BackgroundWith an upsurge in research in developing countries, researchers from allied sciences need to augment their skills for disseminating research work worldwide. Training workshop is one of the quick interventions which can enhance writing skills and ease research publication.ObjectiveWe designed this research to explore the perception of the faculty of different higher education institutes (HEIs) regarding manuscript writing and to assess the impact of these workshops in the improvement of cognitive capabilities of preliminary researchers in Pakistan.MethodologyWe conducted workshops in HEIs of Sindh, Pakistan. Contents of the workshop covered algorithm of writing manuscript and related descriptions, choice of quality journals, correspondence with the editor, and dealing with rejection. The knowledge of the participants was assessed by 15 items pre and post evaluation tests. McNamar's test assessed the significance of the change in knowledge. Kruskal Wallis test was performed to check the difference in the opinion of workshop quality among different institutes.ResultsA significant improvement was observed in participants’ knowledge on the readers’ prospects (P=0.001), the algorithm of writing (P<0.001), interpretations of results (P<0.001), and selection quality journal for publication (P <0.001). The agreement with the workshop's quality based on need, knowledge, and content was above average.ConclusionThe participants’ response regarding the effectiveness of manuscript writing for publication workshop was overwhelmingly positive, and there was a significant impact on the knowledge of the participants. There is a need for research training that will help for better capacity building in different HEIs of Pakistan. The progress of any country is gauged by the quality of research papers published from that country. Now science not only flourishes in the scientific laboratories but also the educational institutes. In developing countries, there is a need to adopt a research-oriented approach by higher education institutes (HEIs). A research-oriented institute would be able to inculcate research skills among its students.In Pakistan, there is a mushroom growth of degree awarding institutes in the private sector . Still, All over the world, the developing countries are in the surge of inducing scientific research and its dissemination. Scientific writing demands keen interest, learning, and practices to disseminate research work. Nevertheless, health sciences researchers find impedance in publishing scientific work -9. MedicScientific writing is essential for researchers, but due to a lack of skills and interests, many good research pieces do not place their positions in quality journals. There is a need for intervention to improve writing skills in preliminary researchers . Since aThe reputed journals reject several of the manuscripts because of the poor manuscript writing skills and flaws in the study designs. Then, the researchers are compelled to send their manuscripts to sub-standard and non-indexed journals. By keeping these points in mind, we designed a very interactive workshop for enhancing the manuscript writing skills among the teaching faculty of different HEIs. Over two years, we conducted six five workshops in different HEIs in Pakistan to transfer the best of our knowledge and skills to various HEIs faculty members. We designed this research to explore the knowledge and perception of the faculty of HEIs regarding manuscript writing and to assess these workshops' improvement in the cognitive capabilities of preliminary researchers in Pakistan.Study design and settingThere are 22 medical HEIs affiliated with ten universities in Sindh, as recognized by Pakistan, Medical and Dental College . This miContents coveredThe content of the workshop and evaluation questionnaires were then modified after scrutinizing responses of the participants in the pilot workshop. The content of the workshop covered discussion on the introduction of research writing, checklist of writing a different type of papers, the algorithm of writing research, the structure of methodology, pattern of writing results, data presentations, discussion, conclusion, abstract, title of the manuscript, publication ethics, choice of the journal, correspondence with editors, leading reasons and dealing with rejections and considerations in revising and submitting the manuscript. The workshops were kept interactive with the inclusion of different types of activities such as pair-discussion, activity articles, quick group presentation, and facilitator-participant communication environment throughout the workshop.Instruments for evaluationFifteen test items assessed the knowledge of the participants on these features of publications. Each of the items surmised four options with one best answer to be chosen by the participants based on the content of the workshop. The test was distributed to the participant before and after the workshop. Participants were also asked to fill an evaluation form after the workshop, which helped to evaluate workshop facilitation and the need for similar activities in the institute. The response of this form was asked in 5 points Likert scale from strongly disagree to strongly agree. The workshop took an average of five hours in the delivery of the content and discussion. Writing for the reader’s mind increases the likelihood of publication in quality journals in each workshop’s take-home message. Fifteen days after the workshop, the workshop’s strengths and weaknesses were discussed with participants in focus-group discussions and further discussed the implementation of workshop content in their professional life.ParticipantsTwenty participants were registered from each institute except in two institutes, where 25 participants were registered for the workshop. The participation rate was varied in each institute. The participants with a rudimentary knowledge of research publications were asked to register for the workshop.Statistical analysesThe responses in the pretest and posttest of the workshop were classified in binary form as correct or incorrect. McNemar’s test was then performed to assess changes in the responses of the participants. Median with interquartile range, Cronbach’s alpha, and intraclass correlation was reported to express participants’ responses on workshop evaluation. Kruskal Wallis test was performed to assess differences in the response of participants on workshop evaluation across different institutes. The data obtained from the pilot workshop was not incorporated with data obtained from later workshops.Participants and participationA total of 87 individuals participated in the workshops, and the highest number were from HEI C. On the other hand, the highest participation was observed from A in the focus group discussion Table .Participants’ knowledgeTable Similarly, 61% of the participants did not correctly know about writing the introduction. This proportion decreased to 21% after the workshop (P<0.001). More than half percent of the participants incorrectly answered about settling authorship criteria before the workshop. After the workshop, 56.3% of participants knew that it should be settled before starting the research work. About two-fifth of the participants did not realize the specified quality of a good journal. After the workshop, 80.5% of the participants knew that a high rejection rate and high impact factor defines the good quality of a journal (P<0.001).Less than half of the participants knew that all the contents of the manuscript should be based on the research question of the study. The workshop could not significantly augment this knowledge of the participants. The correct statement of conclusion was known to 49% of the participants before the workshop. There was a slight increase in the number of correct responses on this question after the workshop. Less than half of the participants knew that keyword should be included in the title of the study. After the workshop, knowledge of this consideration was increased to 81.6% (P<0.001). Forty-one participants incorrectly replied on considerations of choice of a journal. This consideration was correctly known to nearly 60% of participants in the post-test. The validation of quality journal inferred incorrectly by sixty-six participants before the workshop. The incorrect response to this question decreased to almost half of this number in the workshop post-test. Nearly 80% of the participants did not correctly answer about author’s trait while drafting and submitting the manuscript. There was a 5.4% decreased in this lack of knowledge about the author’s traits after the workshop.Workshop evaluationThe workshop evaluation forms were returned by 70 (80.4%) participants only. The rest of the 17 forms were missed or did not fill by the participants because they left the workshop after filling the post-test. The workshop was held twice in HEI labeled D, so both groups ' response to the workshop 's efficacy is described in the same column. The intraclass correlation was 0.939, and the value of Cronbach’s alpha was 94.2%, which showed excellent agreement and consistency, respectively, among the responses of participants for workshop evaluation. The median and interquartile range of need for workshop activity was 5 (1), with no significant difference in the responses from different institutes indicating all strongly agreed on average. Participants found timings of the appropriate with an average score of 4 (1). There was a significant difference in the response of the participants for agreeing with the venue and logistic supports . Congruency of objectives with the learning needs of participants was strongly agreed by B and D but agreed by A and C (P=0.04). The delivery of content for objectives of the workshop was strongly agreed by B while just agreed by the participants from another university (P<0.001). Participants were agreed to enjoy the way contents were delivered with little more variation from D (P=0.02). The response of strong agreement was reported by A and B on the adequacy of interaction level while just agreed was reported by C and D (P<0.001). Agreement on time management was most substantial from B (P<0.001). Participants from the same university also provided strongly agree response for the items, including adequate hands-on experience, quality of handouts, training in the session, was worth the time spent, acquiring desired outcomes, and putting knowledge into practice. The workshop developed better interpersonal skills strongly agreed by B and D, while A and C delineated simple agreement in this regard (P<0.0001) Table .Responses in the focus group discussion (FGD)In the FGD, participants strongly appreciated the knowledge gained from the workshops. They got motivation in writing their unfinished manuscript.“After the workshop, we opened our thesis to write a manuscript from it.”“Indeed, the workshop did give me some insight as to how I can better my research writing and especially the discussion part.”Participants also commented on different components of the workshop affirmatively.“The algorithm of writing manuscript was the best part which will surely help us in easy writing.”“Checklist made sure that we went through everything, so it was an important accessory.”“Hands-on activity was a good way to revise every component of the workshop in a short period of time.”Participants got to know about different checklists of writing guidelines such as IMRAD, Consolidated Standards of Reporting Trials (CONSORT), Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) from this workshop. The existence of any predatory journal, selection of any journal according to the subject of the manuscript, authorship placements, and correspondence with the editor were the important issues that participants lacked knowledge before the workshop.Few recommendations were shared by the participants to enhance more knowledge during the delivery of the workshop. They asked if separate workshops could be arranged on different topics such as research methodology, reference management, data analysis, and other related. Participants had an issue with the short duration of time of the workshop and the contents covered.“It should be a whole day workshop and should be conducted step by step; basic for beginners and advanced in the form of series for those who have attended the first workshop.”In Pakistan, generally, most of the public and particularly private sector HEIs want their faculty to do quality research work and get their papers published in the high impact factor journals. However, these institutes do not provide a conducive environment, required infrastructure, and optimal funding for such activities, and this factor compels the faculty to do substandard research and get that published in non-indexed journals. In this regard, the Government of Pakistan spends enormous resources on overseas research training to flourish a scientific base in the research field . MedicalAs has been observed by other researchers, participants in our workshop were not positive about the worth of their ideas, had little understanding of writing their thoughts, and were not familiar IMRAD format . They haPerfection in medical writing skills is likely to improve the submission and publication of research data. Writing is believed to be a starting point, rather than an endpoint of the research process in academic growth and development . In thesOur study is similar to the study from the Kramer, who observed that enabling the environment facilitates the improvement in writing skills, dissemination of scientific knowledge, publication of research data, and achievement of health care prospects . This stWe suggest that HEIs should frequently organize such manuscript writing workshops on their campuses. Besides, we recommend that there should be a research methodology module in their educational program, or it could be introduced as an elective. Good manuscript writing skills are as important as good research. A well-written manuscript has bright chances of acceptability in good impact factor journals and publication in a reputable journal. It is not only important for the faculty members but also crucial for improving the institute’s overall ranking. A better ranking attracts bright students and good faculty members and, consequently, enhances the ranking.LimitationsThere are several limitations to our study. Firstly, the sample size is small. Secondly, we have mentioned the initial change in the participant’s knowledge, but we did not evaluate the long-term impact on their attitude and practice that needs a follow-up study for which the present data would help a lot.The participants’ response regarding the effectiveness of manuscript writing and publication workshop was overwhelmingly positive, and there was a significant impact on the participants’ knowledge. There is a need for research training that will help for better capacity building in different HEIs of Pakistan. We strongly recommend that there should be a full flash series of workshops on statistics in research, scientific writing, and tackling hurdles in publications.


Over the past ten years, medical students have increased their research activity to be competitive for orthopaedic residency positions throughout the country. This increase may favor students at institutions with a strong history of research production and well-established research departments with supporting staff. To compete with these institutions, a Musculoskeletal Research Committee was developed at a southern academic institution to provide a mutually beneficial link between orthopaedic research faculty and medical students. This manuscript describes the formation of this committee and the resultant involvement of young medical students in departmental research over a one year period. Composed of students and faculty, the committee developed a Research Guide for Medical Students, Research Database and Student List, Medical Students’ Webpage, and Routing Form, and holds quarterly meetings for those students active in orthopaedic research. With this platform, the committee aimed to increase young student involvement in research and provide a stratified level of study participation among upper-level students for continued mentorship. In one calendar year, the total number of first and second-year students participating in department research increased 460% (5 to 28). Also, the total number of research projects with student involvement from these two classes increased 780% (5 to 44). The introduction of a research committee is an effective method of stimulating student interest in departmental research. Early participation results are promising, and this method may be applicable to other departments and institutions hoping to increase research productivity.Abbreviations: IRB: Institutional Review Board Research is an important aspect of medical training and plays a vital role in the advancement of clinical medicine. It teaches educational skills that are traditionally absent in many medical school curricula but important in building a career founded on evidence-based medicine –3. ReseaMedical students may then seek to participate in research opportunities external to the formal curriculum, but face significant barriers including a lack of time, competing educational demands, and unfamiliarity with the research process . Many inWith the aid of the departmental Director of Research, a Musculoskeletal Student Research Committee was developed to provide a mutually beneficial link between orthopaedic research faculty and medical students at a southern academic institution. The goal of the committee was to overcome common barriers described previously in order to increase the amount, quality, and interest in research within the department of orthopaedics. Hence the mission statement of the committee was written, ‘To connect students with the information and faculty needed to guide and maximize medical students’ time to choose, start, and complete research of the highest quality.’The committee consists of a Committee Director (Orthopaedic Director of Research), Faculty Advisor (Chairman of the Orthopaedic Department), Faculty Coordinator (Research Coordinator of the Orthopaedic Department), Faculty Statistician, and Faculty Project Developer. The medical student roles of Chairman, Senior Advisor to the Chair, and Chair-Elect are filled with third-year, fourth-year, and second-year students, respectively. At the end of the school year, all students ascend in role, and nominations for the new Chair-Elect are put foward by the student committee members and selected by the faculty on the committee. Only students that are currently participating in committee research are eligible for nomination to ensure continued leadership regarding the responsibilities of the position.These three students serve as a bridge between the medical students, residents, and faculty. The Chairman’s responsibilities include emailing students, faculty, and the Director of Research to assist in all matters related to research. This consists of managing the Medical Students’ page on the department website, maintaining an online research database of existing and proposed projects, and planning all quarterly meetings – explained in further detail below. The Senior Advisor to the Chair provides counsel to the Chairman and Chair-Elect regarding past research experiences, in addition to serving as a mentor to younger students and a liaison to upper-level medical students. The Chair-Elect assists the Chairman with their tasks and acts as a liaison and visible contact for the first and second-year students who spend most of their time in the lecture halls on campus. A responsibility shared between the committee is to continually update the Research Guide, as detailed below.Reflecting on the past experiences and difficulties conducting medical research, the committee developed a ‘Step by Step Research Guide for Medical Students’, detailing how to complete institutional training modules, Institutional Review Board (IRB) documentation, and miscellaneous information such as instructions on obtaining data privileges at various hospitals. Furthermore, specific instructions are included to guide students seeking to join fellow medical students on active projects, assist on a resident’s study, or begin their own project under the guidance of a faculty physician. The Research Guide also includes instructions regarding access to the Research Database and Student List.The Research Database and Student List are documents developed and maintained by members of the committee that communicate opportunities for research activities to students. The Research Database contains potential research ideas generated by the orthopaedic faculty, resident projects in development, and ongoing projects in need of student assistance. A second document, the Student List, contains student-run projects only. Projects on this list are closely monitored by the committee to identify roadblocks to progress and provide quick resolution. The Director of Research, along with the Chairman and Chair-Elect, collaborate to ensure these documents are current. Both documents allow students to view up-to-date project ideas, as well as available spots on a variety of studies in the department and are fundamental to the productivity of the committee. These documents are readily accessible to students on the ‘Medical Students’ portion of the departmental website.The Medical Students’ Webpage was created by the committee on the existing Department of Orthopaedics’ research website and can be visited by students. This was developed to provide access, in one setting, to all resources produced by the committee to assist students in research. These resources include the Step by Step Guide, Student List, examples of literature reviews, completed IRB and Institutional Biosafety Committee (IBC) forms, as well as other documents commonly needed to start research. If a student elects to begin a new study, the department required Routing Form can be found on the webpage as well.The Routing Form, created by the committee, was designed to follow the steps in conducting research. It requires that students complete a literature review, formulate a research question and hypothesis, determine study design, data source, variables of interest, and selection of measurements. The committee also requires assignment of authorship inclusion and order on the form to avoid disagreements upon submission for publication. In order to ensure study progress, students and faculty select target conferences for abstract submissions and other target dates. This form serves as a guide to aid students in the research process, but it also helps to ensure the feasibility and merit of the proposed study by requiring several faculty approvals to proceed.Upon securing approvals from the faculty advisor and director of research, the faculty project developer and statistician meet with students to refine the proposal and aid in preparation of successful IRB submission.The purpose of the quarterly meetings is to discuss new and ongoing projects, educate students in the research process, and provide students with assistance to address common obstacles in research. Preceding these meetings, the committee assembles to set the meeting agenda and discuss any issues with active projects that may require faculty intervention. Also, the Chairman of the committee emails each faculty member to survey for new project ideas to be shared with students. This provides students with a narrower scope of projects aligned with faculty interests to ensure faculty support.Additionally, each meeting has a presentation given on research training as follows:Q1. Introduction to Student Webpage, and Instruction on IRB/Literature Review Completion (given by Chairman)Q2. Research Design and Methodology (given by Faculty Project Developer)Q3. Data Collection, Analysis, and Basic Biostatistics (given by Faculty Statistician)Q4. Manuscript Completion (given by Committee Director)At the end of each meeting, time is reserved for students to address issues with current projects, interact with the Director of Research, and connect with classmates interested in beginning projects. Networking with other students, particularly students in classes above or below, is important as the committee encourages a stratified level of experience on new studies.The committee determined that an attempt should be made to have representation on projects from each level of training. For example, a new study initiated by two first or second-year students should also seek an upper-level student and resident to be a part of the project. This provides for peer mentorship among the team. Upper-level students and residents can offer greater clinical knowledge and research experience. It is expected that as those first and second-year students advance to upper-level students, they assume the same mentor roles on future projects.In one calendar year, from February 2016 to February 2017, the total number of first and second-year medical students  participating in department research increased 460% from 5 to 28 . Which wIn one year, there was a notable increase in research participation among early-year medical students, as indicated by the number of students as well as the total number of projects with student involvement. Although this study did not directly survey medical students regarding their motivations behind increased research participation, the authors postulate that the structure, availability, and creation of resources removed barriers, provided guidance, and created a framework in which motivated students could thrive. The quarterly meetings create a curriculum of learning research skills while providing mentorship for first-year students by more senior students. This support structure may also enable young students to be aggressive in their research endeavors and participate in multiple projects – in 2017, one student was involved in as many as four projects.The benefits of increasing medical student research participation may extend further than the Department of Orthopaedics. As more students gain a greater understanding of the research process and the importance of these efforts, they may utilize these skills to make an impact in other fields and bolster the overall academic contributions of the university. After all, evidence-based medicine is the gold standard of practice in all fields of medicine ,13. At aThe Musculoskeletal Research Committee is a dynamic group centered on student research issues. Before the committee’s existence, students traditionally reached out to the Director of Research with issues, and then scheduled a meeting to discuss starting the research process as well as project ideas. This was burdensome to the Director because of his clinical and educational schedule and normally required multiple meetings before the official start of the project. With the development of the committee, the common research inquiries are directed to the Chairman and Chair-Elect, and answers are outsourced to the student group. This system also informs the Chairman and Chair-Elect of common questions that should be addressed at the quarterly meetings. Having a student-directed line of communication offloads the demand on faculty and improves the pace of communication. Any questions the Chair and Chair-Elect cannot answer can then be forwarded directly to the Director of Research. This shortens the response time and provides more effective communication. In addition, the quarterly meetings provide students with a scheduled opportunity to interact and ask questions to the Director of Research in a face-to-face setting.The committee provides a mutually beneficial relationship that allows students access to projects and assists faculty in finding students interested in participation. Through committee successes regarding the dissemination of research education and resources to students, medical students are provided with research tools that may enhance their contribution to projects. The same benefits can be applied to residents. Since the ACGME requires an orthopaedic resident to complete a study worthy of publication in a respected academic journal, a research partnership with co-investigators who have relatively fewer time demands is a desirable situation. FurtherIt is recognized that continued modification is necessary for improvement. The research guide developed by the committee has thus far been successful in prompting more students to begin research, but undergoes continuous revision and is far from comprehensive. As the number of students involved in research grows, new complications will arise requiring new solutions.As stated previously, one committee goal is to provide mentorship to first and second-year students’ studies by emphasizing third and fourth-year student participation in projects. While the existence of the committee is still young, it is anticipated that the benefit of study member stratification will grow as the current first and second-year students, now with formal training in research, have progressed to senior students. Although the majority of students are participating in or leading retrospective studies as the demand for publications on applications continues to rise , more emIt is possible that the increased participation may have arisen due to increased interest in orthopaedics from class to class. However, the difference in first-year participation was substantial and previous studies describe an indecisiveness most first-year medical students have toward selecting a specialty of interest due to their lack of clinical exposure –20. FurtThe committee has received praise from the student participants in studies before and after the development of this committee for providing a platform that addressed the difficulties they faced in conducting research effectively. Therefore, it is believed that all students may value the guidance and opportunities offered by this committee. This progress has been noted across the local medical school campus – the Student Government Association has requested a presentation by the committee to encourage replication of the committee in additional fields of academic medicine, since a research model such as this has never been implemented. This year-long experience has demonstrated that students are willing to make the time and have the desire to participate in research. While many faculty possess the same desire, this committee provides the structure to connect and benefit both parties. Although data regarding medical student perceptions was not formally collected during the first year of implementation, the purpose of this paper was to provide a guide for medical schools and residency programs to establish similar committees to increase research participation at their institutions. The authors will continue to assess the long-term effect on research productivity. Although this committee structure may not be applicable to all academic settings, the core principles within – prioritization of mentorship and collaboration, along with the establishment of clear and effective lines of communication – are universally beneficial.The amount of research experiences and publications that medical students are participating in to match into competitive residency programs continues to increase. From 2007 to 2014, the mean number of research experiences for successful orthopaedic applicants increased from 2.6 to 3.7. The number of publications, abstracts, and presentations increased from 3.0 to 6.7 during that time frame as well . Not onl


Overweight and obesity are a worldwide pandemic with geographic differences. Possible explanations include variable access to food and its quality, dietary habits of the populations, behavioral patterns, and characteristics of the food markets. This study aimed to examine the acquisition of food in the different regions of Brazil and to relate it with the geography of Brazilian obesity. We used data provided by a Brazilian official organ, which gathers periodic data on the household food acquisition. Descriptive statistics and multidimensional scaling techniques were used to ascertain the similarity of food acquisition among populations in the Brazilian states. High levels of overweight and obesity occur in all states (>44%), especially in the southern half of the country (>54%). We found differences in the food acquisition patterns throughout the country. Furthermore, we identify that states with similar dietary patterns have similar population levels of overweight and obesity, demonstrating a possible relationship between the food supply models and these food insecurity manifestations as expressed in the individual health. However, the occurrence of regional singularities suggests that the food supply model constitutes only one of the multiple variables that compete for diversity in the Brazilian regional distribution of obesity and overweight. We found that socioeconomic conditions influence nutritional misalignment in the geography of Brazil. Our results show that overweight and obesity have a higher occurrence in middle age (35–79 years), and it is more present in females. Moreover, women with lower education and lower incomes have higher levels of overweight and obesity, an association of unhealthy food intake with poverty. In men, obesity is more frequent in those with more schooling and higher incomes. Based on the widely variable geographical characteristics of the distant states of Brazil, we conclude that overweight and obesity go beyond an individual lifestyle and access to quality food, and is more related to a complex framing of factors, like schooling, age, sex, income, feeding patterns, food markets, and anthropological circumstances. Human health is connected to food security—a concept that involves availability, accessibility, and sufficient quantity for the proper use of food. The most widely used definition refers to the access of all people, at any time, to sufficient and adequate food. Food must provide energy and nutrients to maintain an active and healthy life , 2.We live in a state of global alertness about food security . Even wiLocal factors with characteristics that reinforce behaviors related to obesity make up an obesogenic environment. In this sense, understanding the environmental factors that contribute to obesity is an essential step in characterizing and supporting eventual interventions in preventing collective overweight and obesity .Overweight and obesity come from abnormal or excessive fat accumulation, according to the World Health Organization . TherefoIt is not new that the indices of overweight and obesity have assumed high proportions around the world, and it is considered a major threat to public health , 7. ThisAmong the explanations for the problem are, although not restricted, the habits and dietary patterns of the populations. Different factors can affect access to food, such as economic, socio-demographic, cultural, and environmental aspects. All these factors are, in principle, measurable and sensitive to observation, including information about behaviors of peoples located in the same geographic space. Understanding the environmental characteristics of the sites that present high rates of the nutritional disorder is a fundamental tool for public health.The objective of this study is to examine the determinants of the geography of Brazilian obesity and overweight, taken into account that Brazil presents a marked regional heterogeneity in terms of biophysical, socioeconomic, and historic and cultural diversity.In a previous study, we found that food acquisition in the Brazilian states is geographically diversified. The heterogeneity observed emphasizes Brazilian agribusiness development and underscores the influence of the food supply chains on the regional food patterns . In thisThis study was based on the analysis of data obtained in the Family Budget Survey (POF). We were limited to data corresponding to the years 2008–2009, the most updated set published by the Brazilian Institute of Geography and Statistics (IBGE) so far .The POF was organized in partnership with the Ministry of Health and seeks to present a profile of the living conditions of the Brazilian population. Therefore, through the measurement of consumption, expenditures, and income of individuals, the POF has the purpose of assessing relevant themes for the creation of public policies. We decided to use the POF microdata for a more objective view on the prevalence of obesity and overweight in Brazil. From this, we initiated an analysis to identify patterns that could explain the spatial distribution of overweight and obesity in Brazilian populations in a comprehensive way.The microdata of the POF consist of codified numerical data, classified accordingly to the nature of the information and whether it is individual or familiar. We used the acquired food amounts and the anthropometric and socioeconomic data. These numbers were downloaded on TXT archive. From there, we opened the dataset with EXCEL software. Next, we read the sequential numerical data using a dictionary of variables provided in the same URL page of IBGE, which allowed us to build a table with the desirable variables, which were analyzed by Statistical Package for Social Sciences . The data presented in this work are those obtained after this step.2), eutrophic (BMI between 18.5 and 24.9 kg/m2), overweight (BMI between 25 and 29.9 kg/m2), and obesity (BMI ≥ 30 kg/m2).The present investigation uses the anthropometrical perspective to access food insecurity. In this sense, obesity and overweight were quantified, using the specific indicator of body mass index (BMI). To calculate the BMI (weight in kg/square of height in m), the microdata of the POF was used. From this base, the values of body weight and height for the calculation were extracted, whereby we created a new variable. The nutritional status variable was categorized as underweight . It is noteworthy that BMI is considered a less effective index for the measurement of obesity in children, justifying our choice to analyze only individuals aged 25 years or older . In adulTo analyze the Brazilian food acquisition, we worked with data on quantities acquired of food and beverages, which refer to all acquisitions for household consumption, both monetary and non-monetary. To standardize, all items were converted to the metric unit kilogram (kg). Concerning food types, the data were classified into the 17 groups pre-established by IBGE (2010): (1) cereals and legumes, (2) flour and pasta, (3) coconuts, chestnuts, and nuts, (4) vegetables, (5) fruits, (6) sugars and products of confectionery, (7) salts and condiments, (8) meats and offal, (9) fish, (10) canned and preserves, (11) poultry and eggs, (12) dairy products, (13) bakery, (14) industrialized meats, (15) beverages and infusions, (16) oils and fats, and (17) prepared foods.Moreover, we decided to implement multidimensional scaling to investigate the similarity of food acquisition among Brazilian states. Multidimensional scaling consists of an interdependence technique that allows mapping objects, considering the distance or similarity between the elements analyzed . The datWe grouped the Brazilian federative units according to their similarity in the median food quantity acquired from each of the 17 pre-established IBGE food groups. This process allowed us to make judgments of consumers regarding their preferences in multidimensional space.In addition, it is known that there is an impact regarding social class on nutritional patterns –16. ThusThe geopolitical subdivision of Brazil in macro-regions and the spatial variation of excess weight in the population are shown in In our study, we considered 27 federative units and five macro-regions of Brazil . In FiguThe Euclidean distances between Brazilian federative units were calculated according to the food amount purchased. Data on median food acquisition refer to the amount of food per capita per household purchased in each Brazilian federative unit. Dietary patterns are not the only explanation for the spatial division of overweight/obesity. Thus, it makes sense to analyze other factors that may be associated with overweight, such as socioeconomic factors . We identified that obese individuals have a median age higher than the other individuals analyzed. Contrastingly, eutrophic individuals have a lower median age. In Brazil, the largest number of overweight and obese individuals was found in the age group of 50–79 years. Moreover, the nutritional situation of Brazilian women deserves great attention because they are more prominent according to our data, both in the underweight and obesity levels.per capita income. Further, we confront the individual states with the food groups and with the overweight and obesity data. From this analysis, we can see that states with higher average income per individual tend to have higher rates of overweight  and Bahia (45%), are the states with the lowest level of overweight and obesity. The state of Rio Grande do Sul (60%) has the highest percentage of overweight and/or obesity population. The data used in this study are from 2008, but we can verify that the distribution of obesity remained similar over the 10 years . Therefo2 in 2013 was 36.9% for men and 38% for women  may help explain its different overweight/obesity indices, when compared to the other states in the Northeast region of Brazil. The RN has a close/similar food acquisition to the Brazilian south region. We emphasize that Rio Grande do Norte has greater access to certain foods also available in the south of the country where the population lives mostly in the coastal region.The identification of seven distinct dietary patterns emphasizes the influence of agribusiness supply chains on regional dietary patterns. Differences in food supply between states occur due to political, economic, logistic, and biophysical factors. It is obviously impossible to make healthy food choices if there is no local pertinent food availability. Because food security is a concept that also involves food availability, identifying the geographical factors that affect food choices is relevant for promoting health and malnutrition eradication , 2.From a public health viewpoint, identifying dietary determinants of weight gain is critical to understanding and reducing the prevalence of obesity. However, although the dietary pattern is not the only determinant of the geographical distribution of overweight/obesity, in some cases, it is extremely related.Socioeconomic background and food environment can have a strong influence on the nutritional status and health of individuals. Additional evidence can be found in the repeated findings on income and/or education-related obesity growth rates , 14, 18.A possible relationship between income and food acquisition profile is visible. With these results, apparently, economic development does not necessarily result in an improvement in the food-related health of Brazilians. In developing countries, where poverty and wealth coexist, obesity should be an indicator of easy access to food, leading us to believe that in the poorest countries, overweight is present in the higher-income classes.Some studies –23 that Many analyses include sex as a clear effect modifier, concluding the association of different directions between education and obesity . We founOur evidence supports that sex is a factor that should be considered in developing public policies to overcome obesity and overweight. Among low-income people with overweight/obesity, women are conspicuous. In the highest income quartile, we find more men with obesity and overweight.We found different relationships between education and nutritional outcomes in Brazilian women, compared to those in men. This finding deserves attention because education not only facilitates access to health information but also helps the cognitive processes associated with the promotion of healthy habits . A studyWe understand sex as a potential confounding factor or modifier of the effect of the relationship between socioeconomic and nutritional status. It is important, therefore, to continue the investigation on the effect of sex in the relationship of socioeconomic indicators with the nutritional status of individuals.This study provides a set of empirical findings on the relationship between socioeconomic status and the prevalence of obesity and overweight in the geographically spread Brazilian population. Our evidence supports that both age and gender should be considered when designing public policies to fight obesity and overweight.Overweight and obesity cannot be viewed as an individual problem. It is important to recognize that not everyone has access to a healthy lifestyle and quality food. We understand that socio-geographic factors influence nutritional misalignment in Brazil, and we confirm this hypothesis by identifying a spatial distribution in the country's overweight and obesity population levels. We verified the variations in distributing obesity levels, according to dietary patterns and demographic data.However, we realize that the geography of obesity and overweight in Brazil is more complex than might have been seen here or previously assumed. The distinct and changing economic, social, and cultural environments that characterize Brazil make the country very diverse, complex, and dynamic in the patterns of the social determinants of obesity. We shall acknowledge that different population groups may have divergent nutritional situations, which depend on multiple variables that transcend those detectable in dietary patterns.Together, the results of this study indicate that dietary patterns cannot be sentenced as decisive for the high rates of obesity/overweight, as a nutritional evaluation of food standards was not performed. It is possible to consider that the relationships we described between diet and overweight exists; however, a further evaluation of the respective diets is necessary. Moreover, a healthy community is a population that, besides having excellent medical care, also lives in an environment that encourages individuals to carry out a healthy life. An environment that avoids the prevalence of obesity should be based on the availability and supply of food that correspond to a healthy diet and on strong policies that promote general education.In conclusion, we identified a set of factors that suggest why obesity and overweight may prevail in certain populations. A more global look is needed on this pandemic and how it is distributed in different locations. A limitation of this study was its contingency to updated public data and the last Brazilian bank available to us dated from 2008 to 2009. Comparable and updated information on levels and trends are important for better and continuous use of our results. We hope this research can contribute to developing public policies to adjust the regional production and distribution of food to ensure food in quantity and quality for entire populations.https://www.ibge.gov.br/estatisticas/multidominio/condicoes-de-vida-desigualdade-e-pobreza/9050-pesquisa-de-orcamentos-familiares.html?=&t=microdados.Publicly available datasets were analyzed in this study. This data can be found here: CA and GD collected the data and carried out the statistics. KV and HD supported the intellectual and analytical framing of the work. CA and HD wrote the article.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.


Beach litter is a worldwide problem that has several negative effects. A first step in preventing an environmental hazard is to determine and model the level of contamination. In this paper, geostatistical simulation is used to model two main forms of beach litter (cigarette butts and sharp items) in one of the most contaminated beaches in Antofagasta, Chile. A hundred realizations of cigarette butts and broken glass are generated to emulate their joint spatial distribution. The simulation results are used to classify the beach into different areas with respect to the risk of injury by broken glass and the level of contamination by cigarette butts. The models obtained can be used by local authorities in beach clean-up programs and by visitors to beaches in choosing the safest and cleanest areas. The results demonstrate the capability of geostatistical simulation algorithms to model different types of beach litter. Beach litter is a significant problem worldwide with negative effects in terms of the reduction in environmental biodiversity, human health, and tourism ,2. In ad2 [2 [Generally, the contamination level of beaches is one of the main factors for choosing a beach by visitors. According to a study carried out by Krellin et al. 2017), 85% of people avoid visiting a beach if it has more than 15 pieces of beach litter per m, 85% of cientificos de basura has been measuring beach litter on the main beaches in cities throughout the country. The group has found that the beaches in Antofagasta, northern Chile, are the most contaminated [The main sources of beach litter are human activities. Unfortunately, in the last two decades, the amount of beach litter has increased considerably, such that contamination of beaches is currently recognized as a worldwide problem ,10. Theraminated . Moreoveaminated .In this study, cigarette butts and broken glass were modeled by taking advantage of geostatistical methods on one of the most popular beach of Antofagasta. The beach under study receives many visitors during each year and due to human activities, a high level of contamination can be observed in the beach.Geostatistical tools and algorithms are widely used for modeling regionalized data and solving spatial interpolation problems for both natural and anthropogenic variables ,16,17,18As a first step, cigarette butts and broken glass were sampled in the study area. Then, by taking advantage of multivariate geostatistical methods, cigarette butts and broken glass were modeled in the study area. Based on the results, the study area was classified into different sub-areas and the probability of exposure to sharp items (broken glass and bottle caps) was calculated. Finally, the results were processed to assess the capability of geostatistical algorithms to model beach litter.As noted above, Antofagasta has the most contaminated beaches in Chile , which iPlaya Blanca is one of the most popular beaches in Antofagasta because of its proximity to the largest city park (Parque Croata), the two main universities, and many bars and restaurants. The level of contamination and beach litter varies during the year and usually reaches a peak in summer when the number of visitors is the highest. It is important to notice that this beach has no formal cleaning programs. The study area of 50 m × 150 m is part of Playa Blanca beach.As a first step, this area was divided into a 1 m by 1 m grid . During As a result, a high concentration of cigarette butts is expected in an area with a high concentration of broken glass (mainly from beer bottles). Consequently, we applied multivariate geostatistical algorithms to jointly simulate these two forms of beach litter in the study area . During sampling process, metal caps of beer bottles were also found in some grids and as they present the same danger and can cause serious injuries, a new category was generated called ‘sharp items’, which includes broken glass and metal caps. Therefore, hereafter in this study, the term ‘sharp items’ refers to broken glass and metal caps. However, it is worth noting that the sharp items were mostly corresponding to broken glass.The cigarette butts and sharp items  found in each grid were counted. The broken glass was mainly small fragments of beer bottles. Samples were gathered not only on the surface of the study area, but also from approximately 5 cm below the surface. To preserve the same conditions for all samples, the sampling was conducted on one day in January  with the help of twenty volunteers. Before starting sampling, the volunteers were trained to reduce the sampling errors. The samples were gathered at a time when there were practically no visitors to the beach.To apply geostatistical methods, the average densities of cigarette butts and pieces of broken glass per square meter were used, rather than simply the count per grid cell.In addition to the number and position of sampling data, geostatistical algorithms consider the distance between data and target points and the spatial continuity to model the underlying variables . The expThe variogram usually reaches its limits (or sill) at a distance called the range, which indicates the distance from which two data cease to be correlated. The value at very small distances (just beyond the sample size) is called the nugget effect and determines the small-scale variability of the variable.In the presence of more than one variable, it is necessary to calculate cross-variograms between variables. The experimental cross-variogram determines the dependence between two variables at a given separation distance, and is defined as follows:Geostatistical simulation is used to provide multiple outcomes (as many as desired), each of which is considered a possible scenario reproducing the spatial continuity of the variable(s) under study. Apart from providing a prediction of the unknown values at unsampled locations, by averaging the scenarios, one of the advantages of geostatistical simulation is to allow users to define the level of uncertainty and to analyze risks . The ratThe turning-band algorithm ,21 was uOverall, cigarette butts and sharp items were gathered at 530 sampling locations in the study area . Table 1To assess the capability of the geostatistical approach, the sampling data were divided into two subsets: 200 data were chosen randomly (training set) and used for modeling cigarette butts and sharp items in the study area, while the remaining 320 sampling data (testing set) were used for performing split-sample validation. A joint variogram analysis was applied to the normal score transforms of the training data. The sill matrices associated with the nugget and spherical structures are positive semidefinite, which ensures that the model is mathematically consistent . In EquaThe two variables were simulated jointly and 100 conditional realizations were generated with the turning-bands algorithm. K = 20. According to the calculated HII, each beach is classified into one of the following categories from a hazardousness point of view  and cigarette butts. Recently,  proposed of view .By using the results of simulation, the HII index was calculated for the study area with respect to the sharp items. On average over 100 realizations, it is found equal to 9.4, which indicates that most of the area is covered by broken glass or bottle cap and there is a high probability of being affected by sharp items in this part of Playa Blanca beach.K = 20. According to the calculated CCI index, the beach will be classified into one the five following categories from cleanliness point of view  presented by Alkalay et al. (2007) for classifying beach cleanliness with respect to the presence of plastics. This index determined the level of cleanliness of beach and is calculated as follow: of view .In this criterion, all types of beach litter are considered for calculating the Clean Coast Index. Therefore, by using the results of simulation and considering both sharp items (broken glass and bottle cap) and cigarette butt, the CCI index of the study area was calculated. According to calculated index (CCI = 110.8) the study area is classified as ‘Extremely Dirty’.These two indexes can be calculated globally, for the whole beach, or locally, for different sectors of the beach . HoweverVery Clean: Clean: Dirty: Very Dirty: The studied area was also divided into the three groups based on the risk of injury by sharp items:Low risk of injury: Moderate risk of injury: 1 High risk of injury: Because each generated realization is a possible scenario for the variables, the risk can be analyzed and probability maps of the variables can be constructed. The probability that a variable exceeds a specific threshold in any given grid node can be calculated based on one hundred realizations. Split-sample validation can be used to determine the accuracy and quality of the simulated values. As previously mentioned, the original sampling data (530 samples) were divided into two subsets, via a random selection. Then, one of the subsets (training subset including 200 sampling data) was used as conditioning data for simulating the cigarette butts and sharp items at the locations of the other subset (testing subset). The simulated values at the testing subset, as well as their average, can finally be compared to the true values.As observed in ariables .The calculated CCI and HII indexes determine that the study area is extremely dirty and there is a high probability of being affected by sharp items (broken glass and bottle cap) in this part of the beach. As demonstrated in For example, these maps can be useful for beach cleaning programs, which are usually conducted by regional governments. In addition, the visitors can use them to choose the best place to sit in terms of presenting the least contamination and the lowest risk of injury. These maps can be used to monitor and manage the phases of environmental restoration.In this study, sharp items and cigarette butts were modeled in a small part of a beach to demonstrate the capacity of geostatistical modeling. However, different types of beach litter, such as plastic, paper, and small pieces of metal, on other beaches can be also modeled. In addition, other type of contamination such as chemical pollution which can be present in the beaches can be modeled by using geostatistical methods.It is worth noting that the beach litter models vary with time and cannot be generalized for the entire year. For instance, the level of contaminations usually peaks in summer as more people visit beaches. Therefore, samplings should be taken for every season.The sampling was one of the main challenges in this works as it directly affected the obtained models of beach litter. Therefore, in order to preserve the same conditions for all measurements, the sampling was carried out over the course of one day and the volunteers were trained in order to reduce sampling errors. Another point to consider is the size of the pieces of broken glass. In this study, almost all sampled pieces of broken glass had the same small size. However, in a situation where the pieces were of different sizes, the larger pieces should be considered as they pose more danger. In this case, the authors recommend weighing the broken glass in each grid node instead of counting the number of pieces.Beach litter is a multidimensional problem with negative effects on the biodiversity of habitats and species, human health and tourism. Beach cleanliness is, in fact, the most important factor people consider in relation to visiting a beach . Beach lIn addition to the whole study area, each simulated node of the study area was also classified according to the risk of injury by sharp items and the level of contamination by cigarette butts. To this end, simple criteria were established to define the thresholds for every category. In addition, one hundred simulated realizations were used to calculate the map of probability of injury by broken glass. The results can be useful for visitors to beaches in choosing the cleanest and safest parts of a beach. The results can also be used by local authorities in undertaking beach cleanliness programs. In summary, in this paper, we tried to demonstrate the capability and versatility of geostatistical simulation algorithms to model beach litter and to analyze the risk of injury.Finally, it can be deduced that geostatistical approaches are helpful tools that can be applied in environmental science for modeling different contaminated material, such as beach litter. One advantage of these approaches is their applicability when one has an incomplete survey and a few sampling data. Even in this case, one can estimate the contaminated material at unsampled locations with high accuracy.


The developments in global health, digital technology, and persistent health systems challenges, coupled with global commitments like attainment of universal health coverage, have elevated the role of health research in low- and middle-income countries. However, there is a need to strengthen health research governance and create a conducive environment that can promote ethics and research integrity and increase public trust in research.To assess whether the necessary structures are in place to ensure health research governance.Employing a cross-sectional survey, we collected data on research governance components from 35 Member States of the World Health Organization (WHO) African Region. Data were analysed using basic descriptive and comparative analysis. Eighteen out of 35 countries had legislation to regulate the conduct of health research, while this was lacking in 12 countries. Some legislation was either grossly outdated or too limiting in scope, while some countries had multiple laws. Health research policies and strategies were in place in 16 and 15 countries, respectively, while research priority lists were available in 25 countries. Overlapping mandates of institutions responsible for health research partly explained the lack of strategic documents in some countries. The majority of countries had ethical committees performing a dual role of ethical and scientific review. Research partnership frameworks were available to varying degrees to govern both in-country and north–south research collaboration. Twenty-five countries had a focal point and unit within the ministries of health (MoH) to coordinate research.Governance structures must be adaptive to embrace new developments in science. Further, strong coordination is key to ensuring comprehensiveness and complementarity in both research development and generation of evidence. The majority of committees perform a dual role of ethics and scientific review, and these need to ensure representation of relevant expertise. Opportunities that accrue from collaborative research need to be seized through strong MoH leadership and clear partnership frameworks that guide negotiations. Emerging and re-emerging infectious diseases, coupled with commitments to achieving universal health coverage and the growing interest in global health, have accentuated the role of health research in low- and middle-income countries. In the context of evolving population health needs, additional considerations include the need for contextualized evidence to generate local solutions, innovation to improve efficiencies, and the development of more effective treatment regimens given the increasing resistance to commonly used medicines. Various contextual factors call for continual adaptation of health research systems to ensure relevance and effectiveness, for example in conflict settings , multilaThe low domestic financing for health research is a persistent problem in Africa, despite commitments made in the past. In the Algiers Declaration of 2008, African governments committed to investing at least 2% of their health budgets in health research. However, an assessment conducted a decade later in 2018 showed that only 2 out of 39 countries that participated in the assessment within the WHO African Region (WHO/AFR) had met the target . As a reSeveral frameworks have been proposed for strengthening health research capacity; common threads in these include building capacity at the individual (training and skills) and institutional (infrastructure) levels, retention of skilled researchers, promoting partnerships in research (south–south and north–south), building networks of excellence, providing funding for research, promoting uptake of research evidence, and a favourable political environment –14. GhafThe WHO/AFR builds on the work of Pang et al. and proposes research capacity-strengthening interventions in four domains, namely strengthening research governance, creating and sustaining resources, producing and using health research, and financing health research . AlthougHealth research governance encompasses a number of parameters that should provide a conducive environment for the coordination and conduct of health research. Several frameworks propose interventions to be pursued in strengthening research governance, and common among these is articulation of a vision for health research, setting research priorities, coordination of actors’ interventions and investments, ensuring ethical standards, and building research partnerships , 14, 19.The objective of this paper is to assess whether the required structures as outlined in the WHO/AFRO research strategy are in place in the various countries to ensure a conducive environment for conducting health research. We focus on the presence of the governance structures, or lack thereof, as opposed to their implementation or functionality. As much as the latter is important, we believe having these in place lays the foundation.We employed a cross-sectional survey design using a semi-structured mailed questionnaire.The study was undertaken in the Member States of the WHO/AFR. These are the countries that had endorsed and committed to implementing the WHO/AFR research strategy and tasked the WHO Regional Office for Africa (WHO/AFRO) with regular monitoring of the commitments therein.The survey questionnaire was emailed to all 47 Member States of WHO/AFR, and 35 responded (response rate of 74%). Prior to undertaking the survey, country teams  were oriented on the objectives of the assessment and the commitments detailed in the WHO/AFRO research strategy which were to be monitored on a regular basis (these informed the survey instruments), and were trained on completing the questionnaire. The questionnaire was emailed to the WHO Country Office focal person in charge of health research, who then shared it for completion with the person who was in charge of coordinating health research in the country, which was either the MoH focal point for research in the country or the head of the national health research coordination institute, as the arrangements differed from one country to another. The completed questionnaire was validated by an in-country team comprising representatives of institutions conducting health research, the head of the national research coordination institution, the focal point for research in the WHO Country Office, and the focal point for research in the MoH. The WHO Country Office focal point for research emailed the completed questionnaire to the WHO/AFRO.Data were collected on the different parameters that foster health research governance, as shown in Table Data were cleaned by the team put together by the WHO/AFRO who were in charge of data analysis. Data were analysed using basic descriptive and comparative analysis.As shown in Table The legal regimes for health research varied considerably. For example, in Rwanda, the mandate to enforce the different laws lay with different line ministries and government institutions. In some countries the laws were narrow in scope—restricted to regulating clinical trials (Mauritius), biomedical research on humans , and ethics of research . In countries where legislation was in place, this was enacted between 1979  and 2017.National Research Policy developed under the Ministry of Science and Technology in 2010, has not been updated to date and was rarely referred to’, and the cited shortcoming was the perceived insufficiency in some aspects—‘was not sufficient to include technological development’. In Niger, the policy was broad, encompassing both health and education. In Ethiopia there was reportedly no policy, which was attributed to overlapping mandates between the MoH and Ministry of Science and Technology, and the lack of a coordination unit at the MoH.Sixteen countries (~ 46%) had research policies that were under implementation (see Table In 15 countries (~ 43%) there were strategic plans for health research which were at various stages of implementation, but these were lacking in 14 countries (40%). However, those that were available existed in several forms, with some embedded in health sector strategic plans  and others embedded in action plans and strategies of other line ministries (Ministry of Higher Education and Scientific Research in the case of Burundi). In some countries such as Gambia, the research strategic plan was considered ‘expired on arrival’, as its horizon had lapsed while still in draft form, and hence it was never implemented. In contrast, the research strategic plans for other countries like Uganda and Zambia were outdated but still used in guiding investments and interventions on health research. In Ethiopia, they relied on the strategic plan of the health research institute to provide strategic direction for health research.The majority of countries (25/35) had research priority lists, although these varied in comprehensiveness. For example, the research priority list in Ethiopia only addressed the research needs of some programs as opposed to sector priorities.Eight of the countries (~ 23%) had neither health research policy nor health research strategic plan but had a research priority list . In three of the countries  there was no national health research policy, strategy, or priority list.Availability of ethical committees is a critical component in ensuring ethical standards and protection of human subjects, while scientific committees ensure rigour and integrity of research. The availability of such committees in the assessed countries is shown in Table 4All countries had scientific and ethical committees; 11 were at the national level only, while 24 countries had these at the institution and service delivery level as well.The WHO/AFR research strategy advises countries to forge research partnerships at two levels: (1) with relevant international research institutions, collaborators, and funding agencies, and (2) at the country level between the MoH, national health research institutions, and training institutions. As a proxy for existing partnerships, the assessment focused on the availability of collaborative frameworks/guidelines for engagement with international actors and memoranda of understanding (MoU) to guide engagements with in-country actors.As shown in Table However, seven countries (20%) lacked both collaborative agreements and MoUs to guide engagements with national research institutions. In other countries such as Zambia, the development of collaborative agreements was ongoing at the time of the assessment, while in the United Republic ofTanzania, collaboration with foreign agencies was said to be negotiated at the level of the local partner institution and detailed in MoUs.The lack of an MoU between the MoH and the national health research institute, however, needs to be interpreted with caution. The majority of countries without this in place made reference to an understanding that this was not necessary given that both entities were government institutions, and working relationships were not constrained in any way. Some countries have no national research institutions . In the case of Gambia, the ownership of the research institute was reportedly undefined, making it difficult to forge a partnership with the MoH.Across countries where they were available, collaborative agreements with international agencies/institutions mainly addressed the issue of data sharing, while the MoUs between the MoH and universities (which were mostly with public universities) addressed areas of human resource development, providing technical advice, and undertaking research. MoUs with research institutions addressed undertaking research on behalf of the MoH and providing technical assistance.This dimension of the assessment focused on the availability of a research department within the MoH with a designated focal point and having a program of work to champion the health research agenda of the country. As shown in Table Different arrangements were also reported in Cape Verde, Ethiopia, and Kenya, where the coordination of health research was assigned to the national research institutes, which also had mandates to undertake health research, thereby raising potential conflict of interest. In the case of Liberia, Malawi, and Rwanda, although the research coordination units were within the MoH, they were also undertaking research, mainly implementation research. Across nearly all countries, research departments were noted to be underfunded, which undermined their capacity to coordinate and/or supervise health research.The assessment revealed that only slightly more than half of the countries had legislation to regulate the conduct of health research, with as many as 12 countries having no specific legislation. In other countries, the legislative void was filled by embedding health research regulatory frameworks within nonbinding health policies. The lack of legislation to regulate health research has been previously noted to hamper multi-institutional research . Even foan overly restrictive data governance framework will limit the potential of digital health technologies’. In our assessment, the research health policy of the United Republic of Tanzania was perceived as inadequate, with a negative impact on implementation, as respondents noted that ‘the policy was not sufficient to include technological development’.Although the current assessment did not analyse the content of the legislation that was in place in order to identify the specific gaps, it is not unreasonable to assume that narrowly focused health research legislation or outdated laws are likely to have inherent gaps for the levels of sophistication and methodological pluralism employed in modern health research. Advancements in digital technology have been witnessed in the recent past as a means to improve access to quality services and as an opportunity to advance health research. Outdated or restrictive legislation hampers the government’s capacity to steward such advances, for example to ensure data protection and to leverage data and technology to advance research. As Cory and Stevens  note, ‘aAlso, a number of countries reported having dual or multiple legislation on health research, which may also pose a risk of legislative conflict, especially when institutional mandates derived from such legislation are not very clear or overlap. For instance, in the case of Ethiopia, the health research mandate of the MoH reportedly overlapped with that of the Ministry of Science and Technology which also had a mandate for all science-related research in the country—a situation that partly explains the lack of a clear policy direction for health research. Chocarro and Folb  contend Another dimension is the extent to which legislation such as that for health research is enforced or complied with by actors in the health research ecosystem. Although the current study did not assess the level of compliance with the stated national legislation on health research, previous work by Yakubu and Adebamowo  noted, fAnother dimension of health research governance assessed in this study is the need for a clear and unambiguous strategic direction for health research development to be detailed in policies, strategies, and research priority lists . There aThe present assessment revealed that out of 35 countries that responded to the survey, 25 (71%), 16 (46%), and 15 (43%) had a research priority list, health research policy, and strategic plan, respectively. We emphasize, however, that in some of the countries, health research was embedded in the overall policy/strategic plan, and the extent to which this serves to effectively guide health research development cannot be ascertained. Aidam and Sombié highlighted suboptimal consultation to ensure adequate consideration for health research in such approaches . A studyUnfortunately, we found that 15, 18, and 10 countries had no substantive national policy, strategy, or research priority, respectively, at the time of the assessment. Thus, at least one-third of the countries had no national policy or strategic direction driving the conduct, dissemination, and use of health research evidence. This situation undoubtedly not only weakens research interest in-country, but also leads to misalignment between research initiatives and the national health sector development priorities. Corroborating this assertion, respondents also reported that there were just a few nationally and institutionally initiated and funded health research studies, which they attribute in part to the absence of a well-coordinated institutional health agenda-setting mechanism. This was compounded by the fact that in at least 10 of the countries that participated in the assessment, there were no departments with the requisite staff and budget within the MoHs that were specifically tasked with coordinating the health research agenda. Even worse, in two countries no one had official responsibility for coordinating health at the MoH.In some of the countries, research priorities were determined at a program on institutional level. While one may argue that this is perhaps better than nothing, the utility of such limited and fragmented approaches is suboptimal, as it falls short of comprehensively addressing health sector evidence gaps. Indeed, comprehensive approaches focusing on sector-wide health research priority-setting have been advocated by several scholars –31. FurtIn line with the Nuremberg Code and Declaration of Helsinki on health research ethics, the ethical and moral conduct of researchers and the soundness of methods and safeguarding of public/participant interests is vested in the role of ethics and scientific committees . All couIn the majority of countries (80%), the ethical committees double as the scientific committees. There is no consensus as to whether this is the right or wrong approach, as some have argued that it can delay clearance of research protocols and increase costs , while oAlthough the region still hosts relatively few trials relative to its disease burden, more clinical research is being carried out in sub-Saharan Africa. The increasing global interest in conducting trials is placing growing pressure on poorly funded regulatory and ethical review bodies. Furthermore, increasingly complex clinical trial designs and ethical issues, such as those surrounding research on vulnerable populations, pose major challenges to national regulatory authorities as well as national and institutional RECs. Such capacity can however be fostered at a subregional level, where expertise may be pooled to serve several countries, such as the network of national ethics committees in ECOWAS countries .Our results reveal varied efforts at forging research partnerships both at the country level and with agencies outside the country. Out of the 35 countries that participated in the assessment, 15 (43%), 20 (57%), and 14 (40%) had agreements to promote partnerships with foreign universities and agencies, MoUs with universities, and MoUs with national research institutes, respectively. Although the availability of such agreements is a good start, realizing effective partnerships will take more than this. Indeed, a study of 15 ECOWAS countries reported that collaborations between research institutions remained ineffective despite deliberate efforts to improve collaboration between participating institutions through a research project by the West African Health Organization (WAHO) over a 5-year period (2009–2013).The lack of such agreements in some of the countries represents a missed opportunity for effectively harnessing research resources, for example in the 20 countries that lacked collaborative agreements to guide north–south partnerships. These gaps might explain the perception of ‘exploitative research’ in north–south partnerships. Bourn et al. refer to the importance of clarity in expectations and goals if partnerships are to be equitable, and these can be detailed in collaborative agreements . The gloTwenty-five out of 35 countries (71%) had established research departments within the MoH, while eight had only focal points without departments, and two lacked both a department and a focal point. This number is fairly high in comparison to what Sombié et al.  found inRegulation of health research takes more than just the availability of laws, regulations, strategies, and structures. Our assessment focused on the existence of systems and processes rather than their content, comprehensiveness, and functionality. We argue, however, that availability is a prerequisite to functionality, thus the relevance of our study. Beyond open-ended questions in the assessment tool, no follow-up qualitative information was collected through in-depth interviews to provide a comprehensive explanation and insights into some of the issues identified. This notwithstanding, the findings from this assessment do provide clear actions to be undertaken by governments in strengthening research governance.Building strong health research governance cannot become a reality in Africa without having the prerequisites in place. This study has highlighted the key gaps across countries in the WHO/AFR which should serve as a clarion call to governments and partners. Current drawbacks that must be addressed include restricted research priority lists (only addressing program research needs) and restrictive and outdated research legislation and policies, which may be explained by gaps in consultation during the development stage. Strong coordination and stakeholder consultation are key to ensuring comprehensiveness and complementarity in both research development and generation of evidence that can adequately provide answers to policy questions.An adaptive governance structure to embrace new developments in medicine is another consideration to guard against weakness in regulating research on new interventions. In this regard, the outdated laws can be limiting. It is thus imperative that outdated or narrowly scoped laws be updated from time to time to respond to both the challenges and opportunities presented by technological and methodological advancements impacting on or driven by health research.Protecting research participants and ensuring scientific rigour are paramount. In this aspect, almost all countries had scientific and ethical committees in place, albeit performing a dual role in the majority of cases. Emphasis should be on ensuring representation of relevant expertise and functionality.There is a need to seize opportunities that accrue from collaborative research through strong MoH leadership and clear partnership frameworks that guide negotiations. Partnership frameworks to guide north–south partnerships and MoHs with research institutes and universities need to be developed and enforced. Given the limited research capacity, resources available through north–south partnerships, as well as those from in-country research institutes and universities, offer opportunities that need to be embraced, learning from a similar approach in ECOWAS countries that was beneficial. A clear mandate for coordination of research must be ensured between the different government ministries and institutions.


Persons with a disability are at a far higher risk of homelessness than those without. The economic, social and health challenges faced by disabled people are addressed, in Australia, by the recently implemented National Disability Insurance Scheme (NDIS). Using nationally representative, longitudinal household panel data, we construct the Index of Relative Homelessness Risk (IRHR) to track how the risk of homelessness for disabled persons has changed since the introduction of the NDIS. We find that, overall, fewer persons with a disability face moderate risk of homelessness but that many more face high risk. We conclude that the NDIS has not effectively protected disabled people from the risk of homelessness. We reflect on the implications of these findings for policy interventions. In 2018, 4.4 million Australians, almost 18 per cent of the total population, were living with a disability . These cIn an earlier paper , we examFollowing the establishment of these baseline results, we now have the opportunity to conduct a quasi-experiment by constructing the same IRHR for disabled and non-disabled populations in the period since the rollout of the National Disability Insurance Scheme (NDIS)—Australia’s primary vehicle for supporting persons living with a disability. The analysis presented in this paper provides a second point-in-time application of the IRHR, allowing us to monitor change and form conclusions on the impact of the NDIS on the risk of homelessness for disabled persons in Australia.the reduction or loss of an ability to perform an activity which results from an impairment”  [Australia’s NDIS was established “to provide reasonable and necessary supports to people with a permanent and significant disability” . The NDIriginal) . The NDIriginal) ,7.In large measure the NDIS does not provide funding for the housing of persons with a disability as the focus is instead on services, for example, access to assistive technologies, worker-provided care and allied therapies, rather than general living assistance . The NDIIn order to understand whether this substantial national policy intervention, the NDIS, has changed the distribution of the risk of homelessness for persons with a disability in Australia, we construct the IRHR using a nationally representative dataset for the periods pre-NDIS rollout and post-NDIS rollout.In this second paper we explore the changing distribution of the risk of homelessness among populations with a disability, before and after the widespread introduction of the NDIS. Utilizing a large Australian dataset, the Household, Income and Labour Dynamics in Australia (HILDA) Survey, we estimate the risk of homelessness within the Australian population along a 10-point scale from highest relative risk (a score of 10) to lowest relative risk (a score of 1). We compare the homelessness risk for populations with a disability to those without, and across different types of disability.The HILDA survey is an annual, nationally representative longitudinal study of individuals residing in Australian households. At various times it has been supplemented  and it has also been topped up to include recent migrants, making the dataset more representative of the changing nature of the Australian population. The survey has been conducted each year since 2001 and now contains 18 available waves of data . HILDA sThere are two ways to measure disability in the HILDA survey dataset. A general question asks whether a respondent has a long-term disability or health condition, to which around 28 per cent of responses across the 18 waves reply in the positive. This question is collected in all waves of the survey. The second variable measuring disability, asked from wave 2 onwards, asks about specific long-term conditions, where the questions are posed in the form, for example, “Which long-term conditions—Hearing problems”. This variable offers comprehensive coverage, including those conditions currently been treated, for example, nervous or emotional conditions, conditions restricting physical activity or work, chronic or reoccurring pain, and long-term effects of a head injury, stroke or other brain damage. We use both measures in the following analyses. The maximum sample size for these measures depends on the pattern and treatment of missing data for the five variables that are used to construct the IRHR (described below).t-tests for equality of means, with the Bonferroni adjusted p-value for multiple comparisons).The IRHR builds upon previous work on housing precariousness by Mallett et al. . A compop-value < 0.000) and post-NDIS  (using unpaired two-sample t-tests). Compared to unaffected people, those with a disability are on average, significantly over represented in the very high risk category (10) and the mid-risk categories (5 and 6), but under-represented in the very low-risk categories . This post-NDIS patterning is notably different to the pre-NDIS outcomes shown in In this first part of this analysis we calculate the relative risk of homelessness for all individuals, comparing outcomes in the post-NDIS environment for those with and without a disability . While sIn order to explore the potential for uneven risk across persons living with different disability types, we examined outcomes at a finer grain by considering specific disabilities. p-value < 0.000).This analysis has shown that not only do people with disabilities have a different overall pattern of homelessness risk to the wider population, but that some types of disability predispose people to a much higher homelessness risk. A concerning indication of these findings is that, following the introduction of a national scheme broadly designed to improve the lives and living conditions of people with disabilities, homelessness risk does not appear to have improved for this group.In reflecting on the findings of this analysis it is important to be reminded that homelessness is not a mere part of the housing continuum, it is an outcome where an individual has no suitable housing. Importantly, the effects of homelessness also extend well beyond housing into health, poorer employment  , vulnerano disability group recorded a fall in the percentage of the group in the highest risk categories. In regard to housing, The variation in pattern of risk for different disability types suggests that over and above the baseline risk of homelessness for people with different disabilities and long-term health conditions, the impact of the NDIS has also been uneven. The ‘uptick’ pattern of higher homelessness risk shown in the figures suggests that already at-risk groups  within the population with disabilities have missed out on the potential benefits of NDIS, and may be experiencing the double disadvantage of doing so in a policy environment that assumes they have received protection from the NDIS. It is important to acknowledge that when we compare the IRHR pre- and post- the introduction of the NDIS, Finally, we note the limitations of this analysis. Firstly, while Beer et al.  include not reduced the risk of homelessness for persons with a disability in Australia and has certainly not removed this risk. This failure is despite significant public sector outlays on disability services, but service provision alone cannot ensure the quality of life of persons living with an impairment.We are cautious in concluding that the introduction of the NDIS has resulted in a higher level of homelessness risk for this vulnerable group within society, as other changes within Australia’s demography, economy and society may have played a part. While no doubt some people with a disability have benefited from the introduction of the NDIS, improvements have been far from widespread. For example, the structural ageing of the population has reduced the number of persons with a disability remaining in the family home and the further contraction of public housing services has reduced opportunities for this group to reside in this tenure. It is notable, however, that the NDIS has clearly It is important to reflect on which disability types appear to be most vulnerable to homelessness in this analysis. People experiencing conditions categorized into four groupings—blackouts, fits or loss of consciousness, difficulty learning or understanding, nervous or emotional conditions, or mental illness—are shown in to have concerning patterns of high relative risk. To some extent, previous work predicts this patterning, suggesting that a combination of exclusion and system complexity may be drivers. Without advocacy and assistance, some people with these types of disabilities are likely to find it difficult to navigate a complex assistance system , and somAmong ongoing judicial, political, educational and welfare challenges highlighted by the 2019 United Nations Review on the Rights of Persons with a Disability in Australia was the lack of accessible and affordable housing options [