This research sought to assess whether and to what extent the ongoing economic crisis in Italy impacted hospitalizations, in-hospital mortality and expenditures associated with acute myocardial infarction (AMI).The data were obtained from the hospital discharge database of the Italian Health Ministry and aggregated at the hospital level. Each hospital (n = 549) was observed for 4 years and was geographically located within a “Sistema Locale del Lavoro” . For each SLL, the intensity of the crisis was determined, defined as the 2012–2008 increase in the area-specific unemployment rate. A difference-in-differences (DiD) approach was employed to compare the increases in AMI-related outcomes across different quintiles of crisis intensity.Hospitals located in areas with the highest intensity of crisis (in the fifth quintile) had an increase of approximately 30 AMI cases annually (approximately 13%) compared with hospitals in area with lower crisis intensities (p<0.001). A significant increase in total hospital days was observed  in addition to in-hospital mortality . As a consequence, an increase of around €350.000 was incurred in annual hospital expenditures for AMI .More attention should be given to the increase in health needs associated with the financial crisis. Policies aimed to contrast unemployment in the community by keeping and reintegrating workers in jobs could also have positive impacts on adverse health outcomes, especially in areas of high crisis intensity. The ongoing financial and economic turmoil requires policymakers to have a comprehensive understanding of the broad consequences of rising unemployment rates. The medical and health policy literature has raised concerns about the impact of the economic recession on population health, and several recent studies have investigated the effect of the unemployment rate on mortality and healthcare expenditures in Europe after the financial crisis in 2008 –4.The main purpose of this paper is to investigate whether and to what extent the increase in the unemployment rate, due to the recent economic crisis, has impacted hospitalizations and in-hospital mortality associated with acute myocardial infarction (AMI).Among the different health outcomes, AMI is particularly important in this context. The risk factors for heart attacks are well known and could be affected by the stress and anxiety induced by adverse economic and environmental conditions , 6. In aResearch on the health effects of previous recessions has produced results that seem conflicting. In particular, there is a distinction to be made between individual and aggregated/ecological measures of unemployment.When individual job loss experience is considered, the literature is consistent in showing that unemployment is associated with poor health, especially when the job-loss is involuntary. For example, the Health and Retirement Survey in the US has been used to show that involuntary job loss negatively and significantly affected both physical functioning and mental health  and thatWhen studies try to detect a more general  relation between the economic environment  and health, the results are still rather controversial. A recent study of economic fluctuations in Europe, based on aggregate data, showed that worsening employment and other economic indicators  affected mortality from specific causes in different ways. A rise in unemployment of 1% was associated with increases in suicides and murders but decreases in road traffic deaths (reflecting lower car use), whereas a rise of 3% or more was associated with an increase in alcohol related deaths and suicides in people younger than 65 years . SeveralBy linking AMI with the unemployment rate at the local level, the present study provides further evidence of the relationship between health and economic shocks as measured at the ecological level.The study improves the existing evidence in two main directions. First, none of the empirical analyses conducted so far have made use of hospital level administrative data. In the present analysis, AMI cases are identified from individual hospital records from a database with nationwide coverage. Because hospitalization is required for all surviving AMI patients, administrative data are appropriate to capture this phenomenon. Second, much, although not all, of the existing literature has assumed that the economic crisis hits countries uniformly and at the same time –22. ThisThe data were obtained from the hospital discharge database of the Italian Health Ministry.The current regulations of ethics committees in Italy require only standard written informed consent at the time of hospital admission and anonymous publication of scientific data. Our retrospective observational study fulfilled these requirements and was based on anonymized and de-identified hospital records.All citizens in Italy are covered by taxed-based public health insurance. Since 1995, hospital care services delivered by public or private accredited hospitals are reimbursed on a “per case” basis, classified according to Diagnosis Related Groups (DRGs). Each group is assigned a specific “value” (tariff) reflecting the intensity of resource consumption needed to treat patients assigned to that group. In order to be reimbursed, a standard discharge record  must be completed for each patient. Afterwards, the data are sent to the regional and national Health Authorities for reimbursement. Within this framework, hospitals do not have any incentive to under-report cases. On the other hand, the tight budget constraints in recent years have considerably increased controls and reduced over-reporting.Discharge records report information on the diagnosis, the treatment, the demographics, the length of stay and the DRG class. Diagnosis and treatment are classified according to the International Classification of Diseases- ninth revision- Clinical Modification (ICD-9-CM) codes. AMI cases were selected by considering ICD-9-CM codes in the range of 410.00–410.92. A total of 942 hospitals, private clinics and nursing homes have been reimbursed for AMI at least once in the observation period. In order to focus only on the most reliable information, institutions with less than 10 AMI cases per year were omitted from the sample . A total of 549 hospitals were selected for the analysis. Each hospital was observed on a yearly basis from 2009 until 2012, with the exception of 30 hospitals for which one year of observation was missing. It is important here to note that these hospitals did not close during the observation period. Four dependent variables are available for patients with a diagnosis of AMI: the number of cases per hospital, the number of hospital days, the in-hospital mortality and the expenditure evaluated by the DRG tariffs. The number of AMI cases and the in-hospital mortality are also available by sex and age groups.Each hospital is geographically located within a “Sistema Locale del Lavoro” (SLL). A SLL is defined by the Italian National Statistical Office (ISTAT) and aggregates all the neighboring “comuni” (towns) with a common economic structure. As defined, a SLL is thus the ideal geographical unit of analysis for the purpose of this study. There are 686 SLLs across Italy, with an average of 11.7 towns in each SLL. As is standard practice, hospitals are located in the most populated areas, so that only 319 SLLs are actually included in the analysis. For each SLL, increases in the annual unemployment rates provided by ISTAT were used as a measure of the area-specific crisis intensity. Note that by considering the intensity of the changes in unemployment in a five-year period, the analysis did not rely on a priori definition of crisis. In particular, no assumption was made about the exact timing in which the crisis had hit the country or a specific area.The areas (SLLs) were categorized into quintiles according to the changes in their unemployment rates . The first quintile included all of the SLLs associated with a very low crisis intensity, with a mean increase in unemployment of 0.6% . The fifth quintile, in contrast, included the areas strongly hit by the economic crisis, with a relevant average increase in the unemployment rate of 7.2% (3.6% for the fourth quintile).The analysis uses standard difference-in-differences methodology. It sets the two lowest quintiles as the control group and the highest two quintiles as the case group. It then compares the changes in the outcome variables  across the different quintiles. This approach is used both for the rough data and for the predictions, where data are adjusted for a number of control variables.Considering changes rather than levels provides two main advantages. First, the analysis is focused on the within hospital variation only. Hence, time-invariant, hospital specific structural characteristics, even if unobserved, should not affect the results. Second, it is clear that SLLs and hospitals might differ substantially in their AMI prevalence and incidence. The approach taken here controls for this geographic heterogeneity in the levels of AMI by excluding this source of variation.Simple means of the differences-in-differences analysis provide reliable results. Additional covariates, however, are added to the analysis in order to better control for time-changing and non-hospital-specific factors that might affect the results. Non-linear secular trends are crucial and are considered by introducing three year-dummies. In addition, province fixed effects are used in order to control for institutional characteristics that might affect how both the economic crisis and AMIs are managed. The logs of the area-specific population sizes were included in order to control for changes in the size of the population, although it should be noted that mobility is rather low among Italians and no substantial migration from economically depressed areas was observed. When possible , the type of hospital (private vs public) was also included in the analysis.Predictions were calculated by running panel-data models including the abovementioned covariates together with dummies of the quintiles of crisis intensity and the interaction between these and the year-dummies. The precise specification of the model is reported in Descriptive statistics for the available data are reported in Although descriptive statistics did not reveal an overall significant increase in AMI occurrence between 2009 and 2012, when geographic variations and the comparison across areas with a different unemployment rate were considered, the impact of the economic crisis on AMI episodes is more reliably described.In th quintile), it increased by a striking 179 units (or 12%). The P-value column presents the difference in these average changes between the case and the control group and confirms that, obviously, this difference is strongly significant. When another, milder, case group is considered (the 4th quintile), the results are weaker but still significant.As an example of how to read the results from th quintile, and show the strong differential impact of the crisis on the areas more strongly exposed to the increased unemployment rates. Hospitals in the areas within the fifth quintile of crisis intensity had an increase of approximately 30 AMI cases (approximately 13%) with respect to hospitals in all other quintiles (p<0.001). Notably, this difference is entirely due to the increase in AMI in the case areas: on average, hospitals in areas not hit by the crisis did not register any significant increase in the number of AMI cases. The same is true for the number of hospital days . Because the average length of stay increased only slightly (and not significantly in the rough data), the increase in the number of hospital days reflects the increase in the number of hospitalizations. In-hospital mortality in the bottom quintiles was reduced by almost 10% between 2009 and 2012, while the increase in highly affected areas (the 5th quintile) was approximately 9% . Such a marked variation reflects the low numbers involved in these outcomes, but the trend in mortality reduction in the control group hospitals was, in this case, particularly evident. When the 4th quintile is considered as the case group, the differences were significant but smaller in magnitude.The actual and predicted values are remarkably similar, especially for the 5The increase in the incidence of AMIs was translated into an increase of around €350.000 (p<0.001) in expenditures per hospital per year. When the analysis was extended to sex and age subgroups, all the differences were always statistically significant. Importantly, the groups that suffered most in terms of increases in AMI hospitalizations were males between 44 and 65 years old, who were the most directly exposed to the economic and social effects of the increasing rate of unemployment. In-hospital mortality increased more for women than for men, although only slightly.The aim of the present analysis was to investigate the relation between the unemployment rate and the incidence of hospital level AMI in the Italian NHS. The results show that there is a clear and strong pattern: hospitalizations and expenditures between 2009 and 2012 increased significantly in the areas where the crisis hit more strongly. Overall, compared with the other hospitals in the country, in the 107 hospitals situated in the crisis-exposed areas (the fifth quintile), 30 additional (13%) AMI cases, 200 additional hospital days (13%) and 2 additional in-hospital deaths (17%) were observed. This finding translated into an increase in the financial pressure on the system: each hospital in the areas most exposed to the crisis spent an average of 350,000 euros more for AMI hospitalizations.th quintile is weaker. Moving down the “crisis intensity” scale, the role of the economic environment tends to lose importance in predicting changes in AMI occurrence. Accordingly, when the 3rd quintile was considered, no further significant difference was detected (results not shown).The impact of the crisis on the 4th and the 4th quintile areas of crisis intensity. This figure corresponds to an 8.2% increase in the 2009 per-hospital average number of AMIs. In-hospital mortality increased even more. Compared to what might be expected without the crisis , hospitals in the two top quintiles experienced an estimated total of 400 additional deaths (14% more with respect to 2009). Further, the 215 hospitals in the top quintiles spent approximately 30% more on treating AMI patients than the hospitals in the lowest quintiles, with a total of approximately 100 million additional euros spent at the national level.These results provide a more precise estimation of the impact of the crisis on the burden of AMI in areas heavily affected by an increasing unemployment rate. In 2012, the crisis was associated with approximately 4,100 additional AMI hospitalizations in the 215 hospitals located in the 5The results are not trivial because they capture the impact of the economic environment on individual health, clearly showing that economic-related issues are sources of public health concern, even in the short-term. Indeed, the present study focuses on the impact of the crisis on health in the two years following the beginning of a strong economic crisis. The long-term impact of the economic hardships, channeled mainly through riskier health behaviors and the chronicity of stress, are certainly important but do not represent the target of the present analysis.The stress induced by overall economic uncertainty and sudden job loss is probably the main transmission mechanism from the economic environment to individual health. Notably, the stress from economic hardship does not necessarily directly affect the person who lost her/his job. From one perspective, a high level of unemployment increases job insecurity, so that one can feel threatened even without directly experiencing unemployment. From another perspective, insecurity affects the entire household. In Italy, unemployment benefits exist only for a portion of employers and are time-limited. Typically, families rely on the wealth accumulated by the older generations. Women and men over 65 years of age, although not directly affected by the crisis, might thus suffer as well from these stressful conditions.Note also that the results provided here focus on the average relations between the economic environment and health. According to the existing consensus statement , socio-economic characteristics such as education, wealth and social class can, and probably do, play an important role in determining the health of a person, and they are also likely to influence the relationship between an economic shock and most health indicators. Identifying the main socioeconomic protectors in the presence of an economic crisis can thus represent an interesting topic for further research, but it goes beyond the objectives of the present analysis.Our results reinforce the body of evidence in the literature that suggests “this time is different”, by showing that the present and ongoing crisis has an impact beyond well-known variables such as suicides , 23, 24,Although in line with the most recent public health reports, these results might seem at odds with the standard paradigm of “healthy living in hard times” dominating in the social science and economics literature. In addition, our findings also provide evidence that the relationship between the crisis intensity and occurrence and the impact on AMI incidence is U-shaped. Hospitalizations for AMI remain stable (or decrease) in areas less affected by the crisis. Because the economic shock is not particularly strong, the uncertainty regarding present and future jobs is not heavily affected. In these areas, the incidence of AMI does not increase (and can even reduce), as predicted by the “healthy living in hard times” literature. In contrast, unemployment rates suddenly “explode” where the crisis hits hard, a scenario that might be very hard to address for many reasons. In these areas, the entire economic structure is threatened, and job uncertainty increases to levels never experienced before. The burden of stress-related AMI incidence increases as well, as predicted by the “this time is different” literature. This non-linear relationship between economic and health shocks can thus explain much of the apparent inconsistencies between different streams of literature, as already noted by a very recent study focusing on mortality in Europe .From a health policy perspective, our results show that the economic crisis puts hospitals under a strong pressure, stemming from both the reduction in expenditures and increases in demand. This is happening at a time when the budgets for both welfare and healthcare interventions are being cut in the majority of southern European countries. Under these circumstances, it is particularly difficult to see budget cuts as useful ways of increasing the efficiency of the system. The evidence provided in our analysis can be of value to politicians and policy-makers who should be well-informed about the actual consequences of their public finance decisions. While designing policies to cut healthcare expenditures in times of crisis, policy makers should be aware of the potential impact on the health of communities. Policies aimed to contrast unemployment in the community by keeping and reintegrating workers in jobs could also have positive impacts on adverse health outcomes associated with the economic crisis, especially in areas with high crisis intensity.The present analysis has four main limitations. First, the data are not based on the area of residence of the patient. It is thus not possible to identify the precise number of people served by each hospital and to quantify the relative risk associated with living in areas heavily affected by the crisis. In particular, our results would be upward biased if people in low-crisis areas moved to hospitals in high-crisis areas, something that is highly unlikely to have happened on a systematic level. In more detail, a problem would arise if patients chose hospitals according to the quality and the best hospitals are located in the areas highly affected by the crisis. In this case, the results could just signal an increase in AMI incidence for good quality hospitals . Although one cannot exclude this possibility, it should also be considered that AMI is not an elective procedure. Patients are thus normally allocated to hospitals depending mainly on the time needed to access the treatment, which is approximated by distance. In addition, there is no evidence that better hospitals are located in areas highly affected by the crisis. Rather, they are usually found in cities, which are, on average, less affected by the crisis, especially when compared to southern, less urbanized SLLs. In conclusion, although the analysis would benefit from a more precise geo-localization of the AMI cases, we believe that it nevertheless provides a rather reasonable approximation of reality. The strong significance of the results indicates that unemployment rates at the SLL level do capture something relevant for the description of AMI patterns.A second limitation is the observational nature of the data. Different hospitals and practitioners might classify cases in different ways. Although this is unavoidable, our analysis implemented different approaches to limit this problem. The AMI cases were aggregated at a broad level, so that small differences in the interpretation of the ICD coding and in the compilation of the discharge records should not have influenced the outcome variables. Additionally, panel data techniques were used, and the data were controlled at the hospital level. Importantly, we measured the variations of AMI cases within hospitals. Unless procedures and practitioners inside each hospital varied between 2009 and 2012, the changes in outcomes at the hospital level should not be strongly affected by this problem. One further limitation arises from the data used: hospital records do not represent the totality of AMI mortality because people can die before reaching the hospital. However, the financial pressure on the system results mainly from the treatment of patients with AMI who are admitted to the hospital. In addition, we didn’t have 2012 data for 30 hospitals of our sample . Last but not least, this study suffers from the same limitation that affects the related literature: an association does not necessarily imply causation. It is worth noting, however, that the economic crisis is entirely exogenous with respect to individual decisions. The case described here can thus be seen as a “natural experiment”, something that reduces possible endogeneity biases.In conclusion, more attention should be given to the increase in health needs associated with the financial crisis and to the consequent additional financial pressure imposed on health systems.S1 Appendix(DOCX)Click here for additional data file.


The second year of life is a time of rapid developmental changes. This paper aims to describe the pattern of unintentional injuries to one-year old children in three-month age bands to better understand the risks associated with developmental stages and, therefore, identify opportunities for proactive prevention. Injury surveillance data were used to identify children admitted to hospital in Queensland, Australia for an unintentional injury from 2002–2012. Falls were the most common injury, followed by burns and scalds, contact injuries and poisonings. Falls and contact injuries remained roughly constant by age, burns and scalds decreased and poisonings (by medications) increased. Animal- and transport-related injuries also became more common, immersions and other threats to breathing less common. Within the falls and contact categories falls from play equipment and injuries due to contact with persons increased, while falls down stairs and catching fingers in doors decreased. The pattern of injuries varies over the second year of life and is clearly linked to the child’s increasing mobility and boldness. Preventive measures for young children need to be designed—and evaluated—with their developmental stage in mind, using a variety of strategies, including opportunistic, developmentally specific education of parents; and practitioners should also consider potential for lapses in supervision and possible intentional injury in all injury assessments. Injuries to young children can have significant immediate and long-term adverse health and emotional effects, yet are largely potentially avoidable ,2,3. TheMost published analyses of injuries in children over one year and under five years of age do not examine them in single years, whereas this is a period of life when growth and development are so rapid as to necessitate analysis in far narrower age bands. Few papers analyze injury patterns in such narrow age bands. A recent article published by New South Wales researchers identifies the leading causes of injury in children under 5 years of age hospitalized in that state over the years 1999 to 2009 by single year of age and gives age-specific rates . Apart fWe recently published a paper describing the pattern of injuries in hospitalized infants under one year by trimester of age using data collected and supplied by the Queensland Injury Surveillance Unit (QISU) for the years 2002 to 2007 . This paThe categorization of young children by year of age is entirely arbitrary, for the convenience of statistical tabulation rather than for any intrinsic validity. We present below the distribution of causes of injury in children aged under two years in narrower age bands, showing that the largest changes occur at nine months rather than one year, corresponding to the greatly increased mobility which occurs in children at the former age.In the current paper we describe the pattern and causes of injury to one-year-old children admitted to hospital by trimester of age using coded data and textual description and make some comparisons with the patterns in younger children.This paper analyses injury surveillance data collected between 2002 and 2012 by the Queensland Injury Surveillance Unit (QISU). For the one-year-old children we used the same data file supplied by QISU for the years 2002 to 2007 and identical methods as for the infants under a year, supplemented by a similar but more recent file provided by QISU, covering the years 2008 to 2012. The scope of and procedures used by QISU are described in detail in a previous paper [A certain degree of ambiguous classification of the injury is to be expected, despite the significant training provided to triage nurses who collect the data, due to the usual circumstances in an emergency department. Therefore, a large element of the study involved careful reading the brief textual description which accompanies each record in the data file to glean information not readily available in the coded entries. Only children who were admitted to hospital for their injury were included in this analysis , consistent with our previous paper  and, whiInjuries were analyzed in terms of external cause at any age from 12 to 23 months and in three-month (trimester) groupings. In the great majority of cases the coded cause was used in the classification, but where obvious errors and ambiguities were detected from an examination of the coded text, the injury was reclassified. Furthermore, injuries in the categories, Other Specified Cause and Unspecified Cause were re-assigned to specific categories wherever possible by examination of the text description and other relevant data items.As indicated below, the age distribution of hospitalized children in the one-year age group is flat and symmetric, implying that trends by age in the various categories could be tested by standard analysis of variance techniques. Differences in distributions were tested by standard contingency table methods.After the exclusions mentioned above a sample of 3585 one-year-olds was left, 57.0% male. In contrast to the infants, where the number of admitted children in the sample doubled from the first trimester of age to the fourth [The distribution of external causes of injury by trimester is shown in As foreshadowed above, Almost 1400 injuries were due to falls, too many to allow scrutiny of every descriptive text. Only the descriptions for the fifth (12–15 months of age) and eighth (21–24 months of age) trimesters, 289 and 328 records respectively, were read. This allowed for a comparison of falls at the beginning and the end of the time period and provided sufficient detail for comparison. The fall data were recoded to a number of sub-categories, as shown in As in the case of infants, the head was the body region most likely to be injured in a fall, with 80% of falls resulting in head injuries, somewhat less than among infants. No age trend in the proportion of head injuries was evident. A different classification of injury nature was used in the later data to that in the earlier data, with a more specific category of head injury, intracranial injury, being introduced. In the 2008–2012 data file, the prevalence of reported intracranial injury among one-year-olds who fell was 17.2% very similar to that among children under one year of age (16.5%).Burns and scalds decreased absolutely and relatively with age over the year. The breakdown by causative agent is given in Injuries due to poisonings increased markedly absolutely and relatively with age, doubling from the first six months to the last three. The agents fell into five categories, the main ones being medications, comprising 45% of poisonings, and household chemicals  making up a further 36%. Essential oils  formed a separate category comprising 8% of poisonings, with other chemicals and other substances, mainly plant material, making up the remainder . PoisoniInjuries classified under the category, contact, remained more or less constant from trimester to trimester. Those caused by a person rose significantly from about 8% in the first two trimesters to about 20% in the second two. Much of this increase was due to injuries, mainly dislocations, to the child’s arm through being pulled, often to prevent a fall, which formed overall 41% of injuries caused by a person. Over one third of contact-related injuries were due to the child catching fingers or a hand in a door or other object; this mode of injury decreased significantly with age over the twelve months . For some injuries, the presenting problem text elaborated on the role of the parent, sibling or other family member in the injury. In infants 15.8% of injuries showed some involvement of family members [As was the case with younger children, the pattern of injuries in one-year olds continues to evolve over the course of the second year of life. Mobility and competence develop rapidly in children of this age and this is reflected in the changing ways in which children are injured at this stage of their lives. If preventive efforts are to be effective these changes should be recognized and prevention strategies tailored to developmental stages. Parents and caregivers should be provided with knowledge about child development and injury risk when they come into contact with health professionals or other service providers so as to anticipate and prevent, or minimize these injuries. While the incidence of some injury causes, such as falls, contact and foreign body injuries, remained more or less constant, others, notably burns and scalds, but also threats to breathing, decreased or, like poisonings, increased. Even when the overall incidence of an injury class did not alter substantially, within that class there were some changes with age in the modes of injury; for instance, falls from play equipment and from high places other than furniture became more common, while falls down stairs or being dropped by someone became rarer. Similarly in the injury category of contact, having a hand caught in a door or elsewhere became less common with age while injuries due to other persons became more common.The incidence of poisonings increased markedly with age among children aged one year, and this is consistent with the findings of a study of hospital admissions in another state . In our Although there are clear differences in some injuries in these data, details of caregiver supervision are not available to assist in interpreting the data. Injury patterns may change as parents and/or caregivers recognize that, with increasing mobility and a desire to explore their environment, children’s behaviors, and hence risks they are exposed to, are changing. Parental behaviors may be modified as they recognize this change in their children and this may contribute to changing injury patterns, though the concept of “adequate supervision” remains ambiguous and is not well-defined in the literature . There iSeveral studies have pointed out that injury causation in toddlers is often the result of interplay between familial, circumstantial and individual factors ,17. SimiIn a workshop on child injury prevention in Canada in 2013 several experts on child injury pointed out that over-emphasis on keeping small children safe may result in compromising healthy development . In partIn respect of possible interventions, it is clear that regular reminders to care-givers about the importance of keeping hot or hazardous substances out of the reach of small children is fundamental, as is safety in and around motor vehicles and near stairs. It is however worth noting that a recent systematic overview of the evidence of the effectiveness of interventions to prevent scalds in children found little to show for such interventions in reducing the incidence of scalds in children ,25, suggAs discussed in our previous paper, the sample is based on a relatively limited number of participating Queensland hospitals and may not be entirely representative of all injured children in the State. However 85% of the sample were treated in one or other of the two dedicated children’s hospitals in the capital city at the time of the study, often after transfer from other hospitals. Information on the injury background of transferred children is sometimes sketchy, and in a busy emergency department data collection and coding may on occasion be imperfectly done. Nonetheless, as we reported in the previous paper, a prospective study has found data collected in this way to be reliable as an estimator of incidence and severity .Reporting injury patterns in very young children even by single year of age tends to obscure the significant changes in injury profiles which occur as children go through a period of rapid growth and development in the first two years of life and possibly longer. Understanding the way the patterns alter with age can better inform interventions targeted specifically to the various phases of childhood. Where parents have information about the injury risks associated with increased mobility and independence of children they are better able to identify and minimize exposure to risk and prevent what may me a life threatening or limiting injury. Wider dissemination of this understanding to parents, caregivers and health professionals will enable them to anticipate the sort of injuries that children in their care may incur and improve child safety, regardless of the type or intent of injury.


The Farm to Work program is a modified community-supported agriculture model at worksites in Texas.The objective of the Farm to Work program is to increase fruit and vegetable intake among employees and their households by decreasing cost, improving convenience, and increasing access while also creating a new market for local farmers at worksites. The objectives of this article were to describe the development, implementation, and outcome of a 5-year participation trend analysis and to describe the community relationships that were formed to enable the successful implementation of the program.The Farm to Work program began in November 2007 as a collaborative effort between the nonprofit Sustainable Food Center, the Texas Department of State Health Services, the Web development company WebChronic Consulting LLC, and Naegelin Farm. The program provides a weekly or biweekly opportunity for employees to order a basket of produce online to be delivered to the worksite by a local farmer. A 5-year participation trend analysis, including seasonal variation and sales trends, was conducted using sales data from November 2007 through December 2012.The total number of baskets delivered from November 2007 through December 2012 was 38,343; of these, 37,466 were sold and 877 were complimentary. The total value of sold and complimentary baskets was $851,035 and $21,925, respectively. Participation in the program increased over time and was highest in 2012.The Farm to Work program increased access to locally grown fruits and vegetables for employees and created a new market for farmers. Increased program participation indicates that Farm to Work can increase employees’ fruit and vegetable consumption and thus help prevent chronic diseases in this population Consumption of fruits and vegetables in the United States is lower than recommended, and several government health goals and initiatives focus on increasing it –4. A dieAn effective way to increase fruit and vegetable consumption is through community-supported agriculture (CSA) programs. These programs consist of individuals who purchase farm shares, thereby distributing the farm’s risks and benefits, and regularly receive a portion of crops during the growing season . There aThe Farm to Work program is a modified CSA model designed to increase fruit and vegetable consumption by providing access to fresh produce at worksites. This program does not require participants to purchase a share but instead provides a weekly or biweekly opportunity to order a basket of produce online to be delivered to the worksite by a local farmer. The basket consists of 12 to 15 pounds of fresh produce, including mostly vegetables and some fruits and herbs; a trade basket is available for participants to trade produce items. This modified CSA model supports local farmers and has the added convenience of delivery to the worksite. The objectives of this article are to describe the development and implementation of the Farm to Work program, to outline community engagement efforts and community relationships that were formed, and to present outcomes of a 5-year participation trend analysis.Similar to national consumption, consumption of fruits and vegetables is low in Texas; in 2011, the median reported daily consumption rate among Texas adults was 1.0 time per day for vegetables and 1.6 times per day for fruits ,13. The Development of the Farm to Work program required new partnerships that would be mutually beneficial to all organizations. The community engagement effort created a relationship between worksites and farmers. Outcomes of interest for this partnership were increased fruit and vegetable consumption among employees and their households, development of a new market for farmers, relationship formation between farmers and consumers through worksites, increased engagement of consumers and farmers in the local food system, increased access to fruits and vegetables from small farms, and increased knowledge among Farm to Work participants of the local food system related to the seasonality and source of local produce.The Farm to Work program began in November 2007 as a collaborative effort between the nonprofit Sustainable Food Center (SFC), the Texas Department of State Health Services (DSHS), the Web development company WebChronic Consulting LLC (WebChronic), and Naegelin Farm. SFC, a nonprofit organization with a mission to “cultivate a healthy community by strengthening the local food system and improving access to nutritious, affordable food,” operates in central Texas and was identified as a potential partner because of its established relationships and reputation with local farmers and its work in the local food system, including other “farm to institution” endeavors . DSHS waIn developing a method to distribute produce, the partners first considered conventional models, such as CSAs and farmers markets, to increase the availability and intake of locally grown fruits and vegetables at worksites. In most CSAs, members must purchase a basket at consistent intervals  for an entire growing season. CSAs do not allow flexibility for times when the member is unable to pick up or use the produce. The standard CSA model was modified by replacing the weekly or biweekly commitment with a weekly or biweekly opportunity to order a basket, which was made possible by the collective purchasing power at worksites. Farm to Work was intended to reach employees who did not already engage in the local food system and needed to overcome a cost and convenience barrier. The program also provided an additional way of purchasing local food to those employees who already participated in the local food system, such as those who had developed relationships with CSAs and farmers markets. As a state agency worksite, DSHS represented a mixture of employees with various levels of socioeconomic status. This program reached the entire worksite, providing flexibility for the employees and an additional source of income for the farmer.The partners collaboratively implemented the program. A coordinator employed at each worksite volunteered to oversee internal operations, including produce delivery and pickup, program promotion, and direct customer service for program participants. Volunteer coordinators were usually self-selected; they spent a minimum of 2 hours per delivery week on distributing produce, providing customer service, and promoting the program. SFC initially ran the production side of Farm to Work operations by recruiting and training farmers, matching worksites to farmers, and providing ongoing technical support to farmers. The DSHS Nutrition, Physical Activity, and Obesity Prevention Program developed a protocol to implement Farm to Work through worksites and operated the consumer side of Farm to Work by training and providing ongoing support to coordinators. Over time, the responsibility of training and providing ongoing support to coordinators transferred to SFC.SFC contracted with WebChronic to create and maintain the online system. To date, the cost of developing the online order site and administrative system, including initial development and upgrades, is approximately $29,000, and 3% of the purchase price covers monthly maintenance costs. Each worksite had a unique Web address for their ordering website, and the data were linked to an administrative website.The Farm to Work program was launched in November 2007 at the DSHS main campus in Austin and expanded to its second worksite, Austin State Hospital, in December 2007. The program launch was funded by an obesity prevention grant from CDC, which was used to organize a communications plan and purchase promotional materials. The DSHS Communications Unit developed a logo and artwork for the program. DSHS, SFC, and WebChronic created a promotional video and placed it on the Farm to Work website to encourage employees to participate. Communications and promotional materials were developed for dissemination through other worksites to promote the program. For example, logo and artwork files were sent to coordinators when the program was launched at their worksite. These worksites then personalized the marketing materials to meet their own needs. Initially, volunteer coordinators also received a complimentary basket, but this practice was discontinued in the second year of the program due to rules at some worksites related to receiving gifts.Partner communication was essential to promotion of the program. Partners communicated with one another via email and in-person meetings. Farm to Work was promoted to employees through wellness fairs, posters, emails, and a link placed on organizations’ wellness websites. DSHS and SFC met with interested worksite staff to manage expectations related to the content of the basket, online system, and responsibilities. Communication to the public was achieved through the Farm to Work website and the Farm to Work webpage on the SFC and DSHS sites.The Farm to Work program was evaluated using mixed methods in 2007, 2008, 2010, and 2011 . All evaParticipant and partner feedback were used to further refine the program to increase satisfaction for participants and farmers. Results from participant satisfaction surveys conducted in 2010 informed best practices for farmers, which included providing high-quality, fresh produce, adding variety to increase value, ensuring accurate information about the produce list, having a trade box regardless of the number of customers, using creative marketing strategies to inform participants, and making recommendations to improve the website. Results from the 2010 participant satisfaction survey informed the start of a promotion that rewarded participants with a complimentary basket for every 10 baskets ordered during a 1-year period. Participant concerns with the volume and variety of produce offered were addressed by farmers rotating produce in the baskets, providing a trade basket, and ensuring at least 12 to 15 pounds of produce per basket. In 2012, WebChronic contracted with a website usability expert who gathered insights from SFC, DSHS, worksite coordinators, and participants. The findings from the usability testing and participant satisfaction surveys conducted in 2010 informed updates to the ordering and administrative websites in spring 2013. Website features added as a response to user needs included a recipe section and an encyclopedia of produce called the Vegipedia. The interface and design of both websites supported ease of use and consistency in program branding. Employees could ask questions and provide feedback at distribution, use the feedback feature on the order website, or respond to order reminder emails; online questions and feedback were routed to the respective worksite coordinator to reply to the employee.Success of community engagement efforts was assessed with process-related data collected through the online system. The ability to track participation by the number of baskets and sales by worksite was built into the Farm to Work administrative site. SFC, WebChronic, and DSHS used the data for quarterly reports, invoices, and evaluation of participation and sales, respectively. SAS 9.2  was used to analyze the participation and sales data. Analysis of variance (ANOVA) was used to determine if there was a significant difference in participation by season and by month. Because there were significant differences in participation by season and by month, a Student-Newman-Keuls post-hoc test was used to determine which seasons and months were statistically different from the others.t = 2.96, P = .004) and every 7 months . The trend line increased by a slope of 2.947 baskets per month. However, participation decreased from 2009 to 2010 ; however, results of the Student–Newman–Keuls post-hoc test indicated there was no significant difference when comparing the other 4 growing seasons . Basket deliveries were highest in early summer  and lowest in fall . Average basket sales for the remaining 3 growing seasons ranged from 896.8 (late summer: August and September) to 1,302.6 (spring: March and April).From November 2007 through December 2012, the total number of baskets delivered was 38,343; of these, 37,466 were sold and 877 were complimentary. Over the 5-year period, the total value of sold baskets was $851,035, and the total value of complimentary baskets was $21,925. Price per basket differed by worksite and changed over time, ranging from $10 (2 baskets) to $20  and $25 . Participation in the program was highest in 2012, which was likely due to continued growth in the number of participating worksites. A 1-way repeated measures ANOVA indicated that a significantly higher number of basket deliveries occurred in early summer  compared with the other growing seasons   .To build trust with the first farmer to commit to a new program, SFC recruited Naegelin Farm, which had communicated a need for help in increasing sales. SFC trained farmers on how to use the administrative site and on the production needs of the program. On the consumer side, the support from the worksite itself and worksite coordinators created the trust necessary for employees to purchase the produce. DSHS and SFC trained coordinators on how to order a basket, what their involvement entailed, and expectations related to basket contents. To address participant perceptions of the produce being more expensive than grocery store produce, coordinators conducted price comparisons with prices of comparable produce from conventional grocery stores and shared findings with participants.Unexpected successes included the amount of profit generated for the farmers and a waitlist of worksites. There also has been both state and national recognition and interest in replicating the program at other sites. Farm to Work was recognized as an innovative program by national organizations such as CDC’s Center for Training and Research Translation, Association of State and Territorial Health Officials, and the National Association of County and City Health Officials.The Farm to Work program created a new access point for locally grown fruits and vegetables and created a new market for farmers at worksites. The program expanded to 35 active worksites in 2012 and generated $851,035 in sales over a 5-year period from November 2007 through December 2012. Other communities interested in setting up a Farm to Work program can download the Farm to Work Toolkit or consider attending SFC’s Program Replication training to receive hands-on training and a program replication guide ,17. The The Farm to Work program has increased access to locally grown fruits and vegetables for consumers and created a new market for local farmers; increasing participation levels in the program suggest that it has the potential to increase fruit and vegetable consumption and prevent diet-related chronic diseases.


The landscape of the NHS is undergoing significant change in recent times. A £30 billion funding gap is expected to be opened up by 2020/2021 (As medical students who recently completed a BSc in Management, we found that the health economics module in particular allowed us to gain invaluable skills beyond the stethoscope, granting us an insight as to complexity and difficult nature of financial decisions in any healthcare system. Most doctors coming out of medical school will be completely oblivious to this other side of medicine; how, then, can they be expected to rise to the challenges ahead?Failing to prepare is preparing to fail. The current medical school curricula in the UK are guilty of neglecting this increasingly vital aspect of healthcare in the NHS. We strongly believe that an increased effort must be made to integrate health economics into the curricula in the same manner that ethics has become a core element of the course; indeed, the foundation of resource allocation is entwined with key ethical principles of distributive justice .Possible approaches to achieve this could be through a series of online seminars. These might be supplemented by a series of workshops in which students can engage in more practical application of the knowledge gained. Such models have already been proposed , but havInterestingly, the concept of fully student-run clinics has been part of the medical education system in the States for over a decade, with over 100 such clinics in the country now . FurtherWhilst the best method to deliver teaching on health economics is unclear and should be explored further, the current need for this education at the undergraduate level is crystal clear. We believe that the success of our future NHS hinges on it.Muhammad A. AshrafDepartment of MedicineImperial College LondonLondon, UKEmail: muhammad.ashraf10@imperial.ac.ukYusuf SherwaniDepartment of MedicineImperial College LondonLondon, UKMuhammad NajimDepartment of MedicineImperial College LondonLondon, UKMaroof AhmedDepartment of MedicineImperial College LondonLondon, UKRiham RabeeDepartment of MedicineImperial College LondonLondon, UKOsama Al-JiburyDepartment of MedicineImperial College LondonLondon, UKFaisal Al-MayahiDepartment of MedicineImperial College LondonLondon, UKAaniya AhmedDepartment of MedicineImperial College LondonLondon, UK


Pasteurella multocida and Salmonella) diseases, and the infection prevalence of 3 families of endo- and ecto-parasites  in 1056 village chickens from two geographically distinct populations in Ethiopia. Samples were collected during 4 cross-sectional surveys, each approximately 6 months apart. Constrained ordination, a technique for analysis of ecological community data, was used to explore this complex dataset and enabled potential relationships to be uncovered and tested despite the different measurements used for the different parasites. It was found that only a small proportion of variation in the data could be explained by the risk factors measured. Very few birds (9/1280) were found to be seropositive to Newcastle disease. Positive relationships were identified between Pasteurella and Salmonella titres; and between Marek's disease and parasitic infections, and these two groups of diseases were correlated with females and males, respectively. This may suggest differences in the way that the immune systems of male and female chickens interact with these parasites. In conclusion, we find that a number of infectious pathogens and their interactions are likely to impact village chicken health and production. Control of these infections is likely to be of importance in future development planning.Chickens raised under village production systems are exposed to a wide variety of pathogens, and current or previous infections may affect their susceptibility to further infections with another parasite, and/or can alter the manifestation of each infection. It is possible that co-infections may be as important as environmental risk factors. However, in cross-sectional studies, where the timing of infection is unknown, apparent associations between infections may be observed due to parasites sharing common risk factors. This study measured antibody titres to 3 viral  and 2 bacterial ( The importance of interactions between pathogens has been shown in humans , wildlifThere is widespread recognition of the importance of village poultry in developing countries . PoultryInfectious disease is recognised as one of the major constraints to developing backyard poultry production . ControlEimeria species  to assess patterns of co-infection, and (ii) to identify common risk factors for co-infections. The range of pathogens studied necessitated the collection of both serological and parasitological data, and a method of combining these different infection measures was sought. Ordination methods are commonly used in ecology for community analysis: Here they have been applied to this community of pathogens, where each bird may be thought of as a “site”, which has the potential to be exploited by any of the micro- and macroparasite species.Two main techniques were used to explore this data set. Principal component analysis (PCA) is an ordination technique which seeks to extract the main trends in the data set such that it may be explained by a few linearly uncorrelated principal components, which will be less than or equal to the number of original variables. The main structures in the data may then be displayed in a graph(s) constructed from the reduced set of orthogonal axes. Graphs, known as biplots, can be scaled according either to the distances between sites or the correlations between variables . Redunda2This study was approved by the University of Liverpool Committee on Research Ethics (reference RETH000410). The study was carried out between May 2011 and November 2012 in two geographically distinct woredas (administrative districts), Horro and Jarso, within the Oromia region of Ethiopia. Woredas are divided into smaller administrative districts, called kebele, which may comprise several villages. A group of villages which are linked by trading networks is collectively known as a market-shed . Within nth name from each list with a starting place chosen at random, to create lists of 108 potential participants for each kebele. The selected names were split into four groups, one for each sampling season, so that different households were selected to sample on each visit to the kebele. Approximately 30% more names than were required were selected to allow for exclusions or non-participation. A total of 640 households were recruited over the course of the study.A list of names of all household heads in each kebele, grouped by sub-area, was obtained from the respective kebele agricultural development agents. Systematic random sampling was used to select potential participants by selecting every Cnemidocoptes mutans . Data on the chickens’ age, origin and current status of production was collected from the owner. Blood samples were drawn from the brachial vein of the selected birds into sodium citrate and faecal samples were collected from individual birds wherever possible; environmental faecal samples were taken to represent the household, if individual samples were not forthcoming. All samples were kept chilled and were transported to the laboratory for testing.Each kebele visit took place over 2–4 days. Ethiopian staff fluent in the local languages and in English were recruited and trained to collect data for this study. The field teams, assisted by local representatives, visited each selected household to take part in a questionnaire survey and for two of their chickens to be sampled. Households which did not own at least two indigenous-breed chickens of over 6 months of age were excluded from the study. Information on management and disease occurrence within the household flock over the previous 12 months was collected in a questionnaire interview in the local language with an adult member of the household, normally either the household head or the main carer for the chickens. In addition, two chickens of at least 6 months of age were randomly selected from the household flock and each underwent clinical examination, was condition scored using a 0–3 grading scale , and wasP. multocida (PM) and Salmonella O9 serotypes, using S. enterica serovar Gallinarum (SG) antigen, according to the protocols by Pasteurella, and samples from all areas and seasons, with the exception of those from the third sampling season. All samples with high variation between replicates were retested. Positive and negative controls were run on each plate. Optical densities for all ELISA samples were converted into a ratio to the positive control (s:p ratio) to allow comparison of samples tested on different plates, using Eq. Serological testing was carried out for NDV antibodies by haemagglutination inhibition (HAI) assays, according to the Eimeria spp. oocysts and nematode eggs using a modified version of the concentration McMaster technique and identified to genus level where possible using published keys  and the hyperkeratosis grading. In order to make all response variables dimensionally homogeneous, each variable was scaled by centring values on the mean and dividing by the standard deviation. This ensured additional weights were not given to the parasites with larger ranges of values and fulfils one of the basic requirements for application of PCA.Analyses were performed using R software  using the vegan package , and accSalmonella, Pasteurella and MDV, respectively. The analyses were also run with preselected cut-offs of both 0.3 and 0.5 for these three ELISAs. Presence/absence was used to dichotomise the parasite counts and hyperkeratosis.In order to test whether the results were features of the data , data were re-analysed following a number of prior transformations, including log transformations of the ELISA s:p ratios, square root transformations of the individual parasite count data, and Hellinger transformations of the parasite count matrix. In addition, data were re-analysed following dichotomisation. The IBD ELISA was dichotomised using the manufacturer's recommended cut-off (0.306). The range of s:p ratios to the ELISA tests developed in-house did not demonstrate clear cut-off points, and sufficient negative sera were not available to confidently determine positive cut-offs for these tests. A small panel of sera from birds with known exposure to vaccines or experimental infection were used to determine a conservative cut off value for each test which would still detect all known positives. Cut-off values chosen were 0.34, 0.61 and 0.29 for Initially, an unconstrained PCA was carried out on the matrix to identify correlations between parasites; a second matrix of explanatory variables, including household data and bird signalment, was then incorporated using RDA. A category “production status” was used to combine data on sex and the current state of production . Each centred response variable was regressed on the explanatory variables and the fitted values combined in a matrix. A principal component analysis (PCA) of the fitted values produced canonical eigenvalues and a matrix of canonical eigenvectors, used to calculate the coordinates of the sites (chickens), either in the space of the original response variables, or in the space of the explanatory variables (i.e. on the fitted response variables). The residual values from the multiple regressions were also submitted to a PCA to obtain an unconstrained ordination of the residuals.2 value was used to test whether the inclusion of explanatory variables was a significantly better fit than the null model, and a forward selection process was used to select those significant variables which explained the greatest proportion of the variance in the response data  had complete data for all laboratory tests and all explanatory variables of interest and were included in the analysis. All birds were found to be in reasonable health at the time of sampling, with only a very few displaying any clinical signs which may have been attributable to the diseases of interest. Only 9 birds over all four seasons of testing were found to be serologically positive for NDV antibodies (HAI titre of 16 or greater); therefore this disease was not included in the ordination analyses. All other infections were present in each village and at each sampling season with the exception of IBD, where no positive birds were found in one Jarso village at any time point, and seropositive birds were detected in only three villages in Horro during the second year of samplingSalmonella, Pasteurella and MDV, respectively gave corresponding estimated seroprevalence of around 86%, 69% and 32% for the study samples, with only minor fluctuations between different villages and seasons. However, some birds demonstrated OD values far in excess of the positive controls, suggesting unusually high antibody titres. The parasitic diseases were also present in all villages at each time of sampling, with overall detection prevalence of 17%, 56% and 34% for Ascaridida, Eimeria spp. and lice, respectively. Birds showed considerable variation in the intensity of infection. Signs of hyperkeratosis were seen in 41% of birds; identification of hyperkeratosis was strongly associated with a positive identification of scaly leg mites from a skin scrape .Using the manufacturer's cut-off of 0.306, 3.6% of birds tested positive to IBD. Using the chosen cut-off values of 0.34, 0.61 and 0.29 for After constructing the correlation matrix of responses to each infection, PCA was used to explore the variation in the scaled dataset. Regardless of the prior data transformation used, this suggested that three axes represented interesting variation in the data (using the Kaiser–Guttman criterion), and the other axes displayed essentially random variation. However, the first three axes represented less than 50% of the variation, accounting for 17.0%, 14.7% and 13.2% , respectively on the untransformed data. Salmonella and Pasteurella titres, which, as shown in the biplots, make up one group of correlated variables  axis, and has some correlation with Eimeria and IBD.The first axis principally represents the variation contributed by the ariables . The majEimeria; whilst Hellinger transformations gave more weight to the distances between the three transformed parasite counts and highlighted negative correlations between lice and Eimeria, and between Ascaridida and scaly leg (data not shown). All PCA's illustrated a strong correlation between Salmonella and Pasteurella which consistently contributed the 1st principal component and therefore the greatest variation in the data.Analyses following other data transformations showed similar overall groupings, although binarisation emphasised negative correlations between scaly leg and both IBD and A forward selection process identified the following explanatory variables for inclusion in the RDA model: bird production status and weight; and at the household level, the use of chemical sprays for parasite control and whether the household had had any recent outbreaks of disease in their chicks or growing birds. Variables which were tested but not deemed to significantly improve model fit included the season in which the household was sampled, the village or region, body condition, age of the bird, and where the bird had come from.Although statistically significant, the explanatory variables accounted for only a very small proportion of the total variation in the dataset , and a permutation test of these axes suggested that 3 of them described significant variation. However, when the household-level variation was partialled out from the model by fitting this as a fixed effect prior to fitting other explanatory variables (the permutation tests used preclude this variable from being fitted as a random effect), this explained around 59% of the variation in disease responses, and left only bird weight and production status as significant bird-level explanatory variables, and only two significant RDA axes .Fig. 2TrSalmonella, and MDV was also correlated more with males and/or birds with heavier weights. Higher Pasteurella titres were observed in females which were either rearing chicks or not in production. Households reporting recent deaths in chicks appear to have birds with greater Ascaridida shedding, but also this variable appeared correlated with the use of household sprays to control parasites. Scaly leg was also associated with households which were using sprays in the housing to treat parasite infestations.Some relationships were evident between variables: Males birds were positively correlated with lice infestation but negatively with Salmonella and Pasteurella still appear to maintain a positive correlation, even after accounting for the measured explanatory variables they have in common. Lice, MDV and scaly leg also maintain their previous cluster, although Eimeria became more distant from this group.The residuals from the multiple regressions were also subjected to an unconstrained PCA. The Kaiser–Guttman criterion suggested 4 axes may be required to represent the residual variation of interest in the data, and the groupings of the disease variables remain much as they were before. 4Multiple micro- and macroparasites were circulating within the apparently healthy adult village chicken population in Ethiopia. Traditionally, epidemiology has tended to concentrate on individual diseases, but the effect of other parasites on the infection of primary interest should not be overlooked. However, identifying potential interactions between parasites and testing the strength of these associations, especially when the order of infection is unknown, remains a complex issue. The use of ordination methods was found to be a useful exploratory tool with this dataset, and appeared to be robust to the combination of different types of response data , perhaps giving it wider applications within epidemiology.PCA does not require normally distributed variables, but in community ecology count data are frequently transformed (e.g. Hellinger or chord transformations) in order to reduce the effect of large counts and to eliminate the apparent correlation of sites with double zeroes, , there appears to be considerable within-village variation. Although including household as a partial fixed effect in the RDA then prohibited the inclusion of variables measured at the household or village level, it did illustrate the significant contribution of household to many of the disease responses, suggesting that either there are some important, unmeasured, household factors or that exposure to these diseases at any single time point varies significantly even within a village. This may be due to geographical and management factors, but may also be due to the relatedness of birds in the same household giving them similar immune characteristics. The scarcity of co-positive birds may be due to a lack of synchronicity between infections. It is also possible that birds recently infected with two pathogens in a short time period, where we may expect both a high antibody titre and a high parasite burden, frequently do not survive to be measured, hence the lack of these in this dataset. In order to investigate many of these hypotheses, longitudinal studies are required; however, the ordination analyses has proved useful in the generation of these hypotheses, and in illustrating some potential associations, both positive and negative, between different types of pathogens, even with very different types of measurement used.As illustrated by the number of axes required to explain the residual variation in disease responses, there were almost no birds which had high responses/counts to more than one pathogen group. This may in part be due to other opposing and mutually exclusive risk factors, such as sex, in that higher lice burdens are associated with males, but females tend to have higher The impact of these multiple infections in the village chicken population is likely to be of greatest significance within the young stock that families rear for replacements, sale or consumption, and which generally mix freely with the adult population. The observed correlation between birds with high Ascaridida counts and households which had had recent deaths in their chicks may suggest that nematodes are of particular significance for this age group, allowing targeted interventions to be considered. However, any of these infections may also potentially impact the adult stock at times of climactic, nutritional or other stress. The results of this study have implications for interventions to improve chicken health and production in Ethiopia. For example, programmes aiming for genetic improvement of indigenous stock by selective breeding  need to The authors declare they have no competing interests.


Morphometry is introduced as quantitative approach to seek information concerning variations and changes in the forms of organisms that described the relationship between the human body and disease. Scientists of all civilization, who existed until today, examined the human body using anthropometric methods. For these reasons, anthropometric data are used in many contexts to screen for or monitor disease. Anthropometry, a branch of morphometry, is the study of the size and shape of the components of biological forms and their variations in populations. Morphometrics can also be defined as the quantitative analysis of biological forms. The field has developed rapidly over the last two decades to the extent that we now distinguish between traditional morphometrics and the more recent geometric morphometrics. Advances in imaging technology have resulted in the protection of a greater amount of morphological information and have permitted the analysis of this information. The oldest and most commonly used of these methods is radiography. With developments in this area, CT and MRI have also been started to be used in screening of the internal organs. Morphometric measurements that are used in medicine, are widely used in the diagnosis and the follow-up and the treatment of the disease, today. In addition, in cosmetology use of these new measurements is increasing every day. Anthropometria by Johann Sigismund Elsholtz [ pulsilogium, which was invented by Sanctorius at the University of Padua, was one of the first instruments in the field and was used to evaluate the pulse rate. During the 18th century, the well-known French anatomist Jean-Joseph Sue, Swiss physiognomist Johann Kaspar Lavater, and German naturalist Johann Friedrich Blumenbach presented valuable research on different issues concerning measurement [Since ancient times, the human body has been measured for several reasons. During the ancient era, human body measurement was mostly practiced for the figurative arts. Eventually, the practice was adopted by the naturalist field and then by anthropologists to identify human basic morphological characteristics. The term anthropometria dates back to the 17th century in the naturalist field, when it first appeared in the short manualElsholtz . The manElsholtz . ElsholtElsholtz , 5. In tsurement . At the surement . The antsurement . During In the West, the use of measurements and the description of the human body emerged among the artists of classical civilizations; however, more systematic body measurements and records gained importance due to the demands of early modern military organizations . The meaBecause ancient anthropometric research was a relatively current concept, the related medical literature concerning nutrition and physical growth served as a valuable theoretical source. Hence, the biomedical literature of the World Health Organization (WHO) was regarded as one of the best sources that represented general health conditions within a society .Because of its use as a measurement of physiological and developmental human growth, anthropometria appeared in several clinical practices that utilized instruments such as the manometer, sphygmograph, hemocytometer, hemoglobinometer, and spirometer . The neeOver the ages, all civilizations have been interested in the human body. Artists in particular have reflected the effects of this interest in their works.In the ancient Egyptian, Greek, and Roman civilizations, famous artists used male figures in their artwork  with the desire to represent issues such as beauty, virtue, independence, military power, and authority , 7.In the ancient era, artists were interested in the depiction of body parts based on reciprocal proportions. Artists believed that the human body represented as “an ideal human figure” had specific proportions between its constituent parts. Throughout history, these proportions were considered to be canon. In practical use, any given part of the human body could be chosen for measurement and proportioned to the other parts due to the absence of standardized measurement units such as the meter, centimeter, or millimeter. Therefore, any given human body part could be described as a “unit of measurement” (module). These measurement units contained various modules such as the length of the feet, length of the hand, and height of the head , 8, 9.Throughout history there have been studies related to the “human body” branches of art  as well as studies related to anatomy in the field of medicine. In the three most well-known ancient civilizations, scholars evaluated the “human body” using the concepts of canon and modules , 10.The first known dissections with the aim of learning (III century BC) were performed by scholars in Egypt . In the The most famous artist of this era was Polykleitos. Polykleitos evaluated the human body and wrote the first known artistic anatomy book. The renowned scholars used the “width of hand” (WH) as a module and described the proportions he used between various body parts and the width of hand as well as the inequalities. During the period of Greek civilization, for the first time multiple equalities were used in drawings of the human body between the longitudinal, oblique, and transversal dimensions .Roman artists and scholars further developed studies of the “human body.” Moreover, some equalities were described after a human figure in the college position was placed in a square frame. Because notables of the era such as Leonardo da Vinci found that the human figure in the college position had an equal length and width, human paintings were often performed using a square frame , 9, 10. Great artists of the renaissance (Leonardo da Vinci and Albrecht Dürer) created many works based on these rules and proportions. Works related to the human body were developed according to rules that were considered to represent classical anthropometrical measurement techniques .(i) The renowned renaissance artist Leonardo da Vinci was interested in both art and sciences. He performed cadaver dissections and notated his measurements, notes, and drawings with the attention to detail of a scientific investigator. For the first time in history, he investigated the human face, head, neck, and other related parts in detail, mainly following the “Polykleitan theory.” He worked on a drawing belonging to Vitruvius, and after rigorous investigation of this work he demonstrated his success in this field. Indeed, the “Vitruvian man” became one of his most renowned works , 9.(ii) Durer was a versatile artist and architect who worked in both the mathematics and anatomy fields. He was born in Germany and examined both the male and female figures from the perspective of science and art. However, in his era dissection was not allowed in Germany, so his work relied on the use of live models and examinations of the literature. He also has investigated the positions of the internal organs and depicted the projections of the spleen in his work. His most famous work titled “Adam and Eve” showed his incredibly rigorous calculations .After the 19th century, the concept of the “average” male figure was developed based on comprehensive measurements. In the early 20th century, the French doctor of medicine and painter-sculptor Paul Richer performed one of the most detailed and scientific studies of the postrenaissance era due to his use of anthropometric methods. He described the “average human figure” based on comprehensive measurements rather than the “ideal human figure.” He chose “height of head” as the module and depicted the front and the back view. Additionally, he explained human anatomy in the context of the medial and lateral views of the extremities , 10.Morphometrics, a branch of anthropometry, is the study of the size and shape of the components of biological forms and their variations in populations . MorphomIn traditional morphometrics, it is not possible to recover the shape of the original form using the usual data matrices of distance measurements, even as an abstract representation. The overall form is neither archived nor used in the analysis. For example, a researcher may know that several measurements share a common landmark, but this information is not used in the multivariate analyses. As a result, the analyses cannot be expected to be as powerful as they could be if that information were taken into account , 11.Traditional morphometrics consisted of applying multivariate statistical analyses to sets of traditional measurements between points with biological and anatomical meanings to define shapes called landmarks. These measurements usually represented the lengths and widths of structures and the distances between certain landmarks, which are described as the points of correspondence on each matching object between and within populations. Sometimes angles and ratios were used , 12.When multivariate morphometrics was combined with both quantitative morphology and multivariate statistics, several difficulties still remained. As an example, many ways of size correction were proposed, but there were great debates about which method should be utilized , 11. It In the 1960s and 1970s, biometricians began applying multivariate statistical analyses to sets of traditional measurements. Geometric morphometric methods are more valid than traditional morphometric methods in protecting morphological information and permitting the analysis of this information. For morphometrics to fulfill its promise of fusing geometry with biology there must be equal emphasis on the two components. Morphometric techniques need to be designed and applied with biology in mind, and the quantitative results must be directly interpretable using biological methods , 13.In geometric morphometrics, biological shape is defined via transformation of the original shape, which is selected as a reference shape. Thompson proposed the idea in 1942, and although the method was attractive and promising for the analysis of biological shapes, the method did not have an analytical procedure. With the advent of computers, applications for morphometric analysis based on Thompson's idea became possible. Data are recorded to represent the geometry of the structure being studied . These dThe fundamental advantages of geometric morphometrics over traditional approaches  include the development of powerful statistical methods based on models that are used to examine the shape variation of all configurations that correspond to morphologic landmark locations. Indeed, in many biological or biomedical studies, the most efficient way to analyze the forms of whole biological organs or organisms is by registering landmarks . Many stFor over 50 years, qualitative morphometric techniques have been used within limits to assess bone density. Grading systems for the spine and proximal femur were developed with the aim of characterizing the severity of bone loss. However, because the use of such systems could cause highly subjective interpretations, the inclusion of a series of reference radiographs is recommended. Quantitative morphometric techniques are repeatedly used for imaging of the spine or proximal femur with X-rays. However, some measurement parameters were required for these techniques to produce a quantitative assessment of the severity of bone loss –17.Throughout history, many studies have focused on the human body, especially with the aim of identifying anatomical, physiological, and pathological features of the internal organs. Among these studies, those related to imaging modalities of internal organs are especially very valuable , 19. DurIn Turkey, the usage of X-rays in the field of medicine was first performed by medical students Esat Feyzi and Osman Rifat. Both students detected bullets in wounded soldiers during the Ottoman-Greece battle using radiography –24. One The first quantitative CT measurement was proposed by Johann Radon. In 1972, J. N. Hounsfield scanned a section using thin and weak X-rays and turned the result into an image after computer evaluation by reading the signals in the scintillation chamber. Using this technique, a cross-sectional image could be obtained from anywhere in the body. Investigations of the CT accessibility of tissues and body regions showed that CT is more successful in imaging bone tissue than soft tissues due to its working principles and design. This invention was an important development for the imaging of brain and malignant tumors , 27.Quantitative computed tomography (CT) is used for quantifying bone mineral density (BMD) in the spine, proximal femur, forearm, and tibia as a three-dimensional nonprojectional technique. It has several advantages over other densitometric techniques, including the ability to separate the cortical and trabecular bone, the fact that degenerative changes in the spine cannot affect the volumes of interest (VOI), and the ability to determine 3D geometric parameters , 28.The identification of spin-based physic resonance by Wolfgang Pauli in 1920 initiated the first attempts to obtain images using the MR technique. Quantitative measurements in this field were first performed by physicists Bloch and Purcell. In their experiments, they demonstrated that atoms with one nucleon in their core were affected by the magnetic field and that the orbit of the atomic cores was changed in response to the magnetic field. For a long time, this finding was applied solely to the field of physics. Then, in 1970 Paul Lauterbur obtained a clear MR image. The first diagnosis using this modality was performed by Hawkes et al. in 1980. Currently, the ability to obtain fast and quality images of internal organs using the MR technique and the relatively low risk of side effects has led to its common use both internationally and nationally –30.Currently, the direct calculation of the measurements of morphometric quantitative area shapes has been made possible by utilizing various programs after the common usage of MRG. Due to its imaging capacity on multiple planes, absence of ionizing radiation, and utilization for the diagnosis of mediastinum, this method has an important place in the field of medicine .Mathematical analyses are used to identify the shape of an anatomic region in the human body. These evaluations are performed using optic measuring methods with 3D imaging modalities. These methods are especially important for quantitating data in the complex anatomical structures of the human body. The assessment of the validity and safety of these data has led to improvements in human health and quality of life .The most commonly used imaging modality trio today includes the PET/CT modalities. In addition to imaging structures in the human body, these modalities can also detect exact tumor locations and biological properties that are essential for diagnoses in cancer patients , 30.Anthropometric measurements are important for the evaluation of morbidities of individuals in society and thus meet the requirements of that society. For human health, the field of medicine requires constant development and renewal. Throughout history, anthropometric measurements were improved as details of human anatomy were discovered, until the field reached today's standards. In recent years, the utilization of many new measurement devices for clinical use and primary studies has inevitably led to improvements in measurement parameters and techniques , 7.In the eras of the Ancient Egyptian, Greek, and Roman civilizations, artists made detailed evaluations of the human body. Artists of the renaissance period created ideal ratios in their works using mathematical methods . The “golden ratio” that was used by Leonardo da Vinci in his drawings currently remains the norm for beauty. In this ratio, anthropometric data and ratios are used to compare the ratios of disproportions present on the face .A tendency towards plastic surgeries has become widespread over the past several years. Interventions related with this field include corrections of congenital malformations as well as various optional modifications on individual's bodies. Anthropometries of the human body and especially the face are used for the identification of these disproportions. Therefore, more standardized and purpose-oriented measurements in the field of plastic surgery are important for a more objective evaluation of human bodies .The use of imaging techniques in facial cosmetics is an undesirable feature caused by extrinsic photo damage and the intrinsic aging process . A decreToday, many fields, including plastic surgery, depend on photo documentation as a crucial part of both clinical practice and medical education. The most recent advancement in breast plastic surgery is ideally suited for 3D technology. The portrait 3D breast imaging system provides a highly reproducible 3D tool for measuring breast volume and simulating breast augmentation .The main reasons for the widespread use of statistical shape analysis in medicine include the fact that geometric morphometric methods are more valid than traditional morphometric methods. Advances in imaging technology have resulted in the protection of a greater amount of morphological information and have permitted the analysis of this information. There is hope that advances in both screening and diagnostic technology will ultimately have a positive impact on treatment. Furthermore, the use of these treatment modalities for cosmetic use has been rising.