Numerous economic models have assessed the cost-effectiveness of antipsychotic medications in schizophrenia. It is important to understand what key impacts of antipsychotic medications were considered in the existing models and limitations of existing models in order to inform the development of future models.This systematic review aims to identify which clinical benefits, clinical harms, costs and cost savings of antipsychotic medication have been considered by existing models, to assess quality of existing models and to suggest good practice recommendations for future economic models of antipsychotic medications.An electronic search was performed on multiple databases  to identify economic models of schizophrenia published between 2005–2020. Two independent reviewers selected studies for inclusion. Study quality was assessed using the National Institute for Health and Care Excellence (NICE) checklist and the Cooper hierarchy. Key impacts of antipsychotic medications considered by exiting models were descriptively summarised.Sixty models were included. Existing models varied greatly in key impacts of antipsychotic medication included in the model, especially in clinical outcomes used for assessing reduction in psychotic symptoms and types of adverse events considered in the model. Quality of existing models was generally low due to failure to capture the health and cost impact of adverse events of antipsychotic medications and input data not obtained from best available source. Good practices for modelling antipsychotic medications are suggested.This review highlights inconsistency in key impacts considered by different models, and limitations of the existing models. Recommendations on future research are provided. Antipsychotic medications have been the mainstay of treatment for schizophrenia since the 1950s –5, each Clinical trials capturing the health and cost outcomes of antipsychotic medications can be complex, time-consuming, and costly. In addition, clinical trials often do not cover all antipsychotic medications of interest, have a short time horizon and use surrogate endpoints or focus only on specific adverse events instead of assessing the entire spectrum of relevant adverse events. Health economic modelling is therefore advocated as a systematic and transparent method for synthesising all available evidence obtained from multiple sources –11. AlthModels are simplifications of reality which focus only on key relationships and are therefore unable to capture all impacts of using one intervention . TherefoThis systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions . The sysa priori. Studies were included if they met all of the following criteria: (i) model-based economic evaluation adopting either a cost-effectiveness analysis (CEA) or cost-utility analysis (CUA) approach; (ii) young people (under 18 years of age) and/or adults (18 years and older) with a non-specific diagnosis of psychosis or with a diagnosis of schizophrenia ; (iii) evaluation of antipsychotic medications versus each other, placebo or nothing. The reason why non-specific diagnosis of psychosis was included is because in clinical practice, it may take up many years before symptomatic patients receive a formal diagnosis of schizophrenia [Inclusion and exclusion criteria were defined ophrenia . Before ophrenia . No resthttps://ovidsp.ovid.com/). In addition, the NHS Economic Evaluation Database (NHS EED) and the Health Technology Assessment (HTA) Database were searched, accessed through the Cochrane library interface (http://onlinelibrary.wiley.com/cochranelibrary/search8). The search strategies included Medical Subject Heading (MeSH) terms and text words. Each follows a similar structure: population terms AND economic evaluation terms AND modelling terms AND limitation terms. The original search, first update search and second update search were conducted by one reviewer (HJ) on 22nd June 2015, 4th March 2018, and 21st January 2020, respectively. The full search strategy is reported in Electronic biomedical and psychological databases searched included MEDLINE (including in-Process & other non-indexed), EMBASE and PsycINFO, accessed through the Ovid interface  interpedently performed the first screening of the literature search results, by comparing titles and abstracts to the inclusion criteria. The full articles were then obtained for possibly useful studies and checked against the review inclusion criteria by two reviewers . Final inclusion of studies in the review was determined by agreement of both reviewers, with disagreements resolved by discussion. A number of strategies were devised to help ensure that relevant studies were not missed. Firstly, the reference lists of all studies included in the current review were checked for any additional studies that may have been missed by the electronic search strategies. Secondly, key papers and the publications of key health economists were checked for inclusion and for additional relevant papers. Thirdly, published systematic reviews relevant to the target population were located through a separate search of the clinical guidelines and technology appraisals produced by the National Institute for Health and Care Excellence (NICE) and NIHR health technology assessment (HTA) reports. The search terms used by the located systematic reviews were used to inform the development of search strategies for the current systematic review, and the studies included by those reviews were checked for relevance to the inclusion criteria of the current systematic review. Finally, the included studies of all literature reviews identified by the search conducted for the current systematic review were checked for any additional studies that may have been missed by the electronic search strategies.Seven commonly used checklists for economic evaluations –28 were The Cooper hierarchy focuses only on the quality of the data sources used to inform the parameters in a model and was modified from the potential hierarchies of data sources for economic analyses developed by Coyle and Lee . The CooTwo reviewers  performed quality assessment for included studies, with disagreements resolved by discussion.A data extraction form was drafted by one reviewer (HJ) using Microsoft Word  and checked by a second reviewer (EA). The developed data extraction form was piloted on ten studies. The results of pilot testing were discussed among the team to incorporate any necessary refinements before completion of data collection from all included studies. The formal data extraction was conducted by one reviewer (HJ) and checked by a second reviewer , with disagreements resolved by discussion. The following information was extracted from all included studies: author, year, country, study objective, method of economic evaluation, intervention and comparator, modelling method, key impacts of antipsychotic medications to include in the model, and rationale for choosing those impacts. The template for data extraction is reported in Study characteristics and conclusions were synthesised within a narrative review. No quantitative synthesis was undertaken.A total of 1,557 abstracts were retrieved from electronic searches. The detailed results of the literature search are reported in A summary of the characteristics of included studies are reported in As reported in The antipsychotic modelled by included studies are reported in None of the included studies reported a rationale for selection of the different impacts of antipsychotic medications modelled, including choice of clinical benefits, clinical harms, costs and cost savings. To support understanding of the breadth, perspective and strengths and limitations of economic models, it is valuable to report the impacts of antipsychotic medication that were considered for inclusion in the model, the impacts that were included in the final model and the reason for inclusion or exclusion of each impact. For example, it is useful to know if a key impact was excluded due to lack of data rather than due to irrelevance to the question the model is trying to answer, as the former reason, unlike the latter, highlights a limitation of the model and a gap in the literature.Two types of clinical benefits of using antipsychotics were identified:Reduction of psychotic symptoms . All included studies modelled antipsychotics’ effectiveness in reducing psychotic symptoms, but the clinical outcomes that they measured varied and included: risk of relapse ; response rate to antipsychotic ; scores on psychiatric symptom scales   and the Positive and Negative Syndrome Scale (PANSS)), and number of successfully treated patients  . FifteenReduction in mortality . Mortality was modelled in thirty-one studies : twenty assumed antipsychotic medications have no impact on patients’ mortality , five assumed antipsychotic medications reduce patients’ mortality risk  –45, fiveTwo types of clinical harms of antipsychotic medications were identified, both of which are associated with adverse events of antipsychotic medications:Reduction of patient’s utility due to adverse events for CUA studies . The most frequently modelled adverse events were weight gain , movement disorders , and diabetes/impaired glucose tolerance . A bar chart showing the frequency of all adverse events modelled is reported in Increase in mortality due to adverse events 6/60, 10.0%). The adverse events which were assumed to increase patients’ mortality risk included diabetes  , 46, 47,, 10.0%. Two categories of cost related to antipsychotic medication use were modelled by included studies:Acquisition costs of antipsychotic medications .Cost of treating adverse events of antipsychotic medications . Of the thirty-six studies that included the cost of treating adverse events, the most frequently modelled adverse events were movement disorders , weight gain  and diabetes/impaired glucose tolerance . All modelled adverse events and their frequency are shown in The main cost savings resulting from the use of antipsychotic medication related to psychiatric services avoided . Of the fifty-eight studies that included the cost of psychiatric services, fifty-five studies included inpatient and outpatient/community services (94.8%), one study included the cost of inpatient services only (1.7%) , and twoThe performance of included studies on all items of Section 2 of the NICE checklist and the Cooper hierarchy are reported in According to the quality assessment results of the NICE checklist, fifty-four studies were deemed to have very serious limitations (90.0%), four were deemed to have potentially serious limitations (6.7%) , 64–66, Of the six categories included in the Cooper hierarchy , three oet al. [Based on findings of this review and the hierarchy of evidence suggested by Cooper et al. , good prThis review found that the key impacts of antipsychotic medications considered by existing models are:clinical benefits: reduction in psychotic symptoms and reduction in patients’ risk of suicide;clinical harms: the impact of adverse events on patients’ health-related quality of life and mortality;costs: cost of antipsychotic medication, and cost of treating adverse events of antipsychotic medication;cost savings: inpatient and outpatient psychiatric services.The results of this review suggest that models assessing antipsychotic medications were subject to considerable inconsistencies, particularly with respect to two aspects of the analyses: (1) clinical outcomes used for assessing reduction in psychotic symptoms, which included response rate, risk of relapse, scores on psychiatric symptom scales and number of successfully treated patients; and (2) types of adverse events considered in the model. One possible explanation for the variation in choice of adverse events is that different antipsychotic medications are associated with different adverse event profiles. For example, compared to first-generation antipsychotic medications , second-generation antipsychotic medications (e.g. olanzapine) are less likely to cause EPS but more likely to cause weight gain and diabetes. Therefore, models which only assess second-generation antipsychotic medications may choose to include weight gain and diabetes, but not EPS. However, even for studies assessing the same antipsychotic medications, the choice of adverse events still differed.In addition, the review found the quality of existing models assessing antipsychotic medication is generally low. Common reasons for low-quality included failure to capture the health and cost impact of adverse events of antipsychotic medications, input data not obtained from the best available source and potential conflicts of interest. In order to improve the consistency and quality of future models in antipsychotic medications, good practices are suggested based on the findings of this review.This study has three main strengths. Firstly, to our knowledge, this is the first systematic review which explores the key impacts of antipsychotic medications considered by existing health economic models. Secondly, based on the findings of this review, good practice for modelling antipsychotic medications are suggested. These good practice recommendations can be used to improve the consistency and methodological and reporting quality of future health economic models assessing antipsychotic medications. Thirdly, a number of strategies were devised to help ensure that relevant studies were not missed, including checking key papers and the publications of key health economists, and checking references of published systematic reviews.This review is subject to three main limitations. First, only models using a CEA or CUA approach were included. Models using other approaches, such as cost-benefit analysis (CBA), cost-consequences analysis (CCA) and cost-minimisation analysis (CMA), were excluded. However, it has been reported that CBA, CCA and CMA have problems with their reliability, validity and even morality , 68, andS1 Text(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(XLSX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.S7 Table(DOCX)Click here for additional data file.S1 Checklist(DOC)Click here for additional data file.


The viability of the European sheep and goat sector is threatened by market, policy, social and technical challenges. To address such challenges, innovations for efficient farm management, especially with decision support capabilities, are considered a strategic priority. The iSAGEDSS is a web application, based on the Happy GoatS solution, which allows dairy and meat small ruminant farmers to make annual management plans by testing future what-if scenarios. It is designed for the meat sheep production system in the United Kingdom and Spain, the dairy sheep production system in France and Greece and the dairy goat production system in Greece. Moreover, it addresses all important farm parameters  and utilizing an energy and protein-based algorithm for nutritional management assessment it produces reports, which are focused on profitability and productivity. Environmental-related figures are also estimated. Results are illustrated with simple and easily understood charts and plots. Case study application results showed high prediction accuracy and demonstrated the ability of the system to promote efficient farm management. In this regard, iSAGEDSS is expected to help farmers to adjust to the challenges faced by the sector and remain sustainable.The European sheep and goat sector is characterized by low professionalization and management training. Moreover, it is fragmented in terms of production aims and farming systems. Here, iSAGEDSS, a web-based application allowing dairy and meat small ruminant farmers in different countries to make annual management plans by testing future scenarios, is presented. Data were obtained for the meat sheep (United Kingdom and Spain), dairy sheep (France and Greece) and dairy goat production systems (Greece) from partners of the Innovation for Sustainable Sheep and Goat Production in Europe (iSAGE) project. These were used to set default values and ranges for all important farm parameters in each system and country. An algorithm was developed assessing nutritional management and its impact on production and financial performance. Reports focus on profitability, productivity and environmental sustainability. A case study in three dairy sheep farms in Greece was performed. In each case, an evaluation scenario was created using actual farm data that were compared with the estimated ones. Two scenarios testing management decisions for gross margin maximization and milk pricing fluctuations were created. Application results showed high prediction accuracy for gross margin and production estimation . Moreover, the ability to promote financial, production and grazing management efficiency was demonstrated. Market and policy measures have resulted in financial difficulties for sheep and goat farmers. Specifically, the sector is characterized by inadequate farm-gate prices and increased production costs. As a result, many farms operate under the profitability threshold ,2,3. To Moreover, sheep and goat farming require specific skills and a well-established management plan. However, the sector is lacking in professionalization and management training, resulting in varied levels of productivity ,3. At thCloud-based decision support systems utilizing predictive modeling have been successfully developed and applied in the field of agriculture, especially for efficient crop management ,9,10. Inhttp://happygoats.eu/), a web application, which focuses on facilitating farm management decisions through the projectional analysis of future management data [In a previous work, we described Happy GoatS  Horizon 2020 project. The idea was based on an existing web application, Happy GoatS, designed and developed by the authors [The iSAGEDSS was developed within the Innovation for Sustainable Sheep and Goat Production in Europe  and Spain, the dairy sheep production system in France and Greece and the dairy goat production system in Greece .These data were used to set default values that characterize the management of an average typical farm and acceptable ranges (where applicable) in each production system and country for seven different categories of input farm parameters. Such categories included flock size, production , processing (only for the dairy systems), grazing , feeding (forage and concentrate feedstuffs), income and variable costs and prices (for products and feedstuffs) parameters. The initial set of farm parameters (for each production system and country) was presented and discussed with research and industry (farmers and consultants) participants across Europe during regional workshops of the iSAGE project. Industry consultants from the UK pointed out the need to include more options of forage feedstuffs  and, specifically, fodder beet and stubble turnips. Therefore, in order to better meet the needs of the UK meat sheep production system, the above feedstuffs were included in the UK model. Based on all the above, five input data forms with different sets of parameters as well as default values and acceptable ranges per production system and country were developed .An algorithm was developed based on the energy and protein requirements of sheep  and goats , according to their production aim and stage, in order to assess nutritional management and its impact on production and financial performance . A part r = growth of replacement lambs (kg/day); AW = adult weight (kg); BW = birth weight (kg); AM = age at mating (in days).f = growth of finishing lambs (kg/day); CW = carcass weight (kg); DP = dressing out percentage (%); BW = birth weight (kg); AS = age at slaughter (in days).For both dairy and meat production systems, three periods were defined for ewes/does: (i) lactation period, (ii) dry period excluding last month before birth and (iii) last month before birth. Last month before birth was differentiated from the rest of the dry period due to the rapid increase in nutrient demands for the growth of the fetus ,31. MoreIn all cases, the equations for calculating the nutrient requirements (metabolizable energy and protein) of sheep and goats for maintenance, growth, pregnancy and milk production, where applicable, and dry matter appetite were obtained from the existing literature using the Agriculture and Food Research Council (AFRC) system .fat = metabolizable energy from fat :d et al. ); EE = ed et al. ).Then, the average daily metabolizable protein intake is estimated with Equation (4) based on the suggestions of AFRC :(4)MPI =f = carcass weight change of finishing lambs (kg); LWC = live weight change of finishing lambs (kg) based on energy and protein balance; DP = dressing out percentage (%).Based on all the above, the algorithm allows for the calculation of energy and protein balance (the difference between metabolizable energy/protein requirements and intakes) for each animal category. The latter provides the basis for estimating production-related figures such as live weight and milk production change of lactating animals in dairy sheep and goat farms or live weight and carcass weight change in meat sheep farms; change refers to the difference between the goal of production and the actual production achieved based on energy and protein balance. These production estimates are then taken into account for the estimation of the farm’s income . Specifi2 = second estimate of pasture intake for each animal category (kgDM/day); U = utilization (a maximum of 93% assumed); APA = annual pasture available (kgDM/hectare per year); R = residual (a minimum of 300 kgDM/hectare assumed); TP = estimate of total pasture eaten by all animals (kgDM/hectare per year); PA1 = first estimate of pasture intake for each animal category (kgDM/day).Additionally, the algorithm allows for estimating pasture availability at the end of the year based on the annual pasture available and the estimated annual total pasture intake of all animals. To estimate the pasture intake of animals, a two-step approach is followed. Initially, a first estimate of the potential daily pasture intake is calculated for each animal category according to their dry matter appetite and the amounts of supplemented feeds they receive. If the first estimate of the annual total pasture eaten by all animals exceeds the amount of pasture available, a second, reduced, estimate of daily pasture intake is calculated for each animal category using Equation (6) according to the directions of the Agriculture and Horticulture Development Board :(6)PA2 =Finally, simple equations were built to estimate useful farm statistics which affect performance, such as ram/buck to ewe/doe ratio, stocking rate, weaning percentage and animals per laborer.The iSAGEDSS application was architectured around the model-view controller design (MVC) pattern consisting of a RESTful Web Service and a Single Page Application (SPA). The representational state transfer (REST API) is implemented using Java technologies with the following main components: (i) Jersey  used as a library for JAX-RS (Java API for RESTful Web Services), (ii) Guice  used as a dependency injection and annotations framework and (iii) Hibernate  used as the application’s object relational mapping (ORM) framework.The SPA that the end user accesses is an implementation based on the AngularJS (version 1.5.8) framework  along with HTML5 (HyperText markup language) and CSS3 (cascading style sheets). The Web Service application and SPA, which in unison offer the iSAGEDSS solution, are being deployed on an Apache Tomcat Web Application Server .® Cloud .All the aforementioned servers and components are hosted on a virtualized operating system (OS) environment running CentOS Linux . The virtual machine is provided by The DigitalOceanDesignated web forms were created for data input. Data are validated against a range of values’ limitations and erroneous input. Specifically, data input is checked for correctness and then compared with theoretical minimum and maximum limits per category imposed by the production system and country. These data are then processed with a model algorithm, which provides results for farm management decisions.To ensure the protection of farmers’ data, the application implements authentication and authorization processes. Thus, a user must access the system using their unique username and password and they can access only their own farm’s data. All data, both application’s configuration and those submitted by the end users, are stored on a MariaDB relational database management system (RDMS) server .For the purposes of evaluation and demonstration of the utility of the decision support system, a case study application from the dairy sheep production system in Greece is presented. The dairy sheep production system in Greece was chosen on the basis of its lower sustainability scores compared to other European countries shown in relevant assessments . Three di = actual values; ŷi = predicted values.Each farm was visited by the same veterinarian involved in the development of the system. During the visit, the farmer was asked to provide primary farm management data for the recent production period (year 2018) regarding all the input parameters required by iSAGEDSS in order to create an evaluation scenario (Scenario 1). All input data for Farms A, B and C are provided in In Farm A, a second, projectional (what-if) scenario (Scenario 2) for gross margin maximization was created in which inefficient management practices identified from Scenario 1 were altered and an additional source of income by selling 5% of lambs that were initially intended for slaughter was tested. Then, a third, projectional scenario (Scenario 3) was created, simulating the possibility of a future reduction in the price of milk by 5% while incorporating the management changes from Scenario 2.Ethics approval was obtained by the Hellenic Data Protection Authority (ΓΝ/ΕΞ/1473-1/16-06-2016) within the framework of the iSAGE project. Moreover, no data that can be related to or traced to a person’s identity were collected and, in all cases, users tested the system anonymously.www.isage-dss.eu) and login using the unique username and password provided.User login to the iSAGEDSS website: Firstly, users have to access the iSAGEDSS website  and they can create new ones.Scenario data input: In their new scenario, users have to input information regarding all important farm aspects; flock characteristics, production, processing (only in dairy sheep and goat farms), grazing, feeds, income and variable costs  and farm prices. Easy navigation through the different categories is provided by the “index option”. Users can use the “Show help” option in order to be provided with further explanations for each of the required data. This option ensures methodological homogeneity for data provision. Moreover, they can also use the “fill form with default values” option to save time in case they wish to test an average management scenario or they are interested in changing only a few parameters .Report page: After all the information has been filled in and the scenario saved, users are navigated to the report page, where they are provided with financial, production and environmental-related figures.The iSAGEDSS has a user-friendly interface for small ruminant farmers, which includes the following steps:The iSAGEDSS offers simulations of future scenarios for annual farm management planning. It enables farmers to create and compare many different scenarios by testing all important farm aspects that impact on profitability and productivity in order to establish the most efficient management plan. The expected frequency of use is once per year.This decision support system accommodates different production and farming systems and European countries. Specifically, farmers choose the type of model to be used based on the production system and country , and undThe users are provided with reports that are mainly focused on profitability and productivity. Specifically, farm income, variable costs and gross margin are estimated taking into account production estimated figures such as live weight and carcass weight of finishing lambs and milk production of lactating animals (according to the production system) based on their nutritional management . MoreoveThe comparison between the case study farms’ actual and iSAGEDSS-estimated annual financial results and ewe milk production are presented in Detailed production outputs from Scenario 1 of Farms A, B and C are presented in The comparison between the basic outputs of Scenarios 1 and 3 of Farm A  showed tAs asserted in the Introduction, the European sheep and goat sector faces many challenges, which should be properly addressed for a sustainable and competitive future ,35. TowaThe iSAGEDSS is an extension of an existing decision support system, Happy GoatS , which wReliable farm-level data have been highlighted as a significant challenge towards the effective design and delivery of decision support systems in agriculture. In order to improve data reliability, automation in data collection through remote sensors has been proposed ,28. HoweOther innovations in the sheep and goat industry have mostly focused on addressing precision feeding, novel feedstuffs , geneticContrary to all the above, iSAGEDSS offers projectional capabilities for decision-making with an emphasis on profitability and productivity, while considering grazing management. To the best of our knowledge, only PASTOR-DSS, a decision support system for dairy sheep farming, allows for bio-economic simulations. However, since simulations rely on an individual animal models, its use is impaired by the large number of required input animal parameters . AlthougIn terms of accuracy, the presented case study in three dairy sheep farms (two semi-intensive and one intensive) in Greece, where actual data were compared with the estimated ones, showed a MAPE of 9.04% and 4.84% for gross margin and milk production estimation, respectively. According to Lewis , values In terms of impacts, three dimensions can be acknowledged based on the system’s available features. Firstly, iSAGEDSS helps sheep and goat farmers in different European countries to make annual management planning decisions by simulating future scenarios. There are a number of scenarios that could be potentially simulated such as flock size optimization, production optimization, pricing fluctuations, pasture availability fluctuations, extensification/intensification of the production system and different feeding strategies. By creating many different scenarios, farmers could understand the impact that each management decision may have on their profitability and establish an efficient plan for managing their farm. Therefore, iSAGEDSS can help towards increasing the currently low professionalization of the sector ,3.Moreover, it supports production optimization and gross margin maximization while also reducing dependence on public subsidies, which have been described as major challenges for the sheep and goat industry ,5,42. SpSuch impacts were demonstrated in the presented case study application in Farm A by simulating a scenario of alternative management practices, compared to the farm’s current ones, for gross margin maximization and a scenario of milk pricing fluctuation. According to our experience, these are the most common cases of decision-making that farmers are interested in. Moreover, in the past few years, Greek sheep farmers have indeed been faced with reduced milk prices enforced by dairy companies. To test the above, Farm A was chosen as the best representative on the basis of having the most accurate predictions. Based on our results, the gross margin of the studied farm could be increased by ca. 7% by culling all the non-productive ewes, incorporating a more efficient nutritional management strategy and utilizing a new source of income through the selling of lambs as replacements to other farmers. Moreover, changes in nutritional management were feasible without a considerable decrease in pasture availability at the end of the year (ca. 0.5%). Additionally, given all the above management changes, a possible reduction in the price of milk by 5% was found to result in an insubstantial gross margin reduction compared to the farm’s current situation (ca. 0.5%). Such findings confirm that iSAGEDSS can help farmers to plan for efficient and sustainable farm management even under adverse hypothetical scenarios.All the above features and impacts of iSAGEDSS suggest that it has the potential to be easily adopted by farmers. Specifically, according to studies and applications in agriculture, a holistic approach for management solutions, user-friendliness and cloud-based services for greater availability and applications ,9 are keOur main goals for the future are to further evaluate the ease of adoption of iSAGEDSS through an extensive case study/survey with farmers and to achieve the long-term utility of the decision support system. Towards the latter, a team of sheep and goat experts will be available for farmers to communicate with if they require consultancy on their results and would like to discuss more viable solutions. Moreover, given the fact that not all farmers have a good knowledge of managing applications and online products based on their educational status  and are The iSAGEDSS is a web-based, model-driven decision support system which focuses on the efficient management of meat and dairy small ruminant farms. It was developed as a follow-up to the Happy Goats system. iSAGEDSS allows sheep and goat farmers of different production and farming systems in different European countries  to test future annual management decisions by estimating both financial and production-related figures with a high prediction accuracy. Environmental figures relating to grazing management are also estimated. All these are illustrated with simple and comprehensible charts and plots. In this regard, iSAGEDSS is expected to help small ruminant farmers to understand the impact of their management decisions and increase their professionalization with the aim of responding better to the challenges faced by the sector and remaining sustainable.


Good mentoring is key for doctoral student success. In 2010, AGESW began offering the Pre-Dissertation Fellows Program (PDFP) to enhance social work doctoral students’ professional development and skillset for academia. The purpose of this study was to examine student participants’ perceptions of the PDFP in its role to providing mentorship and training for an academic position. This qualitative study examined eight cohorts (2010-2018) of the AGESW PDFP (N=85). Using thematic analysis, responses identified a number of aspects of professional development gained, gratitude for the training, an appreciation for candid advice received, and areas of professional development they felt they were lacking within their doctoral training. Findings bolster support for structured programs and professional development that supplement doctoral education in a student’s first two years. Implications for doctoral education, mentorship training, and avenues to enhance the AGESW pre-dissertation program will be discussed


Integration of community-level health data within Mali’s web-based District Health Information System (DHIS2) is underexplored. This study conducted in Mopti, Mali examined challenges and enablers affecting integration and investigated how digital technology optimizes data quality, availability, and use.This pre-post mixed-methods study compared community health workers’ (CHWs’) experiences reporting routine community-level data using the DHIS2 digital application on tablets and paper forms. 141 CHWs participated in quantitative surveys and focus group discussions at baseline and endline. In-depth interviews were conducted with 18 and eight CHW supervisors and 12 and 11 other stakeholders at baseline and endline, respectively. We calculated changes in CHW performance, and job satisfaction among intervention and comparison groups using the difference-in-difference (DID) estimator controlling for baseline characteristics. Routine longitudinal DHIS2 data described timeliness and completeness of CHW reporting. Thematic analysis of qualitative data explained implementation challenges and enablers, and considerations for data use.P < 0.05 for both), as did aspects of job satisfaction . CHWs reported high levels of comfort and confidence navigating the tablet for data collection and on-time reporting. While CHWs experienced challenges –tablet quality, limited network connection and increased workload, they preferred the digital to paper system. Stakeholder, supervisor and CHW roles in data review and decision-making appear unchanged from baseline to endline, though some supervisors found the tablets improved data timeliness and completeness. Routine longitudinal DHIS2 data confirm high rates of data timeliness and completeness before and after the intervention, with little or no change over time.The median number of health talks and household visits among intervention group CHWs increased from baseline to endline compared to the comparison group (DID estimator; CHW tablet use for data collection and reporting is feasible and desirable, however, program and policy changes are needed for this to be a fully-functional system. Future efforts need to consider how to ensure site-level network connectivity; quality, compatibility and functionality of digital technology; and routine supportive systems for CHWs and community health actors on data use. Community health data are increasingly required in low- and middle-income countries (LMICs) seeking to monitor service delivery, measure performance, improve accountability and make health programming decisions -3. HowevInitiatives to reform paper-based HIS through digitalization have observed cost reductions and more timely delivery of health care services as well as managers and decision-makers being able to use disaggregated data in optimizing health services ,9. HowevMali, like many countries, has adopted a free, web-based, open-source HIS, the District Health Information System (DHIS2), for aggregation and analysis of health service data; however, community health workers (CHWs) continue to collect and report data using a paper-based system due to logistical and human resource challenges. Over 50 countries have deployed the DHIS2 in health facilities, but there is limited experience with its integration at the community level ,17.Within the USAID-funded Integrating Community Health Collaboration, the Aga Khan Foundation (AKF) implemented the Soins Essentiels dans la Communauté Project (SECPro) to improve community health and reduce maternal, newborn, and child mortality by strengthening the implementation of Mali’s national basic community health care strategy (SEC). As part of SECPro, AKF, in collaboration with the Population Council’s Frontline Health project, sought to examine the challenges and enablers that affect integrating community-level health data into DHIS2 and explore how technology could optimize the quality, availability, and utility of that data. Underlying this study is a focus on data use as a critical domain within the CHW Performance Measurement Framework .The objectives of the study were to assess the effect and feasibility of implementing a digital data collection system at community level, specifically baseline-endline differences in (1) CHW ability and willingness to carry out their roles and responsibilities (2) timeliness and completeness of data reporting using the digital system, and (3) experiences using data from a digital community-based information system.This study uses a pre-post mixed-methods design that compared CHWs’ experiences using the DHIS2 digital application with that of paper forms to collect and report routine community health data. The study conducted quantitative interviews with CHWs to gauge changes in performance and experiences with community health data collection and reporting. Routine HIS data were also analyzed for trends in timeliness and completeness. Qualitative data were used to explore and gain a deeper understanding of the intricacies of CHWs’ experience collecting and reporting health data on tablets, describe data use for decision making and corroborate and explain quantitative findings.Responding to inefficiencies in CHW data collection and reporting, AKF proposed to pilot test the use of the DHIS2 tablet-based application, which would improve the timeliness and completeness of community-level data submission. The existing paper data collection and reporting process requires completing individual forms for each client and marking register books, depending on services sought. These paper forms are supplied by the community health association . At the end of each month, the CHW compiles all the client information into an aggregate report that is submitted in person to their supervisor, the directeur technique du centre (DTC) at the community health center  who reviews for quality, gives feedback, and enters aggregated monthly data from all CHWs they supervise into the DHIS2 platform.CHWs in the intervention sites, Mopti and Djenné districts, received tablets with the DHIS2 application. However, due to concerns from the Ministry of Health (MOH) regarding the potential for lost data, the CHWs continued collecting and reporting data using the existing paper-based system in addition to entering the data into the tablet. AKF conducted the initial training and follow-up visits with CHWs and DTCs on tablet use for data collection and reporting. During these trainings, the AKF team members were accompanied by local representatives of the regional MOH and community.The comparison sites, Bandiagara and Bankass districts, continued reporting data using the paper-based system only.Study sites were selected based on where AKF was implementing the SECPro project and in consultation with local stakeholders. Comparison sites were selected with similar geographic, cultural and health characteristics as the intervention sites.In the four study districts, we implemented quantitative surveys and focus group discussions (FGDs) with CHWs, and in-depth interviews (IDIs) with DTCs and other stakeholders at baseline and endline , professional experience  and proficiency in French and at least one local language.Selected data collectors were trained on the study purpose, ethical considerations for research, and use of the study tools. Data collection was conducted over five days in each of the selected health districts. At recruitment, data collectors explained the scope and purpose of the study and received informed consent from all participants. Interviews were conducted primarily in French or Bambara. Some data collectors were proficient in other local languages and during a few FGDs, the respondents provided clarification in other languages when French and Bambara were not sufficient. Two data collectors were present for all qualitative interviews; one facilitated the interview while the other took notes to assist the transcription. The qualitative interviews were conducted in private or semi-private settings convenient for participants and sessions were audio-recorded, transcribed, and translated. Quantitative surveys were administered via a digital questionnaire installed on ARCHOS tablets using the Ona.io platform. Baseline and endline data were collected September-October 2018 and January 2020, respectively.Sociodemographic characteristics include age (continuous), education , currently living in village where working as a CHW (yes vs no), and experience with smartphone/tablet .CHW performance was measured by self-reported number of health talks and number of household visits in the last month. Additionally, CHWs were asked about the number of hours they typically worked in a week. With regards to reporting, CHWs were asked to self-report if they transmitted data on time last month.Six items were used to assess job satisfaction as it relates to data use and decision-making. Response options were: very unsatisfied, unsatisfied, satisfied, and very satisfied. We reported respondents’ level of satisfaction with the following: workload in relation to time available; opportunities to contribute ideas to improve services; coordination with DTC, ASACO, other members of CSCOM; participation in planning of services in catchment area; processes by which decisions are taken up by district officials; and timeliness with which decisions are implemented.At endline, participants assessed their experiences reporting data via DHIS2, answering questions about technology training, confidence in using technology and the DHIS2, changes in workload, preferred method of reporting, and difficulties with mobile health data collection.All statistical analyses were conducted in Stata v15 . Prior to conducting statistical analyses, we matched participant IDs at baseline and endline to ensure accuracy of paired data. Two participants at baseline and nine participants at endline were dropped because they did not have data for both, likely because they were not employed as CHWs in the community at one of the two points in time.t tests for continuous variables and χ2 tests and for binary and categorical variables, as well as Fisher’s exact tests for when cell counts had less than five observations. We calculated changes in CHW performance, reporting, and job satisfaction from baseline to endline among intervention and comparison groups. We tested for significance in these changes using McNemar’s test for binary variables (exact test for cell counts less than five), Wilcoxon signed rank tests and paired t-tests for continuous variables. We calculated the difference-in-difference (DID) estimator controlling for baseline characteristics that were significantly different between groups. When the parallel trends assumption was not met, we used the Abadie semi-parametric DID estimator  improved the (data) completeness; it's not 100% anyway, it improved a little bit the completeness compared to the beginning, the quality also […]. When you compare at the very beginning and now, it's not the same thing.” The quantitative survey results showed that CHWs reported high levels of comfort and confidence navigating the tablet for data collection and reporting and 100% stated that they submitted their reports on time last month  expressing confidence in using the tablet, including for recording new clients, reporting health data as well as being able to access and review data on their tablet after it’s submitted . Specifically, among those who saw a child in the last month (n = 62), 56.5% entered data for a sick child; among those who followed up with a newborn (n = 60), 46.7% entered last month’s data for newborn follow-up; among those who provided family planning care (n = 60), 46.7% entered last month’s data for family planning; among those who led health talks (n = 62), 37.1% entered last month’s data for health talks; and among those who saw pregnant women and/or newborns (n = 60), 35% entered last month’s data for them (data not shown). Monitoring visits to intervention sites demonstrated malfunctioning tablets contributed to some CHW’s low rates of data entry.CHWs experienced various difficulties in using the tablets related to the double workload of using both paper and digital tools to record and report community health data, the tablet quality and limited network connection. Common challenges include access and review of data on their tablet after submission, lack of phone/data credit and battery not charged , and the rapidity of data reporting.Respondents agreed that eliminating paper forms, improving technical quality of tablets, providing airtime, and fully integrating the digital data collection and reporting platform would improve its usability and quality. The CHWs reported that their preferred method for data reporting was the tablet or smartphone (91.9%). Positive opinions CHWs shared include the ease of data entry, the permanence of the data  with their participation in health service planning , while CHWs use site-specific data to focus their health talks. Future efforts should emphasize improving DTC capacity to monitor electronic data from CHWs and organizing local meetings to review data in tablets. Excluding CHWs from programming decisions indicates a normalized process of limited CHW participation consistent with previous studies in East and Southern Africa that found CHWs had limited motivation to engage “beyond their regular tasks” . This haThis study recommends more implementation research to assess strategies that involve CHWs in district planning meetings and strengthen district stakeholder capacity to interpret data. Additional support is needed to enable actors at all levels of the health system to improve data analytics, visualization, and data use to effectively inform decision-making .While findings demonstrate the acceptability of tablets for improving HIS efficiencies, inferences drawn from overall experiences of tablet use suggest that digital innovations can motivate CHWs in their work ,28. TechThis study ought to be interpreted alongside its limitations. During implementation, AKF discovered that a fault in the DHIS2 app led to an initial problem syncing the tablets with the DHIS2 server. Once fixed, the CHWs were then asked to re-enter the data (using paper backups) for the first three months of the pilot. In addition, the poor tablet quality meant that many CHWs had malfunctioning tablets at one point or another throughout implementation. The quantitative sample size was dependent upon the number of active CHWs in the study site. For the matched quantitative analysis, we excluded CHWs for whom we only had data at either baseline or endline (likely due to turnover in the post). All survey measures were self-reported by CHWs which may be subject to some recall bias. Results are not generalizable beyond the study districts.Overall, this study showed that while CHW tablet use for data collection and reporting is feasible and desirable, changes are needed for this to be a fully-functional system. Future efforts to integrate DHIS2 data collection into community health data collection and reporting need to carefully consider how to ensure site-level availability of sufficient network connectivity; quality, compatibility and functionality of technology; and routine supportive systems for CHWs and other community health actors on data use. In Mali, implementors must collaborate closely with the MOH to ensure accuracy of digital collection and reporting tools and design a system that can function on its own without a duplicative paper form system. Taking this intervention to scale could bring improvements timeliness and completeness of community-level health data in areas where these indicators were not as high and may positively affect CHW performance and motivation.


Ticks and tickborne diseases are increasingly problematic. There have been positive developments that should result in improved strategies and better tools to suppress ticks, reduce human tick bites, and roll back tickborne diseases. However, we equally need to address the question of who is responsible for implementing the solutions. The current model of individual responsibility for tick control evolved from a scenario in the 1990s focusing strongly on exposure to blacklegged ticks and Lyme disease spirochetes in peridomestic settings of the northeastern United States. Today, the threat posed by human-biting ticks is more widespread across the eastern United States, increasingly complex (multiple tick species and >10 notable tickborne pathogens), and, across tick species, more spatially diffuse . To mitigate tick-associated negative societal effects, we must consider shifting the responsibility for tick control to include both individual persons and professionally staffed tick-management programs. Federal public health agencies have generated new strategic plans aiming to strengthen both research and operational capacity to more effectively counter the threat of ticks and tickborne diseases (–Ticks and tickborne diseases are distinctly on the increase in the United States (Ixodes scapularis)  is already clearly defined in space  and time (spring and early summer)   with potential to negatively impact the cattle industry and perhaps also public health if this tick is found to commonly bite humans in the United States , and tick encounter locations in the late 1980s and the first half of the 1990s, which made perfect sense at that time. Lyme disease was the near absolute focus among tickborne diseases, most of human infections occurred in the northeastern United States, and residential properties were pinpointed as the most common location for encounters with I. scapularis ticks in Lyme disease–endemic areas  increasingly results in tick encounters. A recent systematic review and meta-analysis on spatial risk factors for I. scapularis tick bites and I. scapularis tick–associated diseases in eastern North America concluded that risk occurs in backyards, as well as in neighborhood green spaces and public lands used for recreation  are spreading northward from their previous core ranges in the southeastern United States  are transmitted by I. scapularis ticks , A. americanum ticks , and A. maculatum ticks (Rickettsia parkeri)  remains a threat across its wide geographic range as a vector of the agents causing Rocky Mountain spotted fever (R. rickettsii) and tularemia (Francisella tularensis) (I. pacificus), the Rocky Mountain wood tick (D. andersoni), the Pacific Coast tick , the brown dog tick , and Ornithodoros spp. soft ticks  and local public health programs with professional staff . This 2-pronged concept for responsibility should be accompanied by a 2-pronged spatial concept: first, making the backyard a safe, tick-free zone; and second, achieving area-wide suppression of ticks and tickborne pathogens to reduce the risk for tick encounters in other high-use environments.I. scapularis and A. americanum, in backyards is problematic because we have a poor understanding of how effectively host-seeking ticks are suppressed across the full extent of a residential property through broadcast of synthetic acaricides, natural acaricides, or fungal control agents by homeowners or commercial pest control companies. A large-scale study that limited application of synthetic acaricide to include only a barrier zone along the lawn–woods ecotone on residential properties did not find the observed suppression of host-seeking ticks within this treated portion of the residential properties to result in reduced human tick bites for the residents , whereas the local intensity of transmission of mosquitoborne viruses fluctuates dramatically among years and builds over the warm time of the year when mosquitoes are active. This advantage for tick control is counteracted by the fact that mosquito control can focus initially on known larval development sites and then, as needed based on surveillance data, move to a space spray emergency measure not requiring physical access to residential properties. For ticks, every year brings a seasonally predictable emergency situation, risk habitats are diffuse and include both private and public lands, and current options for area-wide tick suppression are limited and have weak evidence bases for impact on human tick bites and disease  and staffed with professionals experienced in public outreach, mosquito biology, pesticide use, and operational surveillance and control concepts. Expanding the activities of existing mosquito management programs to also include ticks (The most productive way of exploring the concept of integrated tick-management programs would be (well-funded) demonstration projects focused on geographic locations with strong existing mosquito management programs and severe problems with a wide range of tick species and tickborne diseases. Such an effort is guaranteed to be challenging because it needs to include development of tick-specific knowledge and acquisition of tick-specific equipment; development, implementation, and evaluation of a locally appropriate, standardized tick/pathogen surveillance scheme to address key knowledge gaps, if they exist, for human-biting ticks of local concern and their associated pathogens; development, implementation, and evaluation of a public outreach program to raise local awareness of spatially and seasonally variable risk for exposure to locally found ticks and tickborne pathogens; and development, implementation, and evaluation of schemes for suppression of locally found human-biting ticks on high-use portions of public lands  and on private properties in conjunction with homeowners and using different tick suppression models . The lessons learned from such demonstration projects to establish integrated tick-management programs staffed by public health professionals would greatly improve our ability to produce specific and realistic guidance for best management practices.–,,I. scapularis ticks, only A. americanum ticks, or both species). Cost assessments would be critical to clarify the resources needed to either build ticks into an existing mosquito management program or build an integrated tick-management program from the ground up in settings lacking existing mosquito management programs. Finally, the need for adequate funding for operational tick management cannot be overstated; tick management cannot be incorporated into an existing mosquito management program as an unfunded activity or mandate, and a stand-alone tick-management program equally will require substantial and sustained funding.Moreover, selection of specific tick and pathogen suppression methods to include for either backyard control or area-wide tick management will be challenging because the evidence base for existing approaches is reasonably strong for acarologic outcomes  but extremely weak for human-based outcomes (human–tick encounters and human illness) (


Outdoor Learning in natural environments is a burgeoning approach in the educational sector. However, the evidence-base of research has not kept pace with teacher perceptions and increased practitioner usage. Anecdotal evidence and formal research suggest the significant health and wellbeing benefits of nature connection. Offering low-cost, non-invasive pedagogical solutions to public health challenges—particularly around mental health, wellbeing, physical literacy, and increasing physical activity–the pedagogical benefits of Outdoor Learning are yet to be fully enunciated. The proposed systematic review will search for studies across eight academic databases which measure the academic and socio-emotional benefits of Outdoor Learning, with a focus on school-aged educational settings. Using the inclusion criteria set out in this paper (and registered with PROSPERO: CRD42020153171), relevant studies will be identified then summarised to provide a synthesis of the current literature on Outdoor Learning. The goal of this review is to document the widespread international investigation into Outdoor Learning and its associated benefits for development, wellbeing, and personal growth. The systematic review will provide insights for teacher-training institutions, educational policy makers, and frontline teachers to improve the learning experiences of future students.  Learning outdoors has been the norm through most of human history. Gaining an understanding of how to thrive and maintain a balance in the natural environment was the learning context for Indigenous cultures across the world ,2. When Learning outdoors has been defined as taking students outdoors into their immediate or nearby surroundings to learn essential lessons of the curriculum, with four possible zones: (a) school grounds, (b) local neighbourhoods, (c) day excursions, and (d) overnight stays/residential camps and expeditions . TeacherLearning Outside the Classroom, with the aim of helping mainstream teachers “incorporate more meaningful Outdoor Learning opportunities into their daily teaching activities” (inside cover). This manual provides classroom teachers with an overview of educational theory supporting Outdoor Learning, and a practical guide for how to use school grounds and local neighbourhoods as an extension of their classroom [The literature on Outdoor Learning, as we have defined above, is generally sparse, however four examples stand out. Firstly, Scottish outdoor educators Beames, Higgins, and Nicol  wrote a lassroom .Elsewhere in the UK, the Natural Connections Demonstration Project  used a dThe third landmark for Outdoor Learning is Denmark’s concept of ‘udeskole’ (outdoor school), where students spend regular hours every week learning outside (irrespective of the weather). Denmark is often recognised as a world leader in Outdoor Learning , and itsIn terms of a comprehensive overview of Outdoor Learning research around the world, the final highlight is a systematic review of ‘regular classes in outdoor settings’ . This paStanding on this foundation of initial research into the emerging field of Outdoor Learning, the authors set out to undertake a systematic review of international literature on Outdoor Learning benefits to students’ academic and socio-emotional development. In order to spread the net wider than the previous systematic review , our minThis systematic review protocol is both timely and prescient and aims to determine the characteristics of Outdoor Learning that lead to beneficial outcomes. These may include the frequency of connection with the natural world, activities that foster executive function, structuring Outdoor Learning, cognitive growth and the development of new skills. Teacher confidence and skill level  may alsoThe term ‘Outdoor Learning’ has been used in the literature to describe a range of educational activities from neighbourhood nature play settings to lessons formally embedded within school curriculum ,31,32,33A number of mechanisms through which contact with nature influences whole child development have been documented ,37,38,39Additional benefits attributed to participation in Outdoor Learning include: building a sense of identity, analytical skills, life ownership, stress relief , and incThe potency of Outdoor Learning is being underpinned by a mounting number of literature reviews that highlight the evidence-based research for the developmental and wellbeing benefits on children and adolescents ,72,73,74The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines  will be The international peer-reviewed literature included in this systematic review will be limited to literature published between 2000 and 2020, which has been published in English.Academic searches will be conducted using the following databases: (1) Education Resources Information Center (ERIC) (2) Proquest, (3) PsycINFO, (4) PubMed, (5) Sage, (6) Scopus, (7) Web of Science, and (8) Wiley. Forward citation searches will be performed on all included studies. Grey literature will also be accessed using Google Scholar (first 50 hits) and OpenGrey. The title and abstract of initial search hits will be screened by one reviewer according to the inclusion criteria, with a sample being verified by a second reviewer. Potentially relevant articles will then be read independently by two reviewers.For a detailed protocol and search strategy, please refer to our registered and published protocol under the International Prospective Register of Systematic Reviews (PROSPERO) Number CRD42020153171.An interdisciplinary team with a diverse range of expertise  was consulted in the development of this strategy, which should lead to an exhaustive and relevant search process. The specific search terms are listed in The search strategy will be adapted as appropriate for each database, with searches conducted on title and abstract. Included studies will be stored on Endnote reference management software, and initial screening decisions will be made using Rayyan software.The first stage of screening articles’ title and abstract will delete non-English language papers, duplicate articles, and other studies clearly identified as inappropriate according to the criteria of this review. Quantitative and qualitative research methods will be considered, including randomized controlled trials (RCTs), quasi-experimental, case-control, pre-post, cross-sectional, and cohort studies.One reviewer will screen all records for inclusion, and a second reviewer will independently screen 10% of records early in the process. Any discrepancies will be discussed in order to determine the relevance of that study, and to refine the inclusion criteria for the remainder of the screening process.The focus of this systematic review is research that investigates the impact of intentional Outdoor Learning. Included programs must report on measurable learning outcomes and be conducted in an outdoor setting (either on school grounds or in the community). The program must involve school-aged students spending regular or extended time in an outdoor environment rather than a one-off excursion, and there needs to be a connection between the characteristics of the physical setting and the learning outcomes.Studies that do not fulfil all the inclusion criteria will be removed from the review. Specific exclusion criteria include non-school aged participants, indoor off-campus environments, no identifiable learning outcomes, unstructured outdoor play, and poor research quality. Papers need to report on original research, therefore, secondary sources such as commentaries, theoretical papers, literature reviews, opinion, and editorial articles will be excluded. Case studies and conference proceedings will also be excluded from the review.The second stage of the review involves two reviewers independently reading the full text of all records which remain after the screening stage, to confirm that they meet the inclusion criteria. Similarly to the screening stage, any disagreements will be resolved through dialogue between the two reviewers, or if needed, deferment to a third reviewer. Data from the final set of included studies will be categorised using a bespoke Excel spreadsheet, including: publication year, author(s), national/regional context, funding sources, research objectives, sample/population characteristics , research method(s), location type , type of learning activity , program characteristics , measured outcomes , comparison environment or activity if applicable, and main findings.Similarly to the data extraction process, one reviewer will apply an appropriate risk of bias assessment tool for each included study, and a second reviewer will independently assess risk of bias for 10% of studies to ensure consistency.(1)Population(2)Randomised selection of participants(3)Sample size(4)Response and attrition rate(5)Main variables or concepts(6)Operationalization of concepts(7)Numeric tables(8)Missing data(9)Appropriateness of statistical techniques(10)Omitted variable bias(11)Analysis of main effect variables(12)Ethics approvalThe quality of quantitative studies will be appraised using the CCEERC Quantitative Research Assessment Tool  which as(1)Is there congruity between the stated philosophical perspective and the research methodology?(2)Is there congruity between the research methodology and the research question or objectives?(3)Is there congruity between the research methodology and the methods used to collect data?(4)Is there congruity between the research methodology and the representation and analysis of data?(5)Is there congruity between the research methodology and the interpretation of results?(6)Is there a statement locating the researcher culturally or theoretically?(7)Is the influence of the researcher on the research, and vice- versa, addressed?(8)Are participants, and their voices, adequately represented?(9)Is the research ethical according to current criteria or, for recent studies, and is there evidence of ethical approval by an appropriate body?(10)Do the conclusions drawn in the research report flow from the analysis or interpretation of the data?The quality of qualitative studies will be appraised using the JBI Checklist for Qualitative Research , which aIt is anticipated that the included studies will be diverse in methods and results, which will preclude a quantitative meta-analytic approach. Instead, a narrative synthesis of the included papers will be offered, including development of a preliminary synthesis of findings, exploration of relationships within the data, and an assessment of the robustness of the synthesis .The stated limitation of this systematic review to articles published in English may exclude pertinent studies written in other languages. This review is focused on school aged children, and therefore will omit research data from the early childhood sector internationally, where adoption of Outdoor Learning has been in place for a number of years and has resulted in many interesting studies.The strength of systematic reviews is their clearly defined criteria and explicitly stated search terms, however, it is possible that the selected criteria miss other pertinent key terms which relate to the topic area. It is hoped that the broad list of search terms utilized in this review will capture the vast majority of relevant research in the area of school-based Outdoor Learning.Physical education often occurs in an outdoor environment, but has been excluded from the parameters of this review. Although the distinction could be made between natural settings and ‘hardened’ outdoor spaces  which have been modified for human use, there is no doubt that students benefit simply from being outside and undertaking physical activity . HoweverThe systematic review protocol set out in this paper outlines a transparent and reproducible procedure for assessing the cognitive and socio-emotional benefits of Outdoor Learning. The research protocol will also provide an audit of research quality in the area of Outdoor Learning, reducing risk of bias and selective outcome reporting in individual studies.A significant proportion of Outdoor Learning occurs in natural settings, and there is a discrete body of literature on the benefits of ‘nature connection’ ,86. It wThis review will bring together research on Outdoor Learning initiatives arising from distinct local contexts, to provide an international audit in this important field. Coalface educators, and even local policy makers, may only be aware of their particular iteration of Outdoor Learning, however this review will broaden their knowledge of various forms of Outdoor Learning, and help them to appreciate how their efforts fit into an international movement toward incorporating outdoor environments into the learning landscape.The systematic review set out in this paper will produce a thorough exploration of Outdoor Learning outcomes for school children. The review will synthesize emerging evidence about the academic and socio-emotional benefits of education outside the classroom, and broaden understandings of holistic educational outcomes. It will also provide some commentary on the common themes which underly effective practice in Outdoor Learning.The findings of this review will suggest relevant focus areas for future research and educational programs, by highlighting program and pedagogical characteristics which are most beneficial across contexts, as well as promising areas in which further research is needed. This synthesis of effective factors in Outdoor Learning will allow governments and policy makers to be better informed as they work with curriculum designers and education practitioners to utilize natural environments for maximising holistic student outcomes.


Smallholder farmers provide the foundation for food security in South Asia. However, increasing seasonal labor scarcity caused by rural out-migration has resulted in growing agricultural labor costs, presenting challenges to cash-constrained smallholder farmers that hire manual labor for land preparation, sowing, harvest and post-harvest operations. Technological innovations in small-scale agricultural machinery appropriate for the small field sizes and limited resource endowments of South Asia's farmers have been proposed as a potential solution to this problem. An increasing number of development initiatives also promote rural entrepreneurial approaches to mechanization, whereby smallholder farmers can access and use machinery in their own fields on an affordable fee-for-service basis offered by machinery owners. This approach reduces capital constraints for smallholder farmers while enabling entrepreneurs who can afford equipment to enter into business serving stallholder farmers as clients. This approach is now widely practiced in Bangladesh, where machinery entrepreneurs play a crucial role in providing access to productive technologies for smallholder farmers who could not otherwise afford direct purchase of labor- and cost-saving machinery. In order to maintain low machinery purchase costs for emerging yet capital constrained rural entrepreneurs, while also assuring high quality standards, cost-effective domestic production of agricultural machinery is increasingly championed as an important long-term national development objective. With no safety standards or guidelines for best production practices, the few manufacturing workshops that exist within Bangladesh operate inefficiently and without clear rationalization of manufacturing processes. Haphazard copying of prototypes or imported available machinery is common. This leads to inefficient production and poor product quality in an emerging but potentially highly beneficial industry. This paper addresses these problems and presents a case study to increase machinery manufacturers' capacity while improving manufacturing operations and workplace safety through equipment selection, workshop layout, and usability.Janata Engineering (JE) is a small-scale machinery manufacturing enterprise in Bangladesh, specializing in two-wheel tractor attachments such as bed planters, local derivations of power-tiller operated seeders, and other equipment for planting, irrigating, and processing crops. JE was expanding and setting up a second factory for which the authors provided assistance on its design. Our research question was whether participatory action research (PAR) supported by empirical data could provide improved factory design in terms of functionality, safety and human interactions, when compared with conventional approaches driven by technical efficiency concerns alone. Using PAR, we developed a number of alternative process and layout recommendations for JE to increase the efficiency of labor and machinery through improved workflow, throughput, and output. While immediately useful for JE, the process and protocols proposed in this paper are relevant for emerging agricultural machinery manufacturers in Bangladesh and more widely in South Asia. •A method is presented for factory design for small agricultural machinery manufacturers in developing countries.•Participatory action research improves design relevancy for emerging-world agricultural machinery manufacturers.•Lowering overall handling distance reduces labor, probability of product damage and costs, by increasing throughput. AlthougContemporary development initiatives focusing on farm mechanization therefore increasingly point to the need for ‘scale-appropriate’ mechanization that makes use of affordable equipment custom-designed for the small fields and low-resource endowments of smallholder farming systems . These i−2  first visited the factory site to prepare a scale diagram of current equipment layout section . Followi3.22, laid out in an L-shape. The workshop had access to reliable electricity and was sub-divided into sections used for storage and construction of a variety of agricultural machineries  without electrical or material location constraints, (b) with electrical location constraints, and (c) with material location constraints. These are shown in 3.6Based on the collaboratively identified alternative workshop and work flow configurations, we analyzed the resulting use frequency of each tool needed in the fabrication process of the bed planter. The overall productivity of a workshop is improved by several factors including reducing labor, lowering chances of product damage, and increasing throughput speed. Lowering overall handling distance directly affects and reduces labor, probability of product damage, and throughput which, in turn, lowers costs. The best layout minimizes handling distance and cost. A travel or “from-to” chart accounts for these factors by tracking two sets of data: usage frequency of and distance between each material and tool in a potential layout . The resThese two sets of data were multiplied to provide the total distance traveled between each pair of materials or tools. The sum of all distances is the total distance traveled or total handling distance for that workshop layout. “From-to” charts were created for each proposed layout are shown in 3.7We convened JE staff as a focus group to provide feedback on the functionality and safety included ground clearance to reduce hazards and injuries, location of where the material deliveries would be offloaded, and location where those materials would be most accessible during hours of operation and secure during hours when the facility is inactive. This feedback is provided in 3.8Finally, recommendations were fed-back to JE in the form of a redesign of the workshop workflow through layout of materials, tools, assembly, testing, and facilities areas.44.1Well-designed allocation of space and equipment layout can increase overall productivity by reducing labor, lowering product damage, increasing throughput speed, easing future incorporation of new processes, and improving safety and morale . The fouDiagrams of the tool usage and workflow graphically represent the various actions performed and the tools and materials used in the JE workshop to fabricate bed planter components and subassemblies . Quantif4.2The predefined footprint of the JE workshop dictates that the locations for the primary functions surround a central open space B. This cTravel chart results for each of the layouts shown in 4.3Layouts B and C were considered as alternatives to, but not quite as strong as, layout D in terms of efficiency, functionality, and profitability. Layout B was also considered the safest option by a slight margin. Therefore, layout D appeared to be the most preferable design of the four options for implementation at JE. Feedback on layout D also included preference for the compact design and for the location of raw material storage adjacent to general storage.5processes and procedures that are the core plank of PAR  and manufacturing machinery required to move to the next level of quality and efficiency. As initially demonstrated by this proof-of-concept paper, PAR can support the improvement up to and throughout the period when more advanced technical methods are required to design future manufacturing processes.The process outlined in this paper provides a framework for the design of workshops that can be adapted and utilized in other developing countries. Factory design schemes for developing countries tend to be focused on conventional goals of technical efficiency, rather than incorporating employee's ideas and contributions in terms of functionality, safety, and human interactions. They also tend to be directed toward large companies with resources and technical skills . As a re6This paper presented a process using participatory action research as applied to the design and optimization of agricultural machinery workshops for developing countries, using Janata Engineering and the manufacturing and assembly of two-wheel tractor attachable bed planters in Bangladesh as a case study example. The steps include iterative interactions with the manufacturer to understand the component processes used in manufacturing and assembling the bed planter product, followed by the determination of improved fabrication and assembly operations required to make the components and assemble them, after which alternative workshop layout options were developed with the participation of JE staff. These designs were based upon considerations of importance to workshop workers, including locations of business operations, fabrication, assembly and testing, inventory storage, space for taking breaks, and storage for the employees’ belongings during work hours. Four alternative layout designs for the fabrication and assembly area were generated, which were subsequently analyzed using travel charts and through focus group evaluation with JE staff. This process is useful for the design and optimization of small-scale agricultural machinery workshops in Bangladesh and can be applied to improve agricultural machinery manufacturing in similar developing country contexts.Cereal Systems Initiative for South Asia (CSISA) Phase II and the CSISA-Mechanization and Irrigation projects funded by the 10.13039/100000865Bill and Melinda Gates Foundation (10.13039/100000865BMGF) and 10.13039/100000200USAID. Additional support was provided through the MAIZE CGIAR Research Program. The results of this research do not necessarily reflect the views of USAID, the United States Government, or the BMGF.This research was supported by the


Tracing and quarantining symptomatic and asymptomatic individuals infected by the novel coronavirus SARS-CoV-2 is an important approach to controlling the current epidemic. Tracing the source of an infection can be achieved by conventional interviews, by mobile telephone tracking, or by phylogenetic tracing of the virus genomes themselves, as we have proposed in our work .JMIR Public Health and Surveillance  disappeared due to additional clustering of [five] previously unsampled sequences from Portugal, Brazil, Wales, and [two from] the Netherlands.”Upon request, Dr Mavian provided us with a file of these five new sequences. Comparing these five in our coronavirus sequence alignment table (freely available on the Fluxus Technology website ), it traMoreover, Mavian and colleagues  have not


The COVID-19 pandemic is an unprecedented challenge for nursing homes, where staff have faced rapidly evolving circumstances to care for a vulnerable resident population. To document these healthcare professionals’ experiences during the pandemic, we used social media and professional networks to disseminate an electronic survey with closed- and open-ended questions to a convenience sample of long-term care staff from May 11 through June 4, 2020. Four investigators identified themes from qualitative responses for 152 nursing home staff respondents from 32 states. Key themes included: constraints on personal protective equipment (PPE) and testing; burdensome regulations and guidance; concern for self, family, and residents; workforce burnout; organizational communication and teamwork; and public lack of recognition. Respondents described ongoing constraints on testing, and reliance on crisis standards for extended use and reuse of PPE. Administrators discussed implementing sometimes confusing or contradictory guidance from numerous agencies. Direct-care staff expressed fears of infecting themselves and their families, and expressed empathy and concern for their residents. They described burnout due to increased workloads and the emotional burden of caring for residents facing isolation, illness, and death. Respondents cited the presence or lack of organizational communication and teamwork as factors influencing their ability to work under challenging circumstances. They also described the demoralizing impact of negative media coverage of nursing homes, contrasting this with the heroic public recognition given to hospital staff. These challenges added significant burden to an already strained workforce and are likely to contribute to increased burnout, turnover, and staff shortages in the long-term.


Robotic space exploration to the outer solar system is difficult and expensive and the space science community works inventively and collaboratively to maximize the scientific return of missions. A mission to either of our solar system Ice Giants, Uranus and Neptune, will provide numerous opportunities to address high-level science objectives relevant to multiple disciplines and deliberate cross-disciplinary mission planning should ideally be woven in from the start. In this review, we recount past successes as well as (NASA-focused) challenges in performing cross-disciplinary science from robotic space exploration missions and detail the opportunities for broad-reaching science objectives from potential future missions to the Ice Giants.This article is part of a discussion meeting issue ‘Future exploration of ice giant systems’. Large-scale missions comprise more than just ground-breaking science , they alNASA funding of robotic space missions comes from the Science Mission Directorate (SMD) and is predominantly supported by one of four divisions: Astrophysics, Earth Science, Heliophysics or Planetary Science. Astrophysics focuses on the origin of the universe and extra-solar system celestial bodies and structures ; Earth Science on interconnected terrestrial processes including weather, atmospheric dynamics, geophysics, hydrology and climate change; Heliophysics on solar and space plasma physics, including space weather, planetary magnetospheric dynamics and aeronomy, and the interaction of our solar system with the local interstellar medium (LISM); and Planetary Science on the formation and characterization of all planetary bodies  within our solar system and beyond. Obviously, there are large overlaps and synergies across the Divisions. Our emerging expertise in studying exoplanets (planets orbiting stars besides our own), for example, is spear-headed by Astrophysics (remote sensing of exoplanets with large space-based telescopes) with needed expertise also shared across Planetary Science (characterization of exoplanets in the context of the worlds in our own solar system) and Heliophysics (characterization of planet-stellar wind interactions in our habitable astrosphere).not guiding documents, nor are the Divisions bound (nor at times able) to follow them completely. Though this review focuses primarily on NASA and the funding processes within the USA, it should be noted that the Science Programme at ESA is likewise guided by community-driven long-term plans that occur roughly each decade and place high value in cross-disciplinary themes . The. Thein s from V1  and V2 [ from V1 , Saturn  from V1  and V2 [ from V1 , Uranus  from V1  and Nept from V1 . V2 alsoin situ instrumentation, these diverging trajectories presented a unique opportunity for the Heliophysics and Astrophysics communities: a chance to sample the outer limits of the solar system and its interface with the interstellar medium for the first time and from two spatially removed vantage points. Thus, on 1 January 1990, the Voyager Mission ended and the Voyager Interstellar Mission (VIM) officially began [in situ observations of our solar system's termination shock [Because V1 and V2 planned close flybys of Titan at Saturn and Triton at Neptune, respectively, they left the ecliptic plane as they careened beyond their final planetary targets: V1's trajectory bent northward (or above) the ecliptic and V2 headed southward (or below). Since both Voyager spacecraft were already outfitted with the necessary ly began . Becauseon shock , heliopaon shock  and LISMon shock .Other missions have made similar transitions beyond their original mission objectives and gone on to contribute significant additional cross-disciplinary science in addition to their primary missions. The lunar reconnaissance orbiter (LRO) was conceived as part of NASA's New Vision for Space Exploration . The misin situ measurements from the VIM [A notable example of fortuitous cross-disciplinary science comes in the form of energetic neutral atom imaging—a technique that has quite recently been used, with remarkable results, to map the outermost edges of our Sun's astrosphere. The Interstellar Boundary Explorer (IBEX) mission was launched in 2008 with the goal to map the heliospheric boundary to better understand the nature of the solar system's interaction with the LISM and provide global context to the localized  the VIM ; though Soon after the launch of IBEX, further heliospheric imaging contributions came from an unlikely source: the Ion and Neutral Camera (INCA)  on the CER [NASA missions have demonstrated many examples of cross-Divisional observations over the years. Cassini flybys of both Venus and Earth in 1999  providedRE . Most reRE  completeRE .Several missions have made use of Jupiter gravity assists and in doing so, provided additional measurements of the Jovian system. For instance, the Ulysses (solar physics mission) flyby of Jupiter accessed previously un-investigated regions of the planet's magnetosphere, including higher magnetospheric latitudes, the dusk sector and inner magnetosphere . Similarin situ observations of multiple comet tails [Chance encounters have also provided opportunistic scientific observations for missions carrying appropriate instrumentation. For example, MESSENGER (mission to Mercury)  unexpectet tails ,45 as weet tails .Figure Long cruise durations on the way to planetary targets, especially those in the outer solar system often provide ample opportunities to acquire additional observations, like the previously discussed heliospheric energetic neutral atom images from Cassini/INCA. Voyager and many later planetary missions  obtained UV measurements of interplanetary hydrogen  and werea) [figure 7b) [Finally, Earth-based astrophysics space assets also provide invaluable cross-disciplinary measurements. For instance, the Hubble Space Telescope (HST) has provided a rich legacy of solar system observations, including giant planet images captured as part of the Outer Planets Atmospheres Legacy (OPAL) program . HST imafigure 7a)  and the gure 7b) . HST wasgure 7b)  and bothgure 7b) ,59 and Cgure 7b) –63 had r3.recognized and purposefully planned, where feasible while remaining cognizant of the current fiscal realities. As our review has hopefully demonstrated, a lot of these previous opportunities were not even conceived of until after mission launch; cross-disciplinary opportunities conceived early in mission development will likely yield the strongest return on enhancing cross-disciplinary science.These recollections of the missions that transcended their scope are by no means comprehensive. While such a cogent collection of successes could make the achievement of cross-disciplinary science seem like a routine or easy occurrence, there are significant challenges to realizing such cross-disciplinary science opportunities that all of these successful cross-disciplinary missions have had to navigate. There are several approaches that NASA (and other space agencies such as ESA and JAXA) and the broad scientific community can adopt to help towards the goal of creating and successfully capitalizing on more cross-disciplinary science opportunities in the future: increasingly facilitate and encourage healthy communication both across focused scientific communities and vertically between the leadership and staff at the respective space agencies and NASA Divisions; all members of all of scientific communities are able to actively advocate for cross-disciplinary opportunities and investigations via, for example, white papers to the respective Decadal Surveys, and by proposing cross-disciplinary science investigations by leveraging the existing infrastructure for funding . Most importantly the opportunity for cross-disciplinary science needs to be 4.The Ice Giants, as the least explored and least well-understood planets in our solar system, leave a gaping hole in the completeness of our survey of potential planetary regimes. Future missions to the Ice Giants offer prime opportunities for cross-disciplinary science and can benefit from lessons learned on previous missions, such as those discussed above.A decade-long (or longer) cruise to either Ice Giant would provide an opportunity to study the evolution of the solar wind, acceleration processes and interplanetary shocks with radial distance from the sun. Understanding the evolution and variability of these is important for understanding stars and star–planet interactions, and thus informs not only heliophysics and planetary science, but astrophysics and exoplanetary research as well. Likewise, valuable observations of interstellar and interplanetary dust throughout the outer solar system could be obtained, building on the results of New Horizons , CassiniFuture missions to the Ice Giants also provide opportunities to investigate additional targets, like Cassini, New Horizons, Ulysses and other predecessors, these missions would likely provide a wealth of information from measurements obtained while performing a flyby to obtain a gravity assist at another planet . Those observations may be even more advantageous if timelines align such that they happen to occur simultaneously with other missions at the same target, e.g. with Europa Clipper or JUICE in the Jovian system. Such extended solar system trajectories could also provide chance encounters with comets, like MESSENGER and Ulysses experienced.While such cross-disciplinary objectives could largely be met with instruments that already have high value for Ice Giant exploration –59, the 5.Robotic space exploration, especially to the outer solar system, is by its very nature difficult and expensive. As such, it behoves the entire space science community to work collaboratively to maximize the scientific return of missions, regardless of the primary discipline or funding source. NASA and partner international space agencies have consistently navigated these challenges and provided many lessons, both positive and cautionary, that can be learned from previous missions that have successfully bridged traditional disciplinary boundaries.In situ particle and fields measurements advance our understanding of the evolution of the solar wind throughout the solar system, and remote sensing instruments provide unique vantage points of the heliosphere and the planets within it. Our future missions to the Ice Giants not only address outstanding questions about planetary and exoplanetary systems but also offer the chance to achieve even more far-reaching science objectives if we are willing to strive for them.In particular, future missions to the Ice Giants at the outer reaches of the solar system can provide many opportunities for cross-disciplinary science, especially if they are purposefully planned for early on in the development of the missions. In particular, long interplanetary cruise phases and opportunities to access infrequently visited regions of the solar system beyond 10 AU should not be squandered.