AgRP) in both incubating and transferred animals compared to controls. Also pro‐opiomelanocortin (POMC) mRNA was higher in incubating hens and significantly increased 6 days after exposure to the stressor. Conversely expression of neuropeptide Y and cocaine‐ and amphetamine‐regulated transcript gene was unchanged in both experimental situations. We conclude that AgRP expression remains sensitive to the level of energy stores during natural anorexias, which is of adaptive advantage, although its normal orexigenic effects are over‐ridden by inhibitory signals. In the case of stress‐induced anorexia, increased POMC may contribute to this inhibitory role, whereas, for incubation, reduced feeding may also be associated with increased expression in the hypothalamus of the anorexigenic peptide vasoactive intestinal peptide.As part of their natural lives, animals can undergo periods of voluntarily reduced food intake and body weight  that are beneficial for survival or breeding, such as during territorial behaviour, hibernation, migration and incubation of eggs. For incubation, a change in the defended level of body weight or ‘sliding set point’ appears to be involved, although the neural mechanisms reponsible for this are unknown. We investigated how neuropeptide gene expression in the arcuate nucleus of the domestic chicken responded to a 60–70% voluntary reduction in food intake measured both after incubation and after an environmental stressor involving transfer to unfamiliar housing. We hypothesised that gene expression would not change in these circumstances because the reduced food intake and body weight represented a defended level in birds with free access to food. Unexpectedly, we observed increased gene expression of the orexigenic peptide agouti‐related peptide ( Vertebrate animals change their feeding behaviour to balance the energetic demands of physiological processes (e.g. reproduction) with environmental conditions and many species show seasonal cycles in food intake and fat deposition. Many rodents, for example, undergo increased appetite and fattening during long days in summer The characterisation of leptin and its receptors led to the identification of neural circuitry in the arcuate nucleus that coordinates the compensatory behavioural and physiological responses to the loss of energy stores induced, for example, by fasting or food restriction There have been limited investigations into the neuroendocrine mechanisms regulating a voluntary reduction in food intake beyond the general context of seasonal cycles in body weight and appetite in mammals. The domestic chicken is a valuable model for such investigations because several strains show the ancestral characteristic of a naturally‐occurring anorexia during incubation of their eggs. Over a 3‐week period, hens display ‘broody’ behaviour Overall, we hypothesised that AgRP levels might remain low or unchanged during both incubation and cage‐to‐pen transfer associated with a reduced drive to eat. Unexpectedly, in both situations, AgRP mRNA levels in the basal hypothalamus were significantly greater compared to control animals. POMC was also significantly increased during stress‐induced anorexia.Experiments were performed using the female offspring (hens) of an F1 cross between female white leghorns and male silkie chickens, which have a high propensity to express natural incubation behaviour Animal experiments were performed according to UK Home Office legislation under project license PPL 60/3964 and the hens were killed by overdose of i.v. pentobarbitone, a schedule 1 method.ad lib. in all pens at all times and intake was monitored daily by weigh‐back where a known weight of food is present at the start and the food is weighed each day to estimate the amount consumed. A voluntary reduction in food intake was expected in the INC group. A LC hen was recruited to the study when the INC hen started to incubate. Therefore, hens were taken through the study as a block of two (INC and LC) and killed at the same time. Birds were examined daily for the outward signs of incubation: sitting, aggression and distinctive vocalisation.Laying hens (20–24 weeks of age) were ranked and randomised on the basis of body weight into two treatment groups and housed in individual pens. The objective was to compare two treatment groups (n = 12 each): (i) incubating hens (INC), comprising an ‘incubation’ treatment where laying hens were provided with the appropriate environment of a nest box, nesting material and a clutch of eggs to allow incubation behaviour to develop and (ii) laying control (LC) hens, comprising a ‘non‐incubating control’ treatment where laying hens were not allowed the appropriate environment for incubation behaviour to develop. An identical nest box was present but upturned to prevent entry and the pen was otherwise identical. Food was available All birds were killed 21 days after INC hens had started incubation and samples of basal hypothalamus were taken as described previously ad lib. access to food and food intake was recorded. (ii) Pair‐fed control (PFC), comprising a control treatment where hens were not allowed the appropriate environment for incubation, preventing the behaviour and provided with rationed food matched to that consumed by birds in the INC treatment (pair‐fed). These birds thus underwent similar but involuntary food restriction. Food intake was averaged over 3 days to derive the pair‐fed level, and so there was a delay in the onset of the reduction in food intake between INC and PFC, which were fed to the same level as the INC bird. After 16 days, the food restriction was maintained on a plane determined by that of the mean on the sixteenth day by which time birds were no longer laying eggs. (iii) PFC Release, comprising a second PFC group similar to the PFC but released from restriction after 16 days. All three hens in the block were killed 21 days after the INC bird had commenced incubation behaviour.The paradigm of Experiment 1 was repeated with a new set of hens ranked and randomised by body weight. However, in light of the experience of the first experiment, the design was modified to include pair‐fed hens to contrast with the voluntary food restriction of the incubating hens and to use a further control group that was released from the pair‐fed restriction. A block of three hens from each of three treatment groups was formed each time an incubating hen was identified. There were three treatment groups (n = 12 each). (i) INC, comprising incubation as in Experiment 1. Hens were allowed This treatment avoiding the potential confounding effect in Experiment 1 of control birds continuing to lay, in contrast to the incubating birds. Therefore, in Experiment 2, all groups were not laying eggs so that we were able to contrast directly a voluntary (INC) and an involuntary reduction (PFC) in food intake with a hen with free access to food (PFC Release).When setting up Experiment 1, it was noted that, after transferring birds from single housing in a cage to an individual pen, the hens showed a pronounced natural anorexia, reducing their food intake to 30% of the control hens, presumably related to the stress of transfer and a new environment. This resulted ultimately in many birds temporarily ceasing laying, which delayed the start of the incubation experiments. We made use of this serendipitous observation to carry out an additional study. For this experiment, we killed hens 6 days after transfer along with birds from a control group that remained in cages (n = 8). Food intake was recorded in both environments by weigh‐back.All tissue sampling and processing were carried out as described previously Plasma corticosterone concentrations were measured using a Corticosterone EIA Kit ADI‐901‐097 . The assay was validated for chicken exactly in accordance with the protocol laid out for white crowned sparrows 2 = 0.94 and was parallel to the standard curve material as supplied in the assay kit. The lower limit of detection was 48.75 pg/ml as determined by the concentration of corticosterone measured at two SDs from the zero along the standard curve. Inter‐ and intra‐assay coefficients of variation were 13.62% and 7.87%, respectively. All quality control samples and plasma samples were stored at −20 °C and assayed at first thaw.The accuracy of the assay as defined by percent recovery of a known amount of corticosterone was 90.7%. Linearity of diluted plasma was Ranova in Genstat, version 13  using log transformed data to approximate to a normal distribution where appropriate. In Experiments 1 and 2, the hen pair or triplet blocks were treated as fixed effects. An exception was the analysis of follicle numbers in Experiment 1, which was performed using a Kruskal–Wallis test because the data distribution was not suitable for anova.Results were analysed by In INC hens, voluntary anorexia was indicated by a 23% reduction in body weight over the 21‐day period, reflecting a loss of approximately 300 g at post mortem compared to a laying hen . There was no difference in the expression of POMC mRNA , nor CART  mRNA was significantly different between the LC or INC. Finally, VIP, the prolactin releasing factor, was expressed at approximately twice the level in the hypothalamus of INC compared to the LC hens    in INC hens than in the LC hens  were examined, there was a statistical difference with the INC hens having lower expression. However, when corrected for the differences as a result of the significantly greater amount of total RNA extracted  from the larger INC hen pituitary  the levels per pituitary were not different. However, circulating corticosterone concentrations were higher  than the birds remaining on voluntary restriction (INC) or involuntary restriction (PFC) Table . Of the anova, F2,21 = 16.96, P < 0.001). The AgRP levels in the INC hens compared to those feeding ad libitum (PFC Released)  Fig.  were higed) Fig. .anova on the basal hypothalamic POMC mRNA levels indicated that there was a near significant effect of treatment . Comparison between the voluntary anorexia (INC) and either of the groups of hens that were either involuntarily restricted (PFC) or released from restriction (PFC Released) revealed higher levels of POMC mRNA in INC hens . anova indicated that neither NPY   was significantly different. VIP levels were significantly different   combined with a higher expression of POMC mRNA   and CART , and the expression of VIP mRNA  levels in the basal hypothalamus was not different between the two groups .Corticosterone levels were not significantly different between transferred birds and LC hens  and was particularly highly expressed in this nucleus during incubation compared to other reproductive states Streptopelia risoria), central administration of mammalian prolactin stimulated feeding and was associated with increased NPY‐immunoreactive cell bodies in the arcuate nucleus For the incubation experiment, the fact that POMC gene expression was only marginally significantly higher in the INC compared to the pair‐fed groups, suggests that other signals may be responsible for reducing voluntary food intake. VIP is the main candidate because its expression was significantly elevated in INC hens in both incubation experiments and VIP peptide reduces food intake in domestic chicks after central injection By contrast to AgRP and POMC, we observed no consistent changes in the expression of the other arcuate nucleus neuropeptides CART and NPY. CART gene expression did not change in any of our experiments, in line with previous observations after manipulations of energy balance in birds Oncorhynchus mykiss), reduced food intake 4 weeks after infection was accompanied by significantly increased AgRP and POMC mRNA but reduced NPY mRNA Our observations of increased AgRP gene expression during anorexia are reminiscent of findings of studies of the effects of parasitic infection in rats and fish Although knowledge of the phenomenon of a voluntary reduction of food intake and body weight in INC hens, as well as experimental evidence that it is homeostatically defended, has been available for more than 35 years, we currently know little about how it is regulated at the molecular level. Our findings on AgRP expression suggest that its responsiveness to a loss of energy stores is maintained during incubation and after a cage‐to‐pen transfer in the face of a voluntary reduction in food intake when food is freely available. This may be of functional significance in allowing INC hens to monitor their energy stores and perhaps to feed vigorously when they do leave the nest, and for the process of recovery following a stressful event. However, the key factors driving the voluntary loss of appetite and body weight remain to be unambiguously confirmed experimentally.


SAH) is one of the most devastating forms of stroke. Multiple pathogenic mechanisms, such as inflammation, apoptosis, and oxidative stress, are all responsible for brain injury and poor outcome after SAH. Most recently, accumulating evidence has demonstrated that the autophagy–lysosomal pathway plays a crucial role in the pathophysiological process after SAH. Appropriate activity of autophagy–lysosomal pathway acts as a pro‐survival mechanism in SAH, while excessive self‐digestion results in cell death after SAH. Consequently, in this review article, we will give an overview of the pathophysiological roles of autophagy–lysosomal pathway in the pathogenesis of SAH. And approaching the molecular mechanisms underlying this pathway in SAH pathology is anticipated, which may ultimately allow development of effective therapeutic strategies for SAH patients through regulating the autophagy–lysosomal machinery.The autophagy–lysosomal pathway is a self‐catabolic process by which dysfunctional or unnecessary intracellular components are degraded by lysosomal enzymes. Proper function of this pathway is critical for maintaining cell homeostasis and survival. Subarachnoid haemorrhage ( The autophagy–lysosomal system is a self‐destructive process by which cytoplasmic substrates are delivered to lysosomes for degradation Subarachnoid haemorrhage (SAH) is a serious, life‐threatening type of stroke, which denotes the presence of blood within the subarachnoid space via modulating this pathway.Currently, early brain injury (EBI) and delayed brain injury (DBI) are conceived as two most important mechanisms for SAH pathology e.g. amino acids) are subsequently exported to the cytoplasm for reuse.Autophagy is a sophisticated catabolic process in which cytosolic components and organelles are transported to lysosomes for degradation et al. reported that high mTOR activity prevents ULK1 activation by phosphorylating ULK1 Ser 757 when nutrients are plentiful Importantly, several hetero‐oligomeric protein complexes that contain autophagy‐related (Atg) proteins exert a critical role at different stages of autophagy 3) pathway and the Ca2+‐calpain‐G‐stimulatory protein α (Gsα) pathway, can also regulate autophagy in mammalian systems 2+ activates calpains, and activated calpain activates Gsα, resulting in enhanced AC activity that generates cAMP to suppress autophagy Because of its pathophysiological significance in cellular self‐cannibalism, the autophagic process must be tightly regulated. In mammalian cells, multiple signalling cascades, including mTOR‐dependent and mTOR‐independent pathways, participate in the regulation of autophagy in response to numerous environmental and cellular stimuli Subarachnoid haemorrhage is a complex, multisystem and multifaceted disorder which involves several ongoing pathological processes et al. demonstrated that the autophagy–lysosomal pathway is activated in the ipsilateral frontobasal cortex following SAH and lasts during the entire phase of EBI (up to 3 days) et al. demonstrated that trichostatin A, a pan‐histone deacetylase inhibitor, significantly increased the levels of Beclin‐1 and LC3‐II/LC3‐I ratio, while decreased the expression of Bax and cleaved caspase‐3 in the cortex at 24 hrs after experimental SAH The autophagy–lysosomal system is a catabolic process that allows the degradation and recycling of intracellular components to ensure cell homeostasis and survival. In a modified endovascular perforation rat model of SAH, Lee et al. found that the expression of LC3 and Beclin‐1 was significantly increased in the cortex and peaked at 24 hrs after prechiasmatic cistern blood injection, indicating the activation of autophagy–lysosomal system in the brain post‐SAH et al. demonstrated that pre‐treatment with a cysteine protease inhibitor Cystatin C with low or medial dosages promotes the autophagic process within neurons, inhibits BBB impairment and ameliorates brain oedema formation, which contributes to alleviation of secondary learning deficits in the prechiasmatic cistern SAH injection model Similar to the data from endovascular perforation SAH models, Wang et al. demonstrated that the autophagic pathway is activated in the spastic basilar arteries after SAH Cerebral vasospasm is one of the most common and devastating sequelae for patients who have sustained SAH. It is involved in the development of delayed cerebral ischaemia and contributes to DBI after SAH i.e. cathepsin B/D) into the cytoplasm, which in turn trigger the lysosomal pathway of apoptosis through cleavage of the pro‐apoptotic Bcl‐2 family member Bid and the degradation of the anti‐apoptotic Bcl‐2 members such as Bcl‐2, Bcl‐xL and Mcl‐1 Lysosomes, the cytoplasmic membrane‐enclosed organelles that contain hydrolytic enzymes, are the key degradative compartments of the cell that control the intracellular turnover of macromolecules i.e. cathepsin B/D) to be released into the cytoplasm to activate caspase‐dependent apoptotic pathway et al. also demonstrated that lysosomes were impaired and cathepsin B/D was up‐regulated in the cerebral cortex of affected rats under SAH conditions via targeting lysosomes and chelating intra‐lysosomal iron in this prechiasmatic cistern SAH model In the setting of SAH, lysosomes may become iron overload and is particularly prone to destabilization, resulting in lysosomal membrane rupture and the release of hydrolytic enzymes into cytoplasm Additionally, an imbalance between cysteine cathepsin enzymes and their inhibitor Cystatin C in the arterial walls may exert a prominent role in the progression and rupture of cerebral aneurysms Taken together, accumulating lines of evidence indicate that the autophagy–lysosomal system is deeply involved in the pathophysiology of SAH. Thus, pharmacological modulation of the autophagy–lysosomal system may represent a potential therapeutic strategy to limit brain injury after SAH. Currently, several pharmacological agents that are able to modulate the autophagy–lysosomal system have been identified, such as mTOR inhibitors, AMPK modulators, calcium lowering agents and lysosome inhibitors Subarachnoid haemorrhage is a complex, multifaceted event that involves multiple ongoing processes contributing to its final pathogenesis. Despite great advances have been made in diagnostic methods, surgical and endovascular repair of ruptured aneurysms and management of medical complications, outcome for patients with SAH remains poor. Early brain injury and DBI, two major pathological mechanisms, are recognized as dominant contributors to the prognosis of SAH. The autophagy–lysosomal system is activated and plays a role in the pathogenesis of EBI and CVS after SAH Table . It is si.e. CMA), as well as the ubiquitin‐proteasome system during the protein degradation process It is noteworthy that even though knowledge of autophagy–lysosomal system in SAH pathology, the precise roles and underlying mechanisms of autophagy–lysosomal pathway in the setting of SAH remain vague. Indeed, ‘self‐eating’ autophagy and ‘self‐killing’ apoptosis crosstalk with each other extensively in the pathophysiological conditions The autophagy–lysosomal system exerts critical roles in maintaining intracellular homeostasis in the brain under SAH conditions. Appropriate autophagy functions as protective mechanisms for cell survival after SAH, while excessive ‘self‐eating’ autophagy may lead to cell death. Therefore, approaching molecular mechanisms of autophagy–lysosomal system in the setting of SAH is anticipated, which may ultimately allow to develop effective therapeutic strategies for SAH patients through regulating this pathway.No potential conflicts of interest were disclosed.


The efficacy of histological analysis of colon sections used for evaluation of inflammation severity can be improved by means of digital imaging giving quantitative estimates of main diagnostic features. The aim of this study was to reveal most valuable diagnostic features reflecting inflammation severity in colon and elaborate the evaluation method for computer-aided diagnostics.n = 6). Non-inflamed colon tissue of control subjects (n = 9) was obtained from patients with irritable bowel syndrome or functional obstipation. Analysis of morphological changes in mice and human colon mucosa was performed using 4-μm haematoxylin-eosin (HE) sections. The features reflecting morphological changes in the images of colon mucosa were calculated by convolution of Gabor filter bank and array of pixel values. All features were generalized by calculating mean, histogram skewness and entropy of every image response. Principal component analysis was used to construct optimal representation of morphological changes.Tissue specimens from 24 BALB/c mice and 15 patients were included in the study. Chronic and acute colon inflammation in mice was induced by oral administration of dextran sulphate sodium (DSS) solution, while mice in the control group did not get DSS. Human samples of inflamed colon tissue were obtained from patients with ulcerative colitis  was representing the major part of features variation (97 % in mice and 71 % in human specimens) and was selected as a measure of inflammation severity. Validation of new measure was performed by means of custom-made software realizing double blind comparison of differences in PC1 with expert’s opinion about inflammation severity presented in two compared pictures. Overall accuracy of 80 % for mice and 67 % for human was reached.Principal component analysis of spatial frequency features of histological images may provide continuous scale estimation of inflammation severity of colon tissue. Ulcerative colitis (UC) is a chronic relapsing-remitting inflammatory disorder affecting intestinal mucosa. The pathogenic mechanisms of UC are complex and involve interaction between genetic, host immune system and environmental factors –3. The dHistological features of chronic active UC listed in the guidelines for visual inspection and evaluation of histologic images include crypt distortion, crypt branching, and lymphoplasmacytic infiltration deep into the crypts . It is pThe aim of this study was to develop a method for automated evaluation of inflammation severity based on evaluation of spatial frequency features in histological images of inflamed mice and human colon tissue.BALB/c mice used in this study come from our previous research that aimed to evaluate the role of NADPH oxidase in pathogenesis of colon inflammation . Acute aImages were taken by means of OLYMPUS IX71 light microscope (×20 magnification) equipped with Q IMAGING EXI aqua camera at 1392 × 1040 pixels resolution (0.6 μm/pixel).+2 or Ca+2 free phosphate-buffered solution (PBS) and immediately fixed by the neutral 10 % formalin for 4 h at room temperature for paraffin embedding. Serial 4-μm sections were cut for each tract and stained with HE. The experts approved the image resolution for further analysis, confirming that all the tissue levels and structures are not distorted and clearly visible. Histological examination was performed using analysis method according to M. Hausmann et al.  range and considered it as the inflammation severity measure. Maximal value “1” was corresponding most severe inflammation and “0”–no inflammation (control). Ordered values of PC1 are presented in Fig. Three histology experts participated in double blind validation of proposed inflammation severity measure using custom made software. The software was showing randomly selected images corresponding to different values of PC1 and registered opinion of the expert which of them was corresponding to more severe inflammation. Expert’s opinion was matching with decision according PC1 values in 79.9 % of 3402 mice image pairs of specimen and in 67 % of 5796 human image pairs of specimen covering whole range of PC1 values. Absolute matching was in cases when difference in PC1 values was maximal. Dependency of ratio of expert’s opinion mismatching with difference in PC1 values is shown in Fig. Proposed measure of inflammation severity–first Principal Component, is constructed by convolution of first eigenvector with initial set of features (see formula ). TherefSeveral studies have shown that image processing and analysis systems may be successfully used for diagnosis and classification of various diseases, such as neuroblastoma, melanoma, lung, prostate, and breast cancer. However, these computerized analysis systems are based mainly on color-space derived features of histological images and indicate only areas with positive or negative diagnostic result –30 ignorCurrently published guidelines for visual evaluation of histological preparations of colon tissue describe expert scoring schemes enabling to classify severity of inflammation into several grades , 10, 31.At the moment we do not have any “golden standard” method for verification of our results, so determination of resolution achieved by our method could be based on maximal yet acceptable value of discordance between expert’s opinion in double blind test and our principal component analysis based estimate. The estimation of maximal yet acceptable value of mismatch ratio could be detected by evaluation of concordance between opinions of different experts on the same image pairs. However, this requires recruitment of many experts into the experiment and should be an interesting task of further research in this field. Detailed analysis of eigenvector values reveals diagnostic value of particular features and could be used for optimization of initial feature set for processing. Particular disease is related with unique tissue structure and changes of it in progress of disease. So, using our methodology we can elaborate disease progress measures for other diseases as well.Currently, clinical, endoscopic, radiological, histological criteria and molecular markers are used to evaluate inflammation severity of colon in UC patients. Estimates obtained from standard clinically approved features could be also used for verification of our method. However, registration of such estimates “in vivo” is technically difficult and such combined experiments remain an interesting topic for future research. We show that complex evaluation of colon inflammation severity using computer-aided analysis could reveal new alternatives for evaluation of the degree of inflammation severity with higher precision and may provide new diagnostic possibilities.Quantitative evaluation of inflammatory changes in histological preparations of colon tissues is feasible by estimation of spatial frequency parameters of histological images. Principal component analysis of the spatial frequency features improves efficacy of estimation of inflammation severity of colon tissue. The method may have potential clinical applications in patients with colon inflammation.


Hum Brain Mapp, 36:1393–1406, 2015. © 2014 The Authors Human Brain Mapping Published by Wiley Periodicals, Inc.The present fMRI study used a spelling task to investigate the hypothesis that the left ventral occipitotemporal cortex (vOT) hosts neuronal representations of whole written words. Such an orthographic word lexicon is posited by cognitive dual‐route theories of reading and spelling. In the scanner, participants performed a spelling task in which they had to indicate if a visually presented letter is present in the written form of an auditorily presented word. The main experimental manipulation distinguished between an orthographic word spelling condition in which correct spelling decisions had to be based on orthographic whole‐word representations, a word spelling condition in which reliance on orthographic whole‐word representations was optional and a phonological pseudoword spelling condition in which no reliance on such representations was possible. To evaluate spelling‐specific activations the spelling conditions were contrasted with control conditions that also presented auditory words and pseudowords, but participants had to indicate if a visually presented letter corresponded to the gender of the speaker. We identified a left vOT cluster activated for the critical orthographic word spelling condition relative to both the control condition and the phonological pseudoword spelling condition. Our results suggest that activation of left vOT during spelling can be attributed to the retrieval of orthographic whole‐word representations and, thus, support the position that the left vOT potentially represents the neuronal equivalent of the cognitive orthographic word lexicon.  One of the issues in the cognitive and neuroscientific study of reading processes concerns the existence of an orthographic word lexicon, that is, a memory system containing representations of the exact letter sequences of all known written words. Such orthographic whole‐word representations are assumed by cognitive dual‐route models of word reading  that exhibited activation for all spelling conditions relative to the control conditions.P < 0.001, uncorrected, also the pseudoword spelling condition led to a similar occipitoparietal cluster with a peak at [−42 −55 49] . In left superior and middle temporal gyrus  only the pseudoword spelling condition elicited activation relative to the pseudoword control condition. Even with a lowered threshold  there was no activation for the word spelling conditions compared to the word control condition. We want to note, however, that relative to rest all spelling conditions elicited marked activation in bilateral STG (see Supporting Information Results). We additionally identified subcortical regions in the caudate/pallidum to be activated by the orthographic and the phonological spelling condition.In occipitoparietal regions only the word spelling conditions evoked activation in a cluster with a peak at the border of left lateral occipital cortex and left superior parietal lobule. This cluster did not extend into the angular gyrus. When lowering the threshold to For these comparisons we limited the search space to regions activated by the spelling conditions relative to the control conditions. The search mask was a combination of the activation maps identified by the contrasts in Table P <  .001, uncorrected) no activation differences were identified between the word spelling conditions in these regions.For our hypotheses differences between the spelling conditions in left vOT were of main interest. Table P < 0.001, uncorrected).In left STG, the pseudoword spelling condition elicited higher activation than both the orthographic‐phonological and the orthographic condition. We want to note that the latter comparison was only significant at a lowered threshold (y= −55 (orthographic) and y = −58 . More specifically, we were interested in whether these peaks were different from the left vOT peak at y = −64 identified for all spelling conditions relative to the control conditions. For this, we computed a spelling > control contrast (collapsed across word and pseudoword conditions). Figure y = −54) and a 10 mm more posterior ROI (y = −74) to cover the entire anterior‐to‐posterior extent of the cluster. The x and z coordinates for these ROIs were kept constant. Figure r = 4 mm) centered at the mentioned coordinates.In addition to the whole‐brain analysis, we investigated differences between the spelling conditions in left vOT with a ROI‐based analysis. Of main interest was the posterior extent of the increased activation for the word spelling conditions relative to the pseudoword spelling condition identified at y = −54 was also present in the middle ROI at y = −64 . As can be seen in Figure The main finding of the ROI analysis was that the activation pattern of higher activation for both word spelling conditions relative to the pseudoword spelling condition found in the anterior ROI at The present fMRI relied on a spelling task to investigate the hypothesis that left vOT serves as memory store for known written words and thereby functions as the orthographic word lexicon assumed by dual‐route theories of reading and spelling  identified for all spelling conditions relative to the control conditions closely corresponds to the left vOT clusters found by previous neuroimaging studies of spelling, especially to activation peaks of the recent spelling meta‐analyses by Planton et al.  at −46  at  identified bilateral STG activations and the study by Rapp and Lipka [a identifSimilar to the spelling meta‐analysis by Purcell et al. , the preThe present fMRI study provides support for the position that the left vOT hosts neuronal representations coding for the exact letter strings of all known words. The assumption of such an orthographic word lexicon is controversial, but constitutes an essential component of cognitive dual‐route models of reading and spelling [e.g., Coltheart, Supplementary InformationClick here for additional data file.


To examine changes in under–5 mortality, coverage of child survivalinterventions and nutritional status of children in Ethiopia between 2000and 2011. Using the Lives Saved Tool, the impact of changes in coverage ofchild survival interventions on under–5 lives saved was estimated.Estimates of child mortality were generated using three Ethiopia Demographicand Health Surveys undertaken between 2000 and 2011. Coverage indicators forhigh impact child health interventions were calculated and the Lives SavedTool (LiST) was used to estimate child lives saved in 2011.The mortality rate in children younger than 5 years decreased rapidly from218 child deaths per 1000 live births in the period 1987–1991 to 88 child deaths per 1000 live births in theperiod 2007–2011 (78 to 98). The prevalence of moderate or severestunting in children aged 6–35 months also declined significantly.Improvements in the coverage of interventions relevant to child survival inrural areas of Ethiopia between 2000 and 2011 were found for tetanus toxoid,DPT3 and measles vaccination, oral rehydration solution (ORS) andcare–seeking for suspected pneumonia. The LiST analysis estimates thatthere were 60 700 child deaths averted in 2011, primarilyattributable to decreases in wasting rates (18%), stunting rates (13%) andwater, sanitation and hygiene (WASH) interventions (13%).Improvements in the nutritional status of children and increases in coverageof high impact interventions most notably WASH and ORS have contributed tothe decline in under–5 mortality in Ethiopia. These proximaldeterminants however do not fully explain the mortality reduction which isplausibly also due to the synergistic effect of major child health andnutrition policies and delivery strategies. Ethiopia has achieved remarkable declines in under–5 mortality. According to the2015 UN Inter–Agency Group for Child Mortality Estimation (IGME) report, Ethiopiareached its target for Millennium Development Goal 4 for child survival with anestimated under–five mortality rate of 59 per 1000 live births in 2015, a declinefrom 205 in 1990. This represents an average reduction in mortality of 5% per year;higher than the average for sub–Saharan Africa (2.9%) [Major policy and program activities related to child survival were initiated in Ethiopiabetween 2003 and 2013 which built on major reforms starting from the 1990s todecentralise and reorganise the health system. An ambitious Health Extension Programme(HEP) was launched in 2003 which aimed to provide universal access to mainly preventiveprimary health care services .The launch of the HEP in 2003 was followed by the Health Sector Development Programme andthe National Child Survival Strategy in 2005. At around the same time there was nationalscale up of community–based treatment of severe acute malnutrition usingready–to–use therapeutic food [This paper examines changes in mortality and coverage of child survival interventions inEthiopia between 2000 and 2011. The impact of changes in coverage of child survivalinterventions on under–5 lives saved was estimated using the Lives Saved Tool.We used full birth and death history data collected from women aged 15 to 49years in nationally representative surveys: namely the 2000 Demographic andHealth Survey (DHS) the first DHS to be undertaken in Ethiopia, 2005 DHS and the2011 DHS to calculate under–5 mortality. The surveys covered14 072, 13 721, and 16 702 households respectively.Online Supplementary Document(Online SupplementaryDocument) for further details on the surveys). To assesscoverage of malaria interventions two separate Malaria Indicator Surveys (MIS)were used since these surveys sample specifically from malaria endemic areas.Malaria is seasonal in most parts of Ethiopia, with variable transmission andprevalence patterns affected by the large diversity in altitude, rainfall, andpopulation movement. The MIS from 2007 [Online SupplementaryDocument(OnlineSupplementary Document).To assess trends in coverage of child survival interventions and nutritionalstatus we used the same three Ethiopian DHS surveys. The surveys providedetailed information about the health and nutritional status of women andchildren and coverage of health care services. The analysis included all surveydata sets available with full data, including sampling weights, to allow forre–analysis (see Table S1 in the rom 2007 and 2011Online Supplementary Document(Online SupplementaryDocument)) [Online Supplementary Document(Online Supplementary Document)).We used a direct method for estimating under–5 mortality based on thesynthetic cohort approach ,9. Undercument)) . A serieWe analyzed primary data from three Ethiopia DHS surveys to assess coveragetrends for 10 indicators which represent high impact maternal and child healthinterventions; three additional malaria intervention indicators arepresented as point estimates. We re–calculated all coverage indicatorsusing standard indicator definitions [We computed anthropometric indicators for stunting (height–for–age)and underweight (weight–for–age) in children younger than threeyears of age from information on age, height and weight in the surveys applyingthe WHO child growth standards .ModeratPlasmodiumfalciparum, stunting rates) and current coverage of more than 60interventions and their associated effectiveness values [Online Supplementary Document(Online SupplementaryDocument)).We used the Lives Saved Tool (LiST) to estimate the number of deaths averted in2011 due to changes in coverage since 2000. We compared the changes in mortalityproduced in LiST with single year estimates from IGME  as well s values –16relats values . WeusedOnline Supplementary Data(Online Supplementary Document). The analysis wasdone with the program Spectrum/Lives Saved Tool, version 5.04 .Specific input values used in this LiST application are available in Table S6 inOnline Supplementary Document(Online SupplementaryDocument)).The national mortality rate in children younger than 5 years decreased rapidly from218 child deaths per 1000 live births (95% CI 183–252) in the period1987–1991 to 88 child deaths per 1000 live births in the period2007–2011 (95% CI 78–98) with an average annual change of –4.5%.The mortality rate was significantly lower in urban areas, compared to rural areasup until the most recent period (2007–2011) where the confidence intervals forthe two estimates overlap indicating that the urban mortality estimate was no longersignificantly different from the rural estimate  (41% to 38%)  and the 2007–2011 5–yearDHS estimate of 88 (78 to 98), and placing it outside the upper confidence range ofboth estimates.We calculated the proportion of child lives saved in 2011, by intervention or changein nutritional status, using the LiST estimation of 60 700 deaths averted in2011 (relative to the situation in 2000) as a denominator. The main factorscontributing to the prevention of these deaths in 2011 included nutritionalinterventions resulting in decreases in wasting rates  and stunting rates , water, sanitation andhygiene (WASH) interventions , ORS for diarrhea , and the introduction of the Hib vaccine   possibly reflecting earlyimpact from the HEP, initiated two years prior to the 2005 DHS, particularlyelements such as outreach services, greater access to curative care at health postlevel, the multi–sectoral approach and a focus on prevention and promotionthrough model families. Coverage of care–seeking for suspected pneumonia andcoverage of ORS treatment for diarrhea was still low in 2011 (both around 25%)although this represents a significant increase from very low coverage levels(around 10%) for both indicators in 2000.With respect to nutritional status of children, we report a significant decline inboth stunting and underweight nationally and our LiST analysis has found that atotal of 31% of deaths averted were estimated to be due to decreases in stunting andwasting rates. These shifts in nutritional status of children do not appear to bedriven by improvements in breastfeeding practices as exclusive breastfeedingremained high across the period 2000–2011 at around 50% of infants 0–6months. The changes could plausibly be due to major policy shifts in nutrition whichoccurred in the country between 2004 and 2008 with the scale up of communitymanagement of acute malnutrition at health post level and the development of anational nutrition strategy and program . An impaIt is difficult to disentangle the mechanisms whereby socio–economic change andimprovements in health coverage interact to generate mortality reduction as thesemechanisms can be either direct or indirect and take place concurrently . There aIn addition to meeting the MDG 4 target, Ethiopia has also met four other MDG targetsincluding MDG 1 (poverty and hunger), MDG 6  andMDG 7 . Furthermore at the end of 2015 the country was“on track” to meet MDGs 2 , 3  and 5  and was only “offtrack” on one out of the eight goals (stabilizing debt) . EvidencSeveral indicators, particularly related to maternal and newborn interventioncoverage, showed no improvement in rural areas over the period under analysis. Ruralskilled attendance at birth and postnatal care coverage were 4% and 3% respectivelyin 2011. An analysis of neonatal mortality in Ethiopia found an annual rate ofdecline of 1.9% between 1995 and 2010, which was even lower (0.9%) for earlyneonatal mortality (death occurring before 7 completed days of life) the period inwhich 74% of neonatal deaths occurred . ArecenThe endline data for this assessment, the 2011 Ethiopia DHS, occurred at the time ofnational scale up of the iCCM program and thus provides a picture of coverage andchild survival in the absence of an established community–based treatmentplatform. It is recommended that a comparable analysis be undertaken following thenext full DHS to establish the impact of the community delivery platform on childsurvival and health.A strength of this study is the re–analysis of primary data to generatemortality and coverage estimates for 10 indicators and nutritional statusmeasures over three time points together with lives saved modeling and a deskreview of broader factors hypothesized to impact on child survival.There are several weaknesses to this analysis. First, primary data were notavailable for the two MIS to enable us to determine significant changes inmalaria interventions; however, for care–seeking and malariatreatment the changes in point estimates are large (>20 percentage points)and the sample sizes for both surveys were over 5000 households, therefore itwould be scientifically plausible that these changes are statisticallysignificant. Second, with the LiST analysis, the household survey indicatordefinitions do not perfectly match LiST indicators in all cases, and somecoverage indicators–particularly those related to delivery care–areimputed based on rates of home and facility births. Additionally, the DHS dataused in this analysis does not capture some of the interventions included inLiST. These interventions are often high impact for children, eg, therapeuticfeeding for severe wasting, and might have changed during the period underconsideration. The collective effect of several positive changes in child nutritional status,and increased coverage of high impact interventions including WASH and ORS havecontributed to the decline in under–5 mortality in Ethiopia. Theseproximal determinants however do not fully explain the mortality reduction whichis plausibly also due to the synergistic effect of major child health andnutrition policies and decentralized delivery strategies. Ethiopia’sprogress confirms the importance of an integrated approach to child survival and the


There is an increasing policy commitment to address the avoidable burdens of unhealthy diet, overweight and obesity. However, to design effective policies, it is important to understand why people make unhealthy dietary choices. Research from behavioural economics suggests a critical role for time discounting, which describes how people's value of a reward, such as better health, decreases with delay to its receipt. We systematically reviewed the literature on the relationship of time discounting with unhealthy diets, overweight and obesity in Web of Science and PubMed. We identified 41 studies that met our inclusion criteria as they examined the association between time discount rates and (i) unhealthy food consumption; (ii) overweight and (iii) response to dietary and weight loss interventions. Nineteen out of 25 cross‐sectional studies found time discount rates positively associated with overweight, obesity and unhealthy diets. Experimental studies indicated that lower time discounting was associated with greater weight loss. Findings varied by how time discount rates were measured; stronger results were observed for food than monetary‐based measurements. Network co‐citation analysis revealed a concentration of research in nutrition journals. Overall, there is moderate evidence that high time discounting is a significant risk factor for unhealthy diets, overweight and obesity and may serve as an important target for intervention. © 2016 The Authors Obesity Reviews published by John Wiley & Sons Ltd on behalf of International Association for the Study of Obesity (IASO) Unhealthy diets, overweight and obesity contribute to a number of chronic non‐communicable diseases and are among the leading risk factors for death and disability worldwide Time discounting is a factor that is receiving growing attention as a potentially common cause of multiple risky behaviours Time discounting varies considerably among individuals Over the past decade, a growing number of studies have found time discounting positively associated with unhealthy diets, overweight, obesity and binge eating disorder (BED) We searched Web of Science and PubMed for articles containing ‘time discounting’, ‘food’ and related terms, as described in Table We conducted our review according to the PRISMA statement for systematic reviews see  26. FiguWe extracted title, author, journal, abstract and year. Additional data were extracted from each paper and used to evaluate risk of bias, including research question, methodology, sample size, sample demographic, discounting measure, diet or weight‐related variables (e.g. body mass index (BMI), obesity and weight loss) and main results . To assuCo‐citation data were collected from Web of Science and PubMed and analysed using VOSviewer version 1.6.1 and network clustering algorithms. These map the spatial location for each journal by minimizing the weighted sum of the squared Euclidean distances between all pairs of journal citations. Weights correspond to the strength of co‐citation, with higher values reflecting a greater tendency for journals to be cited together in the same article. Minimization of the distance between journals is subject to the constraint that the average distance between two items equals 1 First, we describe trends, disciplinary patterns and methods used to measure discount parameters in the reviewed literature. Next, we describe the main findings by the type of studies of the association between time discounting and unhealthy diets, overweight and obesity, discount rate modifiers and treatment response. Finally, we describe results from studies using multiple discount rate measurement methods.Figure Among the 44 articles included in our review, 25 were cross‐sectional, 13 were experiments and three were longitudinal. Sample sizes ranged from 14 to 63,950. The mean sample size was 1748, albeit highly skewed to the right (median = 85). The majority of studies sourced their data via convenience sampling: 40 studies recruited voluntary participants via convenience sampling from local communities, of which 20 also applied sample quotas (i.e. targets for specific demographics), and four studies used large‐scale datasets with probability sampling. A large proportion of studies (14 out of 41) restricted their samples to women only, and 16 studies restricted their samples to children, adolescents and university students only (16 out of 44 studies).Appetite (40.9%) and Plos One (9.1%). Figure The 41 studies were distributed across 22 journals. Half were published in two journals: Appetite. The nutrition cluster has a tendency for co‐citation with pharmacology and a slightly weaker tendency for co‐citation with neuroscience. The economic psychology cluster is the most isolated.As shown in Figure The methods used to measure time discounting varied in three main ways, and these are (i) how the survey was administered; (ii) how the discount rate was estimated and (iii) the nature of the rewards linked to the hypothetical choices.et al., in which choices vary by the size of reward and how long they must wait for the reward et al. 2008) Surveys can be administered in two ways, using a paper or online questionnaire or getting the subject to make choices as the options change incrementally on a computer. In both approaches, individuals state whether they would prefer a smaller reward now or a larger reward at some specified later time. The questionnaire method follows the ‘Monetary Choice Questionnaire’ method of Kirby Y is the subjective value of a reward of amount A, k is the discount parameter and x is the delay to the reward's receipt x‐axis is calculated, with smaller AUC values reflecting steeper discounting In both methods, responses are then used to estimate discount rates. The first step is to determine an ‘indifference point’. This is the point at which respondents switch from preferring a delayed over immediate reward or vice versa. Respondents are said to subjectively value immediate and delayed rewards equivalently at the point at which they switch; that is, they are indifferent between the two The third difference relates to the reward type. In 39 studies, the choices were purely hypothetical. They included hypothetical money (33 studies), food (34 studies) and weight loss (one study). Estimation of non‐monetary rewards followed a similar procedure to money: respondents chose between an amount of food or immediate weight loss and a larger, delayed reward of the same type. A second approach, used in two studies, is to encourage respondents to treat their responses as real by rolling a dice or selecting one response at random at the end of the survey and honouring it, so‐called ‘quasi‐real’ rewards.Our search identified 25 cross‐sectional studies that analysed the association between time discounting and a number of diet and weight‐related variables including BMI Four studies analysed the association between time discounting and unhealthy diets.et al. (2012) report higher demand and lower price elasticity of demand for high‐sugar and high‐fat foods among those with the highest discount rates in a sample of 21 female university students et al. (2013) adopted an ecological approach, reporting higher discounting rates in US regions with more fast‐food restaurants whilst, in the same study, subjects randomly asked to recall experiences of fast food reported higher discount rates than controls who were not asked et al. (2015) test for an association between time discounting for food and a 25‐item Disordered Eating Attitude Scale, with higher values on the scale representing more negative or disordered eating attitudes. The authors report lower discount rates among men with higher Disordered Eating Attitude Scale scores but find no association among women et al. (2013) report lower discounting rates among individuals with higher dietary quality , yet these differences were not significant at the α = 0.05 level once age, gender and education were accounted for Reslan et al. (2015) adopt an ecological approach to analyse the effects of food prices on BMI change. They document an interaction effect with time discounting, with lower prices correlated with greater BMI gains among those with higher discount rates et al. (2012) collect functional magnetic resonance imaging data from 19 obese women whilst conducting a series of delay discounting tasks and find no association between discount rates and BMI or weight change over the subsequent 1.3–2.9 years. Yet individuals with less activation in areas of the brain associated with inhibitory control  during ‘easy’ discounting tasks were more likely to gain weight We identified two longitudinal studies that asked whether there were associations between weight change and changes delay discounting of hypothetical monetary rewards, reporting contrasting results et al. (2015) report higher discounting of hypothetical money and food in individuals wither higher per cent body fat et al. (2011) report higher discounting for food rewards among individuals suffering from BED compared with obese, non‐obese and non‐BED groups. The authors also report higher discount rates for food among obese compared with non‐obese and non‐BED controls. These differences were not significant when testing for differences in discounting for monetary rewards et al. (2008) report higher discounting in obese compared with healthy‐weight women, but find no difference in men et al. (2010) report higher discounting of monetary rewards in a group of obese individuals suffering from BED, but these differences lost significance once education was accounted for. Four studies reported null findings in testing for an association between discounting of hypothetical monetary rewards and BMI Five cross‐sectional studies report higher discount rates in individuals with higher BMIs when measuring discounting using hypothetical monetary et al. (2013) compare the reduction in delay discounting among a sample of university students participating in a mindful eating workshop and those watching an educational video (the ‘control’ condition). They report greater reductions in delay discounting for food but not monetary rewards among those who participated in the workshop, compared with those who watched the video et al. (2013) analyse the effects of a prospective imagery intervention designed to induce increased thinking about the future. The authors compare discount rates for hypothetical monetary rewards in lean and obese individuals, finding no significant difference at the α = 0.05 level in the reduction in discount parameters in both groups et al. (2014) find that carrying out a reasoning task after exposure to a food image cue reduced discount rates among participants with bulimia nervosa et al. and Rollins et al. report a positive association between the ‘relative reinforcing value of food’ and food consumption in a laboratory environment at high but not low discount rates Eight studies identified significant effects of interventions aimed at modifying discount rates et al. 13 comparet al. (2014) compared participants randomly assigned to a ‘hungry condition’ where they were instructed to refrain from eating the previous evening and complete a discounting task before breakfast and sated participants who were first provided with breakfast. Those in the ‘hungry condition’ had lower discounting rates for large hypothetical monetary rewards compared with those in the sated condition et al. (2014) test whether discount rates are modified by aversive cues. These are cues that are designed to stimulate a negative neural wave (error‐related negativity) that is associated with being better able to avoid events with harmful long‐term consequences. The authors hypothesized that time‐discount rates may be reduced by pairing aversive cues with foods (creating ‘error‐prone foods’) designed to stimulate increases in error‐related negativity. They find that combining foods with aversive cues decreased discount rates compared with foods that were not paired with aversive cues in sated participants; yet there was no variation among hungry participants Two studies reported an effect of hunger on discount rates. De Ridder et al. (2014) test whether cortisol reactivity mediates the association between delay discounting and per cent body fat. Cortisol is a hormone released in response to stress, improving the individual's capacity to respond to stress‐inducing situations and environments. However, cortisol also dampens the inflammatory response, which in the long term may increase oxidative damage. Cortisol reactivity is the responsiveness of cortisol levels to a given stimulus and, if excessive, may be harmful because of this impact on the inflammatory response. The authors report significant pairwise correlations in girls, with greater cortisol reactivity to stress associated with both higher discount parameters and higher per cent body fat The remaining two studies identified biological modifiers. In a sample of 87 adolescents, Lu et al. (2013) find that subjects required to fast the night before a laboratory study did not report significantly different discount rates than those who could eat ad libitumet al. (2014) test whether transcranial direct simulation modified discount rates and food cravings, finding no within‐subject differences in discount rates following real compared with sham stimulation, although food cravings for sweet foods were reduced Three studies reported null findings. Leitch et al. (2012) study whether time discounting correlates with successful weight loss among 241 overweight children (aged 7–12 years) enrolled in an obesity programme, in which children were randomized into one of three interventions: dietary change, physical activity and self‐control promotion. Further, the authors test for an interaction with the ‘relative reinforcing value of food’. Reinforcement refers to the propensity of a stimulus to increase the intensity of behaviour that precedes it, such as the actions that an addict might engage in to obtain drugs et al. (2013) test whether time discounting correlates with energy intake in a sample of obese and overweight women enrolled in a programme where subjects were advised how to make a daily calorie deficit in their diets. The authors report steeper delay discounting among those with higher energy intake, but only among those who ate ready‐to‐eat or away‐from‐home meals rather than home‐prepared meals et al. (2015) explore the neural correlations of delay discounting and body weight maintenance in 19 subjects a year after a 12‐week diet. The authors find that lower delay discounting was associated with greater success in weight maintenance Three studies reported that time discounting was correlated with greater weight loss and lower energy intake in response to weight regulation interventions et al. 12 study et al. (2015) report no correlation between discount rates computed for monetary and weight loss rewards. Discount rates were correlated with attitudes towards obese persons. Higher discount rates for weight loss were associated with beliefs that obesity is under the obese persons' control, whilst higher discount rates for money were associated with explicitly positive attitudes towards obese persons et al. (2010) report higher discount rates for hypothetical food in persons with higher percentage body fat. These findings did not extend to discounting for monetary rewards, and there was no association between either discount measure and BMI et al. (2011) also reported significant differences in discount rates for food but not monetary rewards between BED, obese, non‐obese and non‐BED groups Three studies reported varying associations between time discounting and unhealthy diets or body weight according to the discount measure used. Lim Our systematic review highlights a number of important findings on the relationship between diets, body weight and time discounting. First, we found consistent evidence of higher time discount rates in persons consuming unhealthy diets and overweight and obese individuals. Second, the number of studies testing for discount rate modifiers was small, but a mindful eating workshop, a prospective imagery intervention and a reasoning task were all associated with reduced discount rates. Third, experimental studies indicate that higher time discounting is linked to less weight loss and higher energy intake in the context of weight loss interventions. Fourth, time discount rates measured using hypothetical and monetary discounting measures tended to find null results, whereas those using actual and food‐based rewards had stronger patterns.Our review has important limitations. First, because of methodological variations across studies in measuring time discount rates and higher risk of overweight and obesity, it was not possible to perform a meta‐analysis or calculate pooled effect sizes. To address this limitation, we have structured the review by type of study, so permitting comparisons within and across study designs. Second, we identified a relative dearth of higher‐quality longitudinal studies and experimental designs. This may fail to account for potential bi‐directionality, whereby unhealthy diets high in sugar increase time discounting rather than vice versa. For example, unhealthy diets rich in sugary foods could increase discount rates, for example, by reducing the sensitivity of the brain's reward centre n = 19) that could account for null findings. Additionally, there is a need to better understand whether higher discount rates in individuals with higher BMIs and obesity are specific to food discounting or whether they also extend to money. As highlighted in our review, findings varied according to whether discounting of monetary or food rewards was being measured. Importantly, three studies that measured food and monetary rewards found significant results using food but not monetary discount measures. It is also possible that rewards are discounted more steeply than losses The systematic review highlights several important gaps in knowledge for future research. There were gaps in understanding how time discounting affects response to diet and weight loss interventions: two out of the three studies were restricted to children and women, and the third study had a small sample size .Web Appendix 1 – PRISMA checklist of items to include when reporting a systematic review or meta‐analysis (Moher Supporting info itemClick here for additional data file.


Lack of awareness of risk factors and symptoms for cancer may lead to late diagnosis and poor prognosis.We assessed community awareness about cervical cancer risk factors and symptoms and perceptions about prevention and cure of cervical cancer in order to contribute data to inform interventions to improve cervical cancer survival.Cross‐sectional population‐based survey.We conducted this study in Gulu, a post‐conflict district in Uganda in 2012. The sample included 448 persons aged 18 years and above, selected through a multi‐stage stratified cluster sampling process.We collected data using a pretested structured questionnaire. Logistic regressions were used to determine magnitudes of associations between socio‐demographic and outcome variables.Most participants (444/448) had heard about cervical cancer. Known risk factors including multiple sexual partners, human papillomavirus infection, and early onset of sexual activity, were recognized by 88%, 82%, and 78% of respondents respectively. 63% of participants believed that prolonged use of family planning pills and injections caused cervical cancer. The majority of participants recognized symptoms of cervical cancer including inter‐menstrual bleeding (85%), post‐menopausal bleeding (84%), and offensive vaginal discharge (83%). 70% of participants believed that cervical cancer is preventable and 92% believed that it could be cured if diagnosed at an early stage.Recognition of cervical cancer risk factors and symptoms was high among study participants. Targeted interventions including increasing availability of HPV vaccination, population‐based cervical screening and diagnostic services can translate high awareness into actual benefits. Cervical cancer is a leading cause of morbidity and mortality among women in the low‐ and middle‐income countries (LMICs). Of 500 000 new cervical cancer cases diagnosed annually worldwide, 83% occurred in LMICs where more than 80% are diagnosed at advanced stage and have poor treatment outcomes.The reasons for the high incidence and mortality from cervical cancer in sub‐Saharan Africa include lack of awareness of cervical cancer among the population, health‐care providers and policymakers; limited access to high‐quality health‐care services and cervical screening programmes; and lack of functional referral systems. All these lead to advanced stage at diagnoses.There is evidence that raising awareness of cancer symptoms and signs might increase people's ability to detect early symptoms and signs of cancer.In Uganda, there are limited data on levels of population awareness about cervical cancer, including perceptions, beliefs and knowledge about cervical cancer risk factors and symptoms. The objective of this study was to investigate community awareness about cervical cancer risk factors and symptoms and beliefs about cervical cancer prevention and treatment outcomes in post‐conflict northern Uganda. Findings from this study may inform policies relating to cervical cancer in rural and post‐conflict regions and lead to reduction in deaths from cervical cancer.We conducted a population‐based cross‐sectional survey in two of three parliamentary constituencies in Gulu district during September and October 2012; the three parliamentary constituencies include the Municipality, Aswa county and Omoro county with 53, 82 and 148 villages, respectively. Between 1987 to 2006, more than 90% of the rural population of Gulu district and the mid‐northern region was forced into internally displaced peoples (IDP) camps due to a civil conflict between the government of Uganda and the Lord's Resistance Army (LRA) rebels.Sample size was calculated using Kish Leslie formulaWe purposefully selected Gulu municipality; Aswa was randomly sampled from two rural counties – Aswa and Omoro. Computer‐generated random number digits were then used to randomly select 10 of 53 villages from the Municipality and 33 of 82 villages in Aswa. In this study, each selected village was considered a cluster and from each cluster, we randomly selected 10 households and interviewed one participant per household. A household was defined as a dwelling place with a group of people including parents, guardians and children who share food from one cooking place. A homestead was defined as a set of households in one compound. In homesteads where there were three or more households, two households were sampled.In each village, the central point of the habitable area of the village was located; at this point, a research assistant spanned a pen to determine the direction along which households were sampled. The direction where the tip of the pen pointed was chosen. A list of five households was generated, and one household was selected by simple random approach as the starting household. Subsequently, every third household was selected until 10 households were sampled. This sampling approach is a modification of the expanded program on immunization (EPI) sampling method (30 clusters × 7 households) that has been used in Africa and other countries where household lists are lackingCommunity members aged 18 years and above were included. We excluded people with documented or self‐reported hospital diagnosis of cervical cancer, and those whose daughters or wives had diagnoses of cervical cancer (reported or documented). Recruitment was conducted between 1.00 and 6.30 PM when prospective participants were expected to be back home from the gardens. When no adults were found in a selected household, the immediate next household was selected. In each selected household, verbal consent to participate in the study was sought before generating a list of all eligible participants in the household. From the list, a simple random sampling approach was used to select one participant from the household for the interview. The objectives of the study, and potential benefits and harms were read to the selected participants before soliciting written informed consents. Research assistants interviewed study participants in quiet and convenient locations within the homesteads where interruptions were minimal and no non‐participants were present.We collected data using a structured pre‐tested questionnaire which contained items adapted from findings and tools used in studies in East AfricaResearch assistants (RAs) included three men and three women with bachelor degrees in social sciences and education. The RAs were trained for 2 days on principles of quantitative and survey research including data collection, on the objectives of this research, sampling procedures, interview techniques and consent procedures. Pre‐testing of the tools was performed with 5 men and 5 women in the nearby community. The questionnaires were administered by three pairs of research assistants including a man in each pair. Each pair collected data from 10 to 12 participants in a village per day. Each research assistant interviewed participants independently. The principal investigator reviewed the data collected daily to ensure quality and comparability of data between research assistants. Data collection lasted 18 days.Two independent clerks entered data using Epidata 3.1 . EMW synchronized and cleaned the data files and then exported data to STATA I/C version 12  for analysis. Descriptive statistics including means, standard deviations and proportions were generated. Chi‐square tests were used to determine associations between independent variables including socio‐demographic characteristics and dependent variables including awareness and perceptions of cervical cancer risk factors and symptoms. Logistic regression models were used to determine the magnitudes of associations between independent and dependent variables; odds ratios have been reported with accompanying 95% confidence intervals.This study was approved by Makerere University School of Medicine Research and Ethics Committee (SOMREC) and the Uganda National Council of Science and Technology (UNCST). We obtained permission to access communities from the district and local leaders. Research assistants explained the purpose and procedure of the study to all participants and obtained individual written informed consents before conducting interviews. Participants were informed of their freedom to decline participation if they chose to and or join study and withdraw at any point without fear of retribution from the study team. After the interviews, about 5–10 min was allowed for participants to ask questions related to cervical cancer. A modest amount of money for refreshments during the question and answer sessions was provided to participants.P = 0.007). In total, 71.6% of participants were married  and were excluded from analysis, leaving 448 for analysis. The majority of participants (75.7%) were women. More than two‐thirds of participants (77.2%) either had no formal education or had only primary school education. In total, 93.1% of participants were not formally employed; women were less likely to be formally employed compared with men (Ninety nine per cent of participants (444/448) had heard about cervical cancer. Of these, 70.3% reported that cervical cancer is preventable while 92% reported that cervical cancer can be cured in the hospitals when diagnosed at an early stage. However, there was limited awareness that cervical cancer can be prevented through Pap smears (41%) or vaccination of young girls against HPV (8.3%). While about 1 in 3 (30.5%) participants had heard about the role of a sexually transmitted virus the development of cervical cancer, a larger proportion (85%) of participants believed that cervical cancer itself is sexually transmitted. Thine notion that cervical cancer spreads when a patient with cervical cancer has surgical treatment was reported by about 1 in 4 participants (29.9%) , followed by health‐care professionals (31.5%) and then family and friends (18.3%). Men were significantly more likely to have heard about cervical cancer from the radio, unadjusted OR = 1.87  but less likely than women to have heard from the health‐care professionals, unadjusted OR = 0.50   and cervical infection with a sexually transmitted germ or virus (82.0%). However, less than half of participants identified multiparity (48.6%) and cigarette or tobacco smoking (48.6%) as risk factors for cervical cancer  was the most frequently reported cervical cancer symptom. The other symptoms endorsed included intermenstrual vaginal bleeding (84.5%), post‐menopausal bleeding (84.1%), offensive vaginal discharge 83.0%), post‐coital vaginal bleeding (76.1%) and dyspareunia (71.1%) , sexual intercourse with polygamous men (83.9%), prolonged use of family planning pills and injections (63.3%), and engaging in rough sexual intercourse leading to physical trauma to women's genitals (68.5%) Table . Other rThis study describes the perceptions, beliefs and awareness of the general population in Gulu about risk factors and symptoms of cervical cancer. It provides insights into community perspectives on whether cervical cancer is preventable and or curable. Most participants were aware of risk factors and symptoms of cervical cancer and believed that cervical cancer could be prevented and cured if diagnosed at an early stage. However, there was limited awareness about Pap smear and vaccination of young girls as preventive measures which may have been due to inadequate health messages about prevention or because screening services and vaccination against HPV are not widely available in the region. In addition, more than half of participants held certain beliefs about causes of cervical cancer which have the potential to make awareness campaigns on prevention less effective, and divert help‐seeking away from biomedical facilities. In this regard, some participants believed that cervical cancer develops when women defy cultural values prescribed by elders who have already died, women engage in sexual intercourse during menstrual periods and women do not wash their genitals after sexual intercourse. Globally, cultural beliefs, myths and stigmas about cancers are ubiquitous. Cultural beliefs have reduced Pap smear uptake and hampered health‐seeking for cervical cancerA great proportion of participants also reported that cervical cancer can be prevented, treated and cured if diagnosed in early stage. This is consistent with findings in Ethiopia, where more than half of participants believed that cervical cancer can be prevented (63.5%), treated (66.1%) and cured if detected early 52.8%)..8%.52 DiRegarding HPV and its role in cervical cancer aetiology, awareness has varied across nations. In this study, no participant explicitly mentioned the HPV although 82% reported that a sexually transmitted virus may cause cervical cancer. Very limited awareness of the viral aetiology of cervical cancer and HPV vaccination has been observed in high‐income countries as recently as 2004The commonest source of information about cervical cancer in this study was the radio, particularly in urban setting and among men. In this regard, health education interventions to involve men and urban communities in promoting cervical cancer screening uptake and early help‐seeking could be channelled through radio talk shows. The second most common source was health‐care professionals, particularly among women. Perhaps women interact more with health‐care professionals during child and maternal health visits which men in East Africa rarely attend.High parity as a risk factor for cervical cancer was underreported in this study and in other studies in sub‐Saharan Africa. In South Africa, only 44% of respondents identified high parity as a risk factor for cervical cancerIn this study, participants reported other perceived causes of cervical cancer including prolonged use of hormonal contraceptives, not washing genitals following sexual intercourse and intercourse with polygamous men. These perceptions have the potential to reduce use of family planning methods but promote genital hygiene and minimize behaviour that would increase risk of cervical cancer. The perception about family planning was also reported in Kenya where participants thought that intrauterine devices cause wounds and infections in the uterus and eventually cause cervical cancer especially when poorly inserted.Regarding beliefs that sexual intercourse before marriage and with polygamous men can cause cervical cancer, abstinence until marriage will delay onset of sexual activity, delay exposure to high‐risk HPV infections at an early age and therefore reduce chances of developing cervical cancer, while avoiding sexual intercourse with polygamous men may reduce risk of contracting different strains of high‐risk HPV that lead to development of cervical cancer.Furthermore, a substantive proportion of participants held beliefs that cervical cancer is always fatal in spite of medical treatment, while others were unaware that cervical cancer is curable when diagnosed in an early stage. There is therefore need for targeted culture‐sensitive public campaigns to increase awareness about cervical cancer treatment and potential for cure when diagnosed in early stage, discourage fatalistic beliefs about cervical cancer and correct the belief that surgical operation leads to spread of cancer. Health messages could be channelled through health facility‐based talks as well as mass media including the local FM radios.This study is a population‐based survey that involved both men and women. The study provides a benchmark for future evaluation of awareness campaigns and interventions to increase screening uptake and promote early health‐seeking for cervical cancer symptoms. A limitation to this study is the lack of a standard questionnaire for assessment of awareness of cervical cancer in sub‐Saharan Africa which limits our ability to compare results across studies. Second, the lack of equivalence for certain key words and phrases for example ‘cervical cancer development’ in the local language during translation could potentially alter meanings of questions and affect responses. We minimized loss of meaning during translation by adopting forward and backward translations by two pairs of independent translators who are proficient in both English and Acholi languages. In addition, the translators used local illness concepts gained during piloting of tools and from the preceding focus group discussions in the same communities.High awareness about cervical cancer, its risk factors and symptoms provides firm anchorage for targeted interventions to increase uptake of preventive methods and promote early health‐seeking for cervical cancer symptoms. Policymakers and health‐care systems in the LMICs need to make preventive methods available and easily accessed, including HPV vaccination and cervical screening, and facilities for early diagnosis and treatment of symptomatic cervical cancer so that awareness can be translated into actual benefits.The work was supported by Training Health Researchers into Vocational Excellence (THRiVE) in East Africa, Grant number 087540, funded by Wellcome Trust. The funding agency did not have any role in the design of this study, in data collection, analysis and interpretation; in the writing nor the decision to submit or where the manuscript be submitted.The authors declare that they have no conflict of interest.Table S1 (a) Belief that cervical cancer spreads when surgical operation is done on the patient. (b) Belief that cervical cancer is a sexually transmitted disease (STD). (c) Belief that cervical cancer will always lead to death once it has affected a woman. (d) Belief that cervical cancer is curable only with traditional medicines.Table S2 (a) Have often heard about cervical cancer through the local FM radio. (b) Have often heard about cervical cancer from healthcare professionals.Table S3 (a) Awareness that cervical cancer is preventable. (b) Awareness that cervical cancer is curable in hospital when diagnosed in early stage.Table S4 (a) Recognized early onset of sexual intercourse as risk factor for cervical cancer. (b) Recognized multiple male sexual partners as risk factor for cervical cancer. (c) Recognized multi‐parity as risk factor for cervical cancer. (d) Recognized genital infection by a virus as risk factor for cervical cancer.Table S5 Reports contraceptives use as risk factor for cervical cancer.Click here for additional data file.