximately 240,000 victims remained without permanent housing as of March 2014, three years after the earthquake.Hanshin-Awaji earthquake. In the Hanshin-Awaji earthquake of 1995, 48,300 units of temporary housing were built over a seven-month period to provide housing for 100,000 out of an estimated 316,000 homeless refugees. The disaster victims were allowed to remain in the temporary housing for three years after the earthquake. However, after three years, 45 percent of the temporary houses remained occupied due to inadequacies in the supply of affordable permanent housing [The first supplementary budget for the 2011 fiscal year allocated approximately 4 trillion yen (approximately 40 billion dollars) to the recovery process. Of the total budget, approximately 362.6 billion yen (approximately 3.6 billion dollars) was earmarked for the construction of temporary housing. The initial plan was to offer approximately 100,000 units of temporary housing, more than double what was allocated after the Although temporary housing is a common solution for displacement caused by disasters, it is not a permanent solution. During the emergency sheltering phase, living expenses are almost fully covered by outsiders, mostly by the government. During the temporary housing phase, people return to their normal work, school and daily activities while hoping for a more permanent solution . Thus, tWith no constraints, the optimal solution for disaster victims would be to immediately provide permanent housing. The reality, however, is that permanent housing is a costly option that frequently requires either long-term relocation or a long wait until the disaster sites recover and new houses are built. Depending on the circumstances and the preferences of disaster victims, their chosen solution for displacement varies; some choose to move into temporary housing, and some do not.One of the most widely emphasized decision factors is variations in income. Temporary housing is heavily subsidized and thus less costly for victims than other options, particularly over the short term. The housing options for low-income individuals are restricted, whereas high-income individuals are more capable of finding new accommodations and resolving their displacement more quickly because they can afford more costly alternatives. The employment factor, which is closely related to income, also affects the choice of a solution for displacement due to disaster. Unemployed individuals, part-time workers and elderly people who are dependent on social security are more likely to be financially restricted. In addition, individuals in some jobs, such as public servants and individuals in agricultural jobs, are less mobile because of the location-specificity of their jobs. Therefore, disaster victims with jobs that are closely connected to a specific location and community remain in the locality and enter temporary housing until the locality recovers from the disaster.Hanshin-Awaji earthquake had to live in an emergency shelter to qualify to apply for the temporary housing lottery. Moreover, to qualify for permanent government rehousing, a family had to be living in temporary housing at the time of application. Such restrictions may have created an intricate incentive structure for disaster victims when they were selecting a solution for their displacement. With respect to the Great East Japan Earthquake, the restrictions on the applicants were modified from previous disasters. Qualification was mainly based on the degree of property damage, and preferential allocation was based on age and the number of dependents. Hence, the age and family structure of potential applicants affect their decisions regarding whether to move into temporary housing.The choice of a solution for displacement may be partially affected by the restrictions and the preferential treatment that occur in the application process for temporary housing. For example, the disaster victims in the In addition to the generally emphasized decision factors such as age, income and family circumstances, our analysis focuses on the variations in local attachment and the information-seeking behavior of disaster victims as explanatory factors regarding the choice of a solution for displacement. In this section, we review the related literature and discuss the expected effects of these two factors separately.Although the concept of locality attachment is widely discussed in various disciplines, particularly in the fields of sociology and psychology, empirical studies connecting disasters and attachment are scarce. According to the attachment literature, a sense of attachment affects human behavior through the positive recognition of a sense of belonging, and various attachment concepts are defined according to what people feel they belong to. Place attachment is defined as the sense of belonging to a particular location, such as a house or a specific area. For example, according to , the conIn addition to place attachment, the literature also emphasizes social attachments and specifically the interaction between place and social attachment, which leads to the concept of community attachment and a distinction between the effects of place and social attachment –13. The Hanshin-Awaji earthquake that social ties and the sense of attachment to a locale are strong predictors of life recovery. Volunteerism and social connections through community participation directly relate to the concept of social capital proposed by Aldrich through ‘bonding’ between people in the community and people ‘linking’ themselves with their locality [Social interactions and connections are powerful tools of problem solving, particularly during unforeseen shocks such as large-scale natural disasters. , 17 findlocality . We consWe use several proxies of attachment in this study based on various indicators used by previous studies to measure the degree of attachment. The duration of one’s stay in a specific location or locality appears to be widely used as an indicator of place attachment as well as social attachment. For example, the number of years in a residence was first used by  as a proWe expect the empirical results to show that, ceteris paribus, an increase in attachment increases the likelihood of disaster victims applying for local temporary housing. We also expect that disaster victims with strong attachments will apply earlier to move into temporary housing. Disaster victims with strong attachments are more likely to remain in the locality even if the area is heavily damaged. For those who want to remain in their locality, temporary housing is a valuable option because the reconstruction of houses and facilities takes time. Moreover, such disaster victims would apply earlier because they would spend less time considering alternatives other than remaining in their locality.Following a disaster, victims typically face difficulties collecting information relevant to their physical security as well as to their short-term and long-term stability in terms of housing, employment and providing for dependents. Disaster victims must process massive amounts of information regarding disaster damage and the availability of support from various sources; in addition, they must also determine what and how much information they will take in and then actually apply the information to their decisions.Hanshin-Awaji earthquake, the Internet remained available, although satellite communication dishes were crippled. In response to the potentially overwhelming burden of heavy electronic traffic, mirror sites were established around the world. These sites enabled users to continue to receive valuable information such as press releases, lists of missing persons, reports on the extent of damage, and the effects of mitigation efforts [Previous studies that link disaster and information emphasize the Internet as an important information collection tool during a disaster.  notes th efforts .Second, according to , traditiBecause the Internet is a valuable source of information during and after a disaster, how victims utilize the Internet should be considered a factor that determines the information-seeking behavior of disaster victims and the quality of collected information. We incorporate the related measures of Internet access and Internet usage patterns among disaster victims in our study and expect that those who were able to access the Internet and web sources or online communities were able to obtain more accurate information faster than victims without access who did not use ICT as a tool to obtain information despite the availability of the Internet. Although the Internet is given special importance in the analyses, the previous literature does not deny the impact of traditional information sources following a disaster. Therefore, we also use regular subscriptions to national newspapers and weekly magazines that are considered sources of high-quality information. The list of magazines excludes publications that are categorized as gossip magazines or comic books.Collecting information is costly and time-consuming, so those who actively seek information place high value on having more information regarding different options and the details about available choices to justify the cost. Moreover, variations in access and the ability to collect information may affect information-seeking behavior. People with easier access to information who are more capable of using the relevant tools and have good organizational skills accrue a comparatively lower cost of information seeking and are thus more likely to actively seek information.We expect that individuals who actively seek and have the ability to collect high- quality information are less likely to apply for temporary housing than their counterparts because such individuals are more likely to know of and consider options other than temporary housing. Because such information is scattered and likely to be disseminated separately and often privately by provider organizations, obtaining useful details regarding outside options without additional information collection is difficult. If it is reasonable to assume that those with more information have more options with which to address displacement, then even if not all information seekers choose alternative options, the relative probability of choosing temporary housing as a solution would be lower for those who know of more options than for victims who are less likely to be aware of alternative options.Hanshin-Awaji earthquake, temporary housing construction lasted from two weeks to seven months [Iwate prefecture, even at the same temporary housing site, the units that were added later were better built because changes were made in response to complaints regarding the existing construction [Furthermore, we expect that if individuals with more information decide to apply for temporary housing, their decisions tend to be made later because collecting and evaluating information takes time, and these individuals are more likely to decide that waiting would actually allow them to collect more useful information to optimize their decision. There are several reasons why waiting may be beneficial. For example, there are variations in the timing of the construction of temporary housing. In the case of the n months . Furthern months , there wtruction . Hence, To empirically analyze the effects of location attachment and information factors on the likelihood of disaster victims applying for temporary housing and the timing of the application in the event that victims choose to apply, we utilize original survey data collected from disaster victims displaced by the Great East Japan Earthquake. The survey was conducted in March 2012, approximately one year after the earthquake.The data collection process satisfies the requirements of the guidelines provided by the Ministry of Education, Culture, Sports, Science and Technology in Japan (MEXT). We did not seek approval from the university ethics committee because this survey is not clinical research that is designed to verify the effectiveness of newly developed medical drugs or medical equipment, nor is it research that studies a medical illness that requires official approval. However, given the special circumstances of our target respondents, we have constructed our questionnaire and conducted our recruiting process carefully to avoid causing any physical or mental stress. All respondents were required to read statements regarding the content of this survey and had to consent before completing the survey. We have not received any post-survey complaints that it caused physical harm or emotional distress.Fukushima, Miyagi, and Iwate prefectures, which were severely affected by the earthquake, and we used Internet surveys to reach displaced victims who had moved from the disaster area. We received 1,111 responses; out of the 1,111 total observations, 497 respondents applied for temporary housing and 614 respondents did not.We used a paper-based field survey to collect the data from displaced disaster victims who were living in the i applied for temporary housing. This dummy distinguishes neither the timing nor the frequency of application. We also use Timing as the other main dependent variable, which ranges from 0 to 5, where the coded number indicates the phase number of the victim’s first application to the temporary housing entry lottery. We use Timing = 0 if i did not apply for temporary housing. Then, from 1 through 4 indicate the nth housing lottery for which i applied. 5 collapses the 5th to 16th lottery phases. We have chosen 5 as a cut off and have aggregated the later stage lotteries because there were few observations after the 5th round of lotteries.This survey comprises a broad set of questions, including personal characteristics, victims’ financial and family circumstances, and subjective opinions regarding the recovery process. For the details of the variable construction, see i spent in the same house, 2) the level of participation and communication in community activities, 3) whether i had a family member who was a fireman , 4) whether i currently holds, or held at the time of the crisis, a profession that is considered location-specific, such as local public servants, teachers, farmers and fishermen, 5) the number of local neighbors with whom i had discussed temporary housing post-disaster, and 6) whether i subscribed to local newspapers at the time of the earthquake. These variables were expected to cover a range of attachment concepts, including the place, community and social attachments of the disaster victims.The main independent variables are the proxies of attachment and information. We use several factors to measure the degree of local attachment: 1) the number of years that i had access to the Internet, 2) the degree to which i utilized the Internet for information-seeking activities, 3) whether i had a subscription to a national-level newspaper, and 4) whether i regularly read weekly magazines that are considered to have generally high information quality.We also use a set of variables to measure how actively the victims were engaging in information-seeking behaviors and their capacity to collect high-quality information: 1) whether Because we use related variables to measure the concepts of attachment and information-seeking, we use the exploratory factor analysis method (EFA) to aggregate related variables to create the indices of attachment and information. EFA calculates the smallest number of unobserved interpretable factors required to explain the correlations among a set of variables without assuming linear relations among the observed variables. We use the latent variables that were identified as good factor indicators of the observed variables. Employing the EFA in this manner, we attempt to reduce the effect of multi-collinearity among the proxies of attachment and information and also to construct indices that emphasize the concepts rather than the lists of variables.As shown in Fukushima and the neighboring prefectures, we control for the subjective sensitivity of disaster victims regarding radiation to observe whether health concerns affected victims’ decisions to remain in the locality and apply for temporary housing. We also control for the prefectures’ fixed effects using dummy variables to control for other prefecture-specific but unobservable characteristics that affect the decision-making behavior of victims.The analysis also includes other control variables that may affect the likelihood of application for housing and the application’s timing. Past studies and media reports indicate that income and family structure have significant effects on decisions that are related to temporary housing and on general post-disaster relocation decisions. Thus, we control for the following individual characteristics: age, income (per family member), number of dependents, and occupation dummies . In addition, given the large-scale nuclear reactor problem in We use the logistic regression method to analyze decisions to apply and use the ordered logistic method as well as heteroskedastic ordered logistic methods to analyze the timing of applications. Overall, the statistical significance of the variables varies little, and the direction of the effects remains consistent across the two models. Moreover, the signs are consistent with what we expect to observe; attachment positively affects the likelihood of application, and information-seeking negatively affects the likelihood of applying. Moreover, we find that several proxies of attachment have strong and robust effects on the decision to apply for temporary housing. Years in residence, which has commonly been used in previous studies as an attachment proxy, has a statistically significant positive effect. The number of respondents and the level of participation in community activities, which we use as a proxy for community network attachment, have a similar positive robust effect on the likelihood of applying for temporary housing.Other location-specific occupations do not appear to have an effect on the decision to apply for temporary housing; however, the fireman dummy has a positive effect on the likelihood of applying for temporary housing. This result supports the general view that firemen have a strong occupation-specific local attachment.Of the information-seeking variables, the most significant appears to be whether disaster victims read a national newspaper. Without differentiating types of newspapers, the coefficient on the newspaper dummy is statistically insignificant for newspapers; however, when we distinguish between national and local newspapers, a local newspaper has no effect and a national newspaper has an effect. These results imply that distinguishing the type of newspaper is important and that each type of proxy indicates separate concepts. In Japan, newspapers remain a common source of information. A regular subscription to a newspaper, particularly to a national newspaper, may proxy individuals’ attitudes, the degree of interest in information-seeking and the quality of obtained information. Furthermore, as discussed extensively in the previous section, Internet access appears to affect the likelihood of applying for temporary housing through information-seeking activities. Thus, the results appear to suggest that information-seeking and high-quality information reduce the likelihood of applying for temporary housing.timing is an ordinal variable and does not have equal interval intensity between the coded values, we use the ordered logistic regression method, which allows for adjustment for uneven differences between the values of ordinal variables.We also analyzed the variations in application timing among victims who applied for temporary housing. Because Models (3) and (4) in The ordered logistic model assumes a proportional effect for each estimated cut level and does not consider the variation of level effects across explanatory variables. We can test whether the proportionality assumption, often referred to as parallel regression assumption, is violated using the Brant test. Therefore, using the ordered logistic model leads to inaccurate estimation results. To correct this fault and increase the robustness of the estimation results, we use the heteroskedastic ordered logistic regression method, also known as the ordered generalized least moments method. The results of model (5), which incorporates the violation of the proportionality assumption, show that the information index remains highly statistically significant and has an inverse effect on application timing. Furthermore, comparing the coefficients of models (4) and (5) indicates that the regular ordered logistic method underestimates the coefficient value of the information effect.lnsigma value of the variables that failed the Brant test. The statistically significant negative coefficient of the lnsigma of the information index indicates that variations in timing among individuals decrease as the information index increases. In other words, as the information index increases, individuals consistently delay their application. Thus, compared with those with a low degree of information, the behaviors of individuals with a high degree of information exhibit a more uniform pattern.Additionally, the heteroskedastic ordered logistic regression method estimates the lnsigma value.Based on the results of previous studies, we expect to find the following: 1) as the degree of attachment increases, victims are more likely to apply for temporary housing and to apply earlier, and 2) as victims seek information more actively and are able to collect more and higher quality information, they are less likely to apply for temporary housing, and when such better informed victims do apply, they apply later.The results of the analysis suggest that attachment matters in deciding whether to move into temporary housing but not with regard to the timing with which victims apply. This result deviates from the expected effects of attachment. One of the reasons why attachment does not affect timing is the relative dominance of other factors in the timing decision. The results show that the information factor has a significant effect on the timing decision. Moreover, although the income effect disappears when we consider variations in application timing, the number of dependents and age emerge as main decision factors in the timing of the application. This result is consistent with what the media has documented and emphasized regarding the hardships of families with children and elders in emergency shelters. Moreover, families with children and the elderly are likely to receive preferential treatment during the selection process for temporary housing. Therefore, victims without dependents may apply at a later stage with the understanding that they have a relatively slim chance of being selected as occupants; thus, they may decide to use more of their time to explore better outside options.Unlike attachment, the information factor affects both the likelihood and the timing of applications, as expected. Victims who actively seek high-quality information are less likely to apply for temporary housing and are more likely to apply during later phases if they do apply. Victims who seek information are more likely to derive beneficial effects from doing so and are aware of more options. They also collect further information regarding their options and find value in waiting to obtain more information. Therefore, the solution for displacement that they choose is less likely to be temporary housing; moreover, if they do choose to apply for temporary housing, they tend to take longer to make that decision.In addition, we find that highly informed victims, measured by the information index in the analysis, behave more uniformly than their counterparts in terms of timing. This result may be partially explained by the combination of delay factors that were previously discussed and the factors that induce victims not to apply too late. Victims generally stay in emergency shelters immediately following a disaster. In particular, we observe that the application timing of victims is concentrated in the 3rd and 4th application periods. Problems such as lack of privacy, inadequate heating and cooling facilities and inadequate living space make victims want to move out of emergency shelters as soon as possible . The empUnderstanding disaster victims’ behavior is important when considering the distribution policies of resources during the recovery process. To enhance our understanding, we used a unique individual survey dataset collected from displaced victims of the Great East Japan Earthquake. Variations in disaster victims’ behavior with regard to the decision to apply for temporary housing and in the timing of that application indicate that depending on their individual characteristics and circumstances, individuals value temporary housing differently as an option to resolve their displacement problems.The results from the empirical analysis show that both attachment and information factors affect the victims applying for temporary public housing. In terms of application timing, contrary to the prediction, the attachment factor did not have an effect. Conversely, disaster victims with more information apply later. Moreover, we observe that the behaviors of victims with more information are more uniform and their application timing is concentrated in later phases compared with the scattered application timing of victims with less information.From these results, we can draw several conclusions to consider in the disaster recovery process and in future studies. First, a high degree of local attachment increases the demand for temporary housing, depending on the damaged area. If a crisis occurs in a more newly developed area in which residents are likely to have low attachment, there will be comparatively less demand for temporary public housing with respect to the residents of that particular location. Second, the results of the statistical analysis indicate that the timing with which demand is expressed is determined by the family-related circumstances and the information quantity and quality that victims can access rather than the degree of attachment. Therefore, knowledge regarding variations in the information valuation of disaster victims would help governments and other relief organizations that assist with recovery processes to determine resource allocations during the recovery period.We have focused on attachment and information factors, but there are additional factors that may also affect displaced victims’ decision behavior.  providesS1 TableRelated survey questions and comments on coding.(PDF)Click here for additional data file.S2 TableSummary statistics calculated using all sample.(PDF)Click here for additional data file.S1 DataData file (csv) includes all variables used in statistical analyses.(CSV)Click here for additional data file.S1 Survey QuestionnaireQuestionnaire document in Japanese and English.(PDF)Click here for additional data file.S1 Internet SurveyJapanese only.(PDF)Click here for additional data file.


Incomplete reporting has been identified as a major source of avoidable waste in biomedical research. Essential information is often not provided in study reports, impeding the identification, critical appraisal, and replication of studies. To improve the quality of reporting of diagnostic accuracy studies, the Standards for Reporting Diagnostic Accuracy (STARD) statement was developed. Here we present STARD 2015, an updated list of 30 essential items that should be included in every report of a diagnostic accuracy study. This update incorporates recent evidence about sources of bias and variability in diagnostic accuracy and is intended to facilitate the use of STARD. As such, STARD 2015 may help to improve completeness and transparency in reporting of diagnostic accuracy studies. As researchers, we talk and write about our studies, not just because we are happy—or disappointed—with the findings, but also to allow others to appreciate the validity of our methods, to enable our colleagues to replicate what we did, and to disclose our findings to clinicians, other health care professionals, and decision makers, all of whom rely on the results of strong research to guide their actions.Unfortunately, deficiencies in the reporting of research have been highlighted in several areas of clinical medicine.Reports of studies of medical tests are no exception. A growing number of evaluations have identified deficiencies in the reporting of test accuracy studies.Despite their apparent simplicity, such studies are at risk of bias.It is now well established that sensitivity and specificity are not fixed test properties. The relative number of false positive and false negative test results varies across settings, depending on how patients present and which tests they have already undergone. Unfortunately, many authors also fail to completely report the clinical context and when, where, and how they identified and recruited eligible study participants.To assist in the completeness and transparency of reporting diagnostic accuracy studies, a group of researchers, editors, and other stakeholders developed a minimum list of essential items that should be included in every study report. The guiding principle for developing the list was to select items that, if described, would help readers to judge the potential for bias in the study and appraise the applicability of the study findings and the validity of the authors’ conclusions and recommendations.The resulting Standards for Reporting Diagnostic Accuracy (STARD) statement appeared in 2003 in two dozen journals.Since the publication of STARD, several evaluations have pointed to small but statistically significant improvements in reporting accuracy studies ).The STARD steering committee periodically reviews the literature for potentially relevant studies to inform a possible update. In 2013, the steering committee decided that the time was right to update the checklist.Updating had two major goals: first, to incorporate recent evidence about sources of bias, applicability concerns, and factors facilitating generous interpretation in test accuracy research, and, second, to make the list easier to use. In making modifications, we also considered harmonization with other reporting guidelines, such as Consolidated Standards of Reporting Trials (CONSORT) 2010.11www.equator-network.org/reporting-guidelines/stard. In short, we invited the 2003 STARD group members to participate in the updating process, nominate new members, and comment on the general scope of the update. Suggested new members were contacted. As a result, the STARD group has now grown to 85 members that include researchers, editors, journalists, evidence synthesis professionals, funders, and other stakeholders.A complete description of the updating process and the justification for the changes are available on the Enhancing the Quality and Transparency of Health Research (EQUATOR) website at STARD group members were then asked to suggest, and later to endorse, proposed changes in a two round, web based survey. This served to prepare a draft list of essential items, which was discussed in the steering committee in a two day meeting in Amsterdam in September 2014. The list was then piloted in different groups: starting and advanced researchers, peer reviewers, and editors.The general structure of STARD 2015 is similar to that of STARD 2003. A one page document presents 30 items, grouped under sections that follow the introduction, methods, results, and discussion (IMRAD) structure of a scientific article (see table 1STARD 2015 replaces the original version published in 2003; those who would like to refer to STARD are invited to cite this article. The list of essential items can be seen as a minimum set, and an informative study report will typically present more information. Yet we hope to find all applicable items in a well prepared report of a diagnostic accuracy study.Authors are invited to use STARD when preparing their study reports. Reviewers can use the list to verify that all essential information is available in a submitted manuscript and suggest changes if key items are missing.We trust that journals that endorsed STARD in 2003 or later will recommend the use of this updated version and encourage compliance in submitted manuscripts. We hope that even more journals, and journal organizations, will promote the use of this and comparable reporting guidelines. Funders and research institutions may promote or mandate adherence to STARD as a way to maximize the value of research and downstream products or activities.STARD may also be beneficial for reporting other studies that evaluate the performance of tests. This includes prognostic studies, which can classify patients on the basis of whether a future event happens; monitoring studies, in which tests are supposed to detect or predict an adverse event or lack of response; studies evaluating treatment selection markers; and more. We and others have found most of the STARD items useful when reporting and examining such studies, although STARD primarily targets diagnostic accuracy studies.Diagnostic accuracy is not the only expression of test performance, nor is it always the most meaningful.14Although STARD focuses on full study reports of test accuracy studies, the items can also be helpful when writing conference abstracts, including information in trial registries, and developing protocols for such studies. Additional initiatives are underway to provide more specific guidance for each of these applications.The STARD statement was designed to apply to all types of medical tests. The STARD group believed that a single checklist, for all diagnostic accuracy studies, would be more widely disseminated and more easily accepted by authors, peer reviewers, and journal editors than separate lists for different types of tests such as imaging, biochemistry, or histopathology.Having a general list may necessitate additional instructions for informative reporting, with more information for specific types of tests, specific applications, or specific forms of analysis. Such guidance could describe the preferred methods for studying and reporting measurement uncertainty, for example, without changing any of the other STARD items. The STARD group welcomes the development of such STARD extensions and invites interested groups to contact the STARD executive committee before developing them.Other groups may want to develop additional guidance to facilitate the use of STARD for specific applications. An example of such a STARD application was prepared for history taking and physical examination.16The new STARD 2015 list and all related documents can be found on the STARD pages of the EQUATOR website. EQUATOR is an international initiative that seeks to improve the value of published health research literature by promoting transparent and accurate reporting and wider use of robust reporting guidelines.The STARD list is released under a Creative Commons license. This allows everyone to use and distribute the work if they acknowledge the source. The STARD statement was originally reported in English, but several groups have worked on translations in other languages. We welcome such translations, which are preferably developed by groups of researchers, by use of a cyclical development process, with back-translation to the original language and user testing.The STARD steering committee is aware that building a list of essential items is not sufficient to achieve substantial improvements in reporting completeness, as the modest improvement after introduction of the 2003 list has shown. We see this list not as the final product, but as the starting point for building more specific instruments to stimulate complete and transparent reporting, such as a checklist and a writing aid for authors, tools for reviewers and editors, instruction videos, and teaching materials, all based on this STARD list of essential items.Incomplete reporting has been identified as one of the sources of avoidable waste in biomedical research.