Although play has been used as a means to meet therapeutic goals by health care practitioners for a long time, there is a need to continuously review its conceptualisation and use in everyday practice to promote evidence-based practice. This systematic review aimed to evaluate the evidence on how the play of children with Special Health Care Needs (SHCN) is similar or different to that of typically developing children.  Guided by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement, we conducted a comprehensive review across five electronic databases for all studies that compared how the play of children with SHCN was similar or different to that of typically developing children. Data were extracted from the included studies, and methodological quality was assessed.  Eighteen studies met eligibility criteria. All the studies in this review were at risk of bias due to the study design. There was great variation in sample sizes, ranging between five and 112 participants in the diagnostic groups and five and 546 participants in control groups . The included studies investigated different aspects of play, which made it difficult to synthesise. However, of the 18 studies reviewed, thirteen reported that children with SHCN engage in less play, compared with typically developing children.  Evidence supports the assumption that children with SHCN are less playful and spend less time engaging in play compared with typically developing children. This systematic review reveals paucity of research on play for children with several common chronic conditions such as HIV/AIDS, cancer, and cardiovascular diseases. Future studies need to reduce risks of bias, including the use of appropriate sample sizes, and must provide detailed results after investigating play in children with SHCN. Generally, there is an increase in children with Special Health Care Needs (SHCN) ; conseqDespite the great variability in terms of the types and severity of special healthcare needs, children with SHCN experience multiple health conditions, poorer reported health status, and reduced physical activity among other challenges . ChildrePlay-based interventions are part of the several approaches that have been utilised by healthcare professionals to address deficits experienced by children with SHCN . Play haEven though play has been used as both a medium for intervention and a therapeutic agent for a very long time , as a muThe conceptualisation of play has been drawn from many disciplines to describe play at different stages, with implications for both assessment and practice . AlthougIs the overall play profile of children with SHCN similar or different to that of typically developing children?Is the play duration of children with SHCN similar or different to that of typically developing children?Are the types and/or forms of play of children with SHCN similar or different to that of typically developing children?Is the play behaviours of children with SHCN similar or different to that of typically developing children?Despite play being spontaneous, children with SHCN are likely to experience difficulties in engaging and participating in play . RestricCRD42017072269). The systematic review addresses the research question: how is the play of children with SHCN similar or different to that of typically developing children?PRISMA was used to guide the methodology and transparent reporting of this systematic review . The PRIThe study population included children aged 11 years and younger with (1) specified SHCN such as HIV/AIDS, chronic respiratory conditions, cancer, and physical disabilities, such as cerebral palsy and spina bifida; and (2) behavioural and/or emotional disorders which are defined as disruptive impulsive conduct disorders and anxiety disorders according to the DSM 5. However, autism spectrum disorders were excluded from this study as a systematic review on play-based interventions for children with ASD was conducted by Kent et al. , and a rThe studies could be of any design provided play was compared between two groups of childrenAt least one of the comparison groups should be children diagnosed with specified special healthcare needs, compared against typically developing childrenAt least one of the outcome measures should be play; andArticles were published in English and in peer-reviewed journalsThe inclusion criteria for the studies were as follows:Studies that focused on caregivers and/or siblings of participants who meet eligibility criteriaData from presentations, conference proceedings, dissertations, and thesisStudies that reported on a play-based intervention but did not measure play as an outcomeStudies that investigated play in which video games and robotics are used. Play involving video games and robotics is structured and may not provide similar opportunities for social interaction, freedom to suspend reality and framing, and restricts the children to being creative outside the confines of the game/robotics. Moreover, as we were interested in understanding the play profiles of children with SHCN, the play context  needed to be consistent to allow for comparison across different population groupsStudies that used a psychoanalytical approach to play or so-called “play-therapy” approaches. According to , play thThe exclusion criteria were as follows:A systematic literature search was conducted across the following five databases: CINAHL, Embase, ERIC, PsycINFO, and PubMed. The searches were done between September 22 and December 10, 2018. Additionally, reference lists of included studies were searched by hand to ensure that all appropriate articles were included in the review. All search strategies per database are presented in Through consultations with an expert panel experienced in play research and/or measurement development, a data extraction form was developed based on the review question. Variables sought from the checklist included study setting, study population, participant demographics, diagnosis of participants, play/playfulness outcome measures used, and the methodological quality of the included studies. Data on the methodological quality of the studies were extracted and scored independently by reviewers who were not authors of any of the studies included in the review. Authors of the included studies were contacted if additional information was needed to answer questions with regard to eligibility.Assessment of methodological quality of the studies included was done using the Kmet Appraisal checklist, also referred to as “QualSyst” . The KmeA narrative-synthesis was selected to obtain meaningful interpretation of the findings of the included studies and to describe how play is similar or different in children with SHCN, children with behavioural and/or emotional disorders, and children with physical disabilities when compared with children who are typically developing.A total of 3,933 abstracts were retrieved. Eighteen studies published between 1990 and 2018 that compared play in children with SHCN against typically developing children were identified. Of these selected studies, four studies used a quasi-experimental study design –30, and All the studies in this review were at risk of bias due to study design. Twelve of the 18 studies used a cross-sectional study design, four used a quasi-experimental design, one used a longitudinal design, and another one used a multiple case study design. Of the 18 studies, five had small sample sizes of <30 participants, which limits the generalisability of the findings , 37, 42.The 18 studies included in this review had a total of 1,608 participants aged between 8 months and 13 years, with 67.5% being males. Despite adopting a broad search strategy to capture all chronic illness, only studies with the following diagnosis were found: 184 had ADHD, 125 had general developmental delays, 99 had developmental coordination disorder, 79 had cerebral palsy, 31 had cognitive and speech disorders, 15 had prenatal alcohol exposure, and 14 had Down syndrome.All studies reported that participants were observed either playing alone, with another child or with an adult; a summary is provided in Supplementary Tables Participants were observed playing either at home, school, or at a clinic. Seven of the 18 studies reported that participants were observed at school. Of these seven studies, three studies were conducted in the classroom , 31, 34,The observation time varied from 10 seconds to 60 minutes per session. Seven of the 18 studies observed each participant for between 15 and 20 minutes , 35, 39.Although all the studies reviewed involved observing children playing, different assessment tools were used. The Test of Playfulness  was usedOne study by Cairney et al.  used a pThe studies reviewed examined different aspects of play, which makes it difficult to synthesise the findings. However, for the purposes of comparing play patterns, findings were extracted and grouped into four themes: overall play, play duration, types of play, and play behaviours see . Of the Types of play were reported differently across all studies, and most were reported as frequency of occurrence of that type of play. Three of the five studies involving children with ADHD reported that children with ADHD engage less in social play as compared with typically developing children , 20, 42.In terms of play behaviours, only one of the five studies on ADHD , three oThis is the first systematic review to examine how the play profile of children with SHCN is similar or different to that of typically developing children. Although play can be used as a medium to assess children's development, the focus of this review was limited to studies that used play as both an outcome and a medium for intervention for children with SHCN within naturalistic contexts and compared this to typically developing children. Play is a multidimensional and complex construct which is difficult to define . Thus, tAlthough the search strategy was broad to capture all types of conditions that require SHCN in children, the impact of SHCN on the play of children has only been investigated for the following conditions: ADHD, physical conditions , and developmental delays and other disabilities such as cognitive and speech disorders, Down syndrome, and prenatal alcohol disorders. By defining children with SHCN as children who have or are at risk of physical, developmental, behavioural, and emotional difficulties that require more health or related services as compared to typically developing children , this reThe main finding of this review is that sixteen of the eighteen studies reported that children diagnosed with SHCN are generally less playful when compared with typically developing children. This finding supports the notion that conditions requiring special health care in children influence a child's developmental trajectory, including play . Due to Studies reviewed reported play in a variety of ways, which makes it difficult to compare. However, the authors' synthesised the findings against the following four themes: overall playfulness, time engaging in play, types of play, and play behaviours. In terms of types of play, five of the 18 studies reported that children with special health care needs engaged in less social play as compared with typically developing children. Similarly, in a systematic review by Kossyvaki and Papoudi  on play Participants were observed playing in natural environments where they normally play, and these include the home, school, or at a clinic. The setting was important as research on play in children is best done through observations of children in their naturalistic environment . ChildreAlthough this systematic review gives direction on what research has been done, and points out gaps in areas that need more research focus, most of the studies used small sample sizes making it difficult to generalise the findings.There are a number of potential limitations of this study. Due to the heterogeneous nature of the studies and outcome measures, it was not possible to conduct a meta-analysis on the similarities and differences in the play of children with SHCN compared with typically developing children. Inclusion was limited to studies published in English only. Three of the authors in this review were also coauthors of three studies included. However, bias was minimised by asking two independent reviewers to screen and select studies to be included in this study. Most studies included in the review were at high risk of bias due to the study design, lack of randomisation, and inadequate blinding.Although play is viewed as a childhood occupation that is spontaneous , play in


Access to healthy food is considered a key determinant of dietary behavior, and there is mixed evidence that living near a supermarket is associated with a healthier diet. In Africa, supermarkets may contribute to the nutrition transition by offering both healthy and unhealthy foods and by replacing traditional food sellers. In Kisumu, Kenya, a planned hypermarket  will form the basis for a natural experimental evaluation.The aim of this study is to explore the impacts of a new hypermarket on food shopping practices, dietary behaviors, physical activity patterns, and body composition among local residents and to identify concurrent changes in the local foodscape. We also aim to explore how impacts and associations vary by socioeconomic status.We employ a mixed methods, longitudinal study design. Two study areas were defined: the hypermarket intervention area  and a comparison area with no hypermarket . The study is comprised of 4 pieces of primary data collection: a quantitative household survey with local residents, a qualitative study consisting of focus group discussions with local residents and semistructured interviews with government and private sector stakeholders, an audit of the local foodscape using on-the-ground data collection, and an intercept survey of shoppers in the hypermarket. Assessments will be undertaken at baseline and approximately 1 year after the hypermarket opens.Baseline assessments were conducted from March 2019 to June 2019. From a total sampling frame of 400 households, we recruited 376 of these households, giving an overall response rate of 94.0%. The household survey was completed by 516 individuals within these households. Across the two study areas, 8 focus groups and 44 stakeholder interviews were conducted, and 1920 food outlets were geocoded.This study aims to further the understanding of the relationship between food retail and dietary behaviors in Kenya. Baseline assessments for the study have been completed.DERR1-10.2196/17814 Dietary behavior is complex and shaped by multiple interacting factors, including policy, built, and social environments . Access Evidence on the relationship between supermarkets, food purchasing, diet, and health is drawn mostly from high-income countries. There is an inadequate understanding of dietary behaviors and their drivers in low- and middle-income countries (LMICs). It is particularly important to understand dietary behaviors in these settings because of the ongoing nutrition transition that is typified by a movement away from traditional staples toward the consumption of cheap and highly processed food . This isKenya is a low-income  East AfrA new hypermarket  is currently under construction at Lake Basin Mall in Kisumu, Western Kenya see . The malThe opening of the hypermarket provides an opportunity to examine potential impacts on dietary behaviors among residents of Kisumu living nearby and on the local foodscape, using a natural experimental design , as wellWhat are the individual, household, and population impacts of the new hypermarket at Lake Basin Mall on food shopping practices, dietary behaviors, physical activity patterns, and body composition among local residents across different SES groups?How has the local foodscape changed, do these changes relate to the new hypermarket at Lake Basin Mall, and how are they experienced by local residents?This is a protocol for a mixed methods, natural experimental study  that wilThe study is comprised of four core pieces of primary data collection:A longitudinal quantitative household survey with local residents.A longitudinal qualitative study consisting of focus group discussions with local residents and semistructured interviews with government and private sector stakeholders.A longitudinal audit of the local foodscape using on-the-ground data collection.A cross-sectional intercept survey of shoppers in the hypermarket.The baseline data collection took place in 2019, before the anticipated opening of the hypermarket. The follow-up data collection is anticipated to take place in 2021, approximately 1 year after the hypermarket opens, which should provide sufficient time for shopping habits to adjust after an initial period where use of the hypermarket may be atypical. Assessments will ideally be seasonally matched  to account for seasonal variation in behaviors. Should this not happen, seasonality will be addressed in the analysis. Modest incentives will be used to increase retention and to compensate for time spent participating in the study. The incentives include transport reimbursement, refreshments, and bars of soap as tokens of appreciation. If households subsequently move to outside the study areas, they will still be eligible for the follow-up assessment. Depending on attrition, we will also consider the possibility of recruiting a new sample of households from the study areas at follow-up.The study is set in Kisumu County and Homabay County in Western Kenya. Kisumu County has a population of 968,909, and Homabay County has a population of 963,794. Two study areas were defined: the hypermarket intervention area  and a comparison area with no hypermarket . These areas were delineated using existing spatial census data, field visits, and local knowledge of the study investigators. A 2-km radial buffer was drawn around the hypermarket and matched according to population density with a 2-km radial buffer around another landmark in the comparison area. Therefore, both study areas are 2 km in size, by radius, and the two areas lie approximately 100 km apart.Though we aimed to ensure similar aggregate socioeconomic characteristics and broadly similar topographical and food retail characteristics apart from the presence of a hypermarket, the sites are still somewhat heterogeneous. The intervention site may be considered urban and the comparison site maybe be considered periurban. However, both areas include a mix of lower- and higher-SES areas, both informal and formal settlements; both areas have a similar number of supermarkets and encompass the main shopping street; and both areas have major roads. Both areas are located on the shores of Lake Victoria, a freshwater lake and the traditional ancestral lands for the Luo ethnic community of Kenya; thus, they share similar cultural practices.Households living in one of the local study areas at baseline are eligible for the household survey. Individuals are considered household members if they regularly share meals, live together, and pool their monetary resources. A maximum of 5 adults, aged 18 years or over, in the household, including the head of household and the person who is usually responsible for food purchasing, will be eligible to complete interviewer-administered questionnaires and anthropometric measurements. The household head is the adult member of the household who is accepted and recognized by the other household members as the head, which implies a prominent role in making decisions that concern the household. Additionally, a maximum of 5 children, aged between 5 and 17 years, in the household will be eligible to complete anthropometric measurements. Households where either the head or the person responsible for food purchasing is under the age of 18 years will be excluded from the study.Adult householders from each of the local study areas who took part in the household survey will be eligible to participate in subsequent focus group discussions. These will be disaggregated into male and female as well as lower- and higher-SES groups. This was considered necessary to address any social, economic, cultural, or class issues that may impede free discussion. The focus group discussions will be conducted in local community halls owned by churches, local businesses, or the county government.Eligible stakeholders of interest include county government officers from the health, trade, agriculture, and infrastructure departments. Local administration representatives include the county commissioner and representatives of this office. Members of the Lake Basin Development Authority who developed the mall and hypermarket as well as representatives from the local food retail sector, such as the market master, are also considered important stakeholders. Other important local representatives include the motorcycle taxi  and fishing industries as well as local faith and religious leaders who are influential in the community.Once the hypermarket is open, shoppers will be eligible to answer questions on their shopping habits and will be intercepted while they shop.The intervention under study is the new hypermarket at Lake Basin Mall and its associated changes to the local foodscape. At the group level, the intervention dose is operationalized as the geographical proximity to the new mall . At the individual level, the intervention dose is operationalized according to whether the individual shops at the new hypermarket.The primary outcomes are as follows:Change in the self-reported percentage share of monthly household food expenditure from supermarkets between baseline and follow-up.Changes in the number and type of local food outlets between baseline and follow-up.The secondary outcomes are as follows:Change in self-reported, monthly, household food expenditure, in Kenyan shillings, between baseline and follow-up.Change in self-reported household food security between baseline and follow-up.Change in self-reported individual dietary diversity  between baseline and follow-up.2) between baseline and follow-up.Change in measured individual body composition , we plotted a quadrant from the center of each study area to demarcate the area into four subareas—northeast, northwest, southeast, and southwest— and plotted three radii of 500 m, 1 km, and 2 km from the center. Each household in the sampling frame was classified by quadrant, distance from the center, and SES. A stratified random sample of households was drawn from these three strata—400 in total (200 in the intervention area and 200 in the comparison area)—to account for refusal to participate.Study teams consisting of two field workers, guided by a local community health volunteer, will knock at the doors of eligible households to make an initial approach and recruit households to participate in the household survey.Following completion of the household survey, a purposive sample of participants will be drawn for the resident focus groups. We will aim for a diverse sample that mirrors the basic demographic characteristics of the survey sample and includes a mixture of lower- and higher-SES participants, those living in formal and informal settlements, both males and females, and a range of ages. Householders will be approached and recruited by the same field worker teams using contact details provided during the household survey. We aim to conduct four focus groups in each study area, split by gender and SES.We will use existing relationships combined with snowball sampling to identify and recruit a range of stakeholders to participate in semistructured interviews, including mall developers and managers as well as members of the county government, including the trade executive, the health executive, the planning executive, and the local ward representative. We will give preference to those directly involved in the decision making and development of the mall and aim to interview at least 6 stakeholders per study area.Once the hypermarket is open, a minimum of 20 shoppers will be recruited while they shop to answer a short survey.At baseline and follow-up, participants will complete a household and an individual questionnaire. The household questionnaire will be completed by the head of household and by the person who is usually responsible for food purchasing and will assess the following variables:Demographic variables for each individual in the household .Characteristics of the household .Household food purchasing in the previous month, including sources of food, types of food retail accessed, and amount of money spent at different types of food retailers and overall.Number of trips made to purchase food and modes of transport used in the previous month.Household food security, based on the Food and Agriculture Organization’s Food Insecurity Experience Scale .The individual questionnaire will be completed by each eligible adult, aged 18 years or over, and will assess the following variables:Dietary diversity using an unquantified 24-hour dietary recall and following the approach described by the Food and Agriculture Organization and the United States Agency for International Development’s Food and Nutrition Technical Assistance III Project . In ordePhysical activity, using the World Health Organization Global Physical Activity Questionnaire .Well-being, using two items from the abbreviated version of the World Health Organization Quality of Life instrument .Social connectedness, using 3 items from the Social Provisions Scale .Following this, all eligible participants in the household, both adults and children, will complete anthropometric measurements  using standard procedures. A tape measure, stadiometer, and calibrated scales will be used. Each measurement will be taken in duplicate.Assessments will last approximately two hours and will be conducted on different days of the week in order to capture both weekdays and weekends on the dietary recall. Although, ideally, multiple dietary recalls would be used, in order to minimize participant burden we will undertake a single dietary recall to describe the range of food groups consumed on the recall day. A field worker will administer questionnaires by interview with the aid of an electronic tablet, preprogrammed with prompts and validation rules to help limit missing data and ensure data quality. All field workers will be educated at the degree level in a related field  and will attend a minimum of five days of training covering all elements of the primary data collection, including a dedicated session on administering dietary recalls facilitated by a nutrition researcher. Following the training, field workers will have access to bespoke training resources.At baseline and follow-up, focus groups will be oriented around understanding what influences people’s food practices and exploring the role of the hypermarket within the local foodscape. We will explore the day-to-day experience of food, including travel to procure food and the influence of family and community members. We will also investigate the connection people make between food, health and well-being, and the environment.The focus groups will be held at local venues, such as community church halls or appropriate business outlets; will be conducted by two facilitators; and will last approximately two hours. Focus groups will be held for male and female participants as well as for lower- and higher-SES participants separately. Each focus group will start with a short introduction to the project, described as research on the food local people eat and how they get it. Using a topic guide, the facilitator will help to guide and explain the questions, a second facilitator will take notes, and the discussions of each focus group will be tape-recorded. The audio recordings will be transcribed verbatim and, if applicable, translated into English.At baseline, stakeholder interviews in the intervention area will be oriented around determining how decisions to invest in and situate the mall and hypermarket were made as well as projected impacts in relation to food prices and variety, other food outlets in the area, food supply chains, and health among the local people. At follow-up, interviews will focus on the implementation of the intervention and any important short-term outcomes. In the comparison area, stakeholder interviews at both time points will focus more broadly on the impacts of the changing local foodscape.The interviews will be held at a location convenient to the stakeholder, likely their place of work. Semistructured interviews will be conducted by two facilitators according to a topic guide and will last for approximately one hour. The interviews will be tape-recorded; the audio recordings will then be transcribed verbatim and, if applicable, translated into English.At baseline and follow-up, systematic on-the-ground data collection will be undertaken to geolocate and categorize food outlets in each of the local study areas. Teams of field workers will systematically walk around the study areas, coding the location and types of establishments and taking photos of food outlets. Data collection will be undertaken using electronic tablets. In addition, we will explore the availability and accuracy of existing data, such as county records of licensed food sellers.At follow-up, shoppers in the hypermarket will be intercepted while they shop and asked a set of standard questions covering basic demographics, the items being purchased on the shopping trip, the mode of transport used to get there, and the main reasons for using the hypermarket. A field worker will administer the survey by interview with the aid of an electronic tablet. It is anticipated that each survey will take 5 to 10 minutes.The study will be conducted in accordance with relevant current policies, standard operating procedures, and regulatory requirements for data protection, storage and security, and secure data sharing across sites at the Kenya Medical Research Institute and the University of Cambridge. Each participant will be assigned a unique registration number. A master list linking each participant registration number to identifying details will be stored separately from the deidentified data. There will be secure storage of both paper  and electronic  data at the Kenya Medical Research Institute. Electronic data will be stored on a secure server at the Kenya Medical Research Institute.For the household survey, foodscape audit, and shopper intercept survey, data will be captured electronically using preprogrammed forms with existing prompts, codes, and validation rules to help limit missing data and ensure data quality using the mobile app CommCare (Dimagi). Additional quality control checks will be undertaken once these quantitative data are collated in the database.Raw survey data will be collected, stored, and backed up on restricted-access CommCare cloud servers. Raw data sets will be downloaded by a data manager onto local password-protected computers for additional backup and management. Data cleaning will be undertaken using Stata software (StataCorp), in which data will be checked for inconsistencies, variables manipulated, and new variables derived. A cleaned data set will be generated and stored locally alongside cleaning and analysis files. Cleaned, deidentified data sets will be shared between institutions according to local ethical approval and the terms of a formal data sharing agreement.For the qualitative focus groups and stakeholder interviews, all transcripts will be checked for accuracy by specially trained qualitative coders prior to analysis. Transcripts will then be imported into NVivo software  for coding.t tests or analyses of variance for normally distributed variables, while medians will be compared using the Wilcoxon rank-sum test or the Kruskal-Wallis test for skewed data. We will further undertake multivariable regression analyses adjusted for important covariates, using models appropriate to the distribution of the data and accounting for clustering by household. For binary outcomes, we will explore the use of logistic regression models, and for continuous outcomes we will consider linear regression models and negative binomial or zero-inflated generalized linear models. Regression estimates and 95% confidence intervals will be reported.For all quantitative analyses, the level of statistical significance will be set as α<.05. All participants who provide data will be included in analyses, and we will not impute missing data. Net changes between baseline and follow-up will be computed, and significance tests will be conducted using a method appropriate to the distribution of the data. Differences in means will be compared using a priori themes from the topic guides, and new codes may also emerge. All codes will be combined into a master codebook, and this will be used for analysis.The qualitative focus groups and semistructured interviews will be analyzed by a team of qualitative coders using thematic analysis. Double-coding of selected transcripts will be used to facilitate this process. Researchers will develop a codebook based on Food outlets will be counted and categorized  descriptively. Simple change scores will be calculated. Geospatial information will be imported into a GIS and used to inform analyses exploring distance between households and food outlets as well as density of food outlets.Intercept survey data will be analyzed using descriptive statistics. This data will be collected once the hypermarket has opened.To integrate the study findings, a mixed methods, sequential explanatory design will be used. This design consists of two distinct phases: quantitative followed by qualitative . Quantithow  and why . The qualitative thread will allow for some exploration of potential causal inference and mechanisms that would not otherwise be possible from the quantitative design. In addition, the qualitative thread will provide insight into the local context and give some indication of the potential generalizability of findings.The primary reason for mixing the methods is to offset the strengths and weaknesses of each method to provide greater insight than could be gleaned from either method alone. For example, the quantitative thread benefits from larger numbers but does not provide insight into how or why outcomes are brought about. By contrast, the qualitative data will provide complementarity via the explanation, elaboration, and illustration of the results from the quantitative method, but is limited by the smaller sample size. The two approaches are intended to answer different questions: It is anticipated that findings from this study will be relevant for a range of policy areas, including nutrition, health and health inequalities, economic development, urban planning, agriculture, and food supply. Findings will be directly relevant to decision makers in the local study areas. In addition, given the similarity between this development and others taking place in low- and middle-income contexts, as well as wider considerations of health and economic or urban development, there is scope for considerable generalizability of these findings.There will be 3 key windows for knowledge exchange within the study:An initial stakeholder mapping phase will be an opportunity to understand the landscape of the public and private decision makers involved in this process as well as their needs and practices in terms of evidence provision and use.The stakeholder interviews will provide opportunities to further develop this understanding as well as stakeholder perspectives on health and economic development.The dissemination phase will involve sharing the results with the above actors in a way that reflects our increased understanding of their perspectives. Beyond the local stakeholder, we will also engage with national, regional, and international decision makers.Key messages for our knowledge exchange will be guided by the research findings. The methods for dissemination will be guided by what is likely to be most effective for the relevant stakeholders.Baraza—informative or deliberative public meetings held in communities in Kenya—and other existing networks and forums that can engage widely within communities. We will communicate study findings through academic publications and conference presentations. In addition, we will pursue a number of nonacademic outputs, activities, and events, including the production of lay summaries, blogging and social media, communicating via news media, and further Baraza-style meetings for different community and stakeholder audiences.Findings will be communicated to study participants through activities such as meetings based on the principle and approaches of This study forms part of the Global Diet and Activity Research Group and Network (the Network). The Network has a Steering Group comprised of senior investigators across the participating sites, which meets every 6 weeks. The Network Steering Group will act as a study steering committee, providing general oversight and advice on scientific and operational issues. Because of the low-risk nature of the study and the lack of a researcher-manipulated intervention, there will be no formal data monitoring committee for this study. There are no planned interim analyses or stopping guidelines. Minimal monitoring will be undertaken by a member of the investigative team to verify that study procedures are undertaken in accordance with the protocol by communicating deviations where they occur and taking action to prevent recurrence, auditing the completeness of consent forms, and auditing the accuracy and completeness of study data.This is considered a minimal-risk study as defined by the local ethics committee. As such, a formal process of adverse event monitoring will not be implemented. However, if any member of the study team becomes aware of a serious adverse event , it will be reported to the principal investigator, who will report this to the local ethics committee according to the committee’s standard procedures.Ethical approval has been received from the Kenya Medical Research Institute Scientific and Ethics Review Unit (reference KEMRI/SERU/CGHR/174/3730). Important protocol modifications will be updated in the study protocol and a new version released. Protocol amendments will be approved by the Kenya Medical Research Institute Scientific and Ethics Review Unit.All study participants will read an information sheet and provide written informed consent prior to any study procedures taking place. Participants aged 18 years or over who cannot read and write may thumb-print their consent after the document has been read to them in the presence of their chosen witness. All participants aged 18 years or over who are able to write will sign the consent forms. Parents or guardians will sign consent forms on behalf of their children who are under 18 years of age. An assent form will also be signed by children who are under 18 years or age, or a thumbprint will be given if they cannot read or write, after information has been read to them. The consent and assent forms will be translated into Luo and Kiswahili, the local language and national language, respectively.Data will not be copied, removed, or disclosed to anyone outside the collaborating investigators and approved study staff. Approved staff will be given password-restricted access to the data. All participants are entitled to request the details of any personal data relating to them. Confidentiality will be maintained by storing consent forms separately from deidentified data, which will use registration numbers. Deidentified data will be shared between the Network partners under the terms of a formal collaboration and data sharing agreement. Identifiable data will be stored at the Kenya Medical Research Institute only and will not be shared.As of December 2020, we have undertaken initial stakeholder mapping and completed the baseline assessment. The follow-up assessment, data analysis, and publication are anticipated to take place in 2021.In November 2018, stakeholders were identified and a meeting convened in each of the study areas. In Kisumu , the meeting was attending by 32 stakeholders, including representatives from the Ministry of Health, the Lake Basin Development Authority, the county health department, trade and agriculture departments, faith and religious leaders, community health volunteers, and the private food retail and transport industries. In Homabay , the meeting was attended by 19 stakeholders mostly representing the county health department. Investigators briefly described the study and chaired an open forum discussion in which stakeholders could reflect on aspects relevant to them.We undertook baseline assessments in Kisumu  in March 2019 and in Homabay  in June 2019. From a total sampling frame of 400 households, we recruited 376 of these, giving an overall response rate of 94.0%. This exceeded our target of recruiting 250 households at baseline. Numbers of respondents completing each element of the assessment are reported in In this paper, we report the protocol for a mixed methods, natural experimental study evaluating the impacts of a new hypermarket on dietary behavior and other related outcomes among local residents in Western Kenya. In addition, we aim to develop a broader understanding of the impacts of a rapidly changing local foodscape, the meaning that local people attribute to these changes, and local people’s food practices more generally. A number of reflections on study design and conduct arising from this study are likely to be of interest to those undertaking similar work.A defining feature of natural experimental designs is that the intervention of interest is not controlled by researchers, which can raise practical challenges for evaluation. Since the timing of the intervention is not under researcher control, it can be difficult to complete baseline assessments in the interval between the identification of the natural experiment opportunity and the implementation of the intervention. Equally, if an intervention is delayed, it can be difficult to complete an evaluation within the time constraints of research funding. In this study, the opening of the Lake Basin Mall and the hypermarket has been delayed. The baseline assessment has been completed, allowing detailed quantitative and qualitative exploration of associations between food retail, including supermarkets, and the outcomes of interest, which is an important contribution to the broader goal of understanding the role of food retail in shaping dietary and other health behaviors.To date, much of the evidence from research on supermarkets, and studies using natural experimental designs, is drawn from high-income countries. However, the evidence generated from these types of studies tends to be at least somewhat specific to the context, and it is unlikely that findings from high-income countries would be completely generalizable to LMICs. In particular, key differences in LMICs include resource constraints from the individual to the governmental level, the co-occurring burden of infectious disease, and, particularly for research on diet, the nutrition transition and triple burden of malnutrition. It is likely that the identification of generalizable causal relationships from natural experimental studies will rely on the cumulation of studies across different contexts ,32. It iWith natural experimental designs, the delineation of exposed  and unexposed  groups is required in order to take advantage of the variation in exposure generated. This is not always straightforward and depends on the research question and putative causal chain. For example, the use of area-based exposures is often used , encompaThe use of controlled comparisons is intended to account for confounders. However, it is acknowledged that comparison groups in natural experimental studies are typically imperfect and not akin to those achieved through randomization. Groups that are broadly similar across a range of important demographic, environmental, and behavioral variables are often the best that can be achieved. In this study, we acknowledge that our comparison area differed in some respects to the intervention area; nevertheless, this design will still allow researchers to account for measured confounding. The possibility of unmeasured confounding related to other concurrent changes is a core limitation of this study and of natural experimental designs in general.This is one of very few studies examining how changes in the food environment relate to changes in behavior and health in LMICs. The strengths of the study include the use of established and validated quantitative methods and the collection of complementary qualitative data, making this a unique data set for this setting. We particularly focus on inequality and the potential for differing impacts in different SES groups. The limitations of this study relate mainly to the general limitations of natural experimental designs and are discussed in detail in the previous section.This study aims to further the understanding of the relationship between food retail and dietary behaviors in Kenya. Baseline assessments for the study have been completed.


I.1 the epidemic has quickly spread to other parts of the world and has been eventually recognised by the World Health Organization as a pandemic. The existing interconnectedness among countries obviously facilitated that expansion.The COVID-19 epidemic has taken the world by surprise. Initially, it was seen as a Chinese, and later South-East Asian, problem. Decision-makers around the world apparently believed that the disease could be contained and controlled within the region, following a pattern that was evident in previous outbreaks, such as SARS. However, due to a combination of different factors of natural, political and regulatory character,2 These numbers are expected to rise sharply in the near future. While some countries appear to be gaining control over the situation (eg China), others are either still battling to slow down the spread of the disease  or are in the early stages, which are typically characterised by exponential growth in cases (eg the USA and Poland). There are, however, other potentially equally serious consequences, the importance of which will only be appreciated as time passes. The current public health emergency will be followed by the mutually reinforcing economic and political crises that may ultimately lead to serious social disturbance as the costs of the pandemic will not only be high, but also unevenly distributed, both among countries and among different social groups within states.3So far, the pandemic has been predominantly seen as a public health problem. As of 3 April 2020, there were more than 1 million confirmed cases globally, with almost 60,000 registered deaths.4 The pace and extent of potential recovery still remain open questions. The political crisis may manifest not only at the national level, by undermining the electoral support for current governments, but also at the regional or international level. In this context, some experts, for example, worry about the future of the European integration project, pointing to the inadequate response of the European institutions. Others see the COVID-19 pandemic as an existential threat to liberal democracy. Indeed, there are some early signs indicating that current autocratic tendencies may be strengthened in the future.5As far as the economic aspect is concerned, most experts expect to see in 2020 a global recession that may take a severe form for some countries or regions. For example, JP Morgan Research anticipates a two-quarter GDP contraction in the USA of between –10% and –25%, and for the Euro Area of between –15% and –22%.International trade is also one of the potential victims of the current pandemic. As it is too early to assess the real impact of the various processes that are taking place now, the objective of this text is limited. Instead of identifying and analysing the probabilities of different scenarios, the intention is to highlight one possible course of action that seems to be emerging in the field. To this end, the two following sections discuss the short- and long-term consequences of the current pandemic for international trade. The final section offers some brief conclusions.II.6 Moreover, according to the recent United Nations Conference on Trade and Development (UNCTAD) assessment, which is actually based on conservative assumptions, the COVID-19 outbreak will cause global foreign direct investments (service mode 3) to shrink by 5–15% in 2020.7 The demand side has also been affected as consumers around the globe are unwilling at the moment to spend their money. This phenomenon can be attributed to a common fear of loss of income (eg due to unemployment) and heightened uncertainty. Overall, one may expect to see a continued decline in the volume of international trade in the coming months. The extent of this decline is difficult to predict.The COVID-19 outbreak has already caused deep disruption to world trade, affecting both the supply and demand sides of the global economy. Many governments have ordered temporary closure of non-essential manufacturing facilities, while numerous corporations either have taken such measures voluntarily (eg because of the reduction in the supply of labour) or have simply decreased production due to disruptions in their supply chains. The impact of the COVID-19 pandemic is, however, most visible in the international service sector. The main victims are international tourism, passenger air travel and container shipping. Global financial transactions as well as information and communications technology services have also declined significantly.8 Other countries, concerned with the security of their food supplies, have introduced export restrictions over specific agricultural products, and these decisions have generated genuine concerns about potential food shortages in the global market in the second part of the year.9 The problem appears sufficiently serious that it has led to a joint statement by the Directors-General of the Food and Agriculture Organization, the World Health Organization and the World Trade Organization (WTO), in which they noted that “uncertainty about food availability can spark a wave of [additional] export restrictions, creating a shortage on the global market”. In this context, they called on countries to ensure that their trade-related measures do not disrupt the food supply chain.10These past weeks have also seen a significant increase in states’ recourse to COVID-19-related trade policy measures. In particular, some countries have decided to establish export controls over certain medical products  in the form of temporary export bans or the addition of licensing/authorisation requirements.11 The aim of all of these measures is to ensure that there are sufficient supplies to domestic markets (either by decreasing exports or increasing imports). Interestingly, some trade restrictions have been reduced (at least temporarily) even between the USA and China, the two rivals that have been stuck in a trade war for the last two years. In particular, the USA has decided to exclude a range of medical protective gear and equipment from additional duties imposed previously under its Section 301, and new products may be added to that list in the future. Similarly, China has granted temporary exclusions for certain US goods (eg reagents or disinfectants) from its counter-duties.12However, it would be a mistake to think that the current epidemiological situation has only resulted in a wave of trade restrictions. The picture is much more complex. In fact, a number of states have recently removed or suspended some trade controls. For example, Argentina has suspended its anti-dumping duties on imports of certain medical products from China, while Canada has temporarily eliminated tariffs for specific categories of products if they are imported by public health agencies, hospitals and testing sites, or for use by first-response organisations.13 Similar problems may be faced by the US–China Phase 1 trade deal concluded in January 2020 – the preliminary agreement that sets prerequisites for ending  the trade war between the two countries. On its basis, China undertook to purchase more US goods and service, while the US agreed to lower some of its tariffs introduced for Chinese products between 2017 and 2019. It is unclear whether, in the present situation, China will be able to meet the required purchase thresholds, and equally whether the USA will be able to deliver a sufficient amount of goods and services.The pandemic has also slowed down the progress of various international trade initiatives around the globe, as states are currently preoccupied with the crisis. A good example is the new agreement between the USA, Mexico and Canada  that is supposed to replace the current NAFTA arrangement. Although it has already been ratified by all three parties, its entry into force depends on the successful implementation of its obligations at the national level. While the initial plan was slated for 1 June 2020, this initiation date is now unsustainable.14 According to the withdrawal agreement, the transition period for the UK ends on 31 December 2020. If no deal is reached, the mutual trade relations will be governed by WTO rules. That seems to be a very unappealing option, particularly for the post-COVID-19 world, so one may expect to see (probably relatively soon) the extension of the deadline.On the other side of the Atlantic, talks between the UK and the European Union over future trade relations have also stalled.III.15 Such disruptions can have significant impacts, both on individual companies and on global systems of distribution. For example, China is a dominant global supplier of active pharmaceutical ingredients for many important medications. In 2018, it accounted for 95% of the US imports of ibuprofen, 91% of hydrocortisone, 40–45% of penicillin and 40% of heparin.16 Such a situation becomes particularly problematic in times of crisis when production facilities are not fully operational, while the demand of the domestic market may require countries to redirect part of their export. This is also true for other sectors, even if the consequences of possible disruptions are not so dramatic.The global economy is built on the specialisation of labour across countries. In line with the theory of comparative advantage, which provides the foundation for the current system of the international exchange of goods and services, such specialisation allows for maximisation of total output and improvement in welfare. The COVID-19 pandemic has shown, however, that clear benefits of the system come with costs. As noted by two commentators, “single-source providers, or regions of the world that specialize in one particular product, can create unexpected fragility in moments of crisis, causing supply chains to break down”.18 It seems that this approach will be followed regardless of who wins the upcoming presidential election. In the past, regulatory initiatives aimed at reducing vulnerabilities in supply chains have attracted bipartisan support in the American Congress.19This newly discovered risk may eventually lead to profound changes in existing supply chains. The early signs of such a process have been visible over recent years with the Trump Administration pressuring American companies  to move their production back to the USA, or at least to outside of China.20 The new world, as expected to emerge, will be characterised by tighter immigration rules, newly erected trade and investment barriers and technological decoupling, with a central role reserved for states rather than for international institutions .21 The probability of this scenario is further increased by various recent developments. It seems that some fundamental reorganisation of the global economy and international order has actually been going on for some time. In this context, it is worth noting that some multilateral institutions have already been marginalised. The WTO may serve here as a perfect example with its partially paralysed dispute settlement system.22 In response to the series of recent migration crises, immigration rules have also been strengthened in many countries. Global trade restrictions have been on the rise for last couple of years, and they are not limited to the economic relations between the USA and China.23 The European Union, which is traditionally very open to international trade, has recently taken a more assertive stance in its willingness to impose more vigorously its anti-dumping duties, countervailing measures and trade sanctions, as well as to undertake strategic investment screening.24 Technological decoupling – seen by both China and the USA in terms of competition for global technological supremacy – has been an important part of their trade war.25 A series of the recent competition proceedings by the European Commission against American technological companies also seems to constitute one of the elements of this process. Whether this will lead to the resurrection of national states (as suggested above) or rather to a segmentation of the world that will be based on regional economic blocs around local hegemons that compete against each other in the global power game is still an open question.26Drawing on historical parallels, some commentators argue that the consequences of the pandemic will be even more far-reaching. They forecast a resulting deep and lasting transformation of the process of globalisation.IV.Although some of the short-term consequences of the COVID-19 pandemic for international trade are serious, they do not appear to be unmanageable. From this perspective, one could expect that once the pandemic disappears (or is at least under control), international trade will go back to business as usual. However, in a different time frame, the potential impact of the pandemic may be more profound than initially anticipated, leading to structural changes in the process of economic globalisation. While the seeds of such a process were sown some time ago, the COVID-19 pandemic may exacerbate existing tendencies for states to turn inwards and compete more openly for economic and political dominance in the world. Whether this actually happens will greatly depend on the length and severity of the current pandemic. The bigger its impact, the greater are the chances that we will see the paradigm shift in international trade relations and governance.


The abundant faunal remains from the Takarkori rock shelter in the Tadrart Acacus region of southwestern Libya are described. The material that covers the period between 10,200 to 4650 years cal BP illustrates the more humid environmental conditions in the Central Sahara during early and middle Holocene times. Particular attention is focussed on the aquatic fauna that shows marked diachronic changes related to increasing aridification. This is reflected in the decreasing amount of fish remains compared to mammals and, within the fish fauna, by changes through time in the proportion of the species and by a reduction of fish size. The aquatic fauna can, in addition, be used to formulate hypotheses about the former palaeohydrographical network. This is done by considering the possible location of pre-Holocene relic populations combined with observations on the topography and palaeohydrological settings of the Central Sahara. The late Quaternary palaeoecological reconstruction in desert environments is often limited by a number of factors including the lack of continuous and well-preserved archives for proxy data. For instance, the present-day, strong erosion removes sediments and destroys open air palaeontological assemblages, thus limiting the comprehension of past ecological settings. However, late Pleistocene and Holocene archaeological caves and rock shelters offer the opportunity to investigate–besides cultural aspects–well-dated archives preserving information on the composition of past faunal and plant communities. Archaeozoology of desert sheltered sites is a precious tool to reconstruct late Quaternary ecological changes especially when aquatic species are considered, thus providing information on climatic and environmental changes.Archaeozoological studies on early Holocene sites are rare in Libya: besides the work carried out in Haua Fteah and some other late Quaternary sites excavated in Cyrenaica , and theThe fauna discovered during the excavations in the late 1950s and early 1960s in the rock shelter at Uan Muhuggiag was first briefly reported in Pasa and Pasa-Durante  and Mori2) and the sampling strategies allowed us to collect an extensive faunal assemblage that offers a unique opportunity to reconstruct the role that animals played in the subsistence during large part of the Holocene. In addition, the material allows documenting climatic and palaeoenvironmental changes, which is the focus of this paper. Terrestrial animals will only be briefly mentioned and emphasis will be on the aquatic fauna that includes a number of taxa that can only propagate efficiently through water ways . The material therefore has the potential of contributing also to a better understanding of the former palaeohydrographic network of the Sahara and its connection with the Nile Valley and the Sahel.In this paper, we present the faunal remains excavated at Takarkori (2003–2006), a rock shelter in the Tadrart Acacus, close to the border with Algeria . The sit2 with a maximum elevation of approximately 1350 m a.s.l. The rocks outcropping in the region are Lower to Middle Silurian to Lower Devonian shales and sandstones . Th. Th13]. If we consider the Tadrart Acacus massif and adjoining regions, we can identify several former wetlands that were active during the AHP, and that are today desiccated Figs  and 4. TThe other hydrographic basin is limited by the western escarpment of the Tadrart Acacus and encompasses the Wadi Tanezzuft valley, the Wadi Takarkori area, and large part of the Tassili plateau. During the AHP a large aquifer sustained the Tanezzuft River , flowingThe first inhabitants at Takarkori rock shelter were early Holocene hunter-gatherer-fishers locally called “Late Acacus” . Archaeological and archaeobotanical evidence indicates prolonged, albeit seasonal, residential occupation and a delayed-return system of resource exploitation , 34, 35.The archaeological deposit has been excavated in 4 distinct areas: Northern, Main, Western and Southern Sector ; see 1313 for deEvidence of former wetlands in the Libyan central Sahara has been identified in remote sensing and explored in the field . The recThe faunal remains that are presented here were recovered during the excavations by the systematic dry sieving of all the sediment on a 4 mm mesh. All the material was shipped to Italy and then Belgium for analysis with all the necessary formal permits granted by the Libyan Department of Antiquities to the mission of Sapienza University of Rome. The material is temporarily stored in the Sapienza University, in order to be resent to the Lybian Department of Antiquities, Tripoli, Libya, as soon as safety conditions in Libya will recover. Identification of the mammal bone was carried out with the aid of the comparative collections of modern skeletons housed at the Istituto Italiano di Paleontologia Umana (IsIPU) in Rome and at the Museo di Storia Naturale La Specola in Florence. The bird bones were partly identified using the IsIPU collections and those of the Museo Preistorico Etnografico "L. Pigorini" in Rome, now part of the Museo delle Civiltà, and partly at the Royal Belgian Institute of Natural Sciences in Brussels. It is also in the latter institute that adequate collections were available to carry out the identifications of the molluscs, fish, amphibians, and reptiles.Identifications were based on both morphological and metrical criteria and included the recording of the skeletal element and the taxon. In the case of fish also a reconstruction of the body length was carried out. For well-preserved bones the corresponding fish lengths could be calculated using published regression formulae . In caseModifications that could be observed on the bone, due to either natural or anthropogenic factors, were noted as well. These include observations on the weathering of the bones, gnaw marks caused by rodents and carnivores, cut marks and traces of burning. These data, combined with the skeletal element representation of each of the taxa, and in some cases also the behaviour of the species, are used to reconstruct the taphonomic history of the finds and to assign the remains as much as possible to so-called taphonomic groups .An overview of all the fauna recorded from Takarkori is provided in Zootecus insularis. This is a small species that is typically found in arid and semi-arid environments of the entire Saharo-Indian region [Corbicula consobrina. This small aquatic bivalve is widespread in the present-day Sahel and in some relic areas of the Sahara and used to occur here more frequently during the early Holocene [Corbicula consobrina has been reported in Libya from localities near Brak [Melanoides tuberculata of which two individuals were found in LA3. It is a panafrican species of which living relic populations can be found on many localities in the Sahara, including in Libya at Ghat [Melanoides and Corbicula shells have been recurrently found in lake and fluvial sediments [The mollusc fauna is limited both in number of specimens and taxa. Of the three terrestrial gastropods that were found only the one in an EP1 context was sufficiently preserved to be identifiable as n region . Its pren region , who alsHolocene . Corbicuear Brak  and Tejeear Brak . This frear Brak . The sam at Ghat . In Liby at Ghat , Wadi Sh at Ghat  and in t at Ghat . In our ediments , 25. Forediments , 56.Heterobranchus and Clarias [Clarias occurs [Heterobranchus. All pectoral spines clearly belong to the genus Clarias  of Clariidae catfish and the remaining third (33.6%) are tilapia (Haplotilapiini).The family of Clariidae is represented by two genera in the Nilo-Sudan ichthyofaunal province, namely  Clarias . Althougs occurs , 59, it s occurs , 61 are  Clarias . The two Algeria . The oth Algeria , 62. Botg 6.2 in ) indicatriepinus . The disOreochromis niloticus, Coptodon zillii and Sarotherodon galilaeus [Coptodon zillii  does not occur in the present-day relic waters of the Sahara [Coptodon zillii is the species that nowadays is found in multiple places in the Sahara, i.e. in the region of Biskra, Touggourt, Arak, Tassili n'Ajjer, Borkou, Tibesti and Ennedi, yet at Takarkori it is less frequently represented than O. niloticus. Sarotherodon galilaeus, of which not a single bone was found, occurs nowadays in the Adrar region of Mauritania. Sarotherodon borkuanus, now considered a subspecies of S. galilaeus [O. niloticus that reaches larger sizes than C.zillii. Holocene finds of tilapia and clariid catfish have been reported regularly from Saharan sites [Synodontis, from the region of the eastern foreland of the Tadrart Acacus massif and the Edeyen of Murzuq, and from the Kufra basin [There are 3 species of tilapia in the Nilo-Sudan ichthyofaunal province, namely alilaeus . Althougalilaeus . A littln zillii  and 228 iloticus . Not a se Sahara , 59, 65.alilaeus . The lenan sites . In Libyra basin , 2.Clarias lazera  was widespread in the Fezzan. From the oasis of el-Barkat, a few kilometers south of Ghat, the presence was reported of Barbus deserti  and of Hemichromis bimaculatus . No archaeozoological evidence for the presence of the latter two species was found. Enteromius deserti is a small cyprinid, the maximum total length of which is 9 cm, whereas Hemichromis bimaculatus is a cichlid with a maximum reported total length of 14 cm (common length 7.5 cm) [Ethnohistorical information, mostly based on reports from Italian expeditions in Libya in the early 1930s, provides a local background on the fish species still living in our study region. As mentioned above  Clarias  7.5 cm) . It is uBufo sp.). Toads are terrestrial but they need water for reproduction. Amphibians are historically documented [Bufo regularis and Bufo viridis, also two frogs Rana zavattarii now known as Pelophylax saharicus and Rana occipitalis now synonymized with Hoplobatrachus occipitalis have been mentioned [Crocodylus niloticus) and Adanson’s mud turtle (Pelusios adansonii). The crocodile remains are mainly dermal scutes (Three bones of anurans (toad or frog) were found, two of which could be identified as toad . One of the remains, consisting of two articulating peripherals (7 and 8), fits perfectly the Pelusios adansonii from the modern reference collection  and the buzzard (Buteo sp.) may have been attracted by the food waste left by the human occupants but it is unclear if they died naturally or if they were killed on purpose and eventually eaten. Birds that must have been typically attracted by the area of Takarkori are the piscivorous taxa. These include two species of pelican identified based on size [Pelecanus rufescens)  and at least two cormorant species: a larger species, probably the great cormorant , and the long-tailed cormorant (Microcarbo africanus) (Microcarbo pygmaeus), a species that in recent times occurred very sporadically in Africa, but that nested in Algeria during the 19th century [M. africanus, a femur from Takarkori fits well the measurements of the modern M. africanus and of the Middle Palaeolithic specimens of Bir Tarfawi (Egypt), attributed to that species [Fulica atra), the common moorhen , the spur-winged goose (Plectropterus gambensis) (Aythya fuligula) and the glossy ibis  (Circaetus sp.) (C. beaudouini), the brown snake-eagle (C. cinereus) and the Western banded snake-eagle (C. cinerascens) breed directly south to the Sahara, frequently near water, while the short-toed snake eagle  occurs as a migrant. All of them are specialized in catching reptiles but they can also eat rodents, amphibia and sometimes fish (C. cinerascens). Other birds of prey that were identified feed on flying insects and sometimes birds  or on invertebrates or small vertebrates (European honey-buzzard Pernis apivorus). Although these species did not feed on the abundant fish or other aquatic animals living in the area, it is likely that they were attracted by the relatively abundant terrestrial prey animals that were present near the site. Also the bustards, species that prefer open dry grassland, may have found a favourable environment near Takarkori.The bird fauna identified at Takarkori consists of 21 taxa, 10 of which are typically associated with aquatic environments. The corvid species, possibly the pied crow   and the ricanus) , a small century . Althoug species . The pin species . In rela species , 78. Thembensis) , the tufinellus)  [79, 78,tus sp.)  come froIt is unclear if the bones of the birds of prey should be seen as parts of carcasses of animals that died naturally on the spot or near the place where the bones were found. Some of the species may have nested on the rocky outcrops of the site, like the buzzard or on trees nearby such as the snake-eagle. Alternatively, these and other raptors may have been killed intentionally by humans either because they were seen as a nuisance, or because they were used for their feathers  and/or Podiceps cristatus) was reported from surface material collected in the Edeyen of Murzuq and dated to the first half of the Holocene [Plectropterus gambensis) has been found in a mid-Holocene site in the Abu Tabari region, lower Wadi Howar [Plegadis falcinellus), of corvids  and of the long-tailed cormorant (Microcarbo africanus), which was the most abundant species. The brown snake-eagle (Circaetus cinereus), the long-legged buzzard (Buteo rufinus), the rock dove (Columba livia) and the brown-necked raven (Corvus ruficollis) were identified at Ti-N-Torha East, Tadrart Acacus and dated to the early Holocene [Some of the bird species encountered at Takarkori have been attested previously in Saharan sites. The great crested grebe  and land birds (n = 11), the latter being the most numerous in terms of number of bones. Among the land birds, raptors are dominant with 52 out of 61 remains. This overrepresentation likely originates from human activities, as the taxa identified with the possible exception of the buzzards, are no rock dwellers and are hence unlikely to accumulate in the rock shelter naturally. The land bird taxa, in particular the snake-eagles and the bustards are typical of open woodlands or savannah.The aquatic bird taxa identified do not reveal much about the water system as most of them occur in very variable habitats, although the long-tailed cormorant prefers waterbodies with riparian vegetation . PelicanC. beaudouini), which breeds occasionally in northern Niger and north-eastern Mali [C. cinereus), which nests nowadays in the south of Mauritania and eastern Senegambia.From a zoogeographical point of view, the presence in the Sahara of afro-tropical or Sahelian bird species occurring nowadays in sub-Saharan regions was highlighted at several locations such as Ti-n-Torha , Edeyen ern Mali  or the bAmmotragus lervia), dorcas gazelle (Gazella dorcas), and rock dassie (Procavia capensis). Others live nowadays south  of the Sahara and their presence at Takarkori can be explained by their over-land migration to the area when the environmental conditions became more favourable at the beginning of the Holocene. The remains of most of the mammalian taxa identified at Takarkori can be seen as a result of human activity . The remains of small, unidentified rodents and of the gerbils, however, may result from natural accumulation, e.g., denning animals, predation by mammalian carnivores or raptors. Although gerbils are routinely eaten when other food resources are scarce, they often dig into archaeological layers and die there. In that case they should be seen as penecontemporaneous intrusives (cf. taphonomic groups in [Xerus erythropus) and the gundi (Massoutiera mzabi) do not dig burrows and they should probably be seen as human food animals or the result of predator activity. The occurrence of carnivore modifications on dassies indicates that sometimes even larger species were predated and accumulated at the site. Porcupine (Hystrix cristata) and cane rat (Thryonomys cf. swinderianus) have been more likely exploited by humans as suggested, at least in the case the first taxon, by the presence of cut marks. The species spectrum is typical of an open environment that was much lusher than today as also indicated by the pollen data [Nanger dama), Barbary sheep, rock dassie and cape hare (Lepus capensis) that are nowadays inhabitants of arid and semi-arid environments. Also the carnivores are capable of surviving in such relatively dry conditions. That is certainly the case for the Libyan striped weasel (Ictonyx libyca), the sand cat (Felis margarita) and the fennec fox (Vulpes zerda), but also for the golden jackal (Canis aureus), the caracal  and the Egyptian mongoose (Herpestes ichneumon) . The solen data , 40. Somioned in ). Most oioned in .Coptodon zillii and Oreochromis niloticus through time. The amount of specifically identified tilapia is low in each phase and in some cases  the percentages are probably not meaningful for that reason. If we only consider the phases that have 20 or more identified tilapia, there seems to be an increase in Coptodon zillii through time: the contribution of that species increases in EP1 and this continues into EP2 and remains at the same level in MP2. Coptodon zillii is better adapted than O. niloticus to survival in extreme conditions, i.e. low oxygen levels, high temperatures and in particular elevated salinity [As already mentioned above, the major animal groups represented at Takarkori are fish (ca. 80%) followed by mammals (ca. 19%) and birds (ca. 1%). It appears however, that there is a diachronic change in the relative importance of these major animal taxa when the proportions are plotted by phase . The amosalinity . These dsalinity . In the The two aquatic reptile species, the crocodile and the Adanson’s mud turtle, occur sporadically at the site. The crocodile is attested since the EP1 and occurs until the LP, whereas the mud turtle is found from the EP1 to MP2 phase. As it seems unlikely that they would have colonised the area later than the fish, their absence in the LA phases might be due either to their overall rarity and chance fluctuations or, alternatively, it could be postulated that people started exploiting these aquatic reptiles only from the EP1 phase onwards. This could then be due to more arid conditions, resulting in less extensive waters with crocodiles and mud turtles that became more vulnerable because the water levels had dropped. If fish became less plentiful, people may also have started exploiting this alternative food source. Hunting crocodiles may also have been a way of reducing numbers of a species that was competing for the same major food resource that fish represented.In the case of mammals, the only trend seen is the adoption of livestock keeping since the early pastoral phase; this is a general local and regional trend, documented at other sites  as muchFrom the paragraphs above, it is clear that the major faunal trends through time are all observed within the fish, besides their changing proportion versus the mammals. It appears that these diachronic trends in exploitation of aquatic resources, and especially fish, can be explained to a large extent by climatic changes in early and middle Holocene times. The closest water environments to Takarkori rock shelter  was the The shallow aquifer feeding basins among dunes were recharged since the beginning of the Holocene and at ca. 10,000 years BP permanent lakes were active. According to sedimentological data , 56, manCompared to the relatively smaller interdune lakes that may have disappeared for a few centuries around 8000 cal BP, the situation must have been less extreme for the Garat Ouda and Takarkori Lakes, which are geomorphologically very different. The Garat Ouda basin survived throughout the wet Holocene–including the 8.2 ka BP–, sustained by the Wadi Tanezzuft, up to its desiccation at ca. 5000 years BP. At Garat Ouda in the middle Holocene the landscape shifted from a lake basin to a delta-lake/playa system. In this phase, we have abundant evidence of fish exploitation in the area; in fact, many middens of–thus far unstudied–fish bones were mapped . The hisCoptodon zillii among the tilapia in the LA3 phase, can be explained by increased aridity. This must have made the waters less suitable for tilapia and in particular Oreochromis niloticus. Clariid catfish, thanks to their accessory breathing organs and greater tolerance to high salinity levels, could thrive much better. Also the increased seasonality in the fluctuation of lake levels may explain the greater consumption of catfish in the middle Holocene and especially in the LP phase, as this species better survives drops in the water level.The palaeohydrological data help interpreting trends in fish exploitation at Takarkori represented in Figs Nowadays, the area of Takarkori does not harbour any aquatic species anymore and the spectrum of terrestrial species is limited compared to the one attested at the archaeological site. The present-day environment may to a large extent be comparable to the one before the onset of the wetter conditions at the beginning of the Holocene. Because the fish species that we described above are unescapably confined to their water basins, they are good indicators for former hydrological connections between areas where relic populations survived during arid periods and areas that were newly colonised after wetter conditions set in.In order to define possible waterways through which fish, and probably also crocodile and aquatic turtle, colonised the area of Takarkori at the beginning of the Holocene, it is necessary to first consider where relic populations of these taxa may have been present in the arid late Pleistocene. Starting from this distribution it is possible to try defining waterways through which the animals from particular refuge areas reached the region of Takarkori.This kind of approach has been used in northwestern Sudan, where Holocene sites with numerous fish bones occur in the now dry Middle Wadi Howar region. The wide species spectrum included many fish taxa not known from refuge areas in the Sahara, and therefore testified a connection with the Nile through the still poorly documented Lower Wadi Howar, during the peak of the Holocene wet phase , 95. ButClarias and tilapia, as well as the crocodile and aquatic turtle that are found there may have come in theory from any of the large rivers or basins further south and east , and some of them are also known from refuge areas in the Sahara itself. The location of these modern or sub-recent populations in the desert have been mentioned in the species descriptions above and the most relevant ones for us include the Ennedi and Tibesti for Clarias, Coptodon zillii and the crocodile. Both Clarias and Coptodon zillii are known nowadays from guelta Efeni  in the Hoggar area. Coptodon zillii has also been reported from the Tassili. However, connections need to be supposed with more distant areas as shown by the presence at Takarkori of Oreochromis niloticus, the other tilapia species identified at the site that is only found today in the Chad, Nile and other large rivers of the Nilo-Sudan ichthyofaunal province. The same is true for the aquatic turtle Pelusios adansonii that is not found in any of the Saharan waterbodies. Crocodiles, finally, live or lived until rather recent times in the Ennedi, Tibesti and Hoggar.The number of aquatic taxa at Takarkori is however limited, the Oreochromis niloticus to colonise the Takarkori area. And if this water-connection existed, it is clear that in theory also Clarias catfish, Coptodon zillii and crocodiles may have taken the same route. Of course, it is not excluded that Saharan relic populations of these taxa may have contributed to the fauna of Takarkori. What still seems strange is why Sarotherodon galilaeus, the third tilapia species known from the Nilo-Sudan ichthyofaunal province is absent at Takarkori despite the fact that it has the same preservation chances as the two other species.Taking into account all the information above, it is clear that the climatic changes at the beginning of the Holocene must have induced changes in the drainage networks–namely their reactivation–that allowed aquatic turtles and Emerging evidence suggests that along the Quaternary, Saharan river systems underwent repeated reactivation in correspondence of interglacial periods e.g., , 98, 99), 9998, 9The nature of the connection should probably not be seen as real waterways running over long distances and crossing the whole Sahara; but rather as a series of catchments that were active and communicating with each other when conditions were periodically or even seasonally more humid. Certainly for the catfish and tilapia, which have limited possibilities of moving over land, it can be hypothesized that they were able to propagate during flood events, when water, with the fish, was decanted from one catchment to the other. Anyway, Saharan watersheds are in many cases difficult to connect even if we consider the occurrence of flooding events, mega-fan divagation, and close basins overflow .Melanoides tuberculata that we also find at Takarkori, but not Corbicula consobrina. However, the relatively high temperatures and low air humidity must have made it extremely unlikely that the less resistant fish eggs or larvae were spread by aquatic birds. During exceptional storms fish can be lifted up [We believe it is unlikely that mechanisms other than the aforementioned migration of fauna during events of exceptional rainfall have played a role in the mobilization of aquatic fauna from a basin to the next one. It has been suggested that in the Holocene birds acted as a mechanism to spread mollusc species between lake and river systems of the Ounianga region as much as in most of the hydrologically isolated sites of the Sahara . Among tifted up  and thisifted up . As we hifted up , these ‘ifted up  also undCoptodon zillii that is better adapted to arid conditions than Oreochromis niloticus and that is still the most common cichlid in the present-day Sahara. Moreover, it appears that the tilapia become smaller in the middle Holocene, possibly as a result of stunting which is known to occur in these fish when waterbodies are small.The remains of both terrestrial and aquatic animals retrieved during the excavation of the Takarkori rock shelter illustrate the more humid climatic conditions in Saharan southwestern Libya during early and middle Holocene times. As the material is so abundant–consisting of 17,551 identifiable remains–and covering a long period–between 10,200 and 4650 years cal BP–it was possible to search for diachronic trends in the faunal spectrum of this unique assemblage. No significant changes in the species composition of the mammals, birds, reptiles or fish are noted except for the appearance of domestic animals (sheep/goat and cattle) from the Early Pastoral phase 1  onwards. However, clear diachronic trends are noted in the proportions of various taxa. In the Late Acacus period  fish remains represent around 90% of all the remains. Interestingly, this proportion remains very robust (80%) until the Middle Pastoral 1  and it then drops in the Late Pastoral phase  when fish contribute only about 48% of the remains. This shift is in line with the palaeohydrological and geomorphological data that could be gathered for the region, indicating the presence of extensive permanent wet environments during the early Holocene, followed by more unstable conditions during the middle Holocene, when the number and extent of waterbodies decreased, and their seasonality increased, resulting in major level fluctuation. The aridification and the increase in seasonality explain the decrease in relative importance of fish compared to the terrestrial fauna as well as the observed changes in the fish fauna itself. Clariid catfish, that can better withstand adverse environmental conditions  become more frequent through time compared to the tilapia. Among the tilapia, an increase is observed in the proportion of the species Pelusios adansonii and the crocodile that are nowadays absent from the region, indicates that connections must have existed in the early Holocene allowing these aquatic animals to colonise the area, starting from places where populations were present in late Pleistocene times. The modern distribution of the aquatic species, which must be comparable to that during the late Pleistocene, was combined with geomorphological and hydrological data of northern Africa to define two possible routes for the colonisation. The species may have come from the Nile, migrating westwards through the eastern Sahara along the hydrographic networks of the Ennedi and Tibesti and the Lake Mega-Chad. Alternatively, the aquatic species may have come from rivers in the Sahel and the Lake Mega-Chad, propagating northwards towards the Hoggar-Tassili hydrographic network and from there towards the Tadrart Acacus area through the palaeotributary of the Niger River. Although it cannot be ascertained which of the postulated routes were actually responsible for the colonisation of the Takarkori area, it is clear that in both scenarios Lake Mega-Chad played an important role in the propagation of aquatic species. It should be underlined as well that these reconstructed palaeohydrographic networks should not be seen as permanently flowing, long waterways. Colonisation may have been a gradual process whereby a series of catchments were active that may have communicated with each other when conditions were periodically, or even seasonally, more humid allowing fish to be ‘decanted’ from one catchment to the next.The presence of the fish, of the aquatic turtle S1 TableList of all the identified fish bone by the chrono-cultural phase. Indicated are the taxon, the skeletal element, the number of these skeletal elements found (NISP), fish length reconstruction expressed in cm standard length (SL), and the number of specimens that could be sized in each case.(PDF)Click here for additional data file.


In the past five months, success in control the national epidemic of coronavirus disease 2019 (COVID-19) has been witnessed in China. The implementation of public health measures accounts for the success which include different interventions in the early or later stages of the outbreak. It is clear that although not all measures were universally effective worldwide, their achievements have been significant. More solidarity is needed to deal with this global pandemic with more learning and understanding. Understanding which of the public health interventions implemented in China were effective may provide ideas for international epidemic control. Aggressive COVID-19 epidemic has hit the health system around the world. In China, a peak-and-fall trend in the national epidemic of COVID-19 was witnessed. We performed an SEIR model  for analysing epidemic trends in China shown in Fig. According to data from the National Health Commission, People’s Republic of China, the number of infected individuals in Wuhan was about 50 000 at the end of February, no inflection points or peaks in cases were expected at the same time . The epiLessons learnt from the influenza pandemic of the early twentieth century in the United States showed that the timing of interventions was crucial for pandemic control: cities with rapid responses had lower excess death rates than cities with slower responses . Hence iThe outbreak of COVID-19 in Wuhan, China coincided with Chinese New Year, and the massive flow of people during the early stages of the Spring Festival promoted the spread of the epidemic. Although there was no effective control of the flow of people at the beginning of the epidemic in the epicentre, a series of measures such as the closure of Wuhan city, traffic control and closed management in community was followed, which has effectively controlled the epidemic. Recent studies found that the closure of Wuhan’s outbound routes postponed outbreaks in other cities by 2.91 days, stopping further spread of the virus and buying time for other cities across the country to prepare for their own epidemics. Among public health interventions, traveling restrictions, quarantine and isolation are the most effective in the early stage of outbreak in Wuhan –6.While Wuhan has implemented various measures to restrict the flow of people, health authorities encouraged people across the country to “stay at home” to avoid unnecessary gatherings and public activities, extended the Spring Festival holiday, and postponed the start of the spring semester. Communities worked with health authorities were responsible for resident information management, outbreak-related education and symptom investigation. In general, the role of “social distancing” and preventive public health policies for epidemic containment were widely understood by the public.Traditional public health interventions undoubtedly played a major role in the containment of the epidemic because no drugs or vaccines have yet been developed against the virus . The detDuring this process, priority always was given to epidemic control. There is no doubt that authorities must reach a consensus with the public, as many limitations and restrictions require a high level of participation from the entire community.Since the COVID-19 outbreak is going to last for a long time worldwide, mass screening which already proved successful in Republic of Korea and disinfection in public places is needed to avoid community communication especially in high risks areas. Containment measures proved to be effective in the early stages of the epidemic also need to be taken seriously in the future, including increasing the production of nucleic acid detection reagents, adopting tailored prevention and control strategies based on different epidemic situations, ensuring sufficient centralising medical resources and encouraging social distancing. Once community communication stars again, second outbreak wave could hardly be prevented. While, we need to constantly monitor reproduction number of COVID-19 and adjust the extent of limitation policies according to the epidemic situation. At the same time, it is also important to solve social contradiction and conflicts caused by limitation policies. Broad solidarity of social groups is required. Policy support for vulnerable populations and industries should be strengthened, especially those below the poverty line and tertiary industries, as COVID- 19 epidemic worsen poverty and inequality by increasing unemployment.Although different countries and regions are experiencing different epidemic situations of COVID-19, the mitigation and suppression measures are effective from China’s experience, which needed to be continuously implemented. According to the severity of the epidemic situation, the extent of public health policies can be adjusted appropriately. Whereas support for vulnerable population and industries is equally important.