We have identified environmental and demographic variables, available in January, that predict the relative magnitude and spatial distribution of West Nile virus (WNV) for the following summer. The yearly magnitude and spatial distribution for WNV incidence in humans in the United States (US) have varied wildly in the past decade. Mosquito control measures are expensive and having better estimates of the expected relative size of a future WNV outbreak can help in planning for the mitigation efforts and costs. West Nile virus is spread primarily between mosquitoes and birds; humans are an incidental host. Previous efforts have demonstrated a strong correlation between environmental factors and the incidence of WNV. A predictive model for human cases must include both the environmental factors for the mosquito-bird epidemic and an anthropological model for the risk of humans being bitten by a mosquito. Using weather data and demographic data available in January for every county in the US, we use logistic regression analysis to predict the probability that the county will have at least one WNV case the following summer. We validate our approach and the spatial and temporal WNV incidence in the US from 2005 to 2013. The methodology was applied to forecast the 2014 WNV incidence in late January 2014. We find the most significant predictors for a county to have a case of WNV to be the mean minimum temperature in January, the deviation of this minimum temperature from the expected minimum temperature, the total population of the county, publicly available samples of local bird populations, and if the county had a case of WNV the previous year. West Nile virus (WNV) is a mosquito-borne flavivirus first identified in Uganda in 1937. WNV continues to be a public health hazard in the continental United States 13 years after its introduction into New York City in 1999 where it initially caused significant bird mortality and neuroinvasive disease (NID) in humans. In 2012, the USA experienced one of the worst years on record for human WNV ,Recent studies indicate that the genetic makeup of the virus isolated from the 2012 outbreak in Dallas is not significantly different from previously circulating isolates, and that all are of the WN02 genotype Culex spp. mosquitoes for the presence of the virus. Wild birds are less easily sampled in large numbers for WNV infection and thus mosquito infections and human WNV disease cases are often the only evidence of local WNV transmission.The WNV cycle is characterized in Figure 1. Birds and mosquitoes amplify and pass on the virus regularly. Humans are only inoculated by mosquitoes and do not, under normal circumstances, reach high enough viremia levels to pass virus back into the system Despite the availability of these samples, increases in surveillance efforts, and the renewed interest in WNV transmission, reliable predictive methods for human disease outbreaks remain elusive, owing to the milieu of interacting factors affecting overall transmission of WNV. We note specifically the review and novel results of a study in which incidence rates per county in years 2003 to 2008 were characterized by rule-based predictive models conditioned on meteorological and GIS data The study noted a cluster of errors in the Northern Great Plains (NGP) region, which grew in magnitude when a locally conditioned model was attempted The effect of these factors and their interaction on transmission---especially on tangential transmission into human populations—remains poorly understood. We create a predictive framework based on the statistical correlations among:the structure of the enzootic host communitydefine differential contact rates of infectious mosquitoes within and tangential to the enzootic transmission cycleinfluence the probability of diagnosing and reporting human casesanthropological factors thatenvironmental and weather conditions.Structure of enzootic host communityThe enzootic cycle of WNV is maintained by avian species and associated mosquitoes, especially Culex spp. Transmission characteristics of the avian hosts include host competence variability (relative infectiousness of bird species), susceptibility profiles of the avian communities, and their relative coincidence with human populations ,Anthropological factors,,Contact between infectious mosquitoes and susceptible humans is a function of many factors, several anthropological in nature. Human population density relative to mosquito population size (mosquito density) is included in the measure of arbovirus transmission, vectorial capacity On a smaller ecological scale, land cover is associated with differences in presumed transmission. In Louisiana, the probability of a mosquito pool being positive is greater in wetland or forested areas than in developed areas Environmental and weather conditions,,,,,,,,Arbovirus transmission is altered by several environmental and weather conditions. For example, temperature is a known modifier of WNV efficiency, directly reducing the time necessary for the mosquito to become infectious after exposure or increasing the number of mosquitoes ultimately infectious Model RationaleAnecdotal evidence from mosquito abatement experts suggests that drought conditions may have contributed to the increase in human WNV activity in 2012, with published research supporting this hypothesis Thus, we continued this line of investigation and included several variables related to the enzootic cycle, human demographic data, and other environmental variables. The study relies on historical and publicly available data sets that are available early in the year in question , so that the model may be employed as an early warning system and results used to support policy decisions and resource allocation.We developed a statistical model to predict yearly national human WNV risk with data collected early in the year and available for all counties in the contiguous United States. We hypothesized that although risk factors vary by region, deviation from minimum temperature in the winter is associated with WNV risk across regions. Based on previous studies and the ecology of WNV, we included multiple demographic, ecological, and climatological variables to build our statistical model with the goal of finding a simple cohort of variables that accurately predict increases in human WNV risk.National geography and WNV reporting We obtained county boundaries for the 48 contiguous US states from the SAS base maps file . The coordinates of the county centroids were approximated by the mean of points on the boundary of each county. Cumulative yearly counts of all reported WNV cases in humans reported to the CDC by county were obtained from the USGS summary for 3,111 counties from 2005 to 2013 We believe that attempts to characterize incidence within a county expose the model to the problem of small numbers. In this case, the number of samples (the population) within a county is usually large and the number of positives is relatively small. Young et al. discusses three methods to address the problem: spatial smoothing, aggregation over geographic areas, or aggregation over time The Young et al. study also concluded that their attempt had not mitigated the small numbers problem. While we suspect, as the authors did, that confounding factors were at least partially responsible, we also suspect that characterization of incidence by incidence rate and multivariate linear models is likely inappropriate Here, if a county had reported any human WNV cases, it was coded as 1 and 0 otherwise. We argue that variations in this (0/1) metric capture the majority of variation in the total number of WNV cases across space and time and a more detailed model is not currently indicated . This dichotomous method has been successfully employed at a regional level CovariatesBird community. We used the Breeding Bird Survey (BBS) to approximate numbers of birds, summarized by order, in an area. Surveys are comprised of counts made along distinct 24.5-mile routes in .5-mile intervals. Each survey was summarized by year conducted, route sampled, and order of bird species identified. Twenty-seven orders were represented and zeros were imputed when no examples of an order were reported along a particular survey route. Two attempts were made to reduce the dimensionality of the set. First, the total number of birds identified in a survey was log-transformed; this correlated poorly with WNV reports and was not further investigated. Next, log-transformed counts by order were subjected to a principal component analysis; the principal components led to a relatively compact description of the BBS. The principal components were computed for each year per route and represent a linear combination of the log (order count) for orders 1-27.It is important to note that the BBS data set was included here not so that individual species or orders could be associated with WNV, but as a means to account for unique regional ecologies and bird community biodiversity. Thus, the parameter estimates for principal components do not correspond to any specific characteristic of the bird community and are meant as markers for underlying environmental intangibles.We extrapolated the set of principal components to county centroids with a power semivariogram model (proc variogram and proc krige2d in SAS 9.3) . Estimates were conditioned on the nearest 50 points to avoid prohibitive computational complexity. Similar semivariogram models were considered and most yielded qualitatively similar results; the power model was chosen for its smaller number of parameters.Anthropological data. We used the 2010 census demographic data on a per-county basis. The data included estimates of the total population, median total income, proportion of the population in the labor force, and proportion of the population by race. The first two variables were log transformed and log-population was included as a second-degree polynomial  from the Multi-Resolution Land Characteristics Consortium (MRLC) classifies land areas into one of 16 categories. We summarized each county by the proportion of pixels within its boundary classified as developed (types 21-24) in Quantum GIS (QGIS).Finally, we investigated the potential for county-level reporting biases by including WNV reporting in the previous year and, in separate models, the previous two years. We reasoned that biases not otherwise addressed might be corrected by continued deviation from expectation. Both year and previous two years were significant predictors of WNV status (p<.05) but were also highly correlated. In the final model, we determined that the previous year’s report was sufficient.Environment and weather. Our models initially included maximum temperature, minimum temperature, precipitation, and deviation from the average for each of these variables. While the WNV cycle depends on covariates throughout the year, mean minimum temperatures in January alone were retained from the Global Historical Climatology Network monthly summary (GHCN-M) for all available stations; stations with any missing values in January 2005 to 2011 were excluded. Expected mean minimum temperatures for a station for January were defined as the average of that month’s data from 2005 to 2011. Various periods were considered (e.g. 1970 to present) to define the expected temperatures but yielded no qualitative differences, indicating that 2005 to 2011 was in some way representative. These indices were extrapolated to county centroids by weighing the nearest 50 stations by distance from the centroid.Maximum and average temperatures were individually significant predictors, but were not as powerful as minimum temperature and deviation from minimum temperature and did not improve on models already containing minimum temperature. We made an attempt to include precipitation, but the semivariogram fits were poor and extrapolation to county centroids was questionable. This seemed to indicate that precipitation was a local phenomenon with scale smaller than we were able to observe. Thus maximum temperature, average temperature, and precipitation are excluded from the final model.Statistical analysisWe carried out logistic regression analyses in SAS 9.3 using the dichotomous (0/1) variable indicating WNV activity for each county-year. A stepwise procedure with entry/exit p < 0.10 (proc logistic) was used to determine which variables best fit the data. We sought influential observations in the selected model by DFBETA; exclusion of the most influential observations produced no qualitative changes and no observations were deemed outliers.Because we repeatedly sampled the same counties over time, we do not model all samples as independent. Two samples from the same county were assumed to correlate even after the influence of all covariates had been removed. In the final model, we employed a generalized estimating equation (GEE) regression with an exchangeable working correlation structure (proc genmod in SAS 9.3) and estimated this correlation coefficient as ρ=.1041 for 2005-2011 data. This indicates that when modeled effects are considered, the remaining, unexplained correlation among WNV reports within a county is not prohibitively large. Regular and standardized regression coefficients and chi-square statistics were calculated for the resulting model.c) and the Hosmer-Lemeshow test statistic were calculated to measure the fit of the model for the 2012 data We recall that the model is conditioned on WNV human reported incidence data from 2005-2011 and we generated predictions for 2012-2013 without training on those years. The area under the receiver operating characteristic curve  are ranked by the magnitude of the standardized parameter estimate, in which larger values indicate more sensitivity of WNV status to changes in the covariate. The five most powerful predictors of WNV reporting in a county in order arethe expected mean minimum temperature in Januarythe actual mean minimum temperatures in Januarythe total population of the county per the 2010 censusthe first principal component of bird datathe WNV status of the county in the previous yearIn 5,000 simulated case-control studies, in which 25% of all positive and 25% of negative counties from years 2005-2012 were randomly chosen for training, the order of these components was unchanged in only 21% of trials. When population is omitted, this rose to 98% and none of the coefficient estimates were ever observed to change sign. This indicates that population is primarily important in differentiating relatively large, rare counties, which might not be present in random samples, from smaller, more numerous counties. This also indicates that the primary hypothesis, dependence on mean and actual temperature in January, is robust against missing data and selection of different training sets.Additionally, WNV is positively associated with employment levels in a county while actual income levels are negatively associated with WNV reported human cases. The percent of African Americans in a county is also a positive predictor for WNV reporting.Observed and estimated proportion of counties reporting positive per year are shown in Figure 4. When conditioned on 2005-2011 reported human WNV cases, the model prediction for 2012 had c-value of .849, which Hosmer and Lemeshow consider to show excellent but not outstanding discrimination We present the empirical and estimated rates of positivity for 2013, but note that the empirical proportion is likely an underestimate, as some states are at the time of writing only reporting on a state-wide level and not all reporting has been completed. Data in 2013 were used neither to condition nor to validate the model. So far, 2,374 human cases were reported in 2013 with 1,205 NID cases reported in the United States. The Hosmer and Lemeshow test for 2013 is well calibrated at the 10% level of significance (p=0.0818) . We also present predictions for 2014 based on the available preliminary 2013 WNV human data (missing 2013 county-level data was replaced with 2012 data) and temperature data for January 2014.The unusual distribution of temperatures in the 2013-2014 winter gives a rare opportunity to further investigate the link between temperature and human WNV. Approximately half of the country (east) experienced record low temperatures while the other half (west) experienced milder, even unusually warm temperatures, as in Figure 5.In Figure 6, we provide the predicted probability of reporting at least one case of human WNV, binned into low, medium, and high risk classes . We predict that there will be more WNV infections than usual in the western US and fewer than usual in the eastern US. However, the total number of positive counties in 2014 is predicted to be comparable to the total in 2013, as nationwide average temperatures were comparable between these two years. Therefore, we encourage increased vigilance in western counties where we predict an increased risk of human WNV cases.,Several modeling, laboratory and field studies have shown that WNV transmission is associated with environmental factors such as temperature, precipitation, drought, and land use, as well as biological factors such as bird community structure and anthropological variables, including urbanization and human density By focusing on the development of an early warning system from a national perspective, we directly speak to this need for better predictive tools to guide decisions regarding control and mitigation. Our model shows that in the contiguous United States, bird presence estimated from the previous year, deviation from minimum temperature in January of the year in question, human density estimates from census data, and history of WNV reporting are sufficient for prediction of risk of WNV human activity later in the year in question.In fact, conditioned on the 2005-2011 data, our model predicted the large upswing in human WNV in 2012, requiring only data from the previous year and temperature data from January 2012. To the extent that the model holds, none of the years in question are anomalous .,,Specifically, we found that the most significant predictors of WNV were the expected and actual minimum temperatures in January of the year in question. These do not seem to admit interpretation as biases and likely have straightforward biological interpretations. For example, unusual, positive deviations in temperature early in the year may increase a mosquito’s probability of surviving the remainder of the winter, may shorten the extrinsic incubation period, or encourage earlier and higher rates of mosquito breeding, and have been associated with heightened bird activity such as greater numbers of resident birds nesting and migration of non-resident birds ,Higher county-level income measures are negatively associated with reported WNV human incidence. This is supported by several studies, which have shown that higher housing density (as seen in lower socio-economic statuses) and increased urbanization are positively associated with WNV in humans The dual importance of human density and general bird presence is intuitive, given that the spillover into humans requires proximity to the otherwise bird-driven WNV transmission cycle. Again, specific orders of birds or specific species composition could be important on a local or regional level. In this model, however, bird orders serve more as proxies for the entirety of the underlying system and do not admit direct interpretation of the specific makeup of avian communities.The idea of birds as proxies is supported by studies that have shown different bird species to have higher seroprevalence than others , land use data, bird data and mosquito surveillance to determine further risk that year.The model uses data from the first month of the year in an effort to provide some confidence in its performance going forward and to provide earliest possible warning of heightened WNV risk. Since this model is based in reported human cases, its predictive capability is limited to just that. Thus, it should not be used to make any assumptions about the total volume of virus in the enzootic cycle, or the true transmission intensity, as most human cases are asymptomatic. This model is proposed on a national scale, and the intention of its use is to raise awareness of a potential heightened WNV season in time for any resulting reactions to have transmission mitigation efficacy. We envision that this model will be the first step in a series of spatially tiered warning systems that will increase in regional specificity and timing.,,,,,,,,,,Since the primary vectors of WNV are regionally dependent and given the spotty nature of consistent county-level mosquito control and surveillance data, mosquitoes were not explicitly considered in this model. Additionally, it is difficult to quantify the impact of mitigation strategies such as spraying on human incidence over multiple years without bird and mosquito surveillance data. This speaks to the lack of consistent data of both bird and mosquito populations in many regions, which would improve the predictive capabilities of any model, the regional scale at which a model could be formulated, and our understanding of WNV dynamics. On county and regional levels, models with access to detailed bird and mosquito surveillance data have had success in explaining WNV incidence in the enzootic and tangential cycles based on ecological and environmental factors


This qualitative study explored the role of sensory characteristics embedded in the built environment and whether they support or hinder people with visual impairment in their use of public spaces. An online survey link was e-mailed to the presidents and committee members of each state’s chapters and associations of the National Federation of the Blind in the United States, resulting in 451 direct invitations to participate. Written responses of the survey questions from 48 respondents with visual impairment were analyzed. Three main themes: Barriers, Supporters, and Context-Dependence emerged from the respondents’ experience of multisensory characteristics within the built environment. The four subthemes subsumed in Barriers were: (1) Population specific design, (2) Extreme sensory backgrounds, (3) Uneven ground surfaces and objects, and (4) Inconsistent lighting. For Supporters, respondents provided specific examples of various sensory characteristics in built environments, including audible cues and echoes, smells, tactile quality of the ground surface, and temperature. Context-Dependence referred to the effects of sensory characteristics embedded in public spaces depending on one’s vision condition, the proximity to the sensory cues and the purpose of the activities one was performing at that moment. Findings provide occupational therapy practitioners an in-depth understanding of the transactional relationship between embedded sensory characteristics in the built environment, occupations, and people with visual impairment in order to make appropriate modifications or removal of barriers that affect occupational performance and engagement. Suggestions for occupational therapists as well as architects, designers, planners, policy makers/legislators related to functional sensory cues in the design of built environments were provided to increase accessibility in the use of public spaces by people with visual impairment. Study of the dynamic relationship between person, environment and occupation is the core of occupational therapy , with ocThe concept of the environment as a significant factor in promoting people’s ability to engage in activities was the foundation for occupational therapy . OccupatSchkade and Schultz (1992) discussed that an environment demands mastery from a person, while the individual desires to behave masterfully ,12. The Within the interaction between the person and the environment, Pallasmaa  stated tIn addition to tactile and audible sources of information, people with visual impairment perceive olfactory and awareness of motion as sensory cues within an environment that facilitate orientation and safe and accurate mobility in public spaces ,21,22,23However, findings of a recent scoping review of 22 articles, which included 15 qualitative and seven quantitative research designs published between 1997 and 2010 on factors associated with activity participation and engagement among adults with low vision, indicated few studies have explored the influence of environmental factors on activity participation and engagement in this population . This isSince the environment in which individuals with visual impairment interact plays a central role as either a barrier or facilitator of activity participation and engagement , exploriThis descriptive study involved a cross-sectional survey research design. The study was approved by the Institutional Review Board of the University of Alabama at Birmingham. Implied consent was provided by participants upon submission of the completed survey.https://nfb.org/state-and-local-organizations). The NFB is the largest organization of blind and low-vision people in the United States, and has affiliates in all fifty states, the District of Columbia, and in Puerto Rico.Participants eligible for study inclusion were presidents and committee members of each state’s chapters and associations of the National Federation of the Blind , an online survey website engine, which provided a Uniform Resource Locator (URL) for the survey. The survey instrument URL and a cover letter explaining the purpose of the survey were e-mailed to the presidents and committee members of NFB chapters and associations for each state and the District of Columbia, excluding Puerto Rico. A total of 451 direct invitation e-mails were sent. Participation in responding to the survey was voluntary with no incentive other than contributing to general knowledge.Through delivery of the specific platform in SurveyMonkey™, and screen reader software that reinterprets graphical user interfaces and communicates the content by refreshable braille or voice synthesis , individThree investigators  used the following steps to analyze the content of the written responses. Two investigators (Laura K. Vogtle and Hon K. Yuen) were not involved in the original design of the questionnaire. The three investigators independently read all written responses several times to gain an overall impression of the content, and to formulate tentative ideas. Initial codes were manually assigned to phrases and sentences; they were closely associated with the original text in order to maintain the respondents’ meaning. Using an ongoing process of comparing text segments across the written responses, the investigators sought similarities or repeated ideas using the constant comparative method; codes were refined, revised and added as new topics emerged . Codes ei.e., 41 + 29) written responses of the two open-ended questions from 48 respondents who responded to either one or both of the two opened-ended questions, we identified three main themes: Barriers, Supporters, and Context-Dependence. Four subthemes subsumed in the theme of Barriers that respondents with visual impairment encountered in multisensory environments were: (1) Population specific design, (2) Extreme sensory backgrounds, (3) Uneven ground surfaces and objects, and (4) Inconsistent lighting.Based on the analysis of the 70 , and style without considering that some features  can serve as barriers that exclude people with visual impairment from accessing the environment or even posing safety hazards to them. Below are some of the quotes from three respondents which illustrate the barriers for people with visual impairment when the environments include population specific design.R5: The popular choice nowadays is very open and spacious areas. These offer we blind much less audio and so forth information. In fact in places like hotel lobbies or large halls the vaulted ceiling that are used can confuse the sound information and in fact magnify it to much higher levels.R25: Too often people plan environments to be visually appealing without even considering some simple options that would still be visually appealing, but would allow for more independence to a person with a vision loss.R25: In traveling, curb cuts that point to the center of the intersection rather than having 2 separate curb cuts to cross each street are difficult to cross correctly.R37: As an example of an environment that works well for the sighted, but is not blind friendly, the central station of our metro bus system. … The buses line up in two lines with a central patio-like area in the middle with a roof over it. … They [the sighted] can jump off one bus, cross the plaza area, then hop onto another bus. For the blind, the setup is a nightmare. With ten buses together, engines running under a roof, it’s like being inside a drum with someone pounding on it. As one totally blind, I rely almost solely on sound. I cannot distinguish one bus from another, and the cacophony of noise seems to jumble my mobility skills. Without sighted help, it's just about impossible for me to go from one bus in one line to a bus in another line. Even to talk within this environment with all buses there is extremely difficult.Extreme sensory backgrounds such as loud persistent noises that mask target signals or desired useful sensory (audible) information  can affect orientation and mobility for directional travel, as well as pose potential safety risks. Likewise, an environment that has significant echo with reverberating noise can create sound distortion. This makes it difficult to isolate sound cues and determine the direction of the source of the sound in locations where people with visual impairment rely on auditory cues for travel. On the other hand, large open spaces, such as open fields and parking lots that are void of any sensory cues, are also difficult to navigate. Similarly, hybrid vehicles that produce very little noise or the absence of parallel traffic surges at street crossings can confuse people with visual impairment as to when to start crossing the street. Below are quotes from two respondents, which illustrate the barriers for people with visual impairment when the environments have extreme sensory backgrounds.R1: Hybrid vehicles are very dangerous for the blind person who depends on the parallel traffic surge to know when to start crossing, how to keep aligned in or near the crosswalk, and just that the street is clear of oncoming vehicles.R40: Also in certain buildings, it is difficult to determine the direction of sound if the noise is reverberating.Uneven ground surfaces such as cracks, bumps, and drop-offs on the sidewalk can create fall risks. Quotes from two respondents illustrated the potential hazards of uneven ground surfaces and objects in the environment imposed on them.R1: …tree with big roots that may be pushing up the sidewalk and causing dangerous uneven surfaces or drop-offs…R6: Low lying obstacles, like signs are potential hazards that can cause injuries to people who are blind.Finally, inconsistent lighting, which casts shadows, and low contrast signage, can confuse people with visual impairment. One respondent (R41) commented “Trees or other buildings that cast a shadow at step downs cause great trouble for those who have minimal sight or light perception only.”Some of these identified barriers such as inconsistent lighting and uneven ground surfaces and objects, as well as certain features in population specific design, were commonly reported in the literature as impediments for travel in people with visual impairment ,30,31,32i.e., Temperature cues), and textured landmarks  which guide them to a point of interest and indicating directions of travel were mentioned by respondents as supports to their orientation and mobility. These were illustrated by the following quotes from three respondents.Specific sensory cues associated with the auditory, olfactory and somatosensory (haptic and temperature) systems are important to people with visual impairment for orientation and mobility to allow them to participate in various activities. However, such sensory cues need to have specific purpose and meaning to them. Respondents provided specific examples of various sensory characteristics in built environments, including audible cues and echoes, smells, tactile quality of the ground surface, and temperature. These examples were represented by the four subthemes: Temperature cues, Haptic cues, Olfactory cues and Auditory cues, that allowed participants successful use of public spaces. For example, temperature, airflow direction and placement of the sun relative to the individual . As one respondent (R39) remarked “Bathroom deodorizers are sometimes good cues.” Audible pedestrian signals, echoes from buildings and other objects, and landmark sounds  help travelers with visual impairment orient and navigate public spaces. These were illustrated in the follow two quotes.Smell associated with places can assist orientation, and verify one’s location or travel path, as it creates a distinct landmark for a particular area . For example, loud noise, if close to the individual with visual impairment, is problematic because it is likely to mask desired useful sensory (audible) information. However, if the loud noise is far away, it can serve as a directional sound for orientation. In the same vein, quiet sounds (like modern hybrid cars), if close to the individual with visual impairment, may be dangerous, as these sounds cannot be easily heard. Whilst quiet sounds are of little importance if they are far away. These were illustrated by the following two quotes.Respondents also argued that the effect of sensory cues in public space depended on the characteristics of the sensory input , the proximity to the sensory cues, the residual vision of the person (as one respondent (R1) noted that “…depending on the eye condition of the individuals, bright light helps some people and even dull lighting helps others.”), and the type and nature of the activities  but if far are important. …quiet sounds (if close and for example a car) are very problematic as they cannot be easily heard—but would be of little importance if far away...Understanding the dynamic interplay of real world factors that influence use of public spaces by people with visual impairment is essential to facilitate full participation by this population. Shedding light on the role that sensory cues play in the experience for people with visual impairment, will advance understanding of the association between people with vision loss, spaces and levels of participation. People with visual impairment rely on a personal and unique combination of sensory inputs to produce an organized and meaningful understanding and awareness of the spatial experience of public spaces. Congruence between the information processing of people with vision loss and sensory cues in the environment are needed if they are to be successful in using places and spaces. If these sensory signals are effectively comprehended, they will allow the individual to understand and use that space to promote participation and activity ,18. If tOccupational therapy is the pivotal profession in the rehabilitation and habilitation of people with visual impairment and blindness ,34. AcknFindings from this qualitative analysis also provide several tangible ideas for architects, designers, planners, as well as policy makers/legislators, to consider when incorporating functional sensory cues in the design process of public space that are user-friendly to this population. The goal is to provide people with visual impairment with accurate orientation, safe mobility travel and wayfinding, and to support their participation in activities and services present in public space.For outdoor spaces, more attention should be paid to sound and surface texture for safe street crossings, which includes installation of accessible pedestrian signals at traffic light intersections and vehicle detection devices, especially for quiet running hybrid vehicles. In addition, installation of tactile ground surface indicators (such as truncated domes) to assist wayfinding and provide warning of upcoming dangers , changes in traffic direction , and integration of appropriate landmarks cues for inclines, declines, turns, curves, and even suitable placement of street furniture are recommended.For indoor spaces, information sources about the building should be available in auditory and/or tactile format, such as tactile maps with auditory feedback or labeled with braille, for topographical location. Directional signage should be large with bright lettering as effective orientation cues. Consistent, well-lit, non-florescent lighting, without glare, and high luminance for contrast are important. Reduction of non-directional background noise and echo reverberation generated by ventilation fans and machines can be achieved by having acoustic tiles on the ceiling and other soft items on the walls. Strategic placement of certain sound emitting objects, such as fountains, which provide landmark sounds and directional information about the layout of an interior space, are recommended. Using contrasting textures to define different areas, and unique textures for landmarks are important. Floor surface materials that provide distinct tactile and auditory feedback for cane tapping is critical for accurate traveling. Airflow inside the building and control of air quality and temperature  can assist with orientation and travel direction.In the end, the key is to generate a balance of salient sensory cues in the built environment. It may not be feasible, for example, to have different floor surfaces or an announcement at every entry of each facility or store to tell people where they are and at every location while they are in a building. However, within the public domain there can be compromises achieved between forcing issues to accommodate certain populations, a strategy that itself may create stigma, discrimination, and alienation, and designing public spaces to be engaging and welcoming to a broad spectrum of possible users.The underlying philosophy of universal design on the form and function of public space may hold the solution ,36. UnivAs one respondent from the state of Florida succinctly summarized “If parks and paths had some audible cues to let the blind person know when they had strayed away from the path BEFORE the inevitable fall at the drop-off point, we could go to the park on our own. If city planners included the use of talk to speech technology like iPhones, we could cross the streets safely and enjoy a greater measure of freedom. When the “silent” cars all make the same sound to warn the blind of their presence, we will be safe on our streets just like you are. When all of the appliances in an office or home have speech functionality along with the lcd  displays in use today, we will be able to hold jobs and operate equipment just like you.”Using a thorough ergonomic work analysis assessment in work situations, occupational therapists can provide tailored interventions for clients with visual impairment to meet the physical and social demands of the workstation. Interventions may include adjusting and rearranging the work-based environment, providing specialized assistive technology devices that enhance and/or substitute vision to access work-related information or the work environment, and teaching the client to use compensatory strategies for job/task specific duties ,42.However, beyond the structural modification and design of the built environment, awareness and public attitudes towards people with disabilities, including those with visual impairment, need to be considered ,43. The Several strengths of this study are worthwhile for highlighting. First, a unique sampling strategy was used to recruit participants with visual impairment. Capitalizing on the membership database of the state’s chapters and associations of the National Federation of the Blind, we were able to recruit participants with visual impairment from 34 states in the US. Second, an investigator triangulation approach was used in cross-checking and verifying the interpretation of the data . InvestiEven though responses of this survey came from 34 states in the US, of diverse geographic regions, we did not know how representative our data are. The results may be skewed as we only recruited people with visual impairment who have access to technology. Further studies should validate the findings by including people with visual impairment who do not use technology. Finally, we did not collect any social characteristics and information on the severity of visual impairment of the respondents. As a result, we did not know how each category of social characteristics and severity of visual impairment may shape the multisensory experience of the respondents. A purposive sampling of people with visual impairment from orientation and mobility training services and low vision clinics, with specific residual visual condition, diagnostic group, and socio-demographic background can enrich the trustworthiness of the findings.Based on the qualitative synthesis of the participants’ responses, it was concluded that experience of multisensory environments from the perspective of people with visual impairment are not just supportive or inhibiting to their activity participation and engagement, but are also context-dependent. Context-dependence may encompass characteristics and proximity of the sensory cues, type and nature of the activities, and the residual vision of the person. Suggestions for architects, designers, planners, and policy makers/legislators to adopt the principles of universal design on form and function when designing indoor and outdoor public spaces were provided so as to increase accessibility in the use of public spaces by all possible users, including people with visual impairment. Findings from this qualitative analysis also provided occupational therapy practitioners an in-depth understanding of the transactional relationship of embedded sensory characteristics in built environment, occupations, and people with visual impairment to make appropriate modifications or removal of barriers that affect occupational performance and engagement.


Despite significant investments in health systems research (HSR) capacity development, there is a dearth of information regarding how to assess HSR capacity. An alliance of schools of public health (SPHs) in East and Central Africa developed a tool for the self-assessment of HSR capacity with the aim of producing institutional capacity development plans.Between June and November 2011, seven SPHs across the Democratic Republic of Congo, Ethiopia, Kenya, Rwanda, Tanzania, and Uganda implemented this co-created tool. The objectives of the institutional assessments were to assess existing capacities for HSR and to develop capacity development plans to address prioritized gaps. A mixed-method approach was employed consisting of document analysis, self-assessment questionnaires, in-depth interviews, and institutional dialogues aimed at capturing individual perceptions of institutional leadership, collective HSR skills, knowledge translation, and faculty incentives to engage in HSR. Implementation strategies for the capacity assessment varied across the SPHs. This paper reports findings from semi-structured interviews with focal persons from each SPH, to reflect on the process used at each SPH to execute the institutional assessments as well as the perceived strengths and weaknesses of the assessment process.The assessment tool was robust enough to be utilized in its entirety across all seven SPHs resulting in a thorough HSR capacity assessment and a capacity development plan for each SPH. Successful implementation of the capacity assessment exercises depended on four factors: (i) support from senior leadership and collaborators, (ii) a common understanding of HSR, (iii) adequate human and financial resources for the exercise, and (iv) availability of data. Methods of extracting information from the results of the assessments, however, were tailored to the unique objectives of each SPH.This institutional HSR capacity assessment tool and the process for its utilization may be valuable for any SPH. The self-assessments, as well as interviews with external stakeholders, provided diverse sources of input and galvanized interest around HSR at multiple levels. Since the early 2000s there has been increasing recognition of and support for health systems research (HSR) as a means to strengthen health policies, programs, and practices in low- and middle-income countries ,2. It isDespite significant investments in research capacity development by agencies ,6 such aThis paper reports on an initiative supported by the Future Health Systems consortium  through a) Jimma University College of Public Health and Medical Sciences (CPHMS), Ethiopia;b) Kinshasa School of Public Health, (KSPH), Democratic Republic of the Congo (DRC);c) Makerere University College of Health Sciences School of Public Health (MakSPH), Uganda;d) Moi University School of Public Health (MUSOPH), Kenya;e) Muhimbili School of Public Health and Social Sciences (MUSPHSS), Tanzania;f) National University of Rwanda School of Public Health (NURSPH), Rwanda;g) University of Nairobi School of Public Health (SPHUoN), Kenya.Brief details about each of the seven schools are listed in Table As the aim of the assessment was primarily to identify where capacity development investments in HSR would have the greatest impact, a narrow focus on outputs was inappropriate. Our review of the literature found only one other published paper that shared a similar objective, employing a capacity assessment tool that combined both quantitative and qualitative elements, to help strengthen and shape a capacity development intervention; however, the study was focused on a single training intervention and did not concern HSR . Since tPast initiatives in sub-Saharan Africa have focused primarily on identifying and enhancing individual competencies -22, but The main objectives for the capacity assessment process were the following.• Through a process of self assessment, develop a clear picture of existing capacities for HSR at the HEALTH Alliance SPHs.• For each SPH, draft and build consensus around HSR capacity development strategies and work plans for implementing them.• Make an initial and rapid assessment of HSR priorities in the different countries involved in the HEALTH Alliance, in part as a means to strengthen links to the policymaking and decision-making community.While the primary purpose of the assessment was not to provide a “baseline” against which changes in capacity could be assessed, some of the indicators captured may be feasible to use in this way. Findings from the self-assessments are reported separately -27. ThisThe following section presents the self-assessment tool in more detail. We then briefly describe the methods used to review and reflect on experience with the self-assessment tool. The findings section presents (i) the actual capacity assessment process and how it varied across countries, (ii) the key outcomes of the assessment, and (iii) the factors that affected the assessment process.The overall structure of the tool was derived primarily from an instrument that IDRC uses to assess the organizational capacity needs of its partner research organizations , but witA first draft of the capacity assessment tool was developed by Johns Hopkins University (JHU) in early 2011. The Deans of the SPHs identified focal persons (FPs) to lead the initiative, and this group together with JHU colleagues met at a workshop in Uganda in June 2011, where the tool was revised and adapted to meet local needs. The tool consisted of three components described below, designed to provide both internal and external perspectives, as well as subjective and objective information on capacity. The majority of amendments made during the June 2011 workshop were in the order, phrasing, and clarification of the questions. The necessity for ethics approval was discussed across the FPs with a final conclusion that all SPHs will seek clearance from their institutional Ethics Review Committees. KSPH colleagues translated the tool into French for use in the DRC. The final version of the HSR capacity assessment tool is as a separate document , research support, and inter-institutional linkages. There were multiple items regarding capacity under each of these headings, and respondents used a 5-point Likert scale  to indicate the extent to which they agreed with each statement. The data was captured on paper and transferred to electronic Microsoft Excel format. Average scores per item were calculated as described elsewhere  in June 2011. Other times, HSR published papers were used as examples.” “once everyone in the institution knew what was happening, they were responsive. But those who weren’t informed from the onset, they thought they weren’t part of the initiative and didn’t take time to respond.”The lack of understanding of HSR in general affected the number of respondents, many of whom did not classify their own research as HSR and therefore deemed their participation unnecessary. Initial high levels of interest by faculty to participate in the assessment waned quickly resulting in FPs having to first determine why participation rates were low. At MUSOPH, Kenya, the FP approached each faculty member in his or her office to better understand the lack of interest. The purpose seemed unclear and length of the tool seemed to be overwhelming, thereby serving as deterrents. In the case of NURSPH, Rwanda, the FP explained that “Once the reasons for low participation were determined, FPs explored innovative ways to encourage engagement. At KSPH, DRC, the FPs, with support from the Vice Dean of the School of Medicine, invited all senior and junior staff of the SPH to attend a journal club about HSR in advance of the self-assessment. At SPHUoN, Kenya, and MUSOPH, Kenya, the FPs had a sensitization session with department heads and board members during their strategic meetings. Informing staff that the assessment was the first step in a longer process in which capacity development plans were the ultimate aim was key to assuring them that their input was valuable and would lead to change.Perhaps the most-cited challenges were those regarding time and human resources. Although all teams met in June 2011 and agreed on a protocol, the time it took to receive institutional review board approval as well as contact all necessary key informants within the following 3 months proved overly optimistic. Furthermore, according to FPs at SPHUoN, Kenya, and MUSPHSS, Tanzania, the inclusion of extra team members to assist with the roll out also provided an opportunity to mentor junior faculty and students. Financial support was in the range of $7,000 per school and all SPHs felt that the budget was sufficient for such an exercise.The problem isn’t the number of interviewers; it is the availability of data and people to interview! If people don’t have time, or the data doesn’t exist – there is nothing that can be done, regardless of how many interviewers there are!” Each team, however, found a strategy that proved effective.All schools were able to access digital recorders either by borrowing or buying them for the purposes of the assessment. In cases where key informants refused to be taped, extensive notes were taken to ensure that the necessary information was still captured. Key informants were sometimes located far away, so scheduling and keeping appointments proved challenging at times. As articulated by the MUSPHSS, Tanzania, FP, “When I finally decided to just go to the [external stakeholder] offices and ask for 5 minutes of their time, I often received 30 minutes to an hour of discussion because they were interested. So it is negative that they didn’t appear to value academia when solicited by an email or call, but positive when they actually had a chance to engage in dialog.” “In the case of Kenya and DRC, many external persons completed the HSR priority setting exercise via email rather than through face-to-face interviews due to complex travel schedules or being located elsewhere in the country. These two contexts also permitted the teams to leverage existing networks and opportunities to access key informants as described below:A web forum [of external stakeholders] in Congo [DRC] exists. Parts of the questions of the interview were sent to the forum and five responses came this way. Others were met individually after phoning them.” “University of Nairobi is currently working on a curriculum for a Masters in Leadership and Health Services management. There was stakeholders workshop for these discussions and so I took advantage of that and managed all key informant interviews [for HSR priority setting] in one day.” “Acquiring all of the necessary information for the institutional profile was difficult. For instance, garnering financial data relevant to grants and research at the university was frustrating due to fragmented accountability structures and aggregated accounting systems.We had to meet with the project office and dig up data. We also sent a form to the principal investigators if they would be able to provide info on each of their research projects but this was difficult.” “Documenting research outputs was cumbersome for two reasons. First, HSR was poorly understood and so faculty did not list publications that should be classified as HSR. Second, there were difficulties in locating other types of non-peer reviewed research outputs. In the case of CPHMS, Ethiopia, all research outputs were tabulated so as to ensure wide capture and to avoid missing HSR-relevant outputs. MakSPH, Uganda, had similar challenges:We have a list of dissertations and went through each of them to tease out which are related to HSR. With respect to publications, we had to actually read much of the article to know if it was HSR and fit within the definition agreed upon during the June 2011 Uganda meetings. [We also] looked at courses that the faculty coordinate to determine if the individuals are HSR faculty.” “FPs suggested the need to find a better way of classifying, archiving, and referencing research outputs. Short of creating a resource center, the FP at MUSOPH, Kenya, suggested that screening and analyzing research publications routinely submitted to the Dean’s office every year would be more efficient and reliable than requesting abstract submissions from each faculty researcher, as they did during this assessment. Similarly the FP at SPHUoN, Kenya, expressed that having access to the quarterly updates submitted by faculty to the Director of the SPH could have enhanced capture and documentation of outputs.In this section, we describe what transpired in each of the SPHs as a consequence of conducting the capacity assessment. Capturing the strengths, weaknesses, challenges, and opportunities of HSR in each SPH served as a useful basis for enhancing institutional strategic plans. As mentioned by the FP at KSPH, DRC, the assessment provided the justification for investment in capacity strengthening in each SPH and culminated in the creation of a capacity development plan for each SPH.The school had no policies or guidelines on human resource development and so these have been recognized. Insufficient persons with qualitative research skills emerged from the assessment as well. Absence of an HSR agenda in the school was highlighted. Also, people realized that we at the SPH do not communicate very well. We do not (seem to) care about media. Knowledge translation need and capacity was low. It was a concept that was new and unrealized so it has become an area that KSPH is now paying more attention to.” “The exercise also highlighted that HSR is embedded across multiple classes and courses, rather than having an identity in its own right. This may be problematic for students seeking to build HSR skills as they struggle to identify the right classes to take, as well as potentially undermining a systematic approach to teaching HSR.Methods for HSR are different than Epidemiology and Biostatistics. It would be good to know from beginning about the differences – especially in the dissertations so that the right resources can be used to inform the student research.” “Although the primary goal of the initiative was to conduct an assessment that would inform each SPH of its individual capacity to conduct HSR, all seven SPHs mentioned additional outcomes. For instance, discussions around the assessment raised the profile of HSR. These provided NURSPH, Rwanda, with a better sense of the range of research studies currently underway and where each falls in the HSR spectrum. MUSPHSS, Tanzania’s FP echoed this point by stressing that definitions of terms were not enough and that awareness raising and discussion were critical to ensuring a common understanding of HSR.A notable outcome was that the assessment results and the outreach to external stakeholders provided insight about policy-relevant research agendas. Discussions with key informants seem to have increased the profile of some of the SPHs within their own countries. For instance, the lead role that KSPH, DRC, played in convening an HSR priority setting exercise led to renewed interest in involving KSPH, DRC, in healthcare reform in the DRC. Similarly, at CPHMS, Ethiopia, results of the assessment led the university’s Academic Commission to set up a new task force in early 2012 to investigate the reasons behind the low levels of research at the university and propose solutions. Moreover, the FP for the organizational assessment at CPHMS, Ethiopia, was asked to serve on this task force. The task force was subsequently supported by the establishment of a HSR team in September 2012. Exposure to external stakeholders such as colleagues at WHO and at the MOH was mentioned as another important outcome for the CPHMS, Ethiopia, team.Last but not least, the exercise created a sense of collegiality amongst the seven schools that galvanized collective action for shared interests. For instance CPHMS, Ethiopia, initiated a workshop with JHU on HSR methods training for all partners; MUSOPH, Kenya, took the lead on creating a new course on HSR for all the partners and spearheaded the crafting of grant proposals for funding agencies; and all FPs united in the publication of several manuscripts showcasing the results of the capacity assessments -27.The multidisciplinary nature of HSR inevitably proffers multiple interpretations of what it encompasses. Associated with this nebulous understanding is confusion about the types of individual skills and institutional structures needed to support HSR. While such problems have been recognized previously ,32, and Experiences across the seven schools suggest that it would be prudent to allocate approximately 6 months to a project such as this and target a period in the year when faculty and leadership have time to dedicate to the initiative. With the volume of information that needs to be collected as well as the skills and time needed for the various steps of the assessment, it would be necessary to enlist the assistance of 3 to 5 persons in addition to the FPs, depending on the size of the SPH.. Although access to key external stakeholders led to positive outcomes in several cases, the purpose of setting a research agenda was not wholly fulfilled. Alternative strategies for stakeholder engagement need to be explored, perhaps through more deliberative dialogues [When implementing an assessment across schools or even across departments, the importance of collective creation, consultation, and acceptance of the tools cannot be overemphasized. As was demonstrated in the study described in this paper and elsewhere ,25-27,33ialogues .From an analysis of the process of executing HSR institutional capacity assessments across these seven SPHs, it would appear that four factors play a critical role: leadership support, a conceptual understanding of HSR, adequate resources, and data availability.An ex post facto reflection such as this allows institutions to learn from the experiences of others. However, reliance on FPs as being the sole source of these reflections subjects the interpretations to response bias. Furthermore, the process evaluation occurred four months after the completion of the organizational capacity assessments and therefore may also suffer from recall bias. Given the collaborative nature of the project and the willingness to learn from the experiences of each of the SPHs, we expect that there is little incentive for FPs to skew their responses. Nevertheless, it may have been interesting to conduct interviews with other members of the assessment team, select respondents, and the Dean. Clearly, this paper has not sought to validate the items used in the self-assessment questionnaire or assess their reliability: our focus was principally on understanding the processes and consequences of implementing the capacity assessment tool. The sample size at each participating SPH in our study was too small for any rigorous assessment of validity or reliability, but future studies with larger samples could usefully contribute to this.The HSR capacity assessments permitted various aspects of capacity at the SPHs to be explored and analyzed. The intent was to roll out a self-led process for capacity assessment in order to devise HSR capacity development strategies for the SPHs and identify where capacity development investments would have the greatest impact. The assessments led to a number of notable outcomes. First, the exercise galvanized interest in HSR among faculty and leadership across all seven SPHs. Second, the assessment was critical in the development of new capacity development plans for each of the SPHs. Third, it spurred action for implementing joint activities such as course development, organizational activities such as local awareness raising, and individual activities such as training in HSR. In addition, the SPHs are independently and collectively seeking funding for the various aspects of their capacity development plans. Fourth, the assessment stimulated the involvement and interest of key external stakeholders in collaborating with the SPHs. The tool  has therefore demonstrated utility for generating much more than just an assessment of SPH capacity. It provides data that can be analyzed in a variety of ways ,25-27 yiIn addition to raising the profile of HSR in each SPH and among that country’s healthcare leadership, an assessment such as this inevitably raises expectations about the next steps. The gaps identified through such a process often require strategic policy and practice changes that are seldom overcome without financial investments. Without the financial and human resources to accompany recommended changes, any momentum gained from galvanizing staff motivation could diminish quickly. This leads one to wonder, what is the best way to plan for capacity development in tandem with resource mobilization with a goal of promoting organizational performance enhancement?CPHMS: Jimma University College of Public Health and Medical Sciences, Ethiopia; CHSRF: Canadian Health Service Research Foundation; FP: Focal person; HEALTH Alliance: Higher Education Alliance for Leadership Through Health; HSR: Health systems research; IDRC: International Development Research Centre, Canada; JHU: Johns Hopkins University, USA; KSPH: Kinshasa School of Public Health, Democratic Republic of Congo; MakSPH: Makerere University College of Health Sciences School of Public Health, Uganda; MUSOPH: Moi University School of Public Health, Kenya; MUSPHSS: Muhimbili School of Public Health and Social Sciences, Tanzania; NURSPH: National University of Rwanda School of Public Health, Rwanda; SPH: School of public health; SPHUoN: University of Nairobi School of Public Health, Kenya.The authors declare that they have no competing interests.All four authors were closely involved in supporting the implementation of the self-assessment tool. SB designed the first draft of the tool. NJ, DL, and EE conducted the first workshop with representatives from the different SPHs where the tool was adapted to meet local needs (June 2011). NJ revised and finalized the tool upon user feedback. All four authors then participated in the analysis and dissemination workshop (December 2011), and reviewed the individual self-assessment reports. NJ and DL conducted semi-structured interviews with all seven of the lead faculty in the different SPHs to document the implementation process in each country. All authors read and approved the final manuscript.SB is CEO of the Future Health Systems (FHS) research programme consortium. DL and NJ worked with FHS from Johns Hopkins University, and EE leads the Uganda FHS team.Health Systems Research in the HEALTH Alliance Schools of Public Health: capacity development and collaborative research: Health Systems Research Capacity Assessment. This additional file contains the complete set of assessment tools that were used by the seven schools of public health that are members of the HEALTH Alliance.Click here for file


Human mobility has been traditionally studied using surveys that deliver snapshots of population displacement patterns. The growing accessibility to ICT information from portable digital media has recently opened the possibility of exploring human behavior at high spatio-temporal resolutions. Mobile phone records, geolocated tweets, check-ins from Foursquare or geotagged photos, have contributed to this purpose at different scales, from cities to countries, in different world areas. Many previous works lacked, however, details on the individuals’ attributes such as age or gender. In this work, we analyze credit-card records from Barcelona and Madrid and by examining the geolocated credit-card transactions of individuals living in the two provinces, we find that the mobility patterns vary according to gender, age and occupation. Differences in distance traveled and travel purpose are observed between younger and older people, but, curiously, either between males and females of similar age. While mobility displays some generic features, here we show that sociodemographic characteristics play a relevant role and must be taken into account for mobility and epidemiological modelization. Everyday, billions of individuals generate a large volume of geolocated data by using their mobile phone, GPS, public transport cards or credit cards. Such a vast amount of data is bringing new opportunities for the research in socio-technical systems12456781112131419Beyond mere location, some datasets offer the opportunity to gather extra information about the type and duration of the interaction or the operation through ICT tools. For instance, it is possible to know from mobile phone records where and when an individual makes a call, but sometimes information such as the ID of the callee and the call duration are also available. This information enables researchers to move further on the study of human behavior by analyzing the structure, intensity and spatial properties of social interactions. Some examples include the analysis of the structure of social networks212223242526282926However, many previous studies lack sociodemographic resolution on the characteristics of the individuals. Except for some features such as language or place of work and/or residence identified in Refs. 434353637383940414243444546484950515253Some works based on smaller-scale surveys point out towards a number of significant differences between men and women in terms of their travel purposes and the activities they pursue555658Our dataset comes from an extraction of the Banco Bilbao Vizcaya Argentaria (BBVA) database on credit card transactions. Different extractions of this data have been used in open data challengesThe geographical extent of our data is restricted to the provinces of Barcelona and Madrid. For both case studies, we only consider the credit card payments made in the province by individuals living in the province . Table 1The statistical features of the data for Barcelona and Madrid are very similar. Therefore, the data is aggregated for analyzing general properties in the next two sections and segregated later in the third one to study mobility patterns. The aggregation provides higher statistical power, while the disaggregation is needed due to the different geographical shapes of both provinces. Due to the optimization of space, only figures obtained for Madrid are displayed in the third section on mobility. Still equivalent results for Barcelona are found and can be seen in the Supporting Information .In order to have a first look at the data, we plot in To highlight differences between individuals having different sociodemographic characteristics, we also plot on To investigate the influence of sociodemographics on the way people spend their money, we plot on Since the proportion of individuals according to the occupation is different for men and women, and in order to take away potential bias, we have studied the average fraction of money spent by an individual according to the business category and his/her sociodemographic characteristics but only for employed individuals. We reach the same conclusions as for the overall sample, see Fig. S7 in Supporting Information.To study how the amount of money spent by BBVA customers changes over time during an average week, the days of the week have been divided into four groups: one, from Monday to Thursday representing a normal working day  distance between men and women’s computed . The KolFirst, we observe that a significant difference between men and women appears whatever the sociodemographic characteristic of the population is filtered out  travel shorter distances and their trajectory stays closer to their center of mass than individuals of the second groups .Among all the differences emphasized in this paper the one between men and women is the most difficult to explain. In all the comparisons we have carefully checked that this difference was not related to other sociodemographic variables and it was not the case. It could be interesting to verify whether this difference is related to other social characteristics such as the number of children for example. Indeed, the fact that the difference in terms of mobility patterns between men and women is less pronounced for old people and students may reflect that women with children move differently than women without children. While further data is required to assess whether these differences between individuals are universal, i.e., to which extend they are specific or not to urban areas or the cities of the country analyzed, our results point toward the possibility that mobility may display significant differences for different types of individuals.M.L. coordinated the study, designed the study, analysed the data and wrote the manuscript; T.L. and M.S.M. coordinated the study and wrote the manuscript; O.G.C., M.P., R.H. and M.B. coordinated the study; J.M.A. obtained the data and coordinated the study; J.J.R. coordinated the study, designed the study and wrote the manuscript. All authors read, comments and approved the final version of the manuscript.How to cite this article: Lenormand, M. et al. Influence of sociodemographics on human mobility. Sci. Rep.5, 10075; doi: 10.1038/srep10075 (2015).


Development of the comprehensive care plan (CCP) is a requirement for nursing homes participating in the federal Medicare and Medicaid programs, referred to as skilled nursing facilities. The plan must be developed within the context of the comprehensive interdisciplinary assessment framework—the Resident Assessment Instrument (RAI). Consistent compliance with this requirement has been difficult to achieve. To improve the quality of CCP development within this framework, an increased understanding of complex factors contributing to inconsistent compliance is required. In this commentary, we examine the history of the comprehensive care plan; its development within the RAI framework; linkages between the RAI and registered nurse staffing; empirical evidence of the CCP’s efficacy; and the limitations of extant standards of practices in CCP development. Because of the registered nurse’s educational preparation, professional practice standards, and licensure obligations, the essential contributions of professional nurses in CCP development are emphasized. Recommendations for evidence-based micro and macro level practice changes with the potential to improve the quality of CCP development and regulatory compliance are presented. Suggestions for future research are given. The Centers for Medicare and Medicaid Services (CMS) is the federal agency responsible for issuing regulatory requirements for nursing homes (NHs) participating in the federal Medicare and Medicaid NH programs, referred to as skilled nursing facilities (SNFs) . The comCMS has defined the CCP as the essential communication tool to be used by the interdisciplinary team to provide coordinated services. The overall care plan orientation recommended by CMS is displayed in In spite of the declarations of CCP’s essential functions by CMS, consistent CCP development has been difficult to achieve. For example, researchers reported that over the seven year period of 1994 to 2000, 17% to 29% of citation deficiencies for substandard care targeted non-compliances with use of CCPs . Two OffComplex factors have influenced how standards of practice for CCP development have evolved. In this commentary, we examine these factors. They include: the history of the comprehensive care plan; its development within the RAI framework; linkages between the RAI and registered nurse (RN) staffing; empirical evidence of the CCP’s efficacy; and limitations of extant standards of practice used in CCP development. Because of the registered nurse’s educational preparation, professional practice standards, and licensure obligations, the essential contributions of professional nurses in CCP development are emphasized . RecommeThe care plan document played seminal roles in nursing’s advancement as an applied science, the development of nursing curricula, and implementation of the federal SNF programs . A detaiThe nursing care plan was invented in the early 1900s by nursing faculty and used as a didactic technique. Its purpose was to teach nursing students cognitive and behavioral skills required to provide holistic and individualized care to hospital patients . The carnursing skill mix [Following World War II, the nation experienced a nursing shortage. It became possible for individuals to earn nursing licenses or certifications through a variety of educational programs. This resulted in a nursing staff that had diverse licensures and educational backgrounds. The resulting mixture of different types of nursing staff was referred to as an institution’s kill mix . Becausekill mix . For exanursing process was codified as the unique domain of RNs. Dr. Ida Orlando, a prominent nursing researcher, defined the nursing process as: assessment, definition of problem, planning, implementation, and evaluation of care [In the late 1950s, clinical problem solving referred to as the  of care . Her def of care . RN comp of care ,14,15,16 of care ,8.The discipline has moved beyond its singular focus on the nursing process to describe the work of the RN. RN practice is conceptualized as dynamic; it requires the RN to think critically and made clinical decisions based on empirical evidence and the preferences of the patient . HoweverImproving the Quality of Care in Nursing Homes [Since the establishment of the SNF conditions of participation in the Medicare and Medicaid NH program, concerns were expressed about the quality of care provided in SNFs. In response, recommendations for structural and process changes in the federal government’s oversight of SNFs were published in the Institute of Medicine (IOM)’s report—ng Homes . A key rng Homes . The nurDescriptions of the development and evolution of the MDS related to studying the reliability and validity of MDS-derived data are available ,19. WhilSince the electronic transmission of MDS data was mandated by 2002, CMS used its technical capacity to develop quality indicators (QI) and quality measures (QM) for use in enforcement and quality improvement efforts ,25. The Researchers have used MDS data for studies in both the United States and internationally. The MDS has been translated into 11 languages  and used in various ways in Italy, United Kingdom (UK), Japan, Iceland, Switzerland, and Czech Republic) ,29,30,31As this brief history demonstrates, the RAI framework is complex and dynamic. Future changes to the RAI are anticipated in response to implementation of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. New and streamlined quality measures for SNFs, home health agencies, and other post-acute providers participating in Medicare will be developed. Referred to as Standardization Resident Patient Assessment Data, this new database will enable CMS to compare quality across post-acute care settings, improve hospital and post-acute discharge planning, and to reform post-acute care payments .After studying the history of the CCP, we conducted a “scoping literature review” to determine the amount and type of research studies and grey literature published on CCPs developed within the RAI framework. Our inclusion criteria were grey literature and research studies published in English between 1997 and 2014 and conducted in the United States or other countries that used the RAI framework. Key words included: skilled nursing facility, nursing care plan, RN practice, care planning, RAI, MDS, nursing process, nursing home, teamwork, interdisciplinary care, and comprehensive care plans. The search excluded advanced care planning related to end-of-life decision making in health care because of the specialized nature of its focus.Study designs included systematic reviews, randomized clinical trials, quasi-experimental, descriptive, cross-sectional, qualitative, mixed methods, case studies, and program evaluations. The quality of the studies was not assessed, as would be done in a systematic review. Our sole purpose was to establish a baseline summary of studies that examined development and or use of the CCP within the RAI framework. The findings were used to provide support for recommendations made in this commentary and as background for a systematic review. Findings are summarized in Four systematic reviews on care plans and interdisciplinary interventions in NHs were found. They did not include quantitative analyses of study findings included in the review, as is currently done in systematic reviews. Moloney (1999) conducted a systematic review of studies that focus on the existence of a relationship between care planning and record keeping in nursing and patient outcomes . MoloneyPatient Safety and Quality: An Evidence-Based Handbook for Nurses (2008), Keenan, Yakel, Tschannen, and Mandeville (2008) reported findings of a systematic review of studies on nursing documentation, care plans, and ICPs used in acute and long term care settings that were published between 1997 and 2006 [In and 2006 . The autGiven the importance of interdisciplinary team work in the SNF, and the lack of rigor reported in earlier systematic reviews, Nazir’s (2013) systematic review of randomized controlled trials of interdisciplinary interventions was noteworthy . Using fAs the findings of the systematic reviews suggest, development of the interdisciplinary care plan and or the CCP involves complex interrelated processes, each of which has unique characteristics. i.e., structural, process, or outcome) measured. Studies that used mixed methods are indicated by shaded rows.Twenty-four studies related to care plans and interdisciplinary teams within the RAI framework were reviewed. The methods used include: quantitative  and qualThe CCP document itself has been used as a structural measure of compliance. Hawes and colleagues (1997) found evidence of more comprehensive  ICPs developed within the RAI framework . They reNursing Facility Assessments and Care Plans for Residents Receiving Atypical Antipsychotic Drugs (2012), analysts found that 99% of randomly sampled records did not comply with federal resident assessment and/or care plan requirements [Skilled Nursing Facilities Often Fail to Meet Care Planning and Discharge Planning Requirements (2013), researchers found that 37% of NH stays lacked documentation of care plans based on a stratified simple random sample of 2009 SNF medical records [In irements . In Skil records .Characteristics of processes measured included: use of physical restraints and indwelling urinary catheters; use of toileting programs for residents with bowel incontinence; rates functional decline, and good care practices , care co® Long Term Care Version [Findings provide support for a relationship between management practices and culture and CCP development and implementation. Interestingly, the practices that promote innovative and valued CCP development are also those that promote effective team work, safe work cultures ,59,60, a Version .versus the control group [Several outcomes were measured to assess efficacy of the RAI framework on clinical outcomes. Hawes and colleagues (1997) found increased resident participation in activities and use of advanced directives, after controlling for differences in resident characteristics between 1990 and 1993 . The gapol group . In a raol group  significol group .Every SNF must develop a CCP within the RAI framework. The CCP document is either hand-written or electronically produced using MDS-related software . As prevCMS provides standardized instructions for different components of the framework. Definition of terms, coding rules, and standardized timelines for acquisition and electronic transmission of MDS 3.0 data are provided in the Utilization Guidelines. For example, the prescribed decision-making process that determines the development of the CCP is contained within the CAAs. These are triggered when previously specified MDS 3.0 codes are selected for a resident. The interdisciplinary team members must then document underlying causes, contributing factors, and risk factors related to each CAA triggered, and explain why the resident issue was care planned or not. Documentation of this process is required; the format of this documentation is left to the SNF to determine .Much of what is considered the standard of practice for CCP development is reminiscent of the early nursing care plans used as didactic tools . The typSNFs that are participating in culture change activities are more likely to include direct care workers, such as nursing assistants, in care plan meetings . The assThe state of current practice cannot be described accurately without discussing the role of the RN MDS Coordinator. Federal regulation 483.20 (h) stipulates that “a RN must conduct or coordinate each assessment with the appropriate participation of health professionals.” We used Prasad and Ioannidis’ (2014) conceptual framework for de-implementation of a standard of practice to guide us in developing micro and macro level practice recommendations . They suThe CCP serves multiple purposes. It is used as a measure of regulatory compliance, a method of interdisciplinary communication and care coordination, and a repository of resident-specific care preferences, needs, and strengths. We recognize that there is a legitimate need for some type of CCP document. However, it is not practical or feasible to require the CCP to serve multiple purposes and necessarily reflect all interventions to be provided to a resident. For example, in an emergency, the competence of the SNF staff member, supported by existing policies and procedures, guides clinical behaviors. The clinical record is the document properly used to reflect the dynamic nature of services needed and used by the resident. Based on the findings of the scoping literature review, we recommend that the CCP’s purpose is realistically assessed, with an emphasis on operational implementation. As a standard of practice, the content of the CCP needs to be changed.The sole purpose of the CCP ought to be that it is the centralized document used to coordinate interdisciplinary care by focusing specifically on those resident preferences, needs, and strengths that need to be known by every team member. This information is to be used in tailoring services provided to the resident in a manner that compliments his unique needs, strengths, and preferences. . Therefore, there is little benefit in documenting approaches and treatments that are found in other components of the clinical record. Similarly, descriptions of standardized approaches to interventions are not useful. Such information is best communicated in the form of a policy and procedure. Excluding this content will help to decrease the length and complexity of the CCP and increase its utility and value. This practice has the potential to support a more efficient and effective use of RN and interdisciplinary team member time.The resident will benefit from a more tailored approach to CCP development. For example, he will have less need to repeat his preferences and particular needs to each staff person over time. Some resident specific information found in MDS 3.0 Manual Section F (Preferences for Customary Routine), could be included in the CCP, assuming that the preferences are actionable . The dirAs important as CCP development may be, the CCP that is produced needs to be viewed as one of the many ways in which information about residents is exchanged and care is coordinated. Examples of other informal and formal ways of exchanging information include morning team meetings, handovers , huddles, and naturally occurring information exchanges among SNF staff that may or may not warrant inclusion in the CCP for all to know . DevelopIf the CCP is developed using these recommendations regarding its purpose and content, it still will not add value to the resident’s experience if it is not integrated into routine practices. Innovative, resident-specific, and useful CCPs are more likely to be implemented in SNFs having organizational cultures in which communication is open, staff are respected and valued, teamwork skills are taught and supported, and punitive managerial practices are absent ,68. CreaImplementing the recommended revisions in the purpose and content of the CCP will require courage. This undertaking is likely to engender fear because of the SNF’s potential risk of being cited for non-compliance with the extant standard of care. Innovation is difficult to achieve in a highly regulated practice environment. One approach that could be used to minimize fears is to define efforts in CCP development and implementation that are not the broadly accepted standard of practice would be to frame efforts as a quality improvement project. This could easily be supported within the mandated Quality Assurance Performance Improvement (QAPI) requirement . Such anMacro-level recommendations address how the CCP development requirement is measured; how staff is educated; and how RN staffing influences CCP development, implementation, and achievement of desired outcomes. Less emphasis needs to be placed on the CCP as a measure of regulatory compliance. Instead, the CAA documentation could be used as a measure of compliance. The CAA should reflect the quality of the decision-making processes used by the interdisciplinary team to develop a CCP. It is already a component of the RAI framework . The reqWe recommend training of state surveyors in evaluating compliance with care plan development and the care plan document from an evidence-based perspective. The intent is to reduce the focus on inclusion of standardized interventions that are documented elsewhere in the clinical record. Instead the focus needs to shift away from CCP content to evaluation of the staff’s implementation of care as defined by the resident’s documented preferences, needs, and strengths. We recognize that this would be more challenging to do compared with the current approach to evaluating compliance with CCP development. The CCP is important because it is a means to an end rather than an end in itself.As previously noted, there is no requirement for RN MDS coordinator training or certification, such as that provided by the American Association of Nurse Assessment Coordination (AANAC) . This isThe mandatory level of RN staffing levels needs to be addressed given that the RN is the only healthcare professional working in a SNF that has been specifically educated and licensed to coordinate care using critical thinking and problem solving skills. A higher level of RN staffing and a higher ratio of RNs to other members of the nursing skill mix have been associated with achieving higher levels of specific quality indicators .CMS’ most recent proposal for federal NH regulatory changes does not include staffing or training requirements, including those of RNs and RN MDS nurses, except for nursing assistants and volunteers. Given this, we recommend that advocates continue their efforts to promote these changes by educating the public and SNF providers about the complex factors that influence the quality of SNF care, including CCP development, to facilitate adoption of our recommended changes.Further research is recommended to demonstrate the value-added by implementing revisions in the current standard of practice for CCP development, measurement of regulatory compliance, and surveyor and interdisciplinary team education. Little is known about how best to implement the RAI framework into the clinical routines of SNF staff. Further research on care plan development and operational implementation of the RAI process is needed to advance our understanding of how these practices add value to the resident’s and staff’s experiences. Studies that explore the relationship between SNF staff training in CCP development that is customized to the resident’s preferences, strengths, and needs, and the resident’s experience are needed.A qualitative and mixed methods approach to studying CCP development is recommended as they have been effectively used to examine the complex process of CCP development and implementation within the RAI framework. In particular, complexity science ,61, an aMultiple factors have affected the level of compliance with the regulatory requirement for CCP development within SNFs. The RAI framework was originally presented as a means of improving CCP development and implementation. Arguably, its primary purpose appears to be a standardized approach to data collection used for reimbursement, quality measurements, public reporting, and research. There is a need to refocus attention on the RAI framework’s use in CCP development and implementation. Empirical evidence provides support for revision of CCP development standards related to its purpose and content in an effort to add greater value to the resident’s experience because of development and implementation of the CCP. Timely consideration of these recommended changes in the existing standard of practice are needed because of the changed role of the SNF in the post-acute care continuum, the increased complexity of residents, and lack of improvement in federal standards for RN staffing. No federal requirements for RAI education among interdisciplinary team members and RN MDS coordinators have been made. In spite of these constraints, it is possible to redefine the standard of CCP development to produce a plan of care that is more likely to add value to the resident’s experience and quality of relationships with SNF staff.