A growing body of evidence highlights the importance of competent mentoring in academic research. We describe the development, implementation, and evaluation of four regional 2-day intensive workshops to train mid- and senior-level investigators conducting public health, clinical, and basic science research across multiple academic institutions in low- and middle-income countries (LMICs) on tools and techniques of effective mentoring. Sponsored by the Fogarty International Center, workshops included didactic presentations, interactive discussions, and small-group problem-based learning and were conducted in Lima, Peru; Mombasa, Kenya; Bangalore, India; and Johannesburg, South Africa, from 2013 to 2016. Mid- or senior-level faculty from multiple academic institutions within each region applied and were selected. Thirty faculty from 12 South America–based institutions, 29 faculty from eight East Africa–based institutions, 37 faculty from 14 South Asia–based institutions, and 36 faculty from 13 Africa-based institutions participated, with diverse representation across disciplines, gender, and academic rank. Discussions and evaluations revealed important comparisons and contrasts in the practice of mentoring, and specific barriers and facilitators to mentoring within each cultural and regional context. Specific regional issues related to hierarchy, the post-colonial legacy, and diversity arose as challenges to mentoring in different parts of the world. Common barriers included a lack of a culture of mentoring, time constraints, lack of formal training, and a lack of recognition for mentoring. These workshops provided valuable training, were among the first of their kind, were well-attended, rated highly, and provided concepts and a structure for the development and strengthening of formal mentoring programs across LMIC institutions. Despite a burgeoning understanding that faculty can benefit from mentoring training,13 there are only a limited number of formal mentorship training programs14 for academic researchers in low- and middle-income country (LMIC) settings that offer faculty the opportunity to develop skills and incorporate best practices.The importance of effective mentorship in the development, success, and retention of trainees and early career investigators in academic research settings is increasingly recognized.13 inadequate mentoring may be a “modifiable risk factor” in the disparate patterns of academic progress observed for early stage investigators in LMIC settings. Robust mentorship training programs geared specifically toward training mentors in the skills and practices that cultivate effective mentoring relationships with early stage investigators could improve the depth and success of the LMIC global health academic workforce. However, there is a dearth of empirical data on the relative efficacy of mentor training methods. Although graduate and health profession programs often provide some content related to overall teaching skills, most graduates are expected to perform mentoring activities eventually without any formal training in the area. These mentors often perform the role ad hoc or may mimic  mentors they have interacted with in their own careers, with mixed results in terms of effectiveness and mentee-reported satisfaction with the mentoring relationship.17 Experiential and/or practical mentoring approaches may improve mentorship skills, especially in resource-limited settings. However, theory-based programs designed to provide systematic training in mentoring and reinforce standard approaches that can be tailored to individual needs, although limited, have been highly effective.18As there is good evidence that trained mentors, as opposed to untrained mentors, are more effective in their interaction with, and support of their mentees,5 and senior faculty and academic leaders at academic institutions in Latin America, East Africa, South Asia, and Southern Africa. Investigators from multiple academic institutions in regions proximal to the hosting academic institution applied and were accepted to the workshops. This article describes the results of each workshop on the practices and facilitators of, and barriers to, mentoring; action plans by individual participants; evaluations and follow-up actions to establish local mentoring programs in each region; and post-workshop surveys to evaluate the impact of the trainings on local mentorship practices and programs.The purpose of this article is to describe the development, implementation, and evaluation of a mentorship workshop to train mid- and senior-level investigators conducting public health, clinical, and basic science research across multiple academic institutions in LMICs to be more effective mentors. The programs were sponsored by the six-funded Fogarty International Center Global Health Program for Fellows and Scholars and were developed collaboratively between United States–based investigators with expertise in mentoringThe Fogarty International Center at the National Institutes of Health (NIH) supports six United States—based university consortia to provide mentored global health research training opportunities in LMICs through the Global Health Program for Fellows and Scholars. The six consortia are focused at Harvard University, Cambridge, MA; University of California Global Health Institute (UCGHI) based at the University of California, San Francisco (UCSF), the University of California, Los Angeles, the University of California, San Diego, and the University of California, Davis; University of North Carolina, Chapel Hill; University of California, Berkeley; University of Washington, Seattle, WA; and Vanderbilt University, Memphis, TN. The GloCal Health Fellowship Consortium at UCGHI, which supports fellows from all 10 University of California campuses, initiated the “Mentoring the Mentors” training workshops in 2013 to train faculty across all international sites supported by the Global Health Program. All six of the consortia contributed resources and faculty to one or more of the four “Mentoring the Mentors” workshops held in Lima, Peru, in May 2013; Mombasa, Kenya, in June 2013; Bangalore, India, in November 2014; and Johannesburg, South Africa, in March 2016.Each “Mentoring the Mentors” workshop in the four LMICs hosted faculty participants from a number of neighboring academic institutions within the region. Each program was developed collaboratively between local faculty and faculty leadership at the host institution and neighboring institutions, with input from UCSF-based faculty on standard program content. Each training program was designed to cover overarching principles of mentorship through a series of didactic trainings, along with a number of small group sessions and large group discussions focusing on the cultural context of mentoring, along with specific barriers and facilitators of mentoring, within each region.21 For instance, the UCSF Center for AIDS Research had established a strong mentoring program in the years before the development of this initiative which had already launched initiatives to mentor early career investigators in HIV research21 and provide mentoring training programs for HIV researchers across the United States.20 In addition, the UCSF-based Clinical and Translational Science Institute (CTSI) launched a robust Mentor Development Program (MDP) in 2006,19 where faculty receive intensive training over a year in mentorship techniques and are provided with tools to enhance mentee success. This program helped define a set of core competencies for mentors in clinical and translational research.22 An interim evaluation of the MDP program demonstrated a sustained impact on mentoring skills, techniques, and focus.12One impetus of the GloCal Health Fellowship Consortium and faculty based at UCSF to help lead this initiative stemmed from strong mentoring initiatives and “Mentoring the Mentor” training programs already being conducted at UCSF through other NIH-funded initiatives.Each training program was developed iteratively over 6–8 months via conference calls between UCSF-based faculty, faculty based at other Global Health Program consortia in the United States, and faculty leadership at the host and neighboring international institutions. The LMIC leadership included deans or department chairs of the hosting institutions, along with Division/Section Heads and key investigators involved in mentoring initiatives. A call for applicants from institutions in LMICs associated with each consortia was made approximately 3 months before each workshop and applicants submitted a curriculum vitae and a paragraph summarizing their interest in mentoring training. Each regional workshop was restricted to around 30 participants to keep the format intimate and interactive, with preference given to mid-level and senior faculty at institutions from neighboring countries who were currently mentoring junior investigators and were in positions to help develop mentoring capacity at the institutional level.Each 2-day workshop included formal presentations, interactive discussions, and small-group problem-based learning activities. Because each workshop had been developed iteratively over time with intimate participation by local faculty leaders, each workshop was unique in its tailored content, although some core principles of mentoring were covered uniformly. The workshops included skill-based learning in a number of topics including: setting goals and expectations for the mentor–mentee relationship; developing a mentoring philosophy; enhancing communication strategies, and identifying and resolving challenges; time management strategies for mentors and mentees; navigation of work-life balance in a research career; sharing online tools and resources developed by the UCSF CTSI’s Mentoring Program; strategies to enhance institutional commitment to mentoring programs; how to mentor mentees in grant writing and manuscript preparation; mentor and mentee evaluation and bidirectional feedback strategies; barriers and facilitators to mentoring at the global and local level; addressing diversity in the mentor–mentee relationship and challenges for mentees from diverse backgrounds in each setting  in academic institutions; and developing a framework and action plan for launching or strengthening mentoring programs at each represented institution. Each program was launched by a keynote speech, usually from a recognized senior leader from the hosting institution in each region.Because of the importance of peer-to-peer mentoring support, each program ended with a “Mentor Consultation Clinic,” which involved organization of the participants into small groups (five to seven mentors each). Each small group was presented with a strict structure for the “clinic” in which one person presented a mentoring challenge (2–3 minutes), followed by an information-gathering/question period from the group (5 minutes), ultimately leading to recommendations from the group for addressing the challenge (5 minutes). Mentors in each clinic were provided with each other’s contact information and groups were encouraged to continue informal peer-to-peer mentoring relationships after each program had ended.Before each workshop, a pre-meeting survey was sent out to assess the academic rank of each participant; experience in mentoring; and current number and training level of mentees. Additional data provided by the workshops came from the small group activities in each workshop where participants identified barriers to mentoring at the individual, institutional, and global levels and proposed possible solutions. Finally, a Mentor Action Plan (MAP) was completed by each participant at the end of the workshop. The MAP solicited each participant’s self-reported individual strengths and areas of improvements as a mentor, learning points from that workshop’s activities, and action plans for implementing recommendations and techniques covered in the workshop in their individual mentoring activities going forward. Copies of the MAPs were retained for qualitative analysis. Members of the project team who were independent of those who designed and implemented the program conducted thematic analysis of the MAPs as presented in Results. The thematic analysis presented in During the fifth year of the program, GloCal hosted a senior-level technical advisory meeting on global health mentoring at LMIC institutions before the Consortium of Universities for Global Health conference in April 2017. Low- and middle-income countries leaders of the four “Mentoring the Mentors” workshops, along with the principal investigators from each of the six Fogarty International Center Global Health Programs for Fellows and Scholars, along with staff from the NIH FIC, gathered to discuss and plan how the program can continue to best support the development, sustainability, and productivity of strong mentorship programs for global health researchers across LMIC institutions. Before this advisory meeting, a survey was sent out to participants in all four “Mentoring the Mentors” training programs to elicit further feedback on the content of the training programs and assess the impact of the training programs on subsequent mentoring efforts and establishment of mentoring programs at participating LMIC institutions.Thirty faculty from 12 Latin America–based institutions participated in the 2013 workshop held in Lima, Peru; 29 faculty from eight East Africa–based institutions participated in the 2013 workshop held in Mombasa, Kenya; 37 faculty from 14 South Asia–based institutions participated in the 2014 workshop held in Bangalore, India; and 36 faculty from 13 Africa-based institutions participated in the 2016 workshop held in Johannesburg, South Africa. Of the 132 mentors trained in the four workshops from 2013 to 2016, 29% were at the full-professor level at their institutions; 21% were associate professors; 18% were assistant professors; 32% were instructors or in another academic series; and 24% of participants were section heads, department chairs, or held other major leadership positions at their respective institutions. Participants of the four workshops were 55% female and each participant had a median of four primary mentees (range 0–12 mentees).Barriers identified for effective mentoring by various faculty independent of region  were a lA variety of solutions, applicable to different regional contexts to different degrees, solu were proposed to improve the effectiveness of the mentor–mentee relationship. These included the implementation of a formalized structure of the mentoring process as developed by the UCSF CTSI program and taught in each workshop. Faculty participants stated that they planned to establish a regular meeting schedule with their mentees and implement individual development plans (IDPs) to be filled out at least annually by mentees to identify expectations and goals, and monitor progress and troubleshoot impasses. Faculty planned to provide greater clarity in delineating expectations for their mentees, including establishment of meeting agendas and follow-up procedures following regular meetings. Many faculty planned to approach their division chiefs, department chairs, or deans to suggest mentoring training programs such as this workshop at their institutions and to aid in the establishment of a greater culture of mentoring, including funding for mentoring efforts and adding mentoring to the criteria list for academic rank promotion. Participants all cited a need for more formalized mentoring workshops such as those provided by these workshops at their institutions, and formal mentoring programs to both structure and evaluate the progress of mentoring relationships over time.Finally, During the fifth year of the program and after the final workshop described here, GloCal hosted a senior-level technical advisory meeting on global health mentoring focused on LMIC institutions in Virginia in April 2017. With representation from the leadership of all six consortia, the NIH FIC, and LMIC faculty leaders from the four “Mentoring the Mentors” workshops, the success of the workshops in launching local mentoring initiatives were discussed. At many of the participating institutions, deans and department chairs had committed to establishing mentoring programs, although many of them were still nascent. The group discussed the need for ongoing FIC presence in LMICs to encourage the development of local mentoring capacity and structured programs.The 47 respondents to the pre-meeting surveys were from 19 LMICs . They reported medians of 18 years of experience in research and 10 years in mentoring trainees. Nineteen were institutional leaders . Only 16 of the 47 respondents had attended one of the four regional workshops. Of these respondents, 11 had shared their mentorship training experience with colleagues in their institutions, six had been able to set up mentorship training workshops or other training opportunities in mentoring within their institutions, and 11 had had opportunities to meet with other mid-level and senior mentors to discuss mentoring.All surveyed individuals were asked whether their institutions have any mentorship programs; 23 of 40 respondents (57.5%) indicated that their institutions did, with 19 of the 23 programs focused on mentees and four geared toward mentor training. Only 11 of the programs (48%) included any evaluation components. There was general support for, and ideas offered, on the possibility of regional mentor training programs to assist institutions that may not be able to launch them on their own. Factors considered key to successful regional programs included clear support from one’s own institution, especially with regard to sustainability, and funding.The survey ascertained whether there was a hierarchical relationship between mentor and mentee at the respondents’ institutions, and how much they thought a hierarchical relationship prohibits effective mentoring. Both questions offered Likert scales where 1 = not hierarchical or no impact, and 10 = extremely hierarchical and high impact. Median responses to both questions were five, including both presence and impact of hierarchical cultures. The final question asked whether mentor training programs could reduce the institution’s hierarchical mentoring culture. Of 34 responses, 19 (55%) said yes, 14 (42%) said maybe or not sure, and only one (3%) said no, implying some degree of optimism for change.In free-text comments entered about challenges and barriers respondents faced in institutionalizing mentorship training, most cited competing time commitments or simply insufficient time. Some individuals also cited lack of sufficient numbers of trained mentors and of mentorship training programs, and lack of prioritization of mentor training. Additional barriers included siloing or lack of communication/coordination among specialties and research groups, and lack of institutional mentorship cultures or mandates from institutional leaders. By contrast, however, several respondents indicated that their leaders were quite receptive to instituting mentorship training. Additional challenges included lack of funding for mentorship training and lack of follow-up training to sustain mentorship skills.Success stories launched by the NIH FIC mentoring initiatives were shared by 10 workshop attendees, including growth of institutional support and establishment of several new institutional mentorship training programs, and initiation of peer mentorship networks, regular mentor–mentee meetings, and IDPs. One newly established mentorship training model in Latin America was reported as being expanded as a national mandate for research training, nested within a required training program in the responsible conduct of research.This article describes robust regional “Mentoring the Mentors” workshops designed to train mid-level and senior faculty in LMICs on techniques and tools to improve mentoring practices for early career investigators and other trainees. The four workshops were conducted from 2013 until 2016 in Lima, Peru; Mombasa, Kenya; Bangalore, India; and Johannesburg, South Africa, and trained mostly mid-level and senior faculty, including department chairs and deans, actively mentoring trainees in global health research from surrounding countries. Each program was co-led and tailored by local experts and faculty leaders from each host institution and surrounding institutions who facilitated each workshop in collaboration with faculty leaders from the United States—based FIC consortia.23 Moreover, the discussion in the four workshops suggested a series of mentoring tools that can be applied and standardized across institutions.24There were a number of shared barriers to mentoring across all institutions, including a lack of a culture of mentoring, time constraints , lack of formal training and a lack of recognition (in terms of either remuneration or advancement in academic rank) for mentoring. A number of creative and robust solutions to the barriers associated with mentoring at LMICs were proposed by the 132 participants in the four workshops, focusing at both the institutional and individual levels. The most consistent solution proposed to effective mentoring was the establishment of sustainable mentoring training programs such as the ones described in this article, dissemination of the training materials associated with these workshops, and the formalization and recognition of the mentoring process within academic institutions to inculcate a culture of mentoring. In the context of newly developed mentorship programs, formal and well-structured evaluation of such programs will be necessary.A number of contextual barriers to mentoring were raised in the four workshops. Although these contextual barriers suggest a number of solutions that can only be enacted locally with support from institutional leadership, these barriers require global health researchers from high-income countries to be sensitive to the local context, and ensure equitable partnerships based on mutual respect and collegiality. Finally, a post-workshop survey administered to both workshop attendees and faculty leadership at LMIC institutions associated with the FIC training programs offered hope and optimism in growing both a mentoring culture and culturally specific mentoring programs to enhance the success of global health researchers and advance health around the world.


Research highlighted that Stressful Life Events have high incidence among infertile patients and significant impact on physical and medical parameters related to reproductive functions, but their potential role among factors influencing the infertile patients’ perception of fertility-related Quality of Life (QoL) has not been explored. The present study aims to investigate the associations of Stressful Life Events  with perceived fertility-related QoL in women attending infertility treatments, examining the potential moderating role of adopted coping strategies and perceived couple’s dyadic adjustment.Results Logistic Regression Analyses after adjusting for socio-demographic and infertility-related characteristics revealed that women who reported Stressful events in the family of origin and In family pre-existing pregnancy difficulties were more likely to report lower levels of perceived Core QoL, while women who reported Health problems in childhood were more likely to report lower levels of perceived Treatment QoL. Couple’s dyadic adjustment and specific coping strategies were significantly associated with perceived Core and Treatment QoL and they also significantly moderated the associations between stressful life events and perceived QoL.A questionnaire consisting of Socio-demographics and Infertility-related characteristics, Stress-inducing events in the couples’ lives Questionnaire (FLS), Coping Orientations to Problem Experienced (COPE), Dyadic Adjustment Scale (DAS), and Core and Treatment subscales of Fertility Quality of Life (FertiQoL) was administered to 266 women attending infertility treatments. A descriptive correlational design with cross-sectional comparison was used. Data provided original evidence on the strong association between stressful life events and perceived fertility-related QoL also highlighting individual and couples’ resources to define counselling interventions with women attending infertility treatments. Infertility is clinically described as a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse –5 that mQoL is a multidimensional construct defined as the perception of individuals of their position in the context of their culture and values system and in relation to their goals, expectations, standards, and concerns, which comprises psychological, physical, social and environmental perceived functioning and health . In the Research also highlighted that stressful life events have to be considered as factors widely influencing physical and psychological health parameters –37 and pNevertheless, according to previous research on couple counseling and therapy with infertile patients , the couAlthough previous studies suggest that stressful life events have a significant impact on essential parameters for the reproductive success, to date, to the best of our knowledge, little is known concerning the associations between the presence of stressful life events and perceived levels of QoL in infertile patients.Therefore, the present study aims at analysing the potential association of Stressful Life Events  with perceived Core and Treatment QoL in women attending infertility treatments. Furthermore, considering the significant role exerted by individual resources  , 51–55, The present cross-sectional study was conducted in collaboration with 9 Italian Centres of Assisted Reproduction of Naples, Udine, and Brescia between March 2016 and January 2017. The study was approved by the Ethical Committee of Psychological Research of the University of Naples Federico II and research was performed in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Prior to data collection, the Heads of all Departments of the University were informed about the purpose of the study and data collection procedures and their consent was acquired. Chairmen were asked to give the authorization for administering a questionnaire in their centres and, after obtaining their adhesion to the project, women undergoing infertility treatments were asked to participate in the study before their medical appointment. Participants were female members of couples that had been diagnosed with infertility , with all aetiologies of infertility. Overall, 300 women were asked by their physician to participate in the study, and 266 out of 300 women (response rate = 88.67%) completed a questionnaire lasting 20–30 min (one session) in a quiet room setting in the medical centre. One of the authors was present to answer any queries raised by participants.A questionnaire composed of six sections was submitted. All variables and measures investigated are displayed in Table p < 0.05; removal criterion: p > 0.01, and Hosmer and Lemeshow Goodness-of-fit statistic fixed at p > 0.05) were separately run to determine main associations of Stressful Life Events, Coping Strategies, and Total Dyadic Adjustment with perceived Core and Treatment FertiQoL. Finally, a further set of Logistic Regression Analyses was carried out to test the potential significant interactions between Stressful Life Events and both adopted Coping Strategies and perceived Total Dyadic Adjustment in predicting perceived levels of Core and Treatment FertiQoL. Relevant Socio-demographic and Infertility-related characteristics  were included in the Logistic Regression Analyses as control variables in order to consider their potential influence on the model parameters. All the different hypotheses have been tested carrying out separated Logistic Regression Analyses.Data were analysed using Statistical Package for Social Science . Firstly, a number of descriptive analyses of socio-demographic and infertility-related characteristics of study participants were conducted. All the study variables were dichotomised. Age and Duration of Infertility were dichotomised referring to the means of our sample. Educational Level (Senior School education/College education), Type of Diagnosis , Type of Treatment , and Stressful Life Events were coded as absence/presence. Coping Strategies, Total Dyadic Adjustment, and FertiQoL subscales scores were dichotomised referring to the cut-off scores of the validation studies reported in Table Table N = 130; 48.9%) was the most frequently reported, followed by In Family pre-existing pregnancy difficulties  and Health problems in childhood . As regards perceived levels of Core and Treatment QoL, 57 (21.4%) women reported low levels of Core FertiQoL and 80 (30.1%) low levels of Treatment FertiQoL.As regards the presence of Stressful life events, Stressful events in the family of origin , followed by Positive Attitude , Problem Solving , Avoidance , and Turning to Religion . Finally, as regards perceived couple’s dyadic adjustment, 97 women (36.5%) reported high levels of Total Dyadic Adjustment.As regards the adopted Coping Strategies, the recourse to Social Support was the most frequently reported  when dealing with infertility experience. Moreover, it emerged that women reporting Health problems in childhood were more likely to perceive lower levels of Treatment FertiQoL, inducing to emphasise the role of early experiences of illness and hospitalisation on the infertile patients’ perception of medical treatments. In this perspective, findings suggested that there is a need to increase consideration of the potential impact of Stressful Life Events on the infertility experience and, therefore, the organisation of infertility counseling interventions and therapy before, during and after treatments, should also carefully address the exploration of individual, relational and transgenerational dimensions associated to Stressful Life Events to identify factors influencing individual and couple risk and resources, meanings of wish for a child and motivation for infertility treatment.Nonetheless, data also highlighted the positive moderating role exerted by specific individual and relational resources, such as the recourse to active coping strategies  and the perception of a satisfactory couple’s dyadic adjustment. In particular, in infertile women experiencing the presence of stressful events in the family of origin, the recourse to Positive Attitude  was found having a significant role in enhancing perceived Core QoL. Moreover, in women reporting experiences of health problems in childhood, the adoption of coping strategies centred on Problem Solving  was found having a positive and significant influence on perceived levels of Treatment QoL. Furthermore, in the presence of more specific in family pre-existing pregnancy difficulties, the recourse to coping strategies centred on Social Support  was found having a significant influence on perceived levels of Core and Treatment QoL. Conversely, the recourse to Avoidance/distancing coping strategies was not adequate to face the psychological impact of the repetition of previous familiar pregnancy difficulties in patients’ current experience, resulting in significantly lower levels of Core and Treatment QoL.Finally, findings emphasised the role of perceiving a satisfactory and gratifying couple’s relationship, able to fulfil the needs for consensus, cohesion, security, and emotional involvement to counteract the negative impact of all previous stressful and adverse events considered on perceived levels of QoL, by sharing negative feelings, worry and tension related to infertility and medical treatments.In this perspective, the present study shared the aim of ESHRE guidelines  to promoHowever, despite these findings, some limitations should be mentioned. Firstly, the present research has a cross-sectional design, and therefore no cause - effect relationships between predictors and outcomes investigated can be suggested. Secondly, the measures used were self-report, increasing the risk of social desirability bias. Thirdly, only the moderating role of coping strategies and perceived dyadic adjustment were considered in the present study, while further research could be developed addressing the potential impact of other variables and other personality characteristics  which may play a role in predicting QoL in infertile patients. Furthermore, future research could also focus on the potential impact of both stressful life events and perceived fertility-related QoL on relevant medical parameters and pregnancy outcomes. Finally, further research should be developed to specifically focus on the impact of Stressful Life Events on fertility-related QoL among male infertile patients, which could give useful information for psychological interventions for both individuals and couples.In conclusion, the present study provided new evidence on the associations between the experience of Stressful Life Events and perceived levels of fertility-related QoL in women undergoing infertility treatments, identifying specific risk and protective factors related to their biographical background to be considered for developing targeted counseling interventions to support and enhance optimal adaptation processes to infertility treatments.


BCL2 transgenic and ETV6/RUNX1;BCL2 double transgenic mice develop a glomerulonephritis phenotype over time, which was displayed by staining of kidney sections. Even before full manifestation of disease serum endostatin concentration rises significantly, whereas BUN levels just slightly increase. This newly developed and commercially available ELISA provides a reliable and accurate tool for the quantification of mouse and rat endostatin and may give new perspectives in the investigation of the role of endostatin as an important and early biomarker for reduced kidney function. Measurement of endostatin concentration is recommended to be used as a superior biomarker for chronic kidney disease compared to BUN.Endostatin, the C-terminal fragment of type XVIII collagen, was shown to be one of the most potent endothelial cell-specific inhibitors of angiogenesis. As altered circulating endostatin concentration is associated with impaired kidney function, new tools for measuring endostatin in rodents may be helpful to further investigate and understand its role within kidney disease progression. A novel and commercially available ELISA for the quantification of mouse and rat endostatin was developed and validated according to international quality guidelines including the parameters specificity, robustness, accuracy, dilution linearity, precision, limit of detection (LOD) and lower limit of quantification (LLOQ). Endostatin and blood urea nitrogen (BUN) concentration were measured in mice with a glomerulonephritis phenotype. The validation revealed that within the range of 0.5–32 nmol/L the immunoassay is robust and highly specific for the measurement of rodent endostatin with high sensitivity  and good reproducibility (intra- and inter-assay CV <10%). Also accuracy and dilution linearity were within the range of acceptance.  Decreased kidney function may have a wide range of reasons like infections, toxins, genetic disorders, metabolic dysfunction like type 2 diabetes or autoimmune diseases. There are various underlying pathological changes, which may result in acute kidney injury (AKI) or promote the development of chronic kidney disease (CKD). AKI is defined as a sudden reduction in the glomerular filtration rate (GFR) and renal output, which results in the accumulation of nitrogenous waste , whereasin vitro and a potent inhibitor of angiogenesis and tumor growth in vivo  and OD values of samples used for the measurement of specificity, cross-reactivity, intra- and inter-assay precision, limit of detection and lower limit of quantification, dilution linearity, accuracy, stability and robustness of the assay.(XLSX)Click here for additional data file.S2 TableConcentration of endostatin [nmol/L] and BUN [mg/dL] in mice with different genotypes and age, as well as in mice, which underwent transplantation.(XLSX)Click here for additional data file.


For 50 years, the Fogarty International Center (FIC) has built research capacity particularly in low and middle-income countries responding to national and global public health priorities. Established in 1968 in honor of U.S. Congressman John E. Fogarty, FIC is one of 27 Institutes and Centers at the U.S. National Institutes of Health (NIH). Initially created in response to the HIV/AIDS pandemic in the 1980s and emerging infectious diseases in the 1990s, the Center provided training for approximately 6,000 health scientists from more than 100 countries including 1,000 from the U.S. Current programs are catalytic, addressing national and international institutional capacity strengthening in HIV and other infectious diseases, environmental and occupational health, research ethics, brain disorders, trauma and injury and other non-communicable diseases, tobacco, health systems implementation research, and medical education. Since 1988, FIC provided over $1.5 billion in extramural grants leveraging its relatively modest $50 million extramural budget by $20–$30 million annually. FIC-trained scientists and public health leaders led key studies about malaria vaccines and AIDS prevention trials, became directors of national HIV/AIDS programs, and achieved leadership positions such as Minister of Health. Between 2009 and 2015, FIC cited-papers averaged approximately 1.1% of the NIH total, in comparison to the FIC budget, which averaged only 0.22% of the NIH budget. While maintaining strong commitments to respond to global health threats caused by communicable diseases, FIC is training the next generation of global health researchers focusing on chronic diseases, implementation science and epidemic modeling needed to predict and help contain future global pandemics. National Institutes of Health (NIH). FIC is named in honor of the late John E. Fogarty, a long-term Congressman from Rhode Island and champion of NIH. Under Congressman Fogarty, who was chairman of the Appropriations Subcommittee that determines NIH funding, the agency experienced one of its greatest periods of growth—from a budget of $37 million in 1949, to $1.24 billion in 1967.In 2018, the Fogarty International Center (FIC) marked its 50Since its formation, FIC has served as a bridge between NIH and the global health community, facilitating exchanges among investigators, providing training opportunities and supporting promising research initiatives in developing countries. FIC programs have provided research training for about 6,000 health scientists worldwide from more than 100 nations, including about 1,000 from the U.S. Many of these individuals have become national scientific and global health leaders.FIC’s programs have made pivotal contributions filling the pipeline of global health leaders in low and middle-income countries (LMICs), and the U.S., extending the frontiers of science and accelerating discovery. FIC has invested and will continue to invest in people—the most important resource in global health research—serving on the front lines of the fight against diseases that threaten populations worldwide.Congressman Fogarty dreamt of establishing an institution where the best scientists from around the world would collaborate to solve the most challenging global health problems. Though the Congressman never lived to see his dream come true due to his sudden death in 1967 at age 53, his “Health for Peace” Center became a reality when his colleagues in Congress passed a resolution to establish the Fogarty Center at NIH in his honor. On July 1, 1968, President Lyndon Johnson issued an Executive Order establishing the John E. Fogarty International Center for Advanced Study in the Health Sciences at NIH.The current mission statement reads, “The Fogarty International Center is dedicated to advancing the mission of the National Institutes of Health (NIH) by supporting and facilitating global health research conducted by U.S. and international investigators, building partnerships between health research institutions in the U.S. and abroad, and training the next generation of scientists to address global health needs.”For FIC, this mission translates into advancing science and strengthening research and public health capacity in areas where resources are limited and challenges to health involve a dual burden of communicable and non-communicable diseases (NCDs). FIC focuses on LMICs that face enormous disease burdens but lack scientific capacity to study these problems or adapt established interventions to suit their context and resources. FIC investments in human resources accelerated the progress of research, and the scientific enterprise building research capacity at institutions across the globe, and, most importantly, developing the knowledge and evidence needed to confront health challenges locally and globally.As LMICs’ research programs matured, benefits also became increasingly bidirectional. For instance, FIC trainees provide local capacity to detect and address disease outbreaks where they occur, helping contain pandemics and contributing to global health security. FIC trainees capitalize on unique research opportunities, for example, studying the Zika virus in Brazil and Peru, or testing a drug that may prevent Alzheimer’s disease among a family in Colombia with an inherited early-onset form of the disease .FIC’s most important contributions during its first two decades were a series of international conferences that stimulated the global campaign to eliminate polio and expand childhood immunizations, and supporting scholars’ exchanges, mainly with high-income countries 3. Today Many scientific advances, such as male circumcision to reduce HIV transmission, prevention of mother-to-child HIV transmission (PMTCT) and antiretroviral (ARV) treatment as prevention were made by FIC trainees and AITRP collaborators 4.FIC has contributed to advancing global health by building research capacity within and outside NIH, essential for advancement of biomedical research to develop new cures, treatments, knowledge and public health interventions. For nearly ten years, NIH has reported to the U.S. Congress on the number of its programs representing collaborations with one or more Institutes and Centers (ICs). Over these years, FIC has consistently ranked as the most collaborative across NIH at a rate 4–5 times the NIH average.FIC subsequently developed cross-cutting research and research training programs designed to build a strong foundation in areas critical to conducting clinical research, including bioethics, informatics, implementation science, genetics, stigma and population studies. As the global disease burden shifted from infectious to chronic diseases, FIC responded with new programs supporting research and training on chronic NCDs, and initiatives studying how best to leverage HIV research and patient care delivery platforms to address NCDs.One of the highest priorities for FIC is mentoring the next generation of global health scientists from both LMICs and the U.S. through the Global Health Fellows and Scholars Program which has provided more than 1,000 fellowships for both U.S. and foreign scientists . AdditioOver the past 30 years, FIC has expanded into other areas for research and research training such as emerging infectious diseases, environmental/occupational health, trauma/injury and tobacco research. FIC has been a pioneer in implementation science (delivery) research and research training, initially through linking clinical, operational and health services research training in both HIV/AIDS and NCDs. FIC’s Division of International Training and Research now oversees more than two dozen programs and a total of about 500 extramural awards each year.The need to explore new directions and expand efforts linking research to public health and health services practice was a major reason for establishing the Center for Global Health Studies (CGHS) within FIC. CGHS aims to identify emerging research priorities, stimulate new scientific directions in global health, and support multidisciplinary collaboration and short-term training addressing pressing global health problems. Among the major initial CGHS efforts were studies to better implement programs preventing mother-to-child HIV transmission and strategies expanding health services in HIV/AIDS to address NCDs associated with HIV infection 7.FIC’s Division of International Epidemiology and Population Studies established a unique program, with support from other Federal agencies, to model and predict emergence of global health threats. Noteworthy studies predict the spread of influenza around the world using genetic epidemiology, focusing on disease patterns in northern and southern hemispheres . FIC’s DDuring the last 30 years, and with substantial co-funding, FIC has invested over $1.5 billion to support research and research capacity building in LMICs. Notable is that since 2004, the FIC extramural core budget has averaged about $50 million yearly, with an additional $20–30 million coming from partners. Significant funding increases occurred in fiscal years (FY) 2010 and 2011 from the American Recovery and Reinvestment Act of 2009 and funds for the Medical Education Partnership Initiative (MEPI) program.With funding from the President’s Emergency Program for AIDS Relief (PEPFAR) and NIH, MEPI was co-administered by FIC and the Health Resources and Services Administration (HRSA) . MEPI haWhile over one hundred LMICs have benefitted from FIC programs, contributions to global health science have been particularly noteworthy in a number of selected countries, many with high HIV/AIDS prevalence. Contributions include:Use of isoniazid to prevent active tuberculosis (TB) and progression of HIV infection in persons infected by HIV and TB in Haiti Effective antiretroviral therapy (ART) in increasing survival in persons with AIDS in Haiti Improved retention and outcome in patients with same day HIV testing and treatment in Haiti Documenting the cycle of HIV transmission in rural South Africa Effectivene and safe use of Tenofovir vaginal gel in prevention of HIV infection in women in South Africa Identification of broadly neutralizing antibodies against HIV in persons in South Africa Strategies to better treat persons with HIV and TB co-infection in South Africa Effectiveness studies of treatment for TB in Brazil Studies of the impact of breastfeeding on HIV-1 infected women in Kenya Studies of the impact of circumcision on STD transmission in Uganda Studies of the effect of circumcision on HIV transmission to women in Uganda Decreased heterosexual HIV transmission in Zambia and Rwanda Prevention of mother-to-child HIV infection in Botswana Prevention of HIV transmission in breastfeeding in Ethiopia, India and Uganda Evolution of China’s response to HIV/AIDS One measure of the impact of FIC’s programs is illustrated by bibliometric analyses conducted by the NIH Library. Researchers identified over 15,000 articles citing FIC support beginning in 1978 through 2015 . Elimination of HIV in high-income countries depends on the above research conducted in LMICs, facilitated greatly by trainees supported through FIC programs, including research to test future HIV vaccines. Other benefits to high-income countries from global health research include development of vaccines against influenza and hepatitis B, improved treatments for breast cancer particularly for African American women, combination therapies against cancer (first demonstrated for Burkitt Lymphoma in Uganda), oral rehydration therapy, and new therapies against tuberculosis. Ongoing research in Colombia involving families genetically predisposed to an early onset form of Alzheimer’s may result in future therapies for the disease. The growth of research sites against communicable diseases exists because of collaborations between institutions and individual scientists in LMICs and high-income countries that evolved through long-term support from FIC.While much has been accomplished, many challenges remain. These include how to build in-country support for superbly trained FIC alumni and advancing careers of U.S. investigators trained through FIC programs. These challenges include how to strengthen and sustain the viability of LMIC research institutions supported by FIC and other global health funders to respond not only to communicable diseases but to the growing burden of non-communicable diseases in LMICs. This includes how to link the results of promising research to implementation science so that future benefits can be achieved through health systems in LMICs. Responding to these challenges requires mobilizing resources from LMIC governments to share the future costs of maintaining these investments long-term. FIC is pursuing strategies to increase local government support for these efforts such as through fellowships for early career LMIC scientists linked to NIH research support in-country. Career development awards for foreign scientists and junior faculty development awarded to LMIC institutions also help to achieve these goals.Research groups are best suited to address global health issues when teams are multinational and sensitive to local culture and context. Building such teams at institutions around the world has been and will continue to be an important FIC strategy.FIC intends to build on this solid record of achievement during its first 50 years to prepare for future global health challenges through catalytic and cost-effective programs and advancing the new field of implementation science. FIC will continue its strong commitment to address threats from communicable diseases such as HIV/AIDS, TB, malaria and influenza.Simultaneously, FIC will increase its commitment to address the growing burden of chronic non-communicable diseases in LMICs, including but not limited to cancer, cardiovascular diseases, child health, lung diseases, diabetes, brain disorders and mental health among others. One strategy is to link current programs to additional U.S. Centers of Excellence in the area of NCDs. FIC intends to build on existing mutually beneficial individual and institutional partnerships (both north-to-south and south-to-south) as well as forge new ones to address future global health threats utilizing shared resources with LMIC governments, foundations and other major funders of global health research.A high priority for FIC is nurturing the next generation of global health scientists from the U.S. and LMICs through expanding training pipelines and supporting early career investigators. These goals can be advanced by building networks and continuing to link FIC training and research investments with research investments by other NIH ICOs and global health funders. One of the greatest opportunities is to strengthen participation in the Global Alliance for Chronic Diseases (GACD) and build upon the NIH-managed, FIC-coordinated World RePORT database, an online interactive map of research investments by international funding agencies, for the benefit of the global health community 38. As LMOne of the keys to future success is mentoring the next generation of LMIC and U.S. scientists. Mentoring is a critical component of all FIC research and research training programs, such as the Global Fellows and Scholars Program. A recent example of mentorship is the Clayton-Dedonder mentorship fellowship, offered as a supplement opportunity under the Global Fellows and Scholars Program using funds from the World AIDS Foundation provided to the NIH .As FIC consults with its partners to plan priorities for the next 50 years, the words of its namesake, Congressman John E. Fogarty, continue to guide the way: “The nations of the world can and must share their knowledge and other resources so that people everywhere may have the blessing of better health, and through health, may move forward to new levels of peaceful productivity.”All authors had access to the data and a role in writing the manuscript.


Providers need to be comfortable addressing obesity and gestational weight gain so they may give appropriate care; however, health care providers lack guidelines for the most effective educational strategies to assist in providing optimal care.To identify studies that involved the obstetric provider in interventions for either the perinatal management of obesity and/or gestational weight gain in a systematic review.A keyword search of databases was performed up to April 2017.Obstetric providers who participated in an intervention with the aim to change a provider’s clinical practice, knowledge, and/or satisfaction with the intervention in relation to the perinatal management of obesity or gestational weight gain were included. Provider intervention could include training or education, changes in systems or organization of care, or resources to support practice. PROSPERO database #42016038921.Bias was assessed according to the validated Mixed Methods Appraisal Tool. The following variables were synthesized: study location and setting, provider and patient characteristics, intervention features, outcomes and efficacy, and strengths and weakness.Of the 6,821 abstracts screened, seven studies  with a total of 335 providers met the inclusion criteria; two of which focused on the management of obesity, three focused on gestational weight gain, and two focused on both topics. Interventions that incorporated motivational interviewing skills (n = 2), required additional training for the research study and addressed specific knowledge deficits such as nutrition and exercise (n = 3), and interfaced with the electronic medical record (n = 1) demonstrated the greatest impact on provider outcomes. Provider reported satisfaction scores were generally favorable, but none addressed provider-level efficacy in practice change.Given the limited number of studies, varying range of provider participation, and lack of provider-level efficacy, further evaluation of provider training and involvement in interventions for perinatal obesity or gestational weight gain is indicated to determine best practices for provider and patient outcomes. The morbidity associated with obesity is magnified in pregnancy, as the risk for pregnancy-related hypertension and diabetes, cesarean delivery, birth defects, abnormal fetal growth, and stillbirth all increase.  Among obSeveral national organizations recommend that prenatal care providers counsel obese women about the risks of obesity in pregnancy, and incorporate into their care early screening for gestational diabetes, diet and exercise counseling, and anesthesia consults for women with obstructive sleep apnea.  The AssoMoreover, providers may inadvertently contribute to inappropriate gestational weight gain when their advice differs from the recommendations.  In focusA librarian (L.C.O.) collaboratively developed the search strategies with the other authors  and ran the searches in the following databases: PubMed MEDLINE, clinicaltrials.gov, Embase (embase.com), Cochrane Central Register of Controlled Trials (CENTRAL) on the Wiley platform, CINAHL (Ebsco), and PsycINFO (Ebsco). The search strategies for the Embase, CENTRAL, CINAHL, and PsycINFO databases were adapted from the MEDLINE search strategy. All databases were searched back to their inception and no language or date limits were applied. Searching for eligible studies to include in the review involved the following approaches: controlled vocabulary (MeSH headings and thesauri of relevant databases) and the keywords of obesity, pregnancy, behavior change, healthcare professionals, trials, and gestational weight gain. Complete search strategies are provided . We alsoThe specific inclusion criteria were: (1) Obstetric care providers who participate in at least one intervention, preferably with the provider being the unit of analysis, with the aim  to change a providers’ clinical practice , knowledge , and/or satisfaction (as demonstrated by surveys) with the intervention in relation to the management of perinatal obesity or gestational weight gain; (2) Type of provider intervention could include training or education interventions, interventions that changed systems or organization of care, provision of resources to support practice ; and (3) Randomized controlled trial (RCT), prospective or retrospective cohort, or case-control studies. We specifically excluded interventions that focused only on the patient; however, if the included studies had provider and patient interventions, we reported findings from both of them.All citations were independently screened by two reviewers  using the Covidence tool. Once agreement was obtained on articles meeting criteria for full-text review, two reviewers  independently extracted the following data from each article: (1) study location and setting, (2) provider characteristics ; (3) intervention features ; (4) outcomes and efficacy; (5) study design; and (6) strengths and weakness of each study. These data were summarized for each full-text article. Where applicable, differences in means or proportions from pre- and post-testing were reported.Due to the combination of quantitative, qualitative, and mixed-methods studies that met criteria for review including RCTs, non-RCTs, and descriptive studies, the risk of bias was evaluated according to the validated Mixed Methods Appraisal Tool.  This tooOf the 6821 abstracts screened, 60 full-text studies were reviewed after conflict resolution by M.A.K. and B.A.P. The mostThe overall quality scores of the seven studies ranged from 25% to 100%, with a median value of 50%  and a wiet al developed an intervention that entailed a “best practice alert” embedded into the EMR of obstetric patients during 2011–2012 at a multi-site health care system in the United States. [Lindberg  States.  A group et al aimed to determine if 12 health care professionals in Denmark could improve their motivational interviewing skills when communicating with obese pregnant women after attending a 3-day training course in motivational interviewing. [In 2014, Lindhart viewing.  Two certet al evaluated the implementation of maternal obesity care pathways or management algorithms of the National Health Service in the United Kingdom. The evaluation utilized a mixed-methods approach and considered the perspective of multiple stakeholders  and used quantitative and qualitative postal surveys and case audits of compliance in delivering the pathways. [In 2015, Heselhurst athways.  The cont2 whereby the hand-held antenatal records for randomly selected women were reviewed and assessed for compliance with elements of the antenatal care pathway. Of the 27 records reviewed, antenatal mean compliance across all areas assessed was 75%. Areas that scored below the 75% cut-off included offering vitamin D supplements, using appropriate-sized blood pressure cuff, weighing at 28 and 32 weeks, anesthesia consult, and reinforcement of diet and physical activity goals. The strengths of this study include its multi-dimensional evaluation process from the perspective of a variety of stakeholders. Objective data from the chart audit provides a measure of efficacy of the intervention pathway, but they were not specific to the provider.The case audits were limited to women with a booking body mass index >40 kg/mWe summarize the findings from the seven studies as follows : The stuWe noted several other similarities among the seven studies in that the majority of provider participants were midwives whose practice was based in the United Kingdom (n = 3), Denmark, Finland, Australia, and the United States. Practices such as routine weighing are common in some countries such as the United States, whereas the American College of Obstetricians and Gynecologists’ (ACOG) guidelines do not advise routine vitamin D supplementation in obese women.  MotivatiIn this systematic review of provider involvement in either maternal obesity or gestational weight gain interventions, we found only seven articles that met our inclusion and exclusion criteria among 6,821 abstracts. There is a dearth of information on provider involvement in such interventions, either as a primary provider or as a member of a multi-disciplinary team in the training and management of these important maternal health issues. As determined from this systematic review, there are many intervention components that have the potential to change provider behavior including interfaces with the EMR, training in motivational interviewing and implementation of maternal care pathways or treatment algorithms. Our study adds to the literature in that it has now identified seven studies that have incorporated the obstetric provider into an intervention or specifically targeted obstetric providers in an intervention with provider-level data as part of a program evaluation; however, the quality of the evidence to support these recommendations was low given that the median bias assessment score was 50%.This systematic review provides a comprehensive and updated assessment of the literature and used a validated quality assessment tool for mixed-methods studies. Future research can adapt these studies, evaluate provider involvement in a more rigorous fashion, and further strengthen the evidence base. We recognize some limitations as a result of the quality of the individual studies including small sample size, convenience sampling, and no universal approach to weight management . Due to the heterogeneity of the individual components of the provider interventions in this systematic review  and the varying approaches to data reporting and analysis, we were not able to perform a meta-analysis to further evaluate their efficacy. Furthermore, none of the studies evaluated the efficacy and sustainability of the intervention on a provider-level basis in a given clinical practice. We acknowledge it is difficult to report individual provider outcomes such as change in knowledge or EMR documentation and maintain provider confidentiality in studies with a small provider sample size.Of all the behavior changes that need to occur to effect improvement in health, we realize that the provider is just one part of the entire team that includes patients, other healthcare professionals, healthcare systems, and national organizations. Even if providers can improve knowledge and demonstrate behavior change with respect to their clinical practice, ultimately the primary question is whether there is a cumulative positive effect on patient outcomes such as improving their health behaviors or meeting gestational weight gain goals. For example, Kinnunen et al concluded from their pilot study, which required 12 hours of training for PHNs in the intervention group, that the strategy was feasible.  This stuOther studies that target either perinatal obesity or gestational weight gain in health behavior interventions for patients typically use nutritionists, physical therapists, psychologists, and other research personnel, but not the actual prenatal care provider to deliver the intervention. Indeed, a systematic review of nine electronic databases in 2014 documented that none of the 3,608 identified studies in which interventions were used to improve gestational weight gain explicitly targeted obstetric providers in their intervention.  In 2011,There are likely other issues to consider for provider interventions such as a perception that counseling about weight-related issues is futile or not important, , 28, 34 Obesity and gestational weight gain are serious problems in pregnancy. Not only are there short-term implications for perinatal outcomes, but long-term maternal and child health are at risk too.  If proviS1 File(DOCX)Click here for additional data file.S2 File(PDF)Click here for additional data file.


Methods: Population wide surveys using the Early Development Instrument (EDI) were conducted among 4–6 years-old children in both Montreal and Melbourne in 2012, measuring five domains of ECD: 1-Physical Health/Well-Being (PHYS); 2-Social Competence (SOC); 3-Emotional Maturity (EMOT); 4-Language/Cognitive Development (COGN); and 5-Communication Skills/General Knowledge (COMM). Descriptive analyses of summary EDI indicators and domain indicators (including median scores and interquartile ranges) were compared between metropolitan areas, using their respective 95% confident intervals (CIs). Analyses were performed using Stata software (v14). Results: The proportion of children developmentally vulnerable in at least one domain of ECD was 26.8%  in Montreal vs. 19.2%  in Melbourne. The Melbourne advantage was greatest for EMOT and COGN . In both Montreal and Melbourne, boys, immigrants, children not speaking the language of the majority at home, and those living in the most deprived areas were at greater risk of being developmentally vulnerable. Relative risks as a function of home language and area-level deprivation subgroups were smaller in Montreal than in Melbourne. Conclusion: This study shows that Melbourne’s children globally experience better ECD outcomes than Montreal’s children, but that inequity gaps are greater in Melbourne for language and area-level deprivation subgroups. Further research is warranted to identify the environmental factors, policies, and programs that account for these observed differences. There is strong consensus about the importance of early childhood development (ECD) for improving population health and closing the health inequity gap. Environmental features and public policies across sectors and jurisdictions are known to influence ECD. International comparisons provide valuable opportunities to better understand the impact of these ecological determinants on ECD. This study compared ECD outcomes between metropolitan Melbourne  and Montreal (Canada), and contrasted disparities across demographic and socioeconomic characteristics.  There is strong international consensus regarding the crucial importance of early childhood development (ECD) for improving population health and reducing inequities throughout the life course ,2,3. InvAt the municipal level, there is growing interest among policy makers, their partners, and the public in regards to how cities might improve health and quality of life for families and children ,13. In mMontreal (MTL) is the biggest city of the province of Quebec and the 2nd largest city in Canada. The city is located on an island, next to the St. Lawrence River. The metropolitan area also comprises North and South shore suburbs where about 50% of the Greater Montreal area population lives . MelbourBoth Canada and Australia are constitutional monarchies with a tripartite political structure, each level having legally defined mandates. In Montreal, municipalities, and districts constitute the local government which is responsible for cultural and sport activities , security issues , as well as vast range of built environment features, such as city streets, bike paths, public transport, green spaces, playgrounds, and housing . AlthougIn Australia, a similar political system based on three levels of government plans, delivers or funds all different services for children and families . Local cAlthough ECD is internationally recognised as a priority target, positively impacting the way children grow and develop remains a tremendous challenge throughout the world ,29,30. JIn keeping with this notion, the first objective of this study was to compare ECD outcomes among kindergarten-aged children between the metropolitan areas of MTL and MEL, as measured by a series of EDI indicators. The second objective was to contrast disparities across demographic and socioeconomic groups between both cities.This study is an international comparison of ECD outcomes at the metropolitan level in 2 states (Victoria and Quebec) in Australia and Canada using two cross-sectional population surveys that took place in 2012. Both surveys were based on the Early Development Instrument ,38,39, wThe study population comprised all children who were in their first year of compulsory schooling in 2012 in the metropolitan areas of MTL and MEL. In both settings, children who had less than four EDI valid domain scores , those younger than 4 years-old or with special needs (SN) were excluded from analyses, as recommended by the instrument authors .The EDI is a validated 103-item questionnaire developed at the Offord Centre for Child Studies  to measure children’s development during their first year of compulsory schooling . AggregaOver the last decade, the EDI has been increasingly used across the world as a measure of ECD across different jurisdictions ,45,46,47Since 2004, 12 out of 13 Canadian provinces and territories have been collecting data on the EDI at regular intervals ,47. In tThe EDI provides summary indicators and domain indicators of ECD, which are then disaggregated by territory or subgroup. Proportions of children vulnerable in at least 1 domain (% DV1) and those vulnerable in at least 2 domains (% DV2) of the EDI were used in this study as summary indicators. Comparisons were also made specifically for each of the 5 EDI domains with proportions of vulnerable children, median scores and interquartile ranges by domain. Results were stratified by sex, home language, place of birth and area-level deprivation.All outcomes of interest and covariates to be compared between MTL and MEL were directly computed with data sets from their respective survey. Descriptive analyses of summary EDI indicators (DV1 and DV2) and domain indicators (including median scores and interquartile ranges) were compared between the metropolitan areas of MTL and MEL, using their respective 95% confident intervals (CIs). Statistically significant differences were defined by no overlap in CIs. To analyse patterns of associations between subgroups and EDI indicators, relative risks (RR), and risk differences (RD) for developmental vulnerability were compared between cities, also using the absence of overlap of CIs. We undertook a number of sensitivity analyses  to ascertain the robustness of the main findings. Stata v.14 was used for all statistical analyses .Characteristics of the children surveyed appear in In 2012, a higher proportion of MTL’s children were developmentally vulnerable in comparison to MEL’s children for almost all EDI indicators , the only exception being in the PHYS domain where both settings show very similar results see . For theOverall, results showed some similar patterns of associations across subgroups of children in MTL and MEL: boys, immigrants , those who did not speak the language of the majority at home and those who lived in deprived areas were all at greater risk of being developmentally vulnerable see . Boys exIn MTL, children who spoke French at home (the most widely spoken language in Quebec) presented the lowest risk of being developmentally vulnerable in at least one domain , compared to English-speaking children  and those speaking a language other than French or English  see . In MEL,Immigrant children are at greater risk of being vulnerable for almost all indicators in both cities see . The onlIn both cities, there is a strong social gradient in the proportions of vulnerable children across quintiles of material deprivation, for all EDI indicators, with the highest proportions of vulnerability being systematically observed in the most deprived areas see . SocioecThe aims of this research were to compare ECD outcomes among children in their first year of schooling between the metropolitan areas of Montreal and Melbourne, as measured by a series of EDI indicators, and to contrast disparities across demographic and socioeconomic groups between both cities. Overall, the proportion of children developmentally vulnerable in at least one domain (DV1) was 26.8%  in MTL and 19.2%  in MEL see . More spTo our knowledge, this is one of the first international comparisons of the EDI results at the metropolitan level. Because the cities of MTL and MEL are relatively similar in terms of demographic and economic characteristics, and the data were collected in the same year, this comparative work represents an interesting opportunity to investigate jurisdictional disparities in ECD outcomes. Furthermore, this study was based on two population-wide surveys using adaptations of the EDI, a population-based measure for which there is growing interest for international comparisons of ECD outcomes ,53. TherSuch international comparisons inevitably include methodological limitations. The most important intergroup difference in terms of participants’ characteristics was in relation to MEL’s children being younger than MTL’s, with a three-month difference in participants’ mean age see . This diAlthough datasets in MTL and MEL were harmonized to make each variable as comparable as possible, some methodological differences remained. For instance, the number of questions in the QSCDK and the AEDC was not the same. The education context in which both surveys took place was not identical either . It was impossible to evaluate if teachers’ rating were influenced by cultural differences across MTL and in MEL. In the last decade, various adapted versions of the original EDI have been used around the world and have showed generally very high convergent validity, including in Canada and in Australia ,49,50,51The applied consequences of the significant differences in results between the two cities are of interest from a population health point of view. For example, if MTL improved ECD outcomes to reach MEL’s levels , how much ‘vulnerability’ might have been avoided? Applied to the total population of children in their first-year of schooling in the metropolitan area of MTL , the MEL lower DV1 proportions would result in about 3000 children not being developmentally vulnerable every year, with potential cost savings in the longer term . This laIt appears important to address the question of why two jurisdictions whose populations share similar demographic and socioeconomic characteristics result in such different proportions of developmentally vulnerable children (i.e., respectively 7.6 and 4.0 percentage point differences between MTL and MEL for DV1 and DV2, see This study also shows similar patterns of associations among subgroups of children in MTL and MEL. Boys, immigrants, children who do not speaking the language of the majority at home and those living in the most deprived areas were all at greater risk of being developmentally vulnerable see . These rThe fact remains that both MTL and MEL face unfair and avoidable subgroup disparities in all EDI indicators, as is the case in many settings throughout the world ,92. To rThis international comparison of ECD outcomes at the metropolitan level points to intriguing similarities and differences between MTL and MEL metropolitan areas. MEL’s children globally experience better ECD outcomes than MTL’s children. However, there were smaller disparities in MTL compared to MEL among the language and area-level deprivation subgroups. This study provides the first opportunity to learn more from each metropolitan jurisdiction to better inform local, regional, and national policies for young children. Further research is warranted to identify the environmental factors, policies and programs that account for these observed differences. A systematic review of universal and targeted services and policies for young children in each setting may provide a better understanding of the results, particularly in the field of early education and primary health care. Future international comparisons using the EDI may lay the ground for considering how jurisdictions could test action-oriented policy interventions to improve early childhood programs and services.


The major challenges of improving food security and biodiversity conservation are intricately linked. To date, the intersection of food security and biodiversity conservation has been viewed primarily through an agricultural “production lens”—for example, via the land sparing/sharing framework, or the concept of sustainable intensification. However, a productionist perspective has been criticized for being too narrow, and failing to consider other relevant factors, including policy, equity, and diversity. We propose an approach that conceptualizes rural landscapes as social–ecological systems embedded within intersecting multi-scalar processes. Based on such a framing, empirical research can be more clearly set in the context of system properties that may influence food security, biodiversity conservation, or both. We illustrate our approach through a description of contrasting agricultural systems within Brazil’s Cerrado region. We emphasize the need for new empirical research involving systematic comparisons of social–ecological system properties in landscapes threatened by food insecurity and ecosystem degradation.The online version of this article (doi:10.1007/s10113-016-1045-9) contains supplementary material, which is available to authorized users. Two of the most pressing challenges of the twenty-first century are to improve global food security and more effectively conserve biodiversity , situated at the interface of tropical forest (Amazon), savannah/grassland (Cerrado) and wetland  biomes  large-scale commodity production systems primarily characterized by beef and soybean exports, and requiring many external inputs including high-yielding seed varieties, chemical fertilizers, and pesticides; and (2) diversified smallholder family farms which focus on domestic consumer markets and commonly rely more heavily on locally available inputs including legumes and animal manures. The two landscape types share many common global and regional system properties . However, biophysical differences across farms and landscapes, differing formal and informal institutional characteristics, and the ways in which material, institutional, policy and regulatory resources are differentially accessed and used have resulted in distinct socioeconomic and ecological outcomes at the landscape and household levels across the two farming systems.Mato Grosso’s contribution to Brazilian soybean production increased from 15 to 27 % between 1990 and 2010, with an average soybean farm measuring approximately 3000 ha. The expanding soybean landscape has been driven by regional, national and global system properties and institutional dynamics. By the 1970s, the Brazilian Agency for Agricultural Research (EMBRAPA), within the Brazilian Ministry of Agriculture, developed soybean varieties adapted to the Cerrado’s climate and soil types, and which are high yielding when grown with chemical inputs. In the 1980s, the federal government supported the migration of land-poor but moderately capitalized farmers from the southern regions of Brazil to the Cerrado through federal land distribution and colonization programs. Land titles were readily granted to soybean cooperatives, and public financing was made available to build supporting infrastructure, including export processing facilities and paved roads  and agrobiodiversity  are higher in small-scale family farm communities in the Cerrado when compared to the soybean production model Below is the link to the electronic supplementary material.


Global mortality rates resulting from non-communicable diseases (NCDs) are reaching alarming levels, especially in low- and middle-income countries, imposing a considerable burden on individuals and health systems as a whole. This scoping review aims at synthesizing the existing literature evaluating the cost associated with the management and treatment of major NCDs across all Arab countries; at evaluating the quality of these studies; and at identifying the gap in existing literature.A systematic search was conducted using Medline electronic database to retrieve articles evaluating costs associated with management of NCDs in Arab countries, published in English between January 2000 and April 2016. 55 studies met the eligibility criteria and were independently screened by two reviewers who extracted/calculated the following information: country, theme , study design, setting, population/sample size, publication year, year for cost data cost conversion (US$), costing approach, costing perspective, type of costs, source of information and quality evaluation using the Newcastle–Ottawa Scale (NOS).The reviewed articles covered 16 countries in the Arab region. Most of the studies were observational with a retrospective or prospective design, with a relatively low to very low quality score. Our synthesis revealed that NCDs’ management costs in the Arab region are high; however, there is a large variation in the methods used to quantify the costs of NCDs in these countries, making it difficult to conduct any type of comparisons.The findings revealed that data on the direct costs of NCDs remains limited by the paucity of this type of evidence and the generally low quality of studies published in this area. There is a need for future studies, of improved and harmonized methodology, as such evidence is key for decision-makers and directs health care planning. Global mortality rates resulting from non-communicable diseases (NCDs) are reaching alarming levels with an increase from below 8 million between 1990 and 2010 to 34.5 million during year 2010 . ConsistWorldwide, the rising burden of death and disability attributed to NCDs threatens the functionality and effectiveness of the health sector and imposes risks on economic stability and development of societies ,16. In sConsiderable literature exists on economic evaluation and costs associated with NCDs in different regions worldwide, mostly in high-income countries (HICs) -23. HoweOnline Supplementary Document(Online Supplementary Document), and key inclusion and exclusion criteria are presented in A systematic search was conducted using Medline electronic database to identify and retrieve articles evaluating the cost associated with management of NCDs in all 22 Arab countries; namely: Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates and Yemen. Based on their global economic burden on governments and populations, the following NCDs were selected: cardiovascular diseases, cancer, chronic respiratory diseases and diabetes . Only paTitles and abstracts of the initially identified articles were screened by two independent reviewers to assess whether they fulfill the selection criteria using keywords including cost/costing, feasibility, utilization, finance/financing, payment, reimbursement, coverage and charge, expenses, monetary outcomes and resource investment. Articles not including any of the above-mentioned keywords in the title or abstract were excluded. Hence, 534 articles were identified for full text review and were assessed by the two reviewers for relevance with regard to the research topic. Only those articles that provided direct quantification of costs associated with NCDs, their treatment, management, or risk factors within the target countries were included. Studies conducted outside of Arab region were excluded. Any disagreement between the two reviewers was resolved by discussion and consensus or through consultation with a third reviewer when needed. The identified eligible articles accounted for a total of 55 articles, tackling the issue of NCDs’ costs within at least one of the Arab countries.Data was extracted from full texts included in this review using a data collection form composed of the following criteria ;Population/Sample size;Year of publication;Year for cost data;Costing approach – classified as bottom up or top down;Costing perspective – classified as societal, governmental, provider or patient;Type of costs – classified as direct medical, indirect medical and indirect;Source of information – classified as survey, medical record, health information survey or electronic database.The findings are presented by type of NCD. US$ were used when assessing economic costs across all studies to enhance comparability. Other reported local currencies were converted to US$ based on the exchange rate specified by the corresponding study. When exchange rate was not mentioned, conversion to US$ was performed using the conversion rate specific to the year of publication of the study.The quality of included cross-sectional, case-control and cohort studies was evaluated using the Newcastle–Ottawa Scale (NOS), which is based on three domains: selection, comparability and exposure . A maximWe initially identified 725 potentially eligible references published between 2000 and 2016  originated from high-income Arab countries, while 19 were conducted in lower-middle income and 12 were from upper-middle income Arab countries. This reflected GDP variation across the reviewed articles. Most studies were conducted in the Kingdom of Saudi Arabia (n = 15), Egypt (n = 8) and Jordan (n = 7) whereas 5 studies were conducted in multiple countries (The most frequently studied NCD was diabetes (n = 18) whereas chronic respiratory diseases  and cancer were each analyzed in 11 studies. Twelve studies focused on cost associated with management of cardiovascular diseases while 7 studies focused on other NCDs mainly chronic renal failure  also included indirect costs such as loss of productivity and premature death. While only one article described direct non-medical costs that are not directly related to medical services such as transportation. (Cost data collected through surveys represented the most commonly used data source (n = 19) while 12 studies relied on data retrieved from health information systems of ministries, hospitals and insurance companies followed by prior estimates published in the literature, which is represented as electronic database (n = 12) in Among the 55 studies included, 23 (42%) studies described the patient’s perspective and 21 (38%) studies described the provider’s perspective in estimating the costs highlighting that the majority of the studies focused on the costs that fall on either patients or health care institutions providing health services. Eight studies looked at the governmental costs associated with NCDs. The remaining studies (n = 8) described the societal level costs.Although most of the studies did not clearly indicate the costing approach used, the overall aim of the cost analysis and the sources of data assisted in determining the costing approaches followed. Most of the studies (n = 36) estimated the costs using a bottom up approach or micro-costing, while only nine studies relied on a top-down approach or gross-costing in their measurements. Only one study reported using both approaches, while identifying the costing approach was not applicable in seven of the included studies.The majority of the studies were appointed a quality score (34 of the 55 included studies). In the studies where a quality score was not assigned, the study design and methodology made quality assessment not feasible. The median quality score over all the studies was three out of nine (interquartile range 2-4). Two thirds of the eligible and scored studies scored three points or less, showing that most of the studies were of low to very low quality.As part of a cost-effectiveness analysis by Mason et al (2014) for the implementation of salt reduction policies , health A second study from Palestine also quantified costs associated with treating cardiovascular diseases; more specifically, the study estimated total cost of the cardiac catheterization unit in a major governmental hospital in Palestine as part of cost-volume-profit analysis . Total cIsma’eel et al (2011) estimated the cost to the public of preventing a single cardiovascular event focusing on statins in seven Arabic countries and those are Lebanon, Bahrain, Jordan, Kuwait, Saudi Arabia, UAE and Oman . The stuThree studies quantified total costs associated with treating or managing cancer  to Moroccan health care authorities for up to one year after diagnosis  calculated annual direct costs to diabetic children attending public and private diabetes clinics in Sudan, that were associated with controlling diabetes mellitus type 1   estimated the total annual national health expenditure to be US$ 0.9 billion, which represents around 21% of the country’s total health expenditure ,64. ThisTwo studies from Kuwait quantified costs associated with treating asthma . The firAs NCDs’ burden in the Arab region continues to grow, it becomes more necessary to assess the impact  of NCDs on patients and governments. In this review, studies providing quantification of costs associated with NCDs in 22 Arab countries, their treatment, management, or risk factors were included. The review identified and summarized only 55 studies covering the 16-year period (2000-2016). Costing studies were derived from LMICs like Sudan, Palestine, and Morocco, upper-middle-income countries and HICs, with four studies covering multiple countries in the Arab region -76,89. AThe studies were classified by costing variables such as costing approach, costing perspective, types of costs, and sources of information, although many of the studies did not indicate the method of costing used, nor specify the types of costs included. Furthermore, there was a large variation in the methods used to quantify NCDs’ costs in these countries. This lack of standardization made it difficult to conduct any type of cross-country, intra-country, or international comparisons. Any kind of cross-country comparison was further impeded by a focus, in the majority of identified studies, on treatment or management of only one class or type of NCD, with the exception of one study from Lebanon, which looked at costs of all smoking-related NCDs . Also liThe closest comparison to findings can be extracted from studies conducted in HICs, and from members of Organization for Economic Co-operation and Development (OECD). One such study looked at NCDs’ impact on national health expenditure . ResearcDue to the fact that our study was part of a larger epidemiological approach scoping review, the included studies analyzed in this review are subject to several limitations including absence of a clear definition of costing method used, wide heterogeneity in methods followed to calculate same and different types of cost and variation in case definition. Other limitations are related to missing data on patient characteristics, which could have affected care or cost, sample representativeness like exclusion of individuals not seeking care for financial reasons and uneven geographical distribution. There are also differences between health systems in Arab countries, affecting the allocation of health funds for NCDs’ management. These factors did not allow us to pool reported cost estimates, to generalize results or to generate comparisons across studies. Another limitation is the search language used. This review only identified studies published in English, or containing an English abstract or keywords, potentially impacting number of studies identified and included in the review.The burden of NCDs in the Arab region is set to continue growing, conforming to local and global trends. This scoping review on the costs of NCDs in Arab region sheds light on an important issue: although NCDs-related morbidity and mortality continue to rise in all Arab countries across different income levels, data on costing remains limited by this type of evidence’s paucity and the generally low quality of studies published in this area. Internationally, NCDs resulted in high health care costs for governments and in great out-of-pocket and catastrophic health expenditures for households. Still, global findings and trends regarding NCDs raises questions of representativeness when inferring about applicability in the local and regional context. Moreover, even at international levels, questions persist concerning methodologies used for inferring costs at the national level.Furthermore, although this review represents the most comprehensive to-date assessment of studies in the region directly quantifying the costs of NCDs, it remains restricted by the paucity of evidence and the generally low to very-low quality of included studies. Hence, if decisions are to be made based on available rough estimates, resources might be used inefficiently.This research represents a foundational step for policymakers in need of evidence when managing the financial burden of NCDs in future reforms. There is also a need for future studies, of improved and harmonized methodology, from the Arab region on the cost management of NCDs and their growing financial impact at household and governmental levels.