With approximately one pathologist for one million people compared to ratios of approximately 1 to 25 000 in the United States and United Kingdom, there is a severe shortage of pathologists in much of Africa. The situation is particularly severe in Zambia, where, in 2009, the ratio was 1 to 1.4 million.To address this, a postgraduate Master of Medicine (MMed) training programme was launched in Lusaka in 2011.The process and most significant challenges and lessons learned were documented, as they may be of value to other countries facing similar challenges.Since 2011, four Zambian pathologists have graduated, doubling the number of indigenous pathologists in the country. Currently 10 students are in training. The most significant problem was issues arising from the split responsibilities of the Ministries of Health and of Education and the most important lesson learned was the crucial need for broad local ownership and commitment.Successfully addressing the shortage of local pathologists by creating country-specific, postgraduate MMed training programmes, even in situations of restricted resources, is feasible. However, having access to and support from the shared resources, expertise and knowledge of a regional College of Pathologists would be a major advantage. It has a high infectious disease burden, but it has also seen a rise in non-communicable diseases, such as ischaemic heart disease and cancer  . Given the shortage of doctors and other healthcare workers needed to face this double healthcare challenge, in 2009, both the 5th National Development Plan and the Ministry of Health National Strategic Plan3 identified human resource development as critical to meeting the United Nations Millennium Development Goals for Health .Zambia has a population of around 17 million. In 2000, it was one of the poorest countries in the world, but over the next decade, rapid growth raised it into the lower middle-income bracket .The shortage was partly due to the general lack of financing for medical education, but also reflected the lack of local faculty to provide the specialist training. In 2009, there were fewer than 10 anatomic pathologists working in Zambia (of whom only 4 were Zambian), a population ratio of 1 to 1.4 million. For comparison, in the United Kingdom, there are about 1800 anatomic pathologists for a population of about 66 million, a population ratio of 1 to 36 000. This deficit meant the majority of the population had very limited access to pathology expertise. To illustrate this, in 2009, the main pathology department in the country, based in the University Teaching Hospital in Lusaka, population around 1.7 million, had around 5000 anatomic pathology cases per year. In contrast, Oxford, United Kingdom, which serves an immediate population of around 750 000 and a wider population of around 2.5 million , has around 55 000 anatomic pathology cases per year . In addition, prior to 2007, cancer therapy had been largely provided in South Africa or Zimbabwe. However, the opening of the Cancer Diseases Hospital in Lusaka in 2007 made provision of appropriate local anatomic pathology services crucial. Furthermore, since 2004, the University of Zambia had trained an increasing number of laboratory scientists, but without a parallel increase in pathologists.Because there was no local pathologist training programme, small numbers of pathologists had been trained abroad , but the great majority had not returned to Zambia. Accordingly, in 2009, in recognition of the need to increase clinical input into laboratory diagnoses and address the shortfall in anatomic pathology, the Ministry of Health identified the local training of pathologists as one of its priorities. To do this, it was decided to set up a Master of Medicine (MMed) degree programme in Pathology at the School of Medicine at University of Zambia. The salary costs of the trainees and of the local trainers and some local infrastructure would be covered by the university and hospital. But given the shortage of specialist staff, equipment and other infrastructure, assistance to set up and run the programme was sought from the Tropical Health Education Trust, London. A grant from the Department for International Development, United Kingdom, to the Tropical Health Education Trust (THET) funded the recruitment and travel of external trainers, infrastructure, such as microscopes, books, modest refurbishment of space and the costs of the external placements of the students.6 and as many other LMICs have a similar lack of pathologists as in Zambia, exploring the problems the Zambia MMed faced and overcame, and describing the lessons learned from this process, may act as a roadmap for such countries. Furthermore, the launch of this programme in 2011 coincided with the launch of the College of Pathologists for East, Central and Southern Africa (COPECSA) (see accompanying article7). As many of the issues identified in Zambia illustrate the potential role for such colleges to assist LMICs in improving the quantity and quality of training in relevant specialties, this article also illustrates how the Zambia MMed could have benefited from the prior existence of COPECSA.As there are very few publications describing the creation of pathologist training programmes in Africa,In 2010, a needs assessment was conducted in Lusaka to analyse the current situation, determine the magnitude of the need and plan the development of a MMed Programme in Pathology. The assessment took into account the major concerns of the public and other stakeholders and health workers, especially clinicians. To do this there were internal interviews with lecturers and students at University of Zambia and key stakeholders including clinicians and Ministry of Health staff, meetings within other clinical departments across the school, and input from a small number of United Kingdom pathologists.Throughout this process, there was considerable discussion about duration and content of the curriculum. Proposals ranged from a one-year or two-year multidisciplinary programme involving haematology, microbiology, clinical biochemistry and anatomic pathology, to a four-year mono-specialty course in cell pathology, with variants in between. The argument for the former was that as the greatest need was for service provision in all the disciplines of pathology, particularly outside the capital city, producing significant numbers of multi-specialty staff as quickly as possible should therefore be the priority. These could be either medical or non-medical staff. Conversely, it was argued that as the ‘clinical pathology’ specialties of microbiology, biochemistry and haematology already had some modest provision through scientists with Bachelor of Science (BSc), Master of Science (MSc), or Doctor of Philosophy (PhD) degrees, the absolute crucial need was for medically qualified anatomic pathologists. As the Ministry of Health had ordained that the objective of the programme was to produce pathologists who would direct provincial hospital laboratories, with overall responsibility for all aspects of pathology, but with personal responsibility for anatomic pathology, eventually the university and ministry agreed that a four-year course, predominantly focused on anatomic pathology, but with some involvement in haematology, microbiology and clinical biochemistry, would be adopted.The process of discussion culminated in a two-day meeting in 2010 for the definition of the aims and objectives of the course, development of a curriculum, determination of the modes of teaching and agreement on the modes of evaluation of the students see . To encoTo recruit students, the School of Medicine placed an advert in one of the local newspapers for Zambian doctors interested in pursuing MMed training in pathology at the University Teaching Hospital, Lusaka. The main criteria for acceptability were the possession of a basic medical degree at the University of Zambia , registration with the Health Professionals Council of Zambia, and completion of at least the intern year and one year as a senior house officer, or equivalent, in country of previous practice. Applicants who satisfied these criteria were interviewed by the course tutors to assess and confirm commitment before selection.The programme, exams and assessments were conducted under the School of Medicine, University of Zambia, regulations for postgraduate degrees. The students had to complete five courses over the four-year programme . ProgresStudents had a weekly programme of tutorials alongside practical sessions and group teaching, the latter taking place around the microscope in the pathology department in the University Teaching Hospital, Lusaka. The great majority of the teaching was done by local pathologists, but some sub-speciality teaching was provided by teachers visiting from the United Kingdom for approximately two weeks . These teachers were all volunteers, recruited on the basis of being long-standing consultants with experience of teaching trainee United Kingdom staff. It was hoped to involve trainee staff from the United Kingdom, but this proved not possible (see section ‘Lesson learned’). Sessions on general skills such as leadership and management, ethics and professionalism  were interspersed throughout the programme. A review of the curriculum and programme was undertaken in 2015, which confirmed that the programme was successful and that only minor changes to timing were needed.Clinical placements outside Zambia in the third year of tuition were an integral part of the programme. They provided trainees with the opportunity to experience techniques and specialisms with limited availability in Zambia – liver, renal, neuro-muscular and bone and joint biopsies and excisions, specialist cytology and autopsy cases and specialist techniques like immune histochemistry and molecular biology. In 2015 and 2016, the clinical placements took place in the Toronto General Hospital, Toronto, Canada, under Professor Runjan Chetty, and to the Aga Khan University Hospital in Nairobi, Kenya, under Dr Shahin Sayed and Dr Zahir Moloo.Through these placements, the trainees acquired new clinical and service development skills. The experience enhanced not only their clinical practice, but also their personal development, as they were exposed to new ways of working in different environments. In addition, the clinical placements encouraged regional collaboration through the exchange of ideas, of lessons learned and through exchange and sharing of resources. They also gave trainees opportunities to attend international conferences while abroad.We do not have access to the costs incurred by the Zambian government, University of Zambia and the University Teaching Hospital, Lusaka, but the costs covered by the THET grant from 2009 until the end of 2015 are shown in After a further one-year preparation period, the MMed in pathology was launched in 2011 with four recruits. The first final exam was held in October 2015 and three out of the four candidates passed. In October 2016, another one of two candidates passed. Thus, in the first two cycles of the programme, the number of local pathologists in Zambia had increased from 4 to 8. All these graduates are currently (2018) working within the University Teaching Hospital, Lusaka. Two have joined the Medical School as lecturers and one is working under the Ministry of Home Affairs as a forensic pathologist. He is currently training in Toronto, Canada, on a year’s forensic pathology fellowship. The fourth graduate has remained in the employ of the Ministry of Health. Currently (2018) there are two students in year 4, five in year 3, one in year 2, and two in year 1 .As one would expect in setting up a new postgraduate programme anywhere, there were a number of challenges and many lessons were learned. However, there were a small number of key challenges . One of BOX 1Main challenges in developing a MMed programme in Zambia, 2010–2016.Differing perspectives of the Ministry of Health and the Ministry of EducationLocal decision-making process sometimes obscureFunding for space, books , equipment (e.g. microscopes)United Kingdom contributions: problems with leave of absence, recruitment of United Kingdom traineesVisa and registration requirements in countries hosting trainees on external placementsGiven the constraints on funding, resources were inevitably another challenge. The biggest constraint was provision of space for the students for private study. Funding for significant new building was primarily the responsibility of the university and the Zambian government and became a prime example of the divergence of opinion between the respective ministries. Even modest refurbishment became difficult as the student numbers increased with each year’s recruits. Obtaining books, journal subscriptions and microscopes, although requiring considerable effort, was less difficult due to the generosity of charities and well-established international organisations dedicated to providing educational support to LMICs. Funding the visits of the external visitors was also largely not an issue as the THET grant covered these costs. Funding the clinical placements was initially well covered by the THET grant, but as numbers increased this became more difficult. In addition, inevitably there were costs associated with the placement that had not been anticipated. For example, in the original budget, we did not allow for fees for the host departments of the clinical placements, necessitating some last-minute budgetary reorganisation (deferred spending and cuts). Similarly accommodation for the trainees abroad proved more expensive than anticipated.The overall spending on the THET grant over the six years was £221 718.62. Accordingly, the cost of each graduate in the first five years of the programme was £55 429.00 ($71 464.00 at current rates). The two biggest costs were the clinical placements and the overheads for the administration of the programme. Most of the rest of the costs were travel and the curriculum review undertaken in 2015. Given that these components had substantial overseas involvement, this is perhaps not surprising. In the future, with much less overseas involvement, the costs per graduate will diminish substantially. Similarly, recruitment of more students in each year will reduce the cost per student.An unexpected issue was the difficulties of United Kingdom staff obtaining time off work to visit and teach. Employers proved very reluctant to view such activity as good for their institution, despite the argument that the returning staff would likely be refreshed with broader horizons. Most visitors had to use holiday entitlement, which inevitably reduced the flexibility and numbers of possible contributors. Similarly, it proved unexpectedly impossible to recruit trainees from the United Kingdom. Originally, we had intended to recruit United Kingdom pathology trainees towards the end of their five-year training programme. It was hoped that, having been through a similar experience recently, they might have a greater insight into the challenges faced by the new Zambian trainees. In addition, like their senior colleagues, it was hoped that the experience would broaden their horizons and benefit their later careers. The recruitment difficulty appeared to be related to constraints within the postgraduate training programmes that had been recently introduced in the United Kingdom where time out from the highly structured programme requires official permission, including formal approval that the external environment is appropriate for training. While this is not unreasonable, it introduced a layer of complexity and bureaucracy which may have deterred some potential participants. Another factor may have been the fact that not all the time spent in Lusaka would have been recognised as equivalent to training time in the United Kingdom, resulting in some extension in the duration of trainee’s overall training. Perhaps not unexpectedly, dealing with the bureaucracy of obtaining visas and registration with the local medical board for the Zambia students while on their clinical placements took more time than anticipated.Firstly, to overcome the inevitable problems of starting a new training programme, it is crucial to have both broad ownership and commitment . This muBOX 2Programme development recommendations.Broad, local ownership and commitment with local champion, leader or driver is crucialAdequate flexible funding necessaryEffective external driver or leader importantRegular (if infrequent) face-to-face meetings necessaryEffective, regular, reliable communication vitalEffective local administration importantCollating information on possible resources would be usefulLong-term planning (> 10 years) is vitalExit strategy crucialSecondly, adequate funding is obviously crucial, but it also needs to be flexible and relatively easily increased – if only modestly. Starting a new programme means that underestimates in budgeting will probably be made, either due to unfamiliarity with costs or because unexpected needs arise – for example, the need to find fees for the clinical placements. Budgetary flexibility is needed to address these unexpected costs. Knowledge of the numerous international charities and organisations that provide free or low-cost access to educational materials is invaluable. A collated list of such organisations would be ideal.Thirdly, in a hybrid programme with both local and external participants, the local leadership needs to be matched with an external leader and champion. The challenges of distance and resource constraints mean there needs to be a clear external individual who is willing and able to take on the challenges. This person needs to be a pathologist. For example, dealing with the problems of identifying external visitors would have been almost impossible via a committee or a non-pathologist. Similarly, it is difficult to imagine identifying and getting the collaboration of external departments and examiners as a non-pathologist. Additionally, it is necessary to have effective external administration. Dealing with several funding bodies, ensuring compliance with appropriate financial and other regulations, identifying external teachers and organising their participation over several years cannot be done without effective administration.Fourthly, in setting up any new programme, there are always problems and regular (e.g. weekly) effective communication between participants is vital. This is particularly true in a hybrid programme such as the Zambian one. When the programme was initiated, even email was somewhat intermittent, proving frustrating. This has improved greatly in recent years with better telecommunication methods such as Skype. It is also necessary to have regular, if infrequent, face-to-face meetings. These are not so much to solve problems  but to provide opportunities for participants to develop relationships and build trust.Lastly, it is crucial to recognise that initiating such a hybrid programme is not a short-term commitment. To allow the programme time enough to stabilise requires at least 5 years and perhaps up to 10 years. This is particularly important to ensuring appropriate continuity of funding and external support. Conversely, it also means ensuring that there is a jointly agreed exit strategy for the external support to allow the local participants sufficient time to prepare for independent ownership.Of the various issues discussed above, two stand out.The first is that the single most difficult and intractable issue was getting the Ministry of Health and the Ministry of Education to agree on which would fund activities and infrastructure that had both educational and service aspects. Such a split between university and hospital perspectives is not unique to Zambia. It is found in most countries where medical education and service delivery are the responsibility of different authorities and is similarly contentious. However, where resources are severely constrained, the tensions are magnified.Given this, what are possible solutions? Once a programme is running, there is no obvious solution to this problem other than repeated discussions with the key individuals – this is where strong local leadership is vital, as identifying such individuals needs local insight. In retrospect, a discussion of the issue during the preliminary stages of setting up the programme, resulting in an agreed allocation of responsibilities, would have been the most appropriate solution. For instance, agreeing during the planning phase to create a joint fund which could have then been used by the programme organisers to fund such combined activities and infrastructure would have saved considerable time, effort and angst. Whatever the approach, the key is to have the issue clearly identified and addressed early in the planning phase.The second issue is that in many low-resource regions, it is very difficult, if not impossible, for any one country to set up and sustain a fully comprehensive training programme. For example, in any one country, there may just not be the necessary number of trainers or the required case mix. The creation of the Zambia MMed in pathology would have been impossible without sharing resources between countries, in this case, between Zambia, the United Kingdom, Canada, Kenya and South Africa. However, the use of trainers from the United Kingdom and of placements in Canada markedly increased the costs of the programme.This is where a regional body, such as a college like COPECSA, could have a key role – especially where such institutions are seen as dedicated to standards and independent of any particular country or government policy. As a transnational organisation, COPECSA could have identified, for example, sites with specialist staff and equipment necessary for specific investigations. It could then have facilitated the short-term transfer of trainees who need training in such topics to this site – this would be analogous to, but much cheaper than, the external clinical placements to Toronto of the Zambia programme. Similarly, having a COPECSA regional core curriculum would have been of major benefit in the creation of the Zambia MMed, saving time and effort. Lastly a regional body such as COPECSA could also have reduced the burden of designing and undertaking examinations by recruiting regional examiners and sharing assessment procedures. A general benefit of such activity would be to ensure high and equivalent standards across the region, perhaps leading in due course to trans-regional recognition of qualifications.The creation of a postgraduate training programme in pathology in countries with limited local resources has many challenges but taking a hybrid approach involving the sharing of resources with other countries is a pragmatic and feasible solution. It is likely that such hybrid programmes are more achievable and sustainable if the countries involved are part of a regional grouping and are facilitated by an independent body such as COPECSA.


Malnutrition is a considerable contributor to child mortality and morbidity. Child malnutrition further affects the country’s economic development. Child malnutrition in South Africa is persistent, continuing to be an alarming burden. The nutritional status of kids under the age of five years is a critical indicator of the country’s economic condition and health status. An understanding of the influencers of the nutritional status of children can act as a catalyst in combatting all forms of malnutrition. The purpose of this paper was to review selected studies concerning the factors that affect the nutritional status of children in South Africa. Studies were selected from electronic databases, which were PubMed, Google Scholar, Science Direct, Sabinet African Journals, and the University of Zululand library catalog. The keywords that were used to search studies and articles from the selected database were: risk factors, child nutritional status, children under the age of five years, South Africa, malnutrition, underweight, stunted, wasting, and over-nutrition. Studies and surveys published from 2010–2019 that reported on the factors influencing the nutritional status of children under the age of five years were included in this review. Twenty-seven articles met the inclusion criteria of the study. The 27 articles were made up of 21 cross-sectional articles and six longitudinal articles. The finding from this review highlights that there is a lack of studies conducted in urban areas. The results show that the nutritional status of children is affected by several factors. These include household food insecurity, low household income, illiterate caregivers, unemployment, inadequate dietary intake, low birth weight, consumption of monotonous diets, poor caregiver’s nutritional knowledge, poor access to water and sanitation, poor weaning practices, age of the caregiver, and demographic characteristics of a child (age and gender). It is critical to have an understanding of the factors that affect the nutritional status of children. Such knowledge can significantly contribute to formulating policies that can enhance nutrition security and the country’s economy. Moreover, insights into strategic interventions to eradicate all forms of malnutrition can be made. Malnutrition is regarded as an intensifying global health challenge that is linked to high-cost care, illness, and death . ChildhoThe problem of child malnutrition is highly concentrated in low and middle income countries, whereby at least one-third of children are malnourished ,5. SouthThe nutritional status of children under the age of five years is regarded as a proxy of the country’s economic condition . TherefoIn South Africa, there is documented evidence of the triple burden of malnutrition, which includes under-nutrition, over-nutrition, and micronutrient deficiency ,14. StunDespite all programs and policies set to combat hunger, malnutrition is still persistent in South Africa. The influencers of the nutritional status in children under the age of five years are not well understood in South Africa. Available studies are geographically limited primarily to rural areas. Yet, poverty-stricken urban areas have shown a high prevalence of child malnutrition.Global scholars convey several factors that cause child malnutrition. Factors that cause child malnutrition differ with geographical location. Child malnutrition in low and middle income countries is also highly manifested by overweightness and obesity, which result from the consumption of food with high calorie content without dispensing the energy consumed through physical activities ,17. StudLittle is known about specific factors influencing the nutritional status of children under the age of five years at a micro level in different geographical locations in South Africa. This situation triggers a need to generate knowledge about factors influencing the nutritional status of children under the age of five years in South Africa. Therefore, this review paper intends to fill this research gap by assessing the factors that influence the nutritional status of children under five years in South Africa using available literature. The United Nations International Children Emergency Funds’ theoretical framework of causes of child malnutrition groups factors that cause child malnutrition into three groups, which are basic, underlying, and immediate causes . The UNIThis paper reviewed the literature on factors associated with the nutrition status of children under five years of age in South Africa from 2010 to 2019. This paper extracted relevant information from literature sources. To ensure that the extracted data was descriptive, we applied a robust selection and exclusion criteria when selecting studies. The inclusion and eligibility criteria are explained in the following section.Longitudinal and cross-sectional studies that determined factors that influence the nutritional status of children under five years of age were considered in this review. This review focused on studies undertaken only in South Africa. The review fixated on peer-reviewed papers published in international scientific journals. Only high-quality articles were considered. High-quality articles were those that met the inclusion criteria for this review and had a meaningful sample size of at least 100 children under the age of five years. This meant that grey literature, such as unpublished studies, conference proceedings, and those that were not peer-reviewed were not included. Although the risk of bias assessment was not a strict requirement in evidence synthesis methods outside of systematic reviews, to avoid bias, we identified all available studies on the topic for the South African context. We also applied an eligibility criterion as described in the inclusion/exclusion criteria . MoreoveOver the past decade, urbanization, political, economic, and social-demographic transition have been witnessed in South Africa . TherefoArticles were searched in the following databases: PubMed, Google Scholar, Science Direct, Sabinet African Journals, and the University of Zululand library catalog search for journals. Key terms that were used to search studies from the selected databases were: risk factors, child nutrition status, children under five years, South Africa, malnutrition, underweight, stunted, wasting, and over-nutrition. In addition to the key terms, factors influencing the nutritional status of children under the age of five years were hypothesized based on the theoretical framework of causes of child malnutrition provided by the United Nations International Children’s Emergency Fund (UNICEF).Factors included basic factors , underlying factors , and immediate factors (such as diseases and inadequate dietary intake). Neighbouring countries such as Botswana and Namibia identified low birth weight as one of the contributing factors to child malnutrition ,27. TherRelevant data were extracted and further analyzed in terms of the characteristics of the included articles. Data were separated in terms of the region covered, such as provinces, urban or rural areas, and informal settlements. Information based on the study date of collection, study design, setting, sample size, nutritional status, and factors influencing nutritional status were extracted independently. Studies with data that were not clear or contradicting and information obtained through reading the discussions of the articles were excluded in this paper.A majority (77.78%) of the reviewed studies were cross-sectional . The remA higher proportion (40% and 29%) of the studies were confined to the Limpopo and Gauteng Provinces, respectively . There wThe majority (62.96%) of the reviewed studies were primarily conducted in rural areas. Of the remaining 33.30% of the reviewed studies that were conducted in urban areas, 14.81% and 7.41% were in informal urban settlements and peri-urban areas, respectively.Between 2010–2014, only 44.44% of the reviewed studies focused on the factors influencing the nutritional status of children under five years in South Africa. There was a progressive increase (55.56%) in the number of studies undertaken between 2015–2019. The prevalence of malnutrition was estimated for each province using the nutritional indicators. The average prevalence percentage of each nutritional indicator was calculated for each province from the selected studies. Studies conducted in the Limpopo Province showed a high (69.90%) prevalence of underweightness . StudiesStunting was the highest (85.18%) nutritional indicator in children that represented malnutrition status from the reviewed studies . StuntinThe reviewed studies depicted several factors that influence the nutritional status of children under the age of five years in South Africa. Nearly half (48.14%) of the reviewed studies identified household food insecurity as the primary factor that affected the nutritional status of children under the age of five years . Low houThis study aimed to review selected studies conducted in South Africa concerning the factors that affect the nutritional status of children under the age of five years. The finding from this review shows that studies conducted on the factors that influence the nutritional status of children are not evenly distributed across the provinces in South Africa. Most studies were concentrated in the Limpopo Province. Most studies were conducted in Limpopo because it is mainly dominated by rural areas, which are perceived to have high levels of poverty and malnutrition. This finding suggests that the factors affecting the child nutritional status are not well documented across all provinces in South Africa. As a result, there may be inadequate policy and strategic intervention to eradicate malnutrition in other provinces. Overall, results from this review show that a high proportion of studies were conducted in rural areas, while few were conducted in urban areas. This implies that there is still a growing census of perceptions that poverty and malnutrition are mainly found in rural areas. Recent studies show that the locus of poverty is shifting from rural areas to urban areas . This fiMoreover, the rapid growth of urbanisation increases the number of households who live in informal settlements . TherefoThe review shows that between 2010–2014 and 2015–2019, the number of studies has increased by 44.4% and 55%, respectively. This drastic increase may be due to the need to tackle the persistent problem of child malnutrition in South Africa that can be linked to the economic slowdown South Africa has been experiencing over the past years. The economic downturn does not neglect the nutritional status of children . The groLongitudinal studies can be beneficiary in identifying historical trends to identify possible solutions and recommendations ,59. GlobFindings from this review reflect a high prevalence of malnutrition across different provinces, where stunting growth is found to be the leading form of malnutrition affecting children under the age of five years. These findings are in line with the South African national survey conducted by Ilifa Labantwana  showing Stunting was the most prevalent form of malnutrition present in South Africa reported by the reviewed studies. This finding is a concern for public health and to the economic advancement of South Africa. Stunting has been identified as the primary indicator that has hindered the achievement of the first Millennium Development Goals (MDGs) . BesidesUnderweightness has been classified as the nutritional indicator that can be used to evaluate and monitor the nutritional status of children ,70. DespAccording to UNICEF , wastingThe World Health Organisation  identifiThe nutritional status of children is also reflected by overweightness and obesity . HoweverMtolo  validateMicronutrient deficiency is also used as a nutritional indicator to describe the nutritional status of a child. Results from this review show that few studies identified micronutrient deficiency as a nutritional indicator that reflected the nutritional status of children in South Africa. However, a national survey conducted by the Ilifa Labantwana  validateFood insecurity was identified as the principal factor that affects nutritional status in South Africa. This finding implies that despite all strategies developed to reduce food insecurity in South Africa, such as the food integrated nutrition programme, zero hunger provision of social grants, and food parcels, food insecurity continues to be a challenge. According to Madiba et al. , food-inSimilarly, Agho et al.  identifiAccording to Shinsugi et al. , low houA low household income encourages households to purchase foods that are cheap, thus with poor nutritional value. As a result, the nutritional status of children is negatively affected . DespiteFindings from this review suggest that the caregiver’s level of education is a factor that influences the nutritional status of children. Nguyen et al.  show thaResults from this review show that a considerable proportion of the reviewed studies identified unemployment as a factor that influences the nutritional status of children. The high levels of unemployment reported by the reviewed studies could be attributed to the majority of predominantly rural studies. Rural areas in South Africa are still classified as areas with a high level of unemployment . Phooko In contrast, Page et al.  argue thDietary intake has a vital role in a child’s growth and development, especially for the first 1000 days of a child’s life . Perez-EFrequent and prolonged child illness can cause loss of appetite, absorption, metabolic disorder, and behavioral changes, which can subsequently affect the nutritional status of a child . On the The consumption of a monotonous diet has been found in this review as a factor that affects the nutritional status of children under five years in South Africa. The consumption of a monotonous diet entails eating food that is not diverse in nutrition and may lack other essential nutrients, for example, vitamins and minerals . The conStatistics South Africa  reportedPoor weaning practices are also found to be a significant factor that influences the nutritional status of children. According to Akombi et al. , poor weThe gender and age of the child may be critical factors that influence the nutritional status of a child. The nutrients required for boys and girls are different; this poses endless debates on the nutritional status of children in terms of their gender. However, several studies reveal that boys are more likely to suffer from malnutrition. The finding from this review also shows that the gender of the child is a critical factor that influences the nutritional status of the child, where boys are more likely to be malnourished compared to girls. There is no clear justification for this. However, Olack et al.  stated tContrary to this, Afolabi et al.  showed tSimilarly, the assertion that the age of the child may influence the nutritional status of the child is also supported by the findings from this review. The justification for the high risk of children under five years to suffer from malnutrition may be due to poor weaning practices that may be undertaken . This siCross-sectional studies mainly dominated this review paper. This implies that this paper relied on data that was collected at a single snapshot point in time, which limited the review to identify trends of child malnutrition status in South Africa over time. As much as cross-sectional studies are efficient, inexpensive, and easy to be carried out, they can allow the researcher to be biased with the representation of results, which may affect the secondary studies . On the This review identified several factors that affect the nutritional status of children in South Africa. These factors can be clustered into three categories, which are related to the household, child caregiver, and those that relate to the child. Factors that relate to household include food insecurity, income, unemployment, and poor access to water and sanitation, while factors that relate to the child caregiver include the caregiver’s age, level of education, and poor caregiver’s nutrition education. Factors that relate to the child include low birth weight, inadequate dietary intake, child illness, consumption of a monotonous diet, poor weaning practices, gender, and age of the child. This review further recognizes the influx of rural to informal urban migration. Yet, most research and efforts to eradicate malnutrition in South Africa are primarily rural-based or concentrated on formal urban settlements. These are critical factors to be considered in efforts to enhance the nutritional status of children in South Africa. This review argues that further research is necessary for understanding the dynamics of child malnutrition in South Africa, and should not be geographically limited to rural areas. Equally so, research is needed on poor urban settings, such as informal settlements. Therefore, in light of the findings of this review, policymakers and government practitioners need to develop strategies that are moulded by factors that affect the nutrition status of children.Further research needs to evaluate strategies that would enhance the nutrition security of households. Findings from this review indicate that the causes of malnutrition are multifactorial, hence the need for comprehensive interventions from both the private sector and government institutions. Institutions such as the Department of Agriculture, Land Reform and Rural Development, Department of Health, and Department of Social Development all need to play a coordinating role in combating child malnutrition. This approach can be enhanced through the provision of adequate nutrition education to households, caregivers, and pregnant women. Furthermore, there must be a provision of nutritious food parcels to vulnerable households. The government should also invest in enhancing environmental health by providing adequate basic services, such as water and sanitation, to communities in South Africa.


In recent years, several generic risk assessment (RA) tools have been developed that can be applied to assess the incursion risk of multiple infectious animal diseases allowing for a rapid response to a variety of newly emerging or re-emerging diseases. Although these tools were originally developed for different purposes, they can be used to answer similar or even identical risk questions. To explore the opportunities for cross-validation, seven generic RA tools were used to assess the incursion risk of African swine fever (ASF) to the Netherlands and Finland for the 2017 situation and for two hypothetical scenarios in which ASF cases were reported in wild boar and/or domestic pigs in Germany. The generic tools ranged from qualitative risk assessment tools to stochastic spatial risk models but were all parameterized using the same global databases for disease occurrence and trade in live animals and animal products. A comparison of absolute results was not possible, because output parameters represented different endpoints, varied from qualitative probability levels to quantitative numbers, and were expressed in different units. Therefore, relative risks across countries and scenarios were calculated for each tool, for the three pathways most in common  and compared. For the 2017 situation, all tools evaluated the risk to the Netherlands to be higher than Finland for the live animal trade pathway, the risk to Finland the same or higher as the Netherlands for the wild boar pathway, while the tools were inconclusive on the animal products pathway. All tools agreed that the hypothetical presence of ASF in Germany increased the risk to the Netherlands, but not to Finland. The ultimate aim of generic RA tools is to provide risk-based evidence to support risk managers in making informed decisions to mitigate the incursion risk of infectious animal diseases. The case study illustrated that conclusions on the ASF risk were similar across the generic RA tools, despite differences observed in calculated risks. Hence, it was concluded that the cross-validation contributed to the credibility of their results. Increasing globalization and international trade contribute to rapid expansion of infectious animal diseases, as illustrated by the recent outbreaks of bluetongue (BT), African swine fever (ASF), lumpy skin disease (LSD), and peste des petits ruminants (PPR) in Europe –3. IntroRisk assessment is a useful tool for prioritization of diseases with respect to their incursion risk, the results of which can be used to assign resources for prevention and surveillance to those diseases posing the highest risk or to identify targets for additional research. Most commonly, risk assessments are developed to assess the risk for a single disease and introduction pathway. In recent years, however, several generic risk models or frameworks have been developed that can be applied to assess the incursion risk for multiple animal diseases –15. In cGeneric RA tools, however, tend to have a lower resolution in their algorithms to allow the assessment of risk over multiple diseases that differ with respect to the species of animals affected, transmission modes, and epidemiological and economic impact. Furthermore, uncertainty and variability are not always considered in much detail. To parameterize generic RA tools, global databases are preferred, as these contain information over multiple countries, diseases, and/or introduction pathways. Application of results from generic RA tools vary from a rapid response to new emergencies to horizon scanning and prioritization of diseases, pathways, or regions.A shared problem of generic tools with bespoke models is the validation of their results. Most import risk assessments estimate the probability of rare events occurring in an ever-changing world, leaving the use of a long range of historical data for this purpose useless. Validation of import risk assessments is, nevertheless, an important step in their development to ensure the plausibility of results. Sensitivity analysis to address parameter uncertainty by varying the values of uncertain input parameters in a plausible range contributes to the internal validation of risk assessments , 17. WitAsfarviridae  by any pathway is evaluated, without assessing subsequent exposure of susceptible animals in the target area via this pathway. In the exposure step the probability that a susceptible native host animal in the target area is exposed to the infectious agent is evaluated given its entry into the target area, without assessing the probability that such exposure would result in infection. In the first infection step the probability that contact with the infectious agent results in infection of a first native host in the target area (= index case) is evaluated given its entry into the target area and exposure of the host animal. In the establishment step the probability that the infectious agent will start spreading in the target area is evaluated given it has entered the target area and resulted in a first infection of native host animals. Establishment is an important step when evaluating the incursion risk of vector-borne diseases, where an infection of a native host animal can be a dead-end if, e.g., no competent vectors are present in the target area or if climatic conditions impede subsequent transmission.Regarding the probability of incursion, four separate steps are distinguished in this study. In the Epidemiological consequences have been defined as the expected spread of the infectious agent in the native (susceptible) population in the target area or further geographical spread from the target area to new regions, considering, e.g., the epidemic size and geographic area affected. Economic consequences have been defined as the expected monetary losses resulting from an outbreak with the infectious agent in the target area due to, e.g., morbidity and mortality, production losses, control measures and trade restrictions.Consequences of disease incursion have been separated into epidemiological and economic consequences. Seven generic RA tools, all developed by the G-RAIDAll seven RA tools were built to be flexible with respect to the animal diseases to be evaluated, although MINTRISK was primarily designed to assess the risk of vector-borne diseases. The total number of diseases evaluated so far with each of the tools varies greatly, as does the level of resources  needed to complete a risk assessment. For all tools, the assessment is less rapid if the disease has not been evaluated before with the tool, because additional data collection and parameterization is required. The RRAT and the IDM tool have the data required to perform the risk assessment readily available in the tool for a multitude of diseases. SPARE and COMPARE have only been parameterized for a few diseases, although the data available on disease prevalence worldwide in these tools can theoretically be used to assess the risk of any OIE-listed disease. MINTRISK, NORA, and SVARRA come mostly without underlying databases and have to be filled by the risk assessor.The tools also differ widely with respect to the number of introduction pathways that can be evaluated . Legal tN) with probabilities of infection (p) based on prevalence levels. All tools that evaluate epidemiological consequences  do so by estimating the basic reproductive number R0  the Netherlands and (b) Finland from any country where the virus strain circulates? In addition, the same question was answered considering two hypothetical scenarios in which ASF cases were reported in Germany. In the first hypothetical scenario (HS1), it was assumed that on 30/12/2017 10 separate cases of wild boar found dead, infected with ASF, were reported from the Munster region of Germany at a distance of ~50 km from the Dutch border . In the The majority of the data required for the generic RA tools can be broken down into four categories: (1) pathway movements from source areas to the target area; (2) disease prevalence in source areas; (3) susceptible animals in the target area; and (4) disease-specific parameters. For the case study, input data used by the tools were harmonized wherever possible to ensure that differences in results would result from model uncertainty rather than input parameter uncertainty. An overview of input data shared between the tools is available in Data on pathway movements are relevant to the entry stage of the risk assessment and focus on how many units  will reach the target area from different source areas, regardless of whether or not they are infected. All generic RA tools derive data on pathway movements predominantly from global databases on international trade. For the legal trade pathways, all of the tools can use one or more of TRACES , Comext For the case study, all of the generic RA tools used Comext trade data for 2017  to assesData on disease prevalence are also relevant to the entry stage of the risk assessment and are used to estimate the probability that animals/products are infected. Disease prevalence in source areas is primarily based on information on disease occurrence derived from the World Animal Health Information System (WAHIS) , althougFor the case study, all generic RA tools were fed with data from WAHIS  on the nData on susceptible animals relate to the probabilities of disease transmission to susceptible populations in the target area. For this category of data input, more variation is observed between the seven tools due to contrasting choices made to model contact between susceptible animals and infected animals/products. Whereas some tools include detailed data on number of animals and farms or livestock densities in the target area derived from global databases such as WAHIS  and FAOSAs a result, harmonization of data on susceptible animals in the Netherlands and Finland was difficult. COMPARE used maps on wild boar abundance , whereasThe category of disease-specific input parameters includes all parameters specific to the disease, such as duration of the latent and infectious period, transmission probabilities, severity of clinical signs, test sensitivities, and decay rates in products. For this category of data input, the tools differ in whether and how they incorporate these parameters; however, all of them primarily used published literature and expert opinion to find relevant parameter values.For the case study, disease-specific parameters were sourced individually by each tool from published literature e.g., –61] and  and 61)]Although ideally both the probability of incursion of disease and its consequences are evaluated in assessing the incursion risk of exotic diseases, results of the generic RA tools for the ASF case study could only be compared for the probability of incursion, because consequences were only assessed by some tools. A comparison of absolute results obtained by the seven generic RA tools was not possible though, because endpoints for the probability of incursion varied from entry to establishment . In addiRRcij) for each tool i was calculated for each pathway j as:The relative risk across the two countries  only.where RRHS1ijk and RRHS2ijk) for each tool i were calculated for each pathway j and each country k as:Relative risks across scenarios , RHS1ijk is the calculated risk by tool i for pathway j and country k for the first hypothetical scenario (ASF in wild boar in Germany), and RHS2ijk is the calculated risk by tool i for pathway j and country k for the second hypothetical scenario (ASF in wild boar and domestic pigs in Germany).where −10, based on the lowest results that were calculated by the tools .In order to calculate relative risks for the qualitative RA tool SVARRA, qualitative probability levels were converted to numerical values using a log-scale, where negligible = 1, very low = 10, low = 100, etc. The in-between probability level negligible/very low was given a numerical value of ores see , making 7 times higher).For each of the generic RA tools, the ASF incursion risk to the Netherlands was compared to Finland for the pathways (a) trade in live animals, (b) trade in animal products, and (c) wild boar movements. Results for the baseline scenario (2017 situation) are given in Six of the seven RA tools evaluated the animal products pathway (MINTRISK did not) . COMPAREAgain, six of the seven RA tools evaluated the wild boar pathway (RRAT did not) . COMPAREFor each of the generic RA tools, the ASF incursion risk of both hypothetical scenarios was compared to the baseline scenario. Results for the Netherlands and Finland are given in 3 times higher). NORA was the only tool of those evaluating the wild boar pathway that did not predict an increased risk for this pathway in HS1 to the Netherlands. The addition of a single ASF outbreak at a domestic pig farm (HS2) resulted in a slightly increased risk to the Netherlands for the live animal trade pathway compared to HS1 for MINTRISK, IDM and NORA, and a slightly increased risk for both the live animal trade pathway and the animal products pathway for SPARE, COMPARE and RRAT. SVARRA indicated that the ASF outbreak at a domestic farm in Germany (HS2) did not further increase the ASF risk to the Netherlands compared to HS1.The hypothetical situation in which ASF cases were reported in wild boar in Germany (HS1) resulted in an increased risk to the Netherlands compared to the baseline scenario, especially for the wild boar pathway. In particular SPARE and COMPARE predicted a much higher risk  did not increase the risk to Finland compared to the baseline scenario. Only IDM and NORA predicted a slightly increased risk for the live animal trade pathway and the animal products pathway, respectively. The addition of a single ASF outbreak at a domestic pig farm (HS2) resulted in a slightly increased risk to Finland for the live animal trade pathway compared to HS1 for SPARE and IDM, and a slightly increased risk for the animal products pathway for SPARE, COMPARE, and RRAT. MINTRISK and SVARRA indicated that the presence of ASF in wild boar and/or domestic pigs in Germany did not increase the ASF risk to Finland compared to the baseline scenario.Overall, most tools agreed that (when considered) animal products constituted the highest risk to Finland for all three scenarios, and to the Netherlands in the baseline scenario. For both hypothetical scenarios the animal products pathway was still predicted to have the highest risk to the Netherlands by COMPARE and RRAT. However, NORA indicated a change in risk such that trade in live animals became the pathway with the highest risk for ASF incursion when the disease was assumed to be present in Germany. Under all scenarios the SVARRA tool did not have a single pathway constituting the highest risk to the Netherlands resulting from the lack of resolution available with a qualitative approach when risk estimates are close. The presence of ASF in Germany resulted in an increased risk estimate for the wild boar pathway in SVARRA, such that all three pathways had an equal risk level in the hypothetical scenarios. MINTRISK was the only tool not to consider animal products and concluded that from those that were included , wild boar was the pathway associated with the highest risk, for both the Netherlands and Finland.Some of the tools included more pathways than the three investigated here . When taValidation of generic RA tools is a challenging task for which no gold standard is available. In this study, we explored the opportunity to cross-validate seven generic RA tools by universally applying them to a predefined case study on the incursion risk of ASF. Comparison of the absolute results from the tools was not possible for several reasons, including their differing objectives, endpoints, outputs, and risk pathways considered. However, by comparing relative risks it was possible to cross-validate the generic RA tools across the different pathways, between the two countries of interest (Netherlands and Finland) and between the three scenarios that were evaluated.In general, the tools agreed on the ranking of the target countries for the pathways evaluated, although the magnitude of relative risks calculated differed widely . All of When comparing the hypothetical scenarios to the baseline all of the RA tools indicated an increased risk to the Netherlands due to presence of ASF in wild boar and/or domestic pigs in Germany, especially for the wild boar pathway, whereas most tools agreed that the risk to Finland would stay at the same level or increase slightly. However, differences were observed between the tools on the extent to which the live animal trade pathway contributed to the increased risk to the Netherlands.Investigating the ranking of risk pathways, comparisons could only be made for five of the seven tools, as the risk estimates for individual pathways in SPARE and IDM were given in different units and at a different scale, respectively. Comparisons of rankings were further complicated by the different numbers and types of pathways evaluated by each of the tools. Although Differences in calculated relative risks over countries and scenarios between the tools can be largely explained from (i) differences in endpoints considered when evaluating the risk of ASF incursion, (ii) different quantitative scales on which the risk estimates were scored, and (iii) differences in the definition of pathways.SPARE was the only tool that evaluated the entry of ASF into the target area without considering exposure or first infection of native animals. This has probably contributed to the differences observed between SPARE and the other RA tools when evaluating the relative risk from the animal products and the wild boar pathways to the Netherlands compared to Finland in the baseline scenario . No such−4 to 104 with a scale consisting of five levels (ranging from very low to very high), the relative risks estimated by SVARRA never exceeded 10, since differences in risk were always equal to or less than one probability level.All tools but SVARRA produced numbers to express the incursion risk of ASF to the Netherlands and Finland, although the quantitative scales differed among the tools see . AbsolutDifferences in calculated relative risks over countries and scenarios might also have originated from how pathways were defined in the tools. Trade in live animals was most uniformly defined, although some tools  not only included trade in domestic livestock animals, but also trade in horses, pets, and exotic mammals and birds. This will, however, not have resulted in differences for the ASF risk, since the only animals affected by ASF are porcine species (including wild boar and warthogs) , 59, 62.MINTRISK is the only tool in which pathways are not predefined. The risk assessor can thus decide upon the pathways to include in the risk assessment and will preferably include those that are deemed most important given the transmission mechanisms of the disease. Although trade in animal products was considered an important route for ASF, the risk assessors decided not to include it because of lack of information on whether animal products were derived from domestic pigs or wild boar. The other tools did not offer the opportunity to distinguish between products from domestic pigs and wild boar and included both in the animal products pathway. The asset of having user-defined pathways in MINTRISK thus created another level of uncertainty in the results of the risk assessment which is beyond parameter and model uncertainty.Differences in (implicit) modeling assumptions between the generic RA tools might have further contributed to the observed differences in the evaluated ASF incursion risk between the tools, although it is difficult to predict their impact on the calculated relative risks. For instance, the level of detail at which contact with susceptible animals in the target area was modeled varied widely among the tools, with some of them only using an overall probability estimate , while others explicitly modeled how different animal species (COMPARE) or livestock farms (SVARRA) would be exposed. Another example is that RRAT and NORA used worst case assumptions to evaluate the ASF incursion risk whereas the other tools used more realistic assumptions. Furthermore, the time period for which the risk assessment was performed differed among the tools. Most tools used an annual timescale and thus assessed the ASF incursion risk using data from a 1-year period (here: 2017). However, NORA and SVARRA considered a 3-month period to account for the high-risk period of newly infected territories, when no trade restrictions are in force yet. For some tools, decisions on these issues were embedded in the model structure, and could thus be attributed to model uncertainty, whereas for other tools, decisions were taken by the risk assessor performing the ASF case study.The ultimate aim of these generic RA tools is to provide risk-based evidence to support risk managers in making informed decisions on reducing the incursion risk of infectious animal diseases by, e.g., preventive actions, targeted surveillance, and contingency planning. While absolute risk estimates contribute to the decision on whether any preventive actions are required or not, relative risk estimates are useful for prioritization of risk management options. Prioritization of diseases, pathways and/or target areas is an important output of all seven generic RA tools in this study . CompariFurther validation of generic RA tools could be achieved by comparing their outcome for a specific risk question with results from bespoke models that were specifically developed to address this risk question. Although several bespoke models were developed for ASF in recent years –31, resuApplication of the tools for a prolonged period might create an opportunity for external validation using field data. Some of the generic tools have been up and running for at least 5 years now. IDM was first released in 2011 and has intensively been used in the UK by Defra and the Scottish Government's Center of Expertise on Animal Disease Outbreaks (EPIC) to prioritize their risk levels for incursion of disease at different times of the year. SVARRA was first used in 2013 and has been used for several rapid risk assessments including ASF, BT, LSD, and avian influenza (AI). However, one of the difficulties in validating models evaluating the incursion risk of exotic diseases is that the adverse events being modeled have a low probability of occurrence resulting in too few data points for validation, even when used for a prolonged period.This study clearly illustrates the impact of model uncertainty on risk assessment results. Although the generic RA tools agreed on the direction of the relative risk of ASF to the Netherlands and Finland, the magnitudes of these relative risks varied largely, especially for the live animal trade and wild boar pathways. The range of results obtained when considering the results of all generic RA tools could be interpreted as an indication of the uncertainty included in the risk estimates. The results of the bespoke models fell well within this uncertainty range.Several methods exist to combine the results of different models that predict similar metrics, such as ensemble modeling, structured decision making and model averaging . AlthougOrnithodoros, these vectors do not seem to play a role in ASF virus transmission in Europe (The choice for one or more generic RA tools to answer a specific risk question will depend on the primary objective of the risk assessment, the diseases and pathways that need to be evaluated, the resources and expertise available, and the timescale at which the risk assessment has to be completed see . Some ofn Europe . Hence, All datasets generated for this study are included in the article/CV and ES initiated and conceptualized the research. RS provided harmonized data from Eurostat and WAHIS. RS performed the case study in SPARE. RT and ES performed the case study in COMPARE. AK, MC, and AB performed the case study in MINTRISK. RP, MS, and CV performed the case study in RRAT. HR performed the case study in IDM. TL and LS-L performed the case study in NORA. CH, KS, and AC performed the case study in SVARRA. SN developed the bespoke models to evaluate the ASF incursion risk. CV did the analysis of results and drafted the manuscript. All authors reviewed and edited the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Within-group changes revealed a significant reduction in ODSs within the intervention group from baseline to the third (p < 0.001) and sixth weeks (p < 0.001) of the intervention. This simple interactive LBP module was effective in reducing symptoms of LBP among nurses as early as three weeks, and this effect was sustained until the sixth week of the intervention.The prevalence of low back pain (LBP) among nurses is high. The main aim of this study was to evaluate the effectiveness of an interactive LBP module based on the Back School Program in improving Oswestry Disability Scores (ODSs) among nurses in government hospitals in Penang, Malaysia. A cluster-randomized experimental study was conducted within four public hospitals. These hospitals were randomized to intervention and control groups. A total of 284 nurses from the selected hospitals were randomly selected (142 in each group). An interactive LBP intervention module based on the Back School Program was designed and prescribed. Both the intervention and control groups were assessed using the Oswestry Disability Questionnaire at baseline and at the end of the third and sixth weeks. Out of 284 participants, 281 completed this study. A between-group comparison revealed that ODSs were significantly lower in the intervention group than in the control group at the ends of the third ( Low back pain (LBP) is a common symptom with the potential to cause severe disabilities that constitute a major public health problem worldwide. According to the Global Burden of Disease 2010 Study, LBP ranked sixth from the perspective of the disability-adjusted life year. Globally, nearly 9.4% of people have experienced LBP; further, LBP is the main cause of disability and nonattendance from work in as many as 187 countries [Physical and mental demands may cause nurses to leave their jobs. Nurses may be exposed to several hazards that may result in LBP while providing patient care. An overview of five nations revealed that 17% to 39% of nurses wanted to quit their employment because of the physical and mental commitments required by their jobs . The preToday, nursing associations are working toward the advancement of wellbeing and disease anticipation among nurses. The International Council of Nurses (ICN) has emphasized the importance of establishing work environments that are conducive to positive patient outcomes. The ICN has also recommended the establishment of national and local organizational policies focused on injury prevention, including prevention of LBP among nurses . StrategThe Back School Program is a method of preventing recurrent episodes of LBP developed by Mariane Zachrisson Forssel in 1980 . This inAdmitting the rising burden and negative consequences of LBP among nurses in our study population, an interactive LBP module was developed based on the Back School Program to suit the local context and provide local data for LBP prevention strategies. Specifically, we aimed to evaluate the effectiveness of this module among nurses with LBP in government hospitals in Penang, Malaysia by comparing disability scores between control and intervention groups. We hypothesized that an intervention module based on the Back School Program involving a combination of muscle strengthening, stretching, muscle mobilizing, and core stability exercises using gym balls would be effective in reducing symptoms of LBP among the nurses in our study population.In a previous cross-sectional study, we identified that 898 out of 1292 (76.5%) nurses in the public hospitals of Penang suffered from LBP in 2016 . As a co2 area with a population of 1,902,116 as of 2016. The intervention program was held at Hospital Pulau Pinang and Hospital Balik Pulau (Penang Island), while the control group program was held at Hospital Seberang Jaya and Hospital Kepala Batas (Seberang Perai).This intervention study was conducted in four out of six government hospitals in Penang, Malaysia. The state of Penang is located on the northwest coast of Peninsular Malaysia, allocated by Penang Island and Seberang Perai, and covers a 586 kmA total of 284 nurses with significant LBP were randomly selected from the selected government hospitals in Penang. Significant LBP was defined as persistent, disabling chronic LBP occurring for three consecutive months and self-rated as pain with an intensity of >20 mm on the visual analogue scale for pain . Nurses Participants were given the option to withdraw at any point in time. The withdrawal criteria included pregnancy during the intervention period, injury during the intervention program, worsening back pain, changes in place of work during the intervention, and withdrawal due to personal option.Ethical approval was obtained from the Human Research Ethics Committee of University Sains Malaysia (USM/JEPeM/15090308) and the Malaysian National Medical Research Register (NMRR-15-1668-27637). Permission to use the BACKS Tool was obtained from the Center for Collaborative Innovation of University Kebangsaan in Malaysia. A grant for this research was received from the Division of Research and Innovation of Universiti Sains in Malaysia. At each participating hospital, on-site permission for the nurses to participate in this research was obtained from the hospital director, the matron-in-charge, and the ward/clinic’s sister-in-charge. Verbal and written informed consent were obtained from participants preceding the intervention.The sample size was calculated using the two dependent means option in STATA SE 11 software  with Oswestry Disability Scores (ODSs) as the outcome variable of interest. The correlation between the baseline and follow-up measurements was taken as 0.5 to determine the effectiveness of the intervention (range: 0.5–0.7). To achieve a power of 80% with 5% Type I error, a sample size of 142 per arm was calculated.The government hospitals were stratified into specialist and non-specialist hospitals to ensure that both groups were balanced in terms of work burden. Then, two hospitals were randomly selected from each cluster. A simple random sampling method was used to choose two of three hospitals  to ensure the representativeness of the sample and avoid any selection bias. Simple randomization was implemented to allocate a cluster of two out of three hospitals with specialist services and two out of three hospitals without specialist services into the intervention and control groups. One hospital from each cluster was assigned to the intervention group, and the other hospital from each cluster was assigned to the control group. Individuals who were unaffiliated with the present research drew lots for this process of allocation to the intervention and control groups. To avoid contamination in the intervention program, the selected hospitals were assigned to the intervention and control groups by different hospitals. Nurses from each selected hospital who were identified in our previous study as having LBP were randomly selected using a simple random sampling method. A schematic diagram of this selection process is depicted in In this cluster-randomized trial, an LBP module was developed based on the Back School Program, consisting of a health education module with an exercise method to overcome LBP and prevent LBP from worsening. This module was developed by a group of specialists, including a rehabilitation specialist, an occupational specialist, a public health specialist, and a physiotherapist. The main objective of this module is to help nurses increase their awareness of back pain care, improve their LBP, and subsequently promote a healthy lifestyle in the nursing workplace. This intervention module was designed to be a simple, sustainable, and affordable program that can be practiced at home without supervision.The health education session consists of four sections: The exercise intervention package in this study was based on the Back School Program with the addition of a core stability exercise requiring the use of a gym ball. The Back School Program is a set of exercises aimed at improving mobility, flexibility, and strength. With the addition of a gym ball exercise, the intervention package developed for this study consisted of exercises for stretching, strengthening, mobilizing, and exercising core stability. The participants in the intervention group attended an exercise program for three sessions every alternate week over the course of the first six weeks. The duration of exercise per session was two hours. Exercise sessions were held from Monday to Thursday from 2:30 p.m. to 4:30 p.m. These sessions were held in the evening to allow ample time for nurses working morning shifts to attend the sessions after finishing work at their wards. The nurses were allowed to choose either one of the sessions each week so that the intervention did not disturb their ward duties. During the exercise sessions, the participants were instructed not to go beyond a comfortable range of movement.The exercise sessions were held at the physiotherapy department of each hospital and conducted by a group of experienced physiotherapists in the presence of the researchers. In each session, three physiotherapists were assigned by the Department of Physiotherapy at Penang General Hospital to train the nurses and ensure that their exercise techniques were correct. In each session, the physiotherapists reviewed the nurses’ exercises and home diaries and facilitated their problem in doing exercise. A pamphlet with information regarding the exercise regime was given to all participants in the intervention group to help them carry out the exercise techniques in their homes. This pamphlet described the steps involved in every exercise conducted in this study.The exercise program included muscle stretching, strengthening, mobilizing, and core stability exercises using a gym ball . The musThe back strengthening exercises included (a) a multifidus exercise and (b) the Spiderman exercise. The multifidus exercise required the participants to bear their bodies with both hands and knees bent, keeping their hands under their shoulders and their knees under their hips. The participants were also instructed to make sure that their spines were in a neutral position, to keep their heads in line with their spines, and to breathe in and out. During exhalation, one leg was to be straightened and the opposite arm was to be in line with the spine. This position was held for 5 to 10 s and then repeated on the opposite side. The Spiderman exercise required the participants to lie down on the floor with their faces down and their stomachs flat on the floor. Next, both their arms and their legs were to be raised simultaneously and their chests were to be lifted so that their backs were off the floor. This position was maintained for 2 s before slowly returning to the starting position. This routine was repeated in 10 to 15 repetitions.The muscle-mobilizing exercises included (a) a knee-to-chest exercise and (b) a lower back twist. In the knee-to-chest exercise, the participants were instructed to lie down and bend their knees up, pulling both knees slowly back toward their chests; this movement was repeated ten times. In the lower back twist exercise, they were instructed to lie on their backs, bend and press their knees, and move their knees from side to side ten times.Finally, the core muscle stability exercises included: (a) a supine hip twist with a gym ball and (b) a bridge exercise with the head on a gym ball. For the supine hip twist, the participants were instructed to lie on the floor with their hips and knees bent 90 degrees and their feet set upon the gym ball. Next, they were instructed to tighten and hold their abdominal muscles. Then, they were to lower their knees to one side of the hips in a slow, controlled manner, avoiding contact with the floor. Finally, they were to raise their knees back to the starting position and repeat the exercise on the opposite side. These exercises were repeated 10 to 20 times on each side. The bridge exercise required the participants to align their shoulders at the top and middle of a gym ball with both their hands at their ears. Then, they were to place both feet on the floor and keep their thighs parallel to their bodies, maintaining a straight line from neck to knee. The participants were instructed to hold this position for 3 to 5 s and repeat the exercise 10 to 20 times.The control group was given standard care and advice for a sedentary lifestyle by an attending doctor without referring to any specific module. Then, the controls were given the same questionnaire (the Oswestry Disability Questionnaire) and assessed simultaneously with those in the intervention group. A researcher asked the participants if any problems arose to improve the relationship between the researchers and the respondents. The respondents were advised to feel free to contact the researcher at any time if they needed assistance throughout the intervention program.The Oswestry Disability Questionnaire is a component of the BACKS Tool. It is a self-completed questionnaire containing ten subheadings intended to examine pain intensity, ability to lift, ability to care for oneself, ability to walk, ability to sit, sexual function, ability to stand, social life, sleep quality, and ability to travel . Six staThe study protocol started with a baseline assessment, which was followed by an intervention package of health education sessions and exercises for back pain, some of which involved a gym ball. The respondents attended the intervention program for six weeks. Diary reviews and follow-up assessments were conducted at the ends of the third and sixth weeks post intervention program. Adequate time was allowed for participants to respond to the questionnaire at each assessment session.Baseline assessments of the intervention and control groups were conducted on separate consecutive days. All participants completed the Malay version of the Oswestry Disability Questionnaire, which was administered by a trained interviewer to small groups of eight to ten respondents. This questionnaire takes approximately 15–20 min to complete. At the ends of the third and sixth weeks of the intervention, the participants were required to complete the questionnaire again. The assessments were completed on separate days for the intervention and control groups. The participants’ home diaries and any problems or adverse events reported in these diaries were evaluated on the assessment days.The exercise programs were conducted in four sessions per week, and each nurse was required to attend any two of these sessions per week according to their convenience. The participants were provided with reassurance and motivation to comply with the exercises during each session. Physiotherapists demonstrated, observed, and corrected the performance of the exercises. Clear instructions concerning how to perform the exercises were provided in a manual and a CD that were distributed to each participant in the intervention group. Participants were required to keep logs of their performance of the exercises in a book that was provided to them, and these logs were assessed by the physiotherapist during their weekly appointments. The participants were also required to perform the exercises in front of the physiotherapist at least once per week. This allowed the physiotherapist to confirm the proper execution of these exercises and correct any improper techniques. These regular reviews also served to reinforce the importance of exercising and encourage consistency. For the nurses who could not attend these sessions at the stipulated times, new schedule arrangements were made at follow-up.n) and percentages (%). Sociodemographic characteristics were compared between groups using a chi-square test.In this cluster-randomized trial, the units of analysis were the individual nurses rather than clusters. Data entry and statistical analysis were conducted in IBM SPSS version 22 . The collected data were checked, explored, and cleaned prior to analysis. Each participant’s age was categorized as less than 30 years old, 30 to 40 years old, or more than 40 years old. Other variables included body mass index , gender , marital status (single or married), education level (having a diploma or education above a diploma), and number of children . All variables were presented as frequencies . Descriptive statistics concerning the participants’ ODSs were presented as means (SDs), and baseline scores were compared between the control and intervention groups using an independent samples t-test. p-value of less than 0.05 was set as the level of significance.A repeated measure analysis of variance was conducted to determine the effectiveness of the intervention module by assessing two effects: a time-intervention effect and a time effect. Normality of residuals, homogeneity of variance, and assumptions of compound symmetry were examined as well. For all the aforementioned statistical tests, a Out of 284 nurses , only 281 participants  completed the study. Two nurses in the intervention group discontinued the intervention due to pregnancy, and one nurse in the control group was unable to continue due to a transfer to another state . No adveMost of the nurses were aged less than 30 years old in both the intervention group  and the control group . Further, the body mass index of most participants in both groups were within the normal  or overweight range. The majority of the nurses were female and married with no children. The sociodemographic characteristics of the participants are described in d = 0.33). A similar finding was observed at the end of the sixth week of the intervention , from baseline to the sixth week (Cohen’s d = 1.40), and from the third week to the sixth week of the intervention (Cohen’s d = 0.72).The multivariate test showed that the F-statistics probability was significant, indicating significant within-group changes over time. A pairwise comparison showed that the mean ODS of the intervention group significantly improved from baseline to the third week (Cohen’s d = 0.11) or from the third week to the sixth week of the intervention (Cohen’s d = 0.18). However, the mean ODS of the control group did significantly reduce from baseline to the sixth week of the intervention , range of mobility, or any other objective variables served as a limitation in this study. Based on the discussion above, we can conclude that the combination of muscle stretching, muscle strengthening, muscle mobilization, and core stability exercises using a gym ball has proven effective for the treatment of LBP. The interactive LBP module developed in this study was effective in improving overall LBP among nurses at Penang Public Hospital. This intervention module was constructed to ensure that nurses could complete their exercises using simple, suitable, and sustainable techniques in a home setting with limited facilities. The introduction of interactive LBP modules could impact the physiotherapeutic management of back pain by encouraging new initiatives that may ultimately improve quality of care.


Malaysian Journal of Medical Sciences (MJMS)’ performance as a journal, along with important changes in the administration and achievements of the journal itself. We report here its submission trends, rejection rates, manuscripts accepted based on submitting country/region and impact factor scores for calendar year 2019.Once a year, we report the  Malaysian Journal of Medical Sciences (MJMS) continues to receive increased number of new manuscripts submission every year. In 2019, there were 453 new manuscripts submitted to MJMS (a 26% increase over that of 2018).On average, the New manuscripts submitted to MJMS would initially be assessed to a lesser degree by the Editorial Office to ensure they conform to MJMS requirements and the subject discussed was relevant to MJMS’ main focus. At this level, only a few numbers were desk-rejected and did not make it to the peer-review process. A considerable number of rejections happened to manuscripts which had succeeded to undergo at least the first hurdle of peer-review process and had gone through intense judgement in terms of scientific merit, not technical mistakes. In another word, it depended more on the quality of the manuscripts, not the number of reviewers .™ system  for the second time, after the first award as the Potential Journal received in 2016 from the Ministry of Higher Education, Malaysia.


Rather disappointingly, they have overlooked the purpose and the content of our work and so, we have the following comments.We have read with interest the article by Finsterer J. et al. [3]. A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient [4]. Therefore, our article is not a study of any kind.As our title indicates, our article is a case report, not a clinical trial. The World Health Organization defines the clinical trial as any research study that prospectively assigns human participants or groups of humans to one or more health-related interventions to evaluate the effects on health outcomes . By far the most important issue to be addressed is that the diagnosis was genetically confirmed. Blood mitochondrial analysis was performed . Furthermore, we considered it necessary that the mother was genetically tested, given that “de novo mutation” is rare in LHON, but possible [6]. To the best of our knowledge, in Romania, the determination of the level of heteroplasmy in blood leukocytes of LHON patients and unaffected carriers is not routinely performed in clinical practice, in the public health system, or in the private one. No specific environmental precipitant for vision loss in LHON mutation carriers has been clearly identified. Various other systemic illnesses, medications, and toxins have been proposed as triggers for vision loss in the setting of LHON mutations and nutritional deficiencies (e.g. vitamin B12 deficiency) might also play a role in the disease expression through an insufficiency of important metabolic cofactor, but none of these risk factors has been identified in our patients [7]. Patients are strongly advised to moderate their alcohol intake and not to smoke, in order to minimize mitochondrial stress [8]. The gender could also result from a combination of subtle anatomic, hormonal, and/ or physiologic variations between males and females, the ratio between female and male in symptomatic patients being 1:3 . Due to difficulties in tracing back a more extensive family history, other members of the family could not be genetically tested.Regarding the mutation load, the proportion of mutant mtDNA and the incidence of disease development do not necessarily show a high association. Variable expression of LHON has been considered to result from a variation in additional genetic or environmental factors other than the level of heteroplasmy. However, a correlation between the extent of heteroplasmy in the circulating leukocytes and the risk of developing optic atrophy or the severity of the disease has also been reported. Thus, the accurate quantification of heteroplasmy will help determine the relative risk of disease expression, although heteroplasmy alone cannot determine the risk of developing optic atrophy in LHON [2]. Moreover, idebenone treatment in our country is initiated only in patients included in the National Health Program for LHON, our patient satisfying all the criteria for inclusion in the program [10]: Another very important aspect that needs to be specified is that treatment with idebenone was initiated in our patient only after the diagnosis was genetically confirmed .Furthermore, by the time our article [2]. Also, a multidisciplinary approach for our patient was considered and developed between the initial presentation and the genetic confirmation. This approach aimed both outlining a differential diagnosis and a full systemic evaluation in the context of the strong suspicion of LHON. As such, paraclinical investigations were carried out and all extraocular features were excluded [Fig. 6) in the early stages of the disease was explained in the article [2]. It was consistent with both the fundus examination , which demonstrated bilateral protruding, hyperemic, with blurred margins in the nasal quadrant papilla and reduced excavation, and the compensatory increase of mitochondrial biogenesis and/ or axonal stasis along the fibers, which did not allow detection of optic nerve atrophy in the early stages of the disease [11].Additionally, the observation of RNFL thickening (Finally, considering the arguments presented above, it resulted that our case report was thoroughly grounded, based on objective data, analyzed, and corroborated with maximum diligence, in accordance with the highest national standards, as long as the criticisms made by Finsterer J. et al. are essentially unfounded. Financial DisclosureNone of the authors has any financial or proprietary interests to disclose.