A tragic disaster occurred on April 24, 2013, in Bangladesh, when a nine storied building in a suburban area collapsed and killed 1115 people and injured many more. The study describes the process of rescue operation and emergency management services provided in the event. Data were collected using qualitative methods including in-depth interviews and a focus group discussion with the involved medical students, doctors, volunteers, and local people. Immediately after the disaster, rescue teams came to the place from Bangladesh Armed Forces, Bangladesh Navy, Bangladesh Air Force, and Dhaka Metropolitan and local Police and doctors, medical students, and nurses from nearby medical college hospitals and private hospitals and students from colleges and universities including local civil people. Doctors and medical students provided 24-hour services at the disaster place and in hospitals. Minor injured patients were treated at health camps and major injured patients were immediately carried to nearby hospital. Despite the limitations of a low resource setting, Bangladesh faced a tremendous challenge to manage the man-made disaster and experienced enormous support from different sectors of society to manage the disaster carefully and saved thousands of lives. This effort could help to develop a standard emergency management system applicable to Bangladesh and other counties with similar settings. Building collapses are a major cause of mortality and morbidity around the world. In the last decade, a number of buildings have collapsed causing a significant number of deaths and illness. In recent years, high and middle income countries like USA, South Korea, Turkey, Austria, and China have experienced disasters due to collapsed buildings –6. In NeOn April 24, 2013, a nine-story building named Rana Plaza situated at Savar subdistrict in Dhaka suddenly collapsed around 9 o'clock in the morning . The buiSavar, a subdistrict, is located about 25 kilometers northwest of the capital city Dhaka, Bangladesh. It has a population of over 13 million. The subdistrict has an industrial importance, particularly due to the presence of garments industries. Garment industries are widely located and many thousands of people in the workforce earn their livelihood by their hard work in these industries. The subdistrict is well connected with Dhaka by road. There is one military cantonment, one public university, and two private medical college hospitals with good health facilities .reviewing printed and electronic media reports including newspaper and television coverage;in-depth interviews with the rescuers and personnel involved in emergency medical management;focus group discussions (FGD) with undergraduate medical students who assisted in emergency management.We deployed the following techniques to gather relevant information related to rescue and emergency management:After the event, we reviewed five daily popular local language  and three English newspapers from April 24, 2013, to the end of rescue operation, May 13, 2013. We also followed the news of electronic media (television) to get information and updates of the events and noted the relevant information.To gain deeper understanding we performed in-depth interviews (IDIs) with different personnel. We have performed in-depth interviews (IDIs) with different personnel who were directly involved in rescue and emergency medical management immediately after the event. The interviewees were with two medical doctors, two scout volunteers, and two local untrained volunteers. The in-depth interviews were conducted over the telephone and each interview took around 20–30 minutes. The interviews were conducted by an anthropologist within the research team.Moreover, one focus group discussion (FGD) was conducted with seven undergraduate medical students studying in a private medical college named Gonoshasthaya Samaj Vittik Medical College situated in the subdistrict. These students assisted in emergency management of the victims in the health camp at the scene . The FGDA semistructured checklist was developed and used to conduct IDIs and the FGD. In the checklist seven thematic areas of discussion were identified, which included understanding of the event, initiation of the emergency management, engagement of the media, referral of the injured victims, hospital administrators response to the disaster, challenges encountered during emergency management, and finally the effectiveness and achievement of the emergency management. To explore each of the discussion areas, several prompts were used .In case of IDIs the telephone interviews were audio-recorded with prior permission from the interviewees and hand notes were taken for some of the thematic areas during the telephonic conversation. The facilitator of the FGD session used prompts to explore the desired information, and similar to the IDIs this session was also audio-taped with the respondents' permission.After the interviews and discussion, a two-member team under the guidance of the researchers prepared Bengali transcripts of the audio records. Then the transcripts were translated into English.The analysis was done by examining the transcripts and note-taker's notes in detail to identify the range of ways in which the participants responded to various prompts. Thematic analysis was performed for FGD and IDIs whereas content analysis was made for analyzing electronic and printing media news.We have designed the Results section according to the areas that we identified for the IDIs, and FGD and content analysis from the media has also been incorporated.Media reports revealed that the Rana Plaza, a nine storied building that housed four garment factories, a bank branch, and several general shops, collapsed at 9 a.m. on April 24, 2013. The garments factories were opened on their regular working hour at 8 o'clock in the morning. All the workers of the garment factories and general shops started their regular work in the building. All the machines and generators were switched on. Suddenly, pillars of the building collapsed and the roofs from the top to the bottom floors fell one upon another. Concrete pillars of every shape dangled precariously, ready to snap, and crashed down. Various media reported that the day before the event it was noticed that there were a number of cracks in pillars; however, the building's safety was assured by its owner.The building (Rana Plaza) collapsed all on a sudden after a big bang around 9.00 a.m…hundreds of people died instantly; thousands injured, many of them trapped inside the collapse building alive.Regarding building collapse one of the volunteers who participated in IDI narrated:I have seen most of the floors of the building collapsed and…gaps between each of the roof of different floors looked no more than two feet. The nine storied building became three storied in height…No one could estimate actually how many people were trapped inside…we were so shocked to see this.Another volunteer narrated his experiences in IDI:As reported by different media, the Fire Service and Civil Defense (public fire-fighting authority) arrived at the scene within 30 minutes. Local people also came forward hearing the call for help by the victims who were trapped in the collapsed building. Fire Service and Civil Defense personnel with the help of local people rescued the first person within 30 minutes of the event. Immediately after the collapse other agencies including Police, Rapid Action Battalion , Bangladesh Armed Forces, and Ansar (an aid to regular police force) came to the scene to help. At the beginning of the rescue process, about 200 Fire Service and Civil Defense personnel and around 200 local people participated in the rescue process. Several private ambulance services sent their ambulances voluntarily for transportation of victims to the nearby hospitals. Doctors and undergraduate medical students of different medical colleges of the locality arrived at the scene and set up medical camps to provide emergency services to the victims. Every few minutes for the first few hours of the disaster, seriously injured patients were rescued and emergency care was given by the medical teams at the camps. They were then carried to the nearby hospitals for further management. Red Crescent and volunteers from different organizations brought the patients from the damaged building to the health camps. Some victims were directly sent to the health facilities after the local people rescued them. Some volunteers and law enforcing agencies cleared the highway for immediate transfer of the patients .When we came about an hour later, we saw that in every few minutes a trapped person is pulled out and rushed to the hospital in an ambulance or in microbus.A medical student that worked in the health camp described the following:We set-up our health camp within an hour (after the disaster). At the beginning, we were not prepared much, but we tried to treat minor injuries, the majority of casualties were directly sent to a nearby private hospital.One of the medical students who worked in the health camp narrated:Just after the incident, we tried to rescue people from inside the collapsed building and if we saw any person with blood shedding or broken leg or hand, we put them on the patient trolley…and people waiting outside took the victims immediately to the hospital. Many of the victims were even taken to the hospital by motorcycles of the local people.One local volunteer described the following:Bangladesh Army and police were handling the transferring patients with the support of the local people. There was minimum delay in transferring patients just after rescuing from the building.Another volunteer reported the following during his IDI:Media played a crucial role after the disaster. National TV channels including Bangladesh Television (BTV) and around 12 private TV channels, government radio station Bangladesh Betar, and FM stations started broadcasting live news from the start of the tragic event. Private TV channels scrolled the breaking news and special news was telecasted at regular intervals. A number of TV channels live telecasted from the spot the whole day. Media helped a lot to inform the relatives of those who worked in that building and many of the relatives started to come to Dhaka from villages just after getting information.We took support from them to let the blood donor come to donate blood. We had requirement of thousands bags of blood and some of those had rare negative groups. During an interview a doctor said:I saw the disaster event in television channel; my home is about 100 kilometers from the disaster place. As soon I get the information, me and two of my friends decided to come to the place and help in the rescuing.One volunteer said during IDI:The story of one person who came from a rural village mentioned that he had come from north Bengal, which is about 180 kilometers from the disaster site. He saw that many people were coming to help the victims and rescuers by providing medicines, food, water, and so forth. He collected bananas from his own banana tree and bought packets of bread and caught a bus to Savar, which took about seven hours.Another doctor mentioned that he found that a number of negative blood bags had been collected in the blood donation camp. The need for rare blood groups was transmitted by the television channels.Due to the continuous news updates, many people started to come to the place to help and join the rescue process. Like this, many people also provided support and aid by knowing the facts through live telecasts and radio news updates. Moreover, the printed media detailed the entire situation including regular updates on how many people were rescued, how many were still missing, and how many of them had already died. People also read that news from newspapers and came to help the injured people. A few printed newspapers started a fund for the victims and many people donated money to the newspapers' bank account.Victims rescued from the disaster were primarily treated just outside of the collapsed building. There were two health camps engaged in providing 24-hour first aid treatment. Minor cut injuries were managed locally and released after initial treatment given at the center. Each of the health camps was equipped with first aid medicines and instruments. Doctors were responsible for immediately diagnosing the severity of the condition of the injured and referred to the appropriate health care facilities. However, some patients were directly transferred to referral centers without treatment from the health camps because of the degree of severity .We provided initial treatment, many patients come to us with cut injuries, we cleaned the wound and put bandage. We also found huge number of patients with fractures; we provided first aid of fracture and referred them to the hospital immediately. During in-depth interviews, one doctor who worked in the health camp mentioned the following:We treated not only the people trapped in that building but also the rescuers who became sick during the rescuing. They had dehydration and became injured. He addedWe didn't have any referral form or structured documents, our seniors examined the patients and if it was required to transfer to higher center immediately, local people or fire brigade or armed force brought them by ambulance. During the FGD a medical student working at that health camp reported:We can guess which patients were required to send to hospital directly because many of patients had cut their limbs during rescuing and had severe bleeding, they were transferred immediately. Those with minimum injuries were treated in health camps. The general people engaged in the recue process mentioned the following:I never faced such conditions, patients were coming in every minute, lots of people were coming with patients. We don't have such emergency management system in the hospital but we are committed to tried at best level to manage such condition, our all operation theaters were in action 24 hours.One doctor who worked in the private medical college hospital where most of the patients were transferred was describing his experiences:I found a 22 years old person was trapped behind a concrete beam, his leg was locked in between the beam, there was no way to remove the large beam, the person wanted to be rescued anyway, I used sharp blade to cut his left knee joint and rescued from the hole, immediately I pull him outside and ambulance took him away to government medical college hospital.A university student who volunteers on behalf of Bangladesh Scouts described the following:The disaster occurred away from the capital. There were two private medical college hospitals nearby and a number of private clinics and hospitals were also present. Savar Upazila has a government primary level health care center, Upazila health complex. Dhaka Medical College Hospital is about 30 kilometers from Savar and specialized hospitals like the orthopedic hospital is about 25 kilometers away from Savar. However, the Bangladesh Army has a specialized hospital in Savar near to where the event occurred. As soon as the disaster happened, different hospitals sent ambulances for transferring critical patients to the health centers. Private clinics also contributed by providing ambulances. One private medical college hospital set up an emergency care camp at the site within a few hours of the event, and the medical camp served until the last day of the rescue operation. Another private medical hospital's administration decided to provide services 24 hours a day and all the medical students of the hospital were engaged in the initial management of the casualty. Orthopedic specialized hospitals in Dhaka established a 24-hour emergency wing only for the patients from the Savar disaster. Private clinics in Savar managed primary stages of casualty care and then referred them to higher centers.Our medical college hospital administration allowed me to come to the health camp and we provide 24 hours support. Our health camp unit at the disaster center which existed till the last day of the rescue process.During FDG a medical student that worked at the health camp mentioned the following:I am doing internee in the private medical college in Savar and our director of the hospital was always with us and we were waiting for patients at emergency ward. Our medical students, nurses, word boys-everyone were engaged only in managing emergency situation. A doctor mentioned the following in IDI:As a low income country, Bangladesh has very limited resources to manage a large scale emergency situation. The country has never experienced this type of disaster before. A number of challenges were faced during the rescue operation. Crowd management was crucial; there were thousands of people who came to see what was going on; many of them were relatives of the victims and they were waiting with apprehension to see if their relatives were alive and needed to be rescued or not. Moreover, another mass of people came to help the rescuers and rescued persons by providing food, medicine, and other necessities. Bangladesh Armed forces, Civil Aviation, Rapid Action Battalion, and Police played a tremendous role in managing the crowd. However, there was always a risk of mishap or an accident at any time. The majority of the public did not have any idea or training on how to rescue people from inside the building.A volunteer said, “It was dark all around and I have seen many people crawling around in the light of their mobile phones. There was lot of dust from the collapsing debris, worsening smell of dead bodies were all around, inside the trap was hot because of full summer season and deficit of air ventilation.”Rescue operations had proven to be thoroughly difficult. The pillars and ceilings had collapsed at so many angles and in such precarious ways that any wrong move could cause a fresh tragedy. The army had brought in huge cranes to pull the concrete blocks apart. But these could not be used earlier for the fear of further collapse. There were also limitations for not having necessary equipment to rescue people in such an emergency. Moreover, there was a lack of highly skilled rescuers to manage the critical time; those who are engaged in the rescue period were not properly trained on how to handle such conditions. However, members of the Armed Forces, Border Guard Bangladesh, and Fire Service and locals were carrying out the rescue operations; they pored over huge piles of rubble and twisted metal in the search for survivors at the building.We don't have any training on emergency medical care, like this hospitals also don't have proper emergency management system. We are trying to do what we have learnt during our bachelor course but it's so important to learn in oder [sic] to handle such situations with enough skills.During a discussion with a medical doctor involved in providing emergency care, he mentioned the following:Moreover, in the FGD, one medical student mentioned the spirit of a civilian; he found a vegetable shop keeper who kept coming to the health camp for first aid treatment mentioning that he has a skill of how to climb in the trees and he used that skill in the rescue process. That person heard the screams of those who were trapped inside; some shout for help and others wanted some air; he had believed that he could rescue some people from inside and he contributed.Entire team had a challenge to liaison with different type of rescuers. Bangladesh army was leading the operation with the support of fire brigade but there was huge number of untrained civil people including students engaged in the rescue team.However, medical students working in the health camp said:From in-depth interviews and FGDs it was revealed that, despite a lack of skilled manpower, proper training, necessary equipment, and a number of other challenges, the country expressed huge strength in managing such a devastating situation. Thousands of people from the local area and around it came to join the rescue teams. Battalions from Bangladesh Army, about 200 highly skilled fire fighters, about 275 trained volunteers, 100 young rovers scouts, 100 young red crescent volunteers, students from universities and colleges, medical students, doctors, nurses, volunteers of social organizations, volunteer clubs, and social workers put their efforts as a team to minimize the number of casualties and fatalities. Thousands of blood bags were collected from different parts of Dhaka city and near to Dhaka districts through blood donation camps. Hospitals provided free services for all injured patients; specialized doctors operated on critical cases immediately after admission into the hospitals. Furthermore, the media was telecasting news using live telecast which also helped civil people to know and act quickly. Sometimes they knew from the breaking news that there was certain shortage of a specific blood group at a hospital or that there was unavailability of ambulances to carry patients to referral centers. Bangladesh Armed Forces opened a monitoring cell to provide continuous updates about the situation. Every hour the data base in that cell was updated and people came to know how many persons were rescued, how many of them died, and how many were still missing.We never seen the liberation war of Bangladesh, it was about 42 years back, we were not even born at that time. But for me it's a war, the difference between the two is last time we fight for the entire nation, this time we are fighting to save thousands of lives.When talking to medical students during the FGD, the following was mentioned:During the entire time, people had a commitment, spirit, braveness, and moral courage for the humanity. Many of the rescuers were injured during the rescue operation but they did not stop searching.One of my batch mate studying in 5th year; was too brave, rescued one woman by cut her knee and recued in between two pillars on 5th floor.The achievement was so astonishing that one of the medical students stated:Good examples of humanity and dedication were remarkable. In the daily national Bengali newspaper, Prothom Alo wrote a number of articles about rescuing people alive, including May 1, 2013, stating that four fire fighters gambled with their lives to rescue others who were working for more than 15 years in Fire Brigade. One of them was burnt during a rescue but they altogether saved about 143 people's lives. Garments workers saved a number of people trapped inside believing they were their siblings and it was their responsibility to come forward to rescue them. Another garment worker saved about 24 persons; one of them was a 12-year-old girl and the rescuer cut the hand of that girl with a blade to help rescue her. A teacher of a religious school (madrasa) with the support of others saved about 150 people. He did not know any other rescuers and did not ask for their names even. Their one and only aim was to save people from the building.An outstanding success achieved was reported by BBC online news on May 10, 2013, when a woman was rescued after 17 days of the operation when she was found in the remains of the second floor of the Rana Plaza. The worker who first discovered her told the BBC Bengali service that he was cutting iron rods and suddenly found a silvery stick just moving from a hole. He looked closer and heard someone calling for help. The volunteer immediately called over soldiers and firefighters to rescue the woman. When the woman was rescued it was like a miracle as she had been trapped for such a long time [After 20 days of the rescue operation, the Daily Sun, an English newspaper in Bangladesh, on May 14, featured that Bangladesh retrieved 1,115 dead bodies from the debris and 2,438 rescued alive including 1,744 injured from the rubble of Rana Plaza. However, unfortunately, a total of 12 workers died after they were rescued with injuries. A total of 98 people were missing until the final phase of the rescue operation [Bangladesh has already experienced a number of building collapse tragedies. Even though the magnitudes of these types of disasters were not as great as the one of the Rana Plaza disaster, they also took a toll on humanity. During the review of daily newspaper articles on building collapses, we have found a number of incidents occurring in the last decade in Dhaka. Among those, on June 9, 2004, one three storied building collapsed in old Dhaka city where 19 people died and 11 were seriously injured. Another one was a garment factory; a nine-story building collapsed in Savar on April 11, 2005, killing 64 people working there. Likewise, a five-story building inside the capital city Dhaka suddenly collapsed on February 25, 2006, and death took its toll on 21 innocent people. Moreover, a residential building collapsed on July 1, 2010, in a slum area of Dhaka killing 25 people. Other types of sudden disasters include launch drowning's in Chandpur killing over 800 people in 2003, a fire in a garment factory killing 124 innocent workers on November 24, 2012, a collapse of a flyover during construction killing dozens of men, and other such disasters that keep happening in Bangladesh. An alarming fact is that accidents in the waterways have killed 3,522 people in the last decade.Emergency care is the essential basis for all-hazards disaster responses . Many coHowever, emergency medical systems are a critical component of national health systems in low and middle income countries . In counArmed Forces, volunteers, and local people transferred injured patients to hospital by assessing the severity of casualties but there was no proper referral system. Different types of vehicles were used to transfer patients to hospitals including ambulances, private microbus, motor bike, and nonmotorized vehicles, but this kind of support is not unique for other disasters that have happened in Bangladesh. In EMS, transporting a patient from the location to a hospital is a critical element of prehospital care, since a lack of transportation or suitable transportation is often the major barrier preventing patients from accessing emergency care . In RanaLike this, in nearby private medical hospitals where most of the patients were carried to, the hospital administration gave all of their efforts to manage the situation. All nurses of the hospitals, medical college students, intern doctors, and other doctors were mostly engaged in managing the disaster casualties. At a hospital level there was no structured emergency medical management system too. One study identified that some of the barriers to emergency care at the receiving health facilities were human factors, such as the availability of trained health workers; structural factors, such as availability of medications and equipment; and management factors, including mechanisms for the triage of patients , while iDespite limited resources the trained and untrained rescuers and the service providers of different sectors provided tremendous support for saving lives in the Rana Plaza tragedy; otherwise the toll could have been much more. This tragedy gives us a lesson that the nation needs to develop a structured comprehensive emergency management system involving all sectors, including lay people.


Triatoma dimidiata from the Yucatan peninsula, Mexico, where adult insects seasonally infest houses between March and July.Non-domiciliated (intrusive) triatomine vectors remain a challenge for the sustainability of Chagas disease vector control as these triatomines are able to transiently (re-)infest houses. One of the best-characterized examples is We focused our study on three rural villages in the state of Yucatan, Mexico, in which we performed a situation analysis as a first step before the implementation of an ecohealth  vector control intervention.T. dimidiata was performed by exploring associations between bug presence and qualitative and quantitative variables describing the ecological, biological and social context of the communities. We then used a participatory action research approach for implementation and evaluation of a control strategy based on window insect screens to reduce house infestation by T. dimidiata.The identification of the key determinants affecting the transient invasion of human dwellings by This ecohealth approach may represent a valuable alternative to vertically-organized insecticide spraying. Further evaluation may confirm that it is sustainable and provides effective control (in the sense of limiting infestation of human dwellings and vector/human contacts) of intrusive triatomines in the region. These approaches are based on the concept that human health cannot be considered in isolation, but is linked to the quality of the environment in which people live and the ecosystem to which they belong.20 Thus, ecohealth promotes interventions targeting the multiple determinants of disease transmission in an integrated manner, including biological, ecological and social aspects, for a more effective and sustainable control.22 The approach also focuses on the impact of people on ecosystems, and its implications to improve human health and the quality of life, in a sustainable manner. It is based on the use of transdisciplinary participatory research, which may achieve better health outcomes through integrated vector control.22 Ecohealth strategies are emerging as more rational, sustainable and cost-effective than vertically-organized and widespread empirical insecticide spraying.26In most countries where Chagas disease is endemic, current control of disease transmission is based mostly on empirical insecticide spraying to reduce house infestation by triatomine vectors. However, this vertically-organized approach of vector control is based on a simplistic view focused only on the vectors and not on all the determinants of the disease. In addition, the difficulties associated with the sustainability of this strategy, together with the emergence of insecticide resistanceTriatoma dimidiata from the Yucatan peninsula, Mexico, where we have shown that adult T. dimidiata transiently infest houses on a seasonal basis during the months of March to July.29 Population genetics and mathematical models indicate that house infestation is caused by the seasonal dispersal of bugs from both the peridomestic and sylvatic habitats surrounding the villages, while triatomine reproduction in the domestic habitat (i.e. colonization) plays a negligible role.32Non-domiciliated (intrusive) triatomines disperse from peridomestic and sylvatic sites to occasionally infest or re-infest houses. One of the best-characterized examples is T. dimidiata, both field and modeling studies have shown that conventional insecticide spraying is of limited efficacy to control domestic infestation.34 On the other hand, alternative strategies such as the use of insect screens  and long-lasting insecticide impregnated curtains  were able to reduce house infestation by 80–95% for at least two consecutive years in pilot studies.36 The cleaning of peridomiciles to reduce bug populations has also been found to reduce T. dimidiata abundance inside houses by about 50%, largely because only bugs dispersing from peridomestic colonies are controlled, leaving infestation by sylvatic bugs unaffected.36 Peridomicile cleaning may nonetheless be a valuable component of integrated vector management.36 Combining strategies described above may provide an effective and sustainable vector control alternative to insecticide spraying in Yucatan (in the sense of reducing/eliminating vector populations inside human dwellings and of limiting vector/human contacts rather than in killing vector populations). Nonetheless, further transdisciplinary and integrative studies are needed to provide a deeper understanding of the ecological, biological and social  determinants for house infestation by T. dimidiata and Trypanosoma cruzi transmission to humans. Indeed, a limited understanding of the factors driving transient infestation has restricted the design of targeted vector control interventions. In this work, we review studies aimed at identifying the major eco-bio-social determinants contributing to house infestation by intrusive T. dimidiata, and the implementation process of an integrated ecohealth intervention tailored to control Chagas disease vectors in Yucatan, Mexico.Under the scenario of transient seasonal infestation by 38This phase of the project was carried out between early 2011 and mid-2012. We focused our study on three rural villages  in the state of Yucatan. Typical households in rural Yucatan are composed of four to five individuals who self-identify as Mayan (over 90% are native Mayan speakers). They are mostly subsistence farmers with no education beyond elementary school. Only a minority of the population have formal employment and most receive social welfare benefits. Over the past 15 years government programs have funded the construction of concrete block housing, which has gradually replaced traditional adobe huts. Houses usually consist of two rooms, at least one of which serves as a dedicated bedroom. A cooking area is often located outside. Houses are surrounded by a peridomicile, demarkated by walls made of piled rocks. Most families keep domestic animals in the peridomicile, mainly dogs, chickens, cats and song birds.T. dimidiata in human dwellings was performed by exploring associations between bug presence in houses and a large number of variables describing house environmental factors, as well as the social, cultural and economic context and practices of the inhabitants. Bug presence in houses was monitored by community participation, with households reporting to the village health center any bugs found in their houses. As in previous studies, 15–20% of houses were found to be infested by triatomines.37 Data on the habitat, environmental and sociocultural factors, including gender issues, were collected through a variety of complementary methods. Freelisting (i.e. community members were asked to list biting insects and insect control methods) was first used to gain some perspective on community priorities in terms of insect control, followed by ranking exercises, which in turn informed the development of a focus group discussion guide. Results from all previous methods were used to design a survey to quantify and further explore specific aspects. This mixed methods approach allowed us to triangulate complementary data and corroborate conclusions, making maximum use of both qualitative and quantitative approaches.39 House-level data were georeferenced to produce maps and spatial analyses were performed.The identification of the key determinants affecting the presence or absence of 40 and model averaging41 led to the identification of a limited number of factors that accounted for most of the variability in infestation at the level of groups of houses.A multi-model approach based on logistic regressions followed by model selection using Akaike information criteria42 In order to optimize the installation of screens as a barrier against house infestation with triatomines, we engaged multiple stakeholders  in a participatory planning and implementation process which was developed from late 2012 to mid-2013.Effectiveness and sustainability of vector control relies on community members' acceptance and adoption of interventions. Community participation in intervention planning, including decisions about logistics and coordination, are likely to result in vector control programs that are better tailored to community members' needs as well as increased community ownership of the intervention.Stakeholders meetings were organized in two of the villages  to discuss and organize the vector control intervention. First, the results of Phase I were presented. Next, different strategies for implementation were analyzed in an iterative process over several meetings, until the stakeholders reached an agreement on the best implementation strategy. All participants provided written informed consent before engaging in any research activities.37 Importantly, these determinants were able to account for most of the variability in infestation at the level of groups of houses (R2=0.85), suggesting that we identified the most relevant determinants of infestation and that those we may have missed contributed little.37 These results largely confirmed the intrusive nature of T. dimidiata in the region, the importance of the peridomicile as a habitat for bugs that infest houses, and the contribution of previously-identified risk factors.45 The potential role of chickens and dogs in domestic infestation suggested that these determinants may be targeted for improved vector control. For example, improved chicken coops and the removal of triatomines from dog resting areas may contribute to reduced peridomestic infestation.Analysis of the determinants of house infestation revealed that none of the variables related to the socio-economic status of the household, the education level or general cultural practices such as sleeping or cleaning habits of the house were found to be associated with infestation. On the other hand, we found that the presence of dogs, chickens and potential refuges, such as rock piles in the peridomicile, as well as the proximity of houses to vegetation at the periphery of the village and to public light sources, were major risk factors for infestation.T. dimidiata, its seasonal and nocturnal infestation patterns and blood-feeding habits.38 However, very few individuals related triatomines to a severe disease, and the bugs were perceived as a nuisance rather than a serious health threat. This is a barrier to community involvement in triatomine control and further community awareness on Chagas disease is needed.38 Through drawing contests initially organized to promote Chagas disease awareness, we also explored children's perception of triatomines and Chagas disease based on their drawings. Children were very familiar with these bugs (Figure 46 Nonetheless, children's perceptions also reflected extensive inputs from adults, indicating that information on triatomines and Chagas disease was discussed within the entire community, thereby effectively contributing to increased awareness. Importantly, education activities specifically targeting children may be a very effective strategy to further increase community mobilization against triatomines and Chagas disease, as has been observed for malaria.47Analysis of community members' knowledge, attitudes and perceptions of triatomines and Chagas disease indicated that both men and women were aware of and knowledgeable about s Figure , but sim38 Families spend an average US$32 per year for mosquito control and part of this spending could be re-directed to more effective and sustainable vector control, such as insect screens.38 Importantly, both men and women reported that window insect screens are highly desirable, suggesting that such a strategy would be well accepted by community members. The only significant barrier to the use of window screens was their perceived cost.In the three villages included in the study, most community-based insect control activities are currently focused on mosquitoes, which represent an important preoccupation of inhabitants. Consequently, a variety of tools are routinely used for mosquito control, the most frequently used being aerosol insecticide, mosquito coils, and plug-in repellent.Taken together, these results provided a strong rationale for the further evaluation of window insect screens with or without improved domestic animal management in the peridomicile to reduce house infestation.After discussions with the local government authorities and the communities, the agreed-upon strategy specified roles and responsibilities for several stakeholders Figure . Since tWe are currently monitoring the efficacy of this ecohealth intervention in terms of house infestation, evaluating the perceptions of the different stakeholders about the intervention, and evaluating potential changes in their awareness of triatomines and Chagas disease and in their perception of the concept of vector control.27 installed 7 years ago, are also still present. However, all these preliminary results need to be confirmed to clearly establish the efficacy of the intervention.A preliminary quantitative assessment suggests that following the intervention, the ratio of vector presence inside and outside the houses has been significantly reduced for houses with the insect screens showing, as expected, the physical barrier role played by the screens. This result is very encouraging, taking into account that only two insect screens per house were installed. A few families have also spontaneously installed additional screens on their doors or additional windows after the intervention suggesting some behavioral change. If confirmed to be effective, the evaluation of this intervention will provide a strong rationale for scaling-up to other villages in the region. The intervention also appears sustainable so far, as the large majority of screens are still in place and in perfect condition over 1.5 years after their installation. Many screens from our previous pilot study,Engaging the community and other stakeholders in Chagas disease awareness was a fundamental activity which, together with the wide acceptability of insect screens by both men and women, led to an overall high participation of all stakeholders in the proposed intervention. The inclusion of a Mayan-speaking anthropologist in the research team also facilitated access to the communities and motivated their participation. However, a greater participation of men would be needed in future projects, as our meetings were mostly attended by women while the men were working. As mentioned above, children could also be further involved to promote behavioural changes within entire families. Moreover, many adjustments to the overall implementation process had to be made by the research team to adapt to specific local situations and bypass obstacles. For example, community participation was limited in Sudzal following political tensions during local elections, as the project was perceived to be too strongly linked to the local government. Therefore we had to relocate community meetings in schools and the local health center to emphasize the non-political nature of the vector control intervention. Local governments were very supportive of the interventions, which they have readily incorporated as part of their social programs for housing improvement. For example, in Teya the mayor has agreed to fund the installation of extra window screens to large families who have additional bedrooms not covered by the project. Similarly, in Sudzal the mayor has agreed to provide paint to the villagers to protect the window screen frames and improve their durability. In both cases the research group also agreed to assist the local governments to expand the interventions.38 this habit remained unchanged after the intervention. Thus, strong evidence of the efficacy of insect screens as well as further education and awareness programs are needed to motivate families to redirect this spending towards insect screens, which are often perceived as desirable but too expensive. Changes in community perception of vector control therefore needs to be promoted. Such changes not only need to reach the community, they also need to reach all stakeholders, including decision makers, vector control program personnel and local governments, so that such approaches may be incorporated into national and local guidelines to allow for scaling-up.The cost of about US$35 per house for insect screens spent in this study seems affordable for the households, even considering their modest income. The optimization of the implementation process may achieve even better prices, making scaling-up of the intervention feasible. Also, families usually spend a significant amount of their limited income on a variety of domestic insecticide products for mosquito control, even though they are well aware of the low efficacy of these products,48The ecohealth approach to triatomine control followed here appears to represent a promising alternative to vertically-organized insecticide spraying, allowing for greater community participation and ownership of the control intervention, as well as a potentially more sustainable control of intrusive triatomines in the region. Importantly, the proposed intervention is expected not only to prevent Chagas disease transmission, but also contribute to the prevention of other vector-borne diseases such as dengue fever, since physical barriers will also reduce mosquito abundance in the houses. Cleaner backyards and a reduced incidence of vector-borne diseases are also expected to lead to an improvement of the overall living conditions and quality of life of the communities, bringing them additional benefits beyond Chagas disease prevention, as mentioned earlier in similar ecohealth interventions.


After the 2011 Great East Japan Earthquake, the resource utilization of and the problems encountered with communication devices were examined.A questionnaire survey was submitted to disaster medical assistance teams (DMATs) that were at the primary sites of destruction after the earthquake.We collected data from 196 teams. During the first 4 days after the earthquake, the use of mobile phones, laptop computers, and landline phones was rated as poor to moderate, and satisfaction was very low, while satisfaction with satellite phones was rated as good to moderate (50%). The degree of satisfaction continued to increase gradually over time. Satellite phones, however, had several problems: poor reception, line instability, voice call use only, and inability to send large amounts of data.Disaster Med Public Health Preparedness. 2014:0:1–4)To ensure effective communication during the acute phase in the aftermath of large disasters, a new satellite communication device is needed that not only is portable, battery powered, and able to send large volumes of data, but also offers stable communication. ( The Great East Japan Earthquake occurred at 14:46 on March 11, 2011. It was catastrophic, registering 9.1 on the Richter scale. After the earthquake, a large tsunami occurred in the bay of the eastern Sea of Japan. This disaster brought damage to a wide area, and ongoing effects during the first 2 weeks post-disaster destroyed the local infrastructure.,After a disaster occurs, the communication infrastructure and its associated devices are crucial to the collection of information. Problems of inadequate information acquisition and exchange between the rescue staging care units and the control task force result in a confusion of tasks. Only a few reports of the communication status after the disaster have been published.We conducted a questionnaire survey of disaster medical assistance teams (DMATs) that were at the primary sites of destruction following the Great East Japan Earthquake and resulting tsunami. In Japan, DMATs are defined as mobile medical teams that receive professional training. These teams of medical doctors, nurses, and logistics personnel are activated during the acute phase of a disaster.We sent questionnaires to 375 randomly selected DMATs in Japan that provided medical support just after the earthquake disaster and performed medical services during the acute and subacute phases after the earthquake. A letter and the questionnaire were sent to hospitals with a DMAT on October 18, 2012, and the questionnaires were collected from October 18 to November 10, 2012. The questionnaire was sent to all areas in Japan, including those affected and unaffected by the earthquake. In this disaster, DMATs performed 2 types of medical service. The first was acute-phase services in the disaster such as triage, initial treatment, and patient transport, and the second was medical care in the affected area including public health service.From the questionnaires, we collected data that concerned the location and active period during which the DMATs provided medical support, the kinds of communication tools used, the transmission status of these devices, and the teams’ satisfaction with the communication situation.Level of satisfaction with the communication situation was divided into 3 categories: good, moderate, and poor. We defined good as being able to use the communication tool without a problem; moderate as having some problem with the communication tool, although the problem was not great considering the usual condition of communication; and poor as having a serious problem with the communication tool.Data from 196 teams were collected and could be evaluated. In the acute phase after the earthquake, the percentage of time the DMATs used each device as their communication tool was as follows: mobile phones, 30%; satellite phones, 23%; laptop computers, 21%; transceivers (radio-handy type), 15%; and landline phones, 11%.During the first 2 days after the earthquake, 154 DMATs were working at staging care units in conjunction with the control task force and in hospitals within the affected area. During this period, the satisfaction with mobile phones was the worst except for 6 teams working in the cities of Sendai, Fukushima, and Mito. Satisfaction with satellite phones was similar between DMATs using these phones in affected and unaffected areas. At 3 days after the earthquake, medical teams were offering medical treatment and public health services in affected hospitals or disaster shelters such as schools, gymnasiums, and public halls in the affected area.Mobile phones, laptop computers, and landline phones were often used at the staging care units or by the task force in unaffected areas within the first 4 days after the earthquake. During these first 4 days, mobile phone use was rated as poor to moderate, and satisfaction was very low . HoweverThe reasons for poor satisfaction with mobile phones, laptop computers, and landline phones were mostly due to disconnection from the network and poor reception. Poor operability affected the satisfaction with satellite phones; they could not be used to send large amounts of data, because they could only be used to communicate by voice.After the experience of the Great East Japan earthquake, the 196 responding DMATs indicated the following features were the most necessary in future communications equipment: easy to connect (187 responses), good battery life (162 responses), stability (156 responses), speed (123 responses), portability (121 responses), operability (95 responses), durability (92 responses), and the ability to transmit high volumes of data (65 responses).The Great East Japan Earthquake resulted in profound damage and confusion to the communication system of the affected area. On the first day after the earthquake, discontinued service gradually increased and reached a peak 2 days after the earthquake on March 13.The number of mobile phone base stations without service peaked at 2 or 3 days after the earthquake and then gradually recovered.When a landline phone or mobile phone switchboard handles a large number of calls, traffic control equipment senses this condition and a computer limits the number of calls automatically. The control of landline connections was regulated in this manner, and limited the total number of connections to 10% to 20%. Mobile phone connections were handled similarly; these connections were limited to 5% to 30% of all connections. However, few limitations were placed on the sending of e-mails by mobile phone. Thus, the problem with the communication system on the first day of the disaster was that calls from landline and mobile phones were limited by as much as 80% to 90% of normal traffic.Facilitation of communication within a disaster-affected area is an important problem, along with the ability to provide timely and relevant information and communication to the affected population from the unaffected area. In Japan, almost all hospitals and local authorities have priority landline phones for use in a disaster. In this survey, we could not distinguish whether a common or priority line was used for landline communications.Also in Japan, it is required that the multichannel access (MCA) radio system be used for hospital-to-hospital or hospital-to-local authority communications. MCA is a useful communication system because it is not affected by the automatic congestion control system that affects the public telephone network. However, the DMATs could not use MCA for their activities in the field during the disaster, and the system has limits on call times and locations where it can be used.In general, information derives from many sources such as mobile phones, computers using the Internet, landline phones, and radio and television.Huge natural disasters, such as earthquakes, typhoons, tsunamis, and volcanic eruptions, usually cause a shutdown of the communications infrastructure. Many types of communications equipment are affected by the power failures and destruction of communication lines. In this incident, much information was derived from often incomplete and sketchy voice communications provided by radio transceivers, satellite phones, and disaster prevention radios. Consequently, this situation resulted in a partial understanding of the situation on the ground, which produced operational and tactical errors.–The development of a telecommunication capability that guarantees multimodal data transmission including voice, data, imagery, and videos in severely compromised conditions has become of paramount importance in the United States.,,Difficulties with post-disaster telecommunications are not restricted to wired and fixed networks but affect wireless networks just as intensely: after transmission through a short radio wave path, wireless communication systems eventually connect to a ground segment through an access point. Nevertheless, wireless technology is probably the only modality offering the potential for a relatively rapid post-disaster reconstruction of at least an embryonic version of a functional and capable telecommunications infrastructure.In Japan, portable satellite phones were useful due to narrowed roads and the varied topography in the disaster area. The earthquake and tsunami destroyed buildings and roads, leaving large piles of rubble blocking the roads and railways and creating a situation in which cars and trucks could not gain access to affected areas for rescue or to deliver relief supplies.The findings of our survey showed that the portable satellite phone was found to be a useful communication tool during this disaster. During the immediate 4-day period after the disaster, service to many of the mobile base stations and landlines in the affected area was cut. In such conditions, satellite phones and transceivers become useful devices for communication.However, some problems were also experienced with the Japanese satellite phones after the earthquake. These problems included poor reception, line instability, and the fact that these phones could only be used for voice calls, which meant that large amounts of data could not be sent. Before the Great East Japan Earthquake, DMAT members were trained to operate with simple and small amounts of data. However, the responses from this survey identified a clear need for DMATs to be able to send a large amount of data during a large-scale disaster.To lessen communication problems in future disasters, we identified the following needed resources. Exclusive communication lines are necessary for medical emergencies. Also, many DMATs thought that social networking services (SNS) through mobile phones were useful and effective in the early days after the earthquake; they used Twitter and Facebook to communicate during the disaster. If mobile phones can be used during a disaster, SNS may be one a very useful means of communication.We also noted that a new satellite phone needs to be developed that connects easily to the communication network and Internet and provides good line stability. Finally, a system is needed whereby high volumes of data can be transmitted by satellite phone. Last year, a new battery-powered Japanese satellite phone was introduced that weighs only 1300 g with battery and can be used with the Internet. We expect that this phone will become a part of the communications equipment used in future disasters.In the acute phase after the Great East Japan Earthquake of 2011, medical teams mostly used mobile phones, laptop computers, and satellite phones to communicate. During the first 7 days after the disaster, the communications infrastructure was severely disabled, and it was difficult to use mobile and landline phones and computers with Internet service with the communication system. However, by the end of this initial 7-day period, these devices could be used in the affected area. The development of a new battery-powered satellite communication device that can transmit high volumes of data, is portable, and offers stable communication is necessary to ensure effective communications in the future during the acute phase of such large-scale disasters.This work as supported by Japan Society for the Promotion of Science KAKENHI grant No. 24659799.


Of the three million newborns that die each year, Uganda ranks fifth highest in neonatal mortality rates, with 43,000 neonatal deaths each year. Despite child survival and safe motherhood programmes towards reducing child mortality, insufficient attention has been given to this critical first month of life. There is urgent need to innovatively employ alternative solutions that take into account the intricate complexities of neonatal health and the health systems. In this paper, we set out to empirically contribute to understanding the causes of the stagnating neonatal mortality by applying a systems thinking approach to explore the dynamics arising from the neonatal health complexity and non-linearity and its interplay with health systems factors, using Uganda as a case study.Literature reviews and interviews were conducted in two divisions of Kampala district with high neonatal mortality rates with mothers at antenatal clinics and at home, village health workers, community leaders, healthcare decision and policy makers, and frontline health workers from both public and private health facilities. Data analysis and brainstorming sessions were used to develop causal loop diagrams (CLDs) depicting the causes of neonatal mortality, which were validated by local and international stakeholders.We developed two CLDs for demand and supply side issues, depicting the range of factors associated with neonatal mortality such as maternal health, level of awareness of maternal and newborn health, and availability and quality of health services, among others. Further, the reinforcing and balancing feedback loops that resulted from this complexity were also examined. The potential high leverage points include special gender considerations to ensure that girls receive essential education, thereby increasing maternal literacy rates, improved socioeconomic status enabling mothers to keep healthy and utilise health services, improved supervision, and internal audits at the health facilities as well as addressing the gaps in resources .Synthesis of theoretical concepts through CLDs facilitated our understanding and interpretation of the interactions and feedback loops that contributed to the stagnant neonatal mortality rates in Uganda, which is the first step towards discussing and exploring the potential strategies and their likely impact. With around three million babies dying each year within their first four weeks of life , virtually all (99%) occur in low- and middle-income countries (LMICs) . MoreoveSeveral studies have tried to understand the reasons for this slow progress, employing a range of methods including logistic regression models -4, crossSystems thinking provides a means to understand and work with this complexity. It aims to gain insights into the whole by understanding the linkages, interactions, feedbacks, and processes between the elements that comprise the whole system. In many cases, complexity stems from a combination of the complexity of the disease or condition itself  and the systems in which they are interacting and evolving, in this case the health system . Health This study aimed to contribute to this timely debate by exploring: i) how systems thinking tools, more specifically causal loop diagrams (CLDs) ,14 and sThis study employed the dynamic synthesis methodology (DSM). DSM combines two powerful research strategies, namely the qualitative (case study research method) -20 and tPreliminary information related to neonatal mortality and the associated problems was collected from peer-reviewed literature as well as global and local reports and policy documents in order to understand and better characterize the current problems influencing neonatal health. The collected data included historical trends of mortality rates and coverage of key related interventions, as well as information describing quality of care, perceptions, views, and attitudes of households and health workers in Uganda.Semi-structured interviews were conducted with various stakeholders including mothers, village health workers, community leaders, front-line health workers at the first-level primary facilities and hospitals, and district and national policy and decision makers  of 5.4%, and a level of permissible error (e) of ≤10%, the sample size was determined , one private hospital, two private health Centres, and two government health centre III.During the interviews with the in-charge of the facilities, health workers providing voluntary counselling and testing or prevention of mother to child transmission services were identified. Among the health workers who are performing these services, one staff was interviewed from each available cadre/level, purposively selected in discussion with the in-charge. The total sample included 13 nurse/midwife/clinical officers and 7 doctors from public and private health centres and hospitals in both divisions.A purposive sampling approach was used to select 7 leaders/policy makers, on the basis of their role in formulation and implementation of neonatal health policies. These include two heads of the obstetrics and gynaecology departments of hospitals in each of the selected divisions; two neonatologists, one in a private and one in a public hospital; one district health officer, the person in charge of women and children issues at the district headquarters; one division health officer; and one ministry official involved in neonatal health.Ethical approval was obtained from Mengo Hospital Research Review Committee and the National Council of Science and Technology of Uganda. Consent forms were prepared to protect and ensure the dignity and welfare of all participants, as well as those who may be affected by the results of the research project. All participants were asked to sign a consent form and were informed that participation was voluntary and that they could opt out at any moment. Anonymity was ensured by using study identification numbers and initials rather than names of individuals.Mothers who were able to read and write filled in the questionnaire, while those who could not were interviewed. The socio-demographic characteristics of the mothers who interviewed for those are presented in Table First, we pooled the different sources of data from stages one and two and categorised these according to the following themes: factors associated with the mothers’ attendance to health services; social/personal characteristics associated with mothers’ attendance to health services; factors that contribute as well destroy the health of neonates; factors associated with the health service delivery in health facilities; and factors in the community and family that are associated with mothers’ attendance to health services.We then used thematic analysis to compile and analyse the qualitative data. Descriptive statistics and cross tabulations were used to explore the quantitative data. SPSS 10.0 was used for these analyses . Using tCLDs help us to understand and depict the feedback mechanisms that are generated within complex systems which include the relationships, dynamics, and delays associated with the variables that generate them. They offer a practical way to understand and express the systems’ interrelated parts and the cause-effect linkages for the problem in question. CLDs are composed of two components; variables and influences (links). An influence has direction shown by an arrow and an indicator as to whether the influenced element is changed in the same (+) or opposite (-) direction as the influencing element. That is, a link from element A to element B  and were asked to state whether there were other effects that could be observed as a result of the causes in the CLDs. The validation instrument also included explanations of the objectives of the validation exercise, the meaning of the elements used in the CLDs, and how to respond to the questions; see Additional file Responses from all the interviews were categorized into demand and supply issues. The demand side captures the issues associated with the uptake of health services while the supply side shows the issues associated with the supply of health services. The key findings are presented in turn below.Overall, 44% (8/18) of the mothers who lost their neonates suffered from diseases before pregnancy, including HIV, high blood pressure, malaria, sickle cell, and diabetes, among others.While 97.8% of the mothers in our sample attended ANC at least once, 25.9% of them attended fewer times than recommended, providing the following reasons for failure to attend: lack of money for transport, busy work schedules, attending school, and delayed start of ANC clinic.The majority of the mothers (97.4%) were provided transport to the health centre for deliveries by the community . Only 13.1% used their money for transport.Some of the respondents lacked knowledge on how to care for the babies. For example respondents stated that they used vaseline, herbs, and powder for cord care. Some used breast milk, herbs, urine, water, and saline to care for swollen eyes.While almost all mothers (97.4%) in our sample gave birth at a health facility and believed in the importance of doing so, 40.9% stated that they knew of mothers in their community who did not go to health facilities for their deliveries. Cited reasons for why some of these mothers may have chosen not to go to health facility for their deliveries included traditional beliefs (14.1%), religious beliefs (3.2%), lack of permission from the spouse (3.8%), and lack of trust in the health system (14.7%). On the latter, more elaborations from the mothers included that they knew of mothers who feared that health facilities were poorly equipped, had insufficient health workers, were overcrowded with long waiting lines, lacked 24-hour care, had careless, rude, and abusive health workers who carried out excessive episiotomy, and that they found seeking care at health facilities to be very costly, possibly due to unavailability of drugs and lack of free supplies at health centres such as the Free Mama Kits for those who do not have their own.Mothers stated that they generally obtain health information from various sources including radio, friends, brochures, films, health workers, family, and newspapers. With respect to information provided to the mothers during ANC, 92.8% of the mothers received information on HIV and the value of HIV testing, 84.6% on family planning, 84.3% on breast feeding, and 83.2% on nutrition (83.2%). When asked about what they thought were the best methods to encourage mothers to attend ANCs and give birth at health facilities, they listed the following: home visits by health workers, village meetings, social meetings, community notices, and health education during ANC sessions.… babies born with … no one to wrap them”.Although several mothers perceived hygiene at the health facilities to be generally good, 71% of the mothers reported that hygiene was still in need of further improvement. The surveyors also observed that some of the facilities were not well maintained and infection prevention was not well observed. Community leaders also noted that there were cases of neglect by health workers; one leader said “All of the interviewed health workers mentioned that they were poorly paid. It was also observed by the mothers and the surveyors that staff experienced burnout due to workload arising from few skilled workers at the units resulting in a high provider to number of deliveries ratio. Health workers stated that both remuneration and safety measures at the health facility would increase their motivation. They also stated other demotivating problems such as electric power supply breakdowns during delivery, mothers losing a lot of blood before or after delivery especially where no blood bags were available, and difficulty in getting mothers to a referral hospital in case of emergency due to lack of ambulances.Staff voiced frustration due to unavailability of the necessary equipment and supplies. According to our survey, 34% of health workers had deficiencies in resuscitation equipment and 67% lacked ultrasound facilities.Only 16.8% of the health workers in our sample prepared births and death certificates and 83% kept Health Management Information System child health records and submitted them to higher levels; 50% of the village health workers reported that they lacked birth registers.Community leaders and policy makers noted that some policies and guidelines were not readily available to the public and were not always adhered to. Only 33% of the health facilities had clinical guidelines available to them. For example, guidelines on cord care were not readily available. It was also noted by the policy maker at the district level that there was no clear policy and enforcement on recruitment of appropriate numbers of front-line health workers for the population.Overall, 18.8% of the village health workers reported that they were not supervised, which is consistent with community leaders perceptions of gaps in supervision at the community level. Similarly, supervision of health workers at health units was also considered poorly enforced. In addition, community leaders voiced concerns about the number of unqualified people treating the population in their communities and that efforts to control this health risk should be strengthened.Two CLDs depicting the factors associated with the demand for Figure , and supThe dynamics involved in the demand for neonatal and maternal healthcare are presented in Figure The awareness loop (R1) is a virtuous cycle that enhances the growth of awareness. The level of awareness of neonatal and maternal health issues results in improved health of mothers and increased attendance to neonatal and maternal healthcare services, thereby lowering the death risk of neonates. Awareness is enhanced through health education programmes provided during ANC visits, media , sensitization by community leaders, and word of mouth through peer to peer interactions among mothers. As mothers attend ANC, PNC, and hospital deliveries, the level of awareness increases resulting in mothers’ preparedness for birth. Mothers’ birth preparedness, which is achieved with increased level of awareness, family and community support, and socio-economic status increases the likelihood of attending health services and therefore having safer deliveries, and further enhances the attendance to ANC. The growth in the awareness loop eventually slows down due to the inadequacy of resources exhibited in the frustration loop resulting into the limits to growth archetype (loops R1 and B1). In order to avoid the limits to growth, the quality of service in the health facilities must be sustained.The trust loop (R2) enhances the trust of women in health systems through provision of safe health care deliveries and PNC. As more mothers attend ANC, hospital deliveries, and PNC, the level of safe deliveries and PNC increases, which in turn increases their trust in the healthcare service. The growth in the trust loop eventually encounters limiting action thereby exhibiting the limits to growth archetype (loops R2 and B1). The limits to growth of this cycle arises from inadequate resources that are needed to sustain the quality of maternal and neonatal healthcare service deliveries as exhibited in the frustration loop (B1) explained below. In order to maintain the trust, the quality of the maternal and neonatal service must be observed.The frustration loop (B1) shows that the desired state is to have as many mothers attending ANC, healthcare deliveries, and PNC. Attendance to ANC and delivering at health facilities plays a big role in promoting safe deliveries and obtaining PNC, which will also contribute to increased trust in the health system and improving the general awareness about the benefits of these health services in the community. When the number of women participating in maternal and neonatal health services increases, the resources  in the health facilities are depleted, leading to frustration resulting from effects of poor service delivery such as long waiting times and drug stock outs, which results in a decrease in attendance, thus demonstrating a balancing loop. Efforts should be made to ensure that the resources in the health facilities match the demand, thereby minimising frustration of mothers.The myths loop (R3) produces a desirable effect whereby beliefs in myths are decreasing. As the level of awareness on maternal health care (MHC) and neonatal health care (NHC) increases, belief in perception and myths decreases. As the belief in perceptions and myths decreases, the level of awareness increases. Belief in myths and perceptions that are enhanced as a result of low maternal literacy levels are a hindrance to the level of awareness. Efforts to keep the growth of awareness through community and peer to peer sensitization, health education, and media should be made so that eventually the myths die off.The healthy mothers loop (R4) produces a virtuous cycle where mothers’ attendance to ANC and hospital deliveries results in improved mothers’ health, thereby producing safe deliveries, which builds trust resulting in a further increase in the mothers’ uptaking of health services. This loop interacts with the frustration loop creating the limits to growth archetype.The CLD shows that neonatal health heavily depends on the health of the mothers. The health of the mothers can be increased by increased self and household hygiene, increased level of awareness, attendance to ANC, PNC, and health facility deliveries, and adherence to the recommended nutrition. Factors that lower the mothers’ health include increased frequency of child delivery, diseases such as malaria, and teenage pregnancies, among others. The death risk of a neonate increases with hypothermia, poor breast feeding practices, poor socioeconomic status, and poor care of the neonate resulting from lack of awareness.The dynamics involved in the supply of neonatal and maternal health services are presented in Figure The transport loop (B2) emphasizes the importance of having timely and adequate referrals between hospitals towards improvement of the maternal and neonatal healthcare services, which can be achieved through the provision of transport/ambulances. As the funding for maternal and neonatal healthcare increases, provision of ambulances and transport increases, resulting in timely and adequate referrals between health units. This improves maternal and neonatal healthcare service delivery which lowers the death risk of neonates and in turn lowers neonatal mortality rates. A rise in neonatal mortality rates attracts an increase in advocacy initiatives resulting in increased funding. Funding for purchase and maintenance of vehicles as well as policies for use of these vehicles should be done.The workforce loop (B3) shows that the desired state is to have a motivated workforce in terms of having the right skills, remuneration, and attitude. An increase in the funding for maternal and neonatal healthcare results in an increase in the training, recruitment, and remuneration of health workers, resulting in a motivated workforce. This improves maternal and neonatal healthcare service delivery, which lowers the death risk of neonates and in turn lowers neonatal mortality rates. A rise in neonatal mortality rates attracts an increase in advocacy initiatives resulting in increased funding. For this to happen, governments must be willing to fund and invest in the training, recruitment, and remuneration of health workers. Failure to do so eventually results in poor maternal and neonatal healthcare, thereby increasing the death risks of neonates and resulting in increased neonatal mortality.The logistics loop (B4) shows that the desired state is to have quality maternal and neonatal health services where the health facilities have logistics, drugs, and resuscitation kits. As the funding for maternal and neonatal healthcare increases, provision of infrastructure, diagnostic and resuscitation kits, drugs, and logistics and logistical support increase. This improves maternal and neonatal healthcare service delivery, which lowers the death risk of neonates and in turn lowers neonatal mortality rates. A rise in neonatal mortality rates attracts an increase in advocacy initiatives resulting in increased funding. Governments should provide adequate funding to ensure that the required resources are made available.The motivation loop (R5), together with the workload loop (B5), make up a limits to growth archetype. Limits to growth of this loop result from exceeding the capacity of mothers that can be handled by the workforce. The motivation loop shows that a motivated workforce that is well supervised, remunerated, and trained, and with adequate supplies will increase the maternal and neonatal healthcare service delivery. When the service delivery is good, this, in turn, further motivates the staff resulting in a virtuous cycle. The workload loop (B5), on the other hand, shows that an increase in a motivated workforce increases the number of mothers attending ANC, hospital deliveries, and PNC, which in turn increases the workload thus lowering the workforce that is motivated. It is therefore important that the health services and workforce are upgraded to meet the growing population which will even out the number of patients attending the few health facilities.With adequate financing of maternal and neonatal health services, the following can be made available: training, recruitment, and adequate remuneration of health workers, resulting in a motivated workforce providing quality healthcare service and thus leading to safe deliveries; transport for timely and adequate referrals between health units and obtaining blood bags if necessary; and equipment , medical supplies, emergency drugs, and safe delivery kits. The availability of funding coupled with good governance is necessary for the formulation and enforcement of healthcare guidelines, planning, supervision, and efficient and equitable resource allocation, as well as monitoring and evaluation and audits of health facilities.Although the graph in Figure Respondents used the validation instrument in Additional file This study presents the first of its kind in-depth analysis of the possible causes of neonatal mortality in a given context with an explicit focus on complexity. We explicitly examined the feedback loops that were generated due to the complexities surrounding neonatal mortality as a first step towards considering and testing alternative short- and long-term strategies that may be used to efficiently address the root causes of some of these problems.One of the main points of strength in this study is the inclusion of a wide range of perspectives of the different key stakeholders, including the mothers, front-line health workers, and village health workers. This undoubtedly enriched the analysis and provided a deeper understanding of the real causes of neonatal mortality and its interplay with the complexities of the health system it interacts with . The secA limitation of this study is that it was undertaken in Kampala district. It is possible that there are other factors that are peculiar to other parts of Uganda such as the geographical environment (terrain), extreme poverty, and rural levels that have not been captured in this research. Our findings may, therefore, be more representative of urban Uganda than the whole country. However, this is only relevant for quantitative studies. The main objective of our study was to exploit the strength of qualitative approaches to explore how this problem, and its intricate complexities, can be understood in-depth, using a systems thinking approach. The objective of our study, therefore, included a methodological component and is not only relevant to neonatal health but to other diseases and settings.The findings from the field studies suggest several short- and long-term strategies that would bear fruit in reducing the burden of neonatal mortality. For example, as shown in other studies , 44%  received support by the community and only 13.1% used their money for transport. Our findings also highlighted health system problems that are standing against any possible improvement in neonatal mortality. These include the situation of health facilities in terms of hygiene and infection control, lack of cheap life-saving equipment and supplies, such as resuscitation kits, and suction machines.Leverages are influences within the system where small changes can effect a substantial change in the system. From the analysis of the CLDs, the following were perceived as high leverage points which can effect significant improvement in neonatal healthcare:• Increased awareness on maternal and neonatal healthcare can weaken the vicious cycle exhibited by the myths loop (R3) while strengthening the virtuous cycle of the awareness loop (R1). Mothers’ awareness on the recommended feeding, nutrition, hygiene, household environment, and mothers’ birth preparedness and efforts to avoid untreated diseases results in improved health of the mothers, which in turn lowers neonatal mortality rates. Some of the short-term interventions which may improve awareness include aggressive advertising, campaigns, sensitization, and education of the women and girl child as well as increasing the effectiveness of the health education sessions during ANC and PNC. Special gender considerations to ensure that girls receive essential education thereby increasing maternal mortality rates is a longer term strategy but would synergistically address many other health and non-health issues.• The low socio-economic status is a key determinant in the health of the mothers and the neonates. With improved socio-economic status, mothers are able to obtain the recommended nutrition, healthcare, and the requirements for birth preparedness. While introducing incentives, such as transport vouchers and free birth kits for pregnant women, would motivate them to attend ANCs and enable them to be better prepared for health facility deliveries in the short term, the government should work towards improving the socioeconomic status of the nation.• Funding for maternal and neonatal health care should be prioritized at the national level. Efforts by the government and policy makers to upgrade the health service infrastructure as well as build systems for monitoring the resources  would go a long way in minimizing the effects arising out of the frustration loop B1. Improved maternal and neonatal health service delivery will strengthen the virtuous cycle created by the motivation loop R5. In addition, without a motivated health work force that is well trained, adequately remunerated, and with an acceptable workload there is not much to be expected in terms of the quality of the care provided nor the likelihood that mothers will come to seek care at health facilities. Other short- and long-term strategies may include improved supervision and internal audits at health facilities to ensure that maternal and neonatal guidelines are adhered to as well as establish the current conditions and gaps in resources  to guide the funding for national health care.This study reports on stages 1–3 of our research design. Future work involves the completion of stages 4–6, where we will use empirical data to develop the quantitative (simulation) model including testing of different policy options. Iterations to test and validate the model will be conducted through brainstorming sessions with stakeholders. What-if analysis will be used to test different strategies that have been suggested by this research and by stakeholders, including policy makers, during brainstorming and validation workshops with the aim of improving policy analysis and design in neonatal health. The model will be used to determine the strategies that could have a great impact on neonatal mortality using sensitivity analysis.This study adopted a systems thinking approach to capture and analyse the interactions between technical, policy, behavioural, and cultural issues related to neonatal mortality. It provides a broad integrated view of the dynamics associated with neonatal health, thus accommodating the different stakeholder viewpoints. The synthesis of the various theoretical concepts through the use of CLDs facilitated the understanding and interpretation of the different interacting elements and feedback loops that contributed to the stagnant neonatal mortality rates in Uganda, which is the first step towards discussing and exploring the pros and cons of the different strategies and the priorities that should be addressed based on their likely impact and cost-effectiveness.This paper also illustrated the importance of validation of the structure and relationships of the CLD with key stakeholders, including decision makers, which was beneficial, enriching, and ensured that the variables of the CLDs represent that of the real system. The validation exercise demonstrated that CLDs can help the different stakeholders view complex health problems from different perspectives and facilitate shared understanding and common ownership of the interpretations of health problems. They also provide a broad integrated view of the problems which can be used for learning and process improvement, as well as operational management. The methods, approaches, and findings from this study are not only applicable to neonatal health and Uganda, but also to other settings and questions of a similar nature.ANC: Antenatal care; CLDs: Causal loop diagrams; DSM: Dynamic synthesis methodology; LMICs: Low- and middle-income countries; PNC: Postnatal care.The authors declare that they have no competing interests.ARS conceived the paper, developed the study design and data collection tools, analysed the data, developed the CLDs, and drafted the manuscript. SN and MNK contributed to the study design and data collection and analysis and the interpretation of the results. TA contributed to formulating the study design, data collection, interpretation of the results, and of drafting the manuscript. All authors reviews and approved the final version.Data collection instrument.Click here for fileSample size calculation.Click here for fileList of variables.Click here for fileCausal loop diagram validation instrument.Click here for file