The Nutrition Embedded Evaluation Programme Impact Evaluation (NEEP-IE) study is a cluster randomised controlled trial designed to evaluate the impact of a childcare centre-based integrated nutritional and agricultural intervention on the diets, nutrition and development of young children in Malawi. The intervention includes activities to improve nutritious food production and training/behaviour-change communication to improve food intake, care and hygiene practices. This paper presents the rationale and study design for this randomised control trial.Sixty community-based childcare centres (CBCCs) in rural communities around Zomba district, Malawi, were randomised to either (1) a control group where children were attending CBCCs supported by Save the Children’s Early Childhood Health and Development (ECD) programme, or (2) an intervention group where nutritional and agricultural support activities were provided alongside the routine provision of the Save the Children’s ECD programme. Primary outcomes at child level include dietary intake , whilst secondary outcomes include child development ) and nutritional status (anthropometric measurements). At household level, primary outcomes include smallholder farmer production output and crop-mix . Intermediate outcomes along theorised agricultural and nutritional pathways were measured. During this trial, we will follow a mixed-methods approach and undertake child-, household-, CBCC- and market-level surveys and assessments as well as in-depth interviews and focus group discussions with project stakeholders.Assessing the simultaneous impact of preschool meals on diets, nutrition, child development and agriculture is a complex undertaking. This study is the first to explicitly examine, from a food systems perspective, the impact of a preschool meals programme on dietary choices, alongside outcomes in the nutritional, child development and agricultural domains. The findings of this evaluation will provide evidence to support policymakers in the scale-up of national programmes.ISRCTN96497560. Registered on 21 September 2016.ISRCTN registry, ID: The online version of this article (doi:10.1186/s13063-017-2003-7) contains supplementary material, which is available to authorized users. Lancet series on Maternal and Child Nutrition estimated that the aggregate global burden of undernutrition causes over three million child deaths per year. Stunting prevalence in children under 5 years also affects at least 165 million children [The 2013 Early Childhood Health and Development (ECD) programmes are designed to improve young children’s survival, growth and development. They are considered the most cost-effective form of human capital investment when compared to any subsequent schooling interventions . ECD invThe Nutrition Embedded Evaluation Programme Impact Evaluation (NEEP-IE) study is designed to evaluate the impact of an integrated package of nutritional and agricultural interventions  on the diets, nutrition and development of young children and their households in rural areas of Malawi.This paper presents the rationale and study design for this randomised trial.Malawi ranks 73rd out of 104 countries on the Global Hunger Index  and has The national ECD programme, led by the Ministry of Gender, Children and Social Welfare (MoGCSW) targets all children aged 0–8 years. Preschools (known as community-based childcare centres (CBCCs)) and parenting groups are the two main components of the government ECD programme. CBCCs are community-initiated and community-owned childcare centres which aim to promote holistic child development by providing safe, stimulating environments, access to health and nutritional services, and training for parents and caregivers. Today, there are an estimated 9000 CBCCs across Malawi, serving 32%percent of all 3–5 year olds in the country. Parenting groups are typically linked to the CBCC and aim to reach parents of children aged 0–8 years, as well as parents to be (newly married and pregnant women).One of the main challenges facing CBCCs is lack of food (mid-morning porridge) . The absThe Government of Malawi also recognises the need for multisectoral programming, particularly relating to nutrition  and is lCBCC caregivers receive a 2-week training, provided by government-approved trainers, using a standard government-approved training manual when they start. They receive 5-day refresher trainings annually and they are mentored by one visit/month by ECD facilitatorsCBCCs target all 3–5 year olds in the community. They are managed by the community and are open from 8 a.m. to 11 a.m., 5 days per week. Porridge  is provided at about 10 a.m. by parents/facilitators with food contributions from the communityThe standard package provided to Save the Children-supported communities includes the following activities. For the CBCC activities:CBCC caregivers and mentors received a 3-day training to organise parenting sessions using a standard government parenting education manualThe parenting sessions are organised once or twice a month on average. Topics covered by parenting sessions include: child nutrition, stimulation, and parental role in school readiness, amongst others. Parenting sessions target all parents of children aged 0–8 years old with particular focus on children from 0–2 yearsAgricultural extension workers received a 5-day training to organise parenting sessions using a standard government parenting education manualTrainings were conducted between April and May 2016. The total number of people trained was 437 with 382 women and 55 menOther ECD interventions include children’s corners, mobile phones and interactive radio instructions (IRI)For parenting education:The NEEP-IE integrated nutritional and agricultural intervention is aimed at improving the diets, feeding, health and hygiene knowledge and practices in households with infants and young children. This includes promoting optimal feeding and caring practices through parenting groups; engaging parents, adolescents and other adults in the community in the planning and preparation of meals for children within CBCCs; improving agricultural production of nutritious foods and food diversification by using CBCC gardens as a learning site for communities; forming Village Savings and Loans (VSL) groups to help communities save and access funds to purchase supplies for the CBCC garden and CBCC meals or to start new home-gardens; and by organising farmers into collectives to increase their purchasing and selling power.Amaranthus). In all this the subtopics included: land preparation and planting, weeding and fertiliser application, pests and disease control, harvesting, storage and processing and utilisation in CBCCs. The use of manure as fertiliser was also promotedTraining on nutritious food production, including the following topics: production of foods to use in CBCCs, i.e. production of selected cereals and staples ; selected legumes and nuts ; and green leafy vegetables . An AEDO would start a ridge with the correct spacing and the community would take over after that with the AEDOs making sure that the correct spacing is used and the correct type of ridge is made. This would continue until the rest of the garden has been prepared. The same process was adopted for all the gardens. Where the demonstration coincided with the first rains, the planting was also done, again with guidance from the AEDOs. AEDOs and community agents (CAs) monitor the gardens two to three times per month on averageThe first agricultural production training was facilitated by AEDOs and involved 900 participants in total. Each training session lasted 3 days and included 45 participants. The training took place in December 2015 and farmers (households) began planting soon after the training. The training was two-fold: theory and practice. A second agricultural production training was also facilitated by AEDOs to 120 participants. Each training session lasted 3 days and each session had 20 participants. These trainings took place in August 2016 and covered the following topics: land preparation and planting, weeding and fertiliser application, pests and disease control, harvesting, storage and processing and utilisation in CBCCs for carrots, spinach and tomatoesMore specifically, the agricultural training includes:In addition, participating households received a range of agricultural inputs as summarised in Table Training CBCC management committee members, caregivers, lead farmers and parents on the nutritional needs of children, healthy meals all year round, food selection, storage and preservation, food hygiene, safety and preparation, waste disposal, hand-washing, meal planning and monitoring of meal provision and recipes for CBCCs and householdsPorridges: maize flour porridge with groundnut powder, maize flour porridge with dry fish powder, maize flour porridge with dry vegetables, mango porridge, porridge made from a mixture of maize, soya, millet, beans and groundnuts flour, rice porridge with carrot and oil, and rice porridge with groundnut flourMilk and soya milk productionkidos (boiled cassava dipped in eggs and vegetables and fried), soya coffee, sweet potato doughnuts, peanut butter and soya snacksLegume products: pigeon peas sausage, cassava Amaranthus in groundnut powder and sweet potato leaf snackVegetable products: pumpkin leaf meatballs ; orange-fleshed sweet potato (OFSP) juice, sweet potato leaf juice, dried vegetables (for preservation); pumpkin leaves and Fish products: dry fish with groundnut powder, dry fish with tomato and onionFruit products: pawpaw, guava and lemon juice; pawpaw relish  and banana breadEach training session lasted 3 days and was provided by AEDOs and nutrition assistants The training combined both theory and practice, including cooking demonstrations. The participants were divided into groups of three to five people. Trainers would introduce selected recipes for nutritious meals, with instructions written on a card that was left with the group. The trainer would facilitate each step of the process. Thereafter, the groups would come together and display what they had cooked. At the display table, a member from each group was selected to explain how they made the meal, how many types of food groups the recipe contained, any alternatives and, lastly, answer any questions from the group. After the display, the participants tasted the food that they had made. The recipes included:Trainings were conducted in February 2016 and CBCC caregivers/communities began putting into practice what they had learned from March 2016. CBCC caregivers and parents were then mentored and supervised by community-based organisations (CBOs) with four visits per monthThe nutritional training activities included:Evaluating the impact of integrating nutrition and agriculture with ECD on the diets, nutrition and development of children aged 36 to 72 monthsEvaluating the impact of integrating nutrition and agriculture with ECD on CBCC meal provision, CBCC attendance and enrolmentIdentifying the main factors that influence the impact of the intervention on child- and household-level outcomesEvaluating the effectiveness of CBCCs and parenting groups as entry points to improve nutrition-related outcomes to other critical age groups, including younger siblings of preschoolersEvaluating the cost, feasibility and sustainability of scaling-up the integrated nutritional and agricultural package through CBCCs and parenting groupsThe purpose of the NEEP-IE study is to provide evidence on the effectiveness and costs of delivering an integrated agricultural and nutritional intervention through CBCCs and parenting groups on the diets, nutrition and development of young children in rural areas of Malawi. The findings of the evaluation will be used to inform the Government of Malawi and development partners on the effectiveness and feasibility of scaling-up the intervention. The objectives of the evaluation include:Lancet series framework on Maternal and Child Nutrition [The overall programme theory for the package of nutritional and agricultural interventions is guided by the utrition  and broautrition , 12–14. The three determinants of undernutrition in children include food, health and care practices . The maiThe nutritional impact is mediated by the extent of food substitution effects within the household, and the use of the nutritional intake by the child and their siblingsDiversifying diets and increasing the intake of micronutrient-rich foods can have direct effects on attention and cognitionHealthier and better-nourished children are then better positioned to learn new skills both at the CBCC and elsewhereAll these effects are mediated to some degree by women’s roles in the household, time allocation and decision-makingThe proposed intervention package can potentially have an impact on the nutrition and health of children enrolled in CBCCs and their younger siblings, as summarised in Fig. Substitution, or intrahousehold reallocation, may occur when households readjust consumption patterns in response to the CBCC meals, or to a change in diet, by substituting foods normally consumed at home, or with other foods with similar properties. Substitution is a complex issue involving changing household dynamics where gender plays a fundamental role. Influencing possible substitution effects will be critical in determining the potential impacts on children’s nutrition and health.Changes in individual-level dietary diversity have been found to be strongly associated with micronutrient adequacy of diets for women , 16 and Restoring micronutrients and enhancing energy intake can also have an impact on attention and motivation. Energy  and ironFrom an agricultural perspective, the intervention focusses on increasing food production in the CBCC garden and home-gardens by increasing yields or efficiencies through input provisions or training on farming practices. The intervention can also influence the basket of products that are being produced, supporting the production of higher-value crops and/or more nutritious crops through the provision of seeds, educational campaigns, or the opening of new market channels. The selection of particular crops involves balancing the pros and cons of substitution between crops for production, sale and consumption and the long-term impacts for both incomes and nutrition , investments  and market access . The quantity, quality and timely preparation and delivery of food in the CBCCs will also be explored.A cluster randomised trial (CRT) is being implemented in 60 rural communities with CBCCs supported by Save the Children’s ECD programme in Zomba district, Malawi. The evaluation follows a mixed-methods approach  with two rounds of surveys and assessments timed 1 year apart, including child, caregiver, household, CBCC and market-level data collection.The intervention is targeted to disadvantaged communities within Zomba district in Malawi. The proposed study population includes CBCCs currently supported by Save the Children with an ECD package, including parenting and CBCC quality improvement. The geographical area for intervention was targeted by Save the Children on the basis of a set of education variables that impact pupil attendance and achievement in school. Within Zomba, two traditional authorities (TAs) and two sub-TAs were selected based on need  and the presence of other NGOs to implement the ECD programme. Save the Children’s ECD programme currently reaches 228 communities, 109 in TA Chikowi, 42 in TA Mbiza, 37 in sub-TA (STA) Ntholowa and 40 in STA Ngwelero. Sixty-eight of these (27 in TA Chikowi and 41 in TA Mbiza) had benefited from the agricultural and nutritional components already and were, therefore, excluded from the evaluation.The evaluation targets all children aged 0–6 years in the 60 selected communities and their caregivers. The primary reference group for this study is children aged 3–6 years old living in the service area of a Save the Children‐supported CBCC. Secondary reference groups include their siblings and caregivers.Control group: communities with CBCCs supported by Save the Children’s ECD programme with no additional nutritional or agricultural supportIntervention group: communities with CBCCs supported by Save the Children’s ECD programme with additional nutritional and agricultural supportThe 60 communities were randomly assigned to one of two treatment arms:The integrated intervention package will be implemented in 30 of the 60 rural communities after the baseline survey and extended to the control communities after the end-line survey. There are several reasons why the control group in this case is not a control without intervention. The Government of Malawi is committed to scaling-up the ECD quality improvement across all CBCCs and an impact evaluation on the cost-effectiveness of different ECD quality improvement strategies is underway.The 60 CBCCs were randomly selected in two stages from a pool of 235 CBCCs in 47 clusters currently assisted by Save the Children in Zomba. Due to the clustering of the CBCCs around primary schools, the list of 235 CBCCs was screened to flag clusters where more than one CBCC was being assisted. Twenty-six clusters were excluded from the first stage of randomisation to minimise possible contamination. An additional 10 CBCCs were dropped as they had ongoing activities. The 20 clusters were then randomly assigned to two groups of 10 clusters, where the randomisation was stratified geographically by traditional authority areas. In the second stage of randomisation, within each cluster, three CBCCs were then selected at random for the study. As six clusters had fewer than three CBCCs available for the study, in order to select a full sample of 30 CBCCs per treatment arm, additional CBCCs were randomly selected from three clusters .Initial power calculations and resource availability had suggested the adoption of a sample with 30 clusters (communities) per treatment arm with 20 households in each cluster to identify reasonable treatment impacts of the intervention on the primary study outcomes. Data for power calculations was obtained from the 2010 Demographic and Health Survey (DHS) survey. We calculated means, standard deviations and intracluster correlation coefficients (ICCs) for rural children in Malawi. For Dietary Diversity Score (DDS), the mean and standard deviation for rural children aged 0–5 years were estimated to be 2.5 and 1.03, respectively. The ICC was 0.01. Plots of the standardised minimum detectable effect size (MDES) against the number of clusters assuming a sample of 25 children measured in each community (cluster size), consistent with 20 household interviews per community and considering that several children may end up not being tested, showed that only a marginal gain can be obtained by expanding the sample beyond 20 as power is mainly driven by the number of clusters   and recurrent costs incurred at the school level. The questionnaire will also cover both cash and in-kind contributions and will be used to estimate both financial and economic costs. Financial costs capture actual expenditures in terms of programme implementation on an annual basis. Economic costs included the opportunity costs of community members, teaching staff and other stakeholders involved in the intervention provision. Opportunity costs of preschool staff and community members will be calculated using local pay scales. Capital costs will be annuitised over the useful life of all relevant school-level assets using a discount rate of 3% as per World Bank recommendations. Annuitisation enables an equivalent annual cost to be estimated and reflects the value in-use of capital items, rather than reflecting when the item was purchased. Process and output data covering the adequacy of the service delivery will be collected from monitoring visits on a quarterly basis using standardised data collection forms. Output data will be combined with the costs to provide estimates of cost-efficiency metrics, including costs per beneficiary, kilocalories, iron, and vitamin A delivered. Sensitivity analysis will be undertaken to account for uncertainties in the economic evaluation. The figures obtained in this way will then be compared to figures calculated for other interventions.The enumerators will be recruited from Chancellor College, University of Malawi and trained for the baseline survey. Each team, led by a supervisor and assisted by community leaders, will conduct household listings and sampling in each enumeration area. The data collection will be undertaken using electronic tablets. Data collection will be reviewed daily by a team supervisor and inconsistencies clarified. Dietary assessment will be undertaken by trained and supervised enumerators using the interactive 24-h recall method. Prior to the recall interview, caregivers will be briefed on the purpose and methods of interview. The interview will be conducted using visual aids to assist in estimating portion sizes of the foods consumed. The 24-h dietary assessment will be repeated on nonconsecutive days for a subset of households (approximately 20%) to obtain estimates of usual intake . AnthropEarly childhood development programmes are considered as the most cost-effective form of human capital investment compared to any subsequent schooling interventions . EmerginThis paper describes the design for a CRT of a preschool-feeding-based intervention linked to smallholder agricultural and community engagement. As far as we are aware, it is the first to explicitly examine (from a food systems perspective) the simultaneous impact of a preschool meals programme on dietary choices, alongside outcomes in the nutritional, child development and agricultural domains. As the intervention is complex, the scope of this theory-based evaluation includes measurement of a range of outcome and process metrics across multiple disciplines. The data collection requires multisectoral expertise in the survey teams, including measurements of dietary intake, anthropometry and child development, alongside expenditure and other socioeconomic-related dimensions.The first participant was enrolled on 7 September 2015. Data collection for the last of 120 participants will be completed by December 2016 Additional file 2:SPIRIT 2013 Checklist. (DOC 120 kb)


Compact cities and their urban forms have implications on sustainable city development because of high density urban settlement, increased accessibility, and a balanced land use mix. This paper uses quantitative means of understanding urban morphological characteristics with reference to the differing qualities of the urban form . The results, based on 89 neighborhood communities of Hong Kong, show varying degrees of regional differences in the urban built form supported by numerical statistics and graphical illustrations. This paper offers empirical evidence on some morphological characteristics that can be estimated objectively using modern geospatial technologies and applied universally to inform urban planning. However, more studies linking these quantifiable measures of the physical form with sustainable urban living are needed to account for human comfort in the totality of environmental, social, and economic responsibilities. Urban morphology describes the physical form of a city in terms of its building layout, road patterns, land uses, and green space . The curA wide range of descriptive and quantitative urban morphological measures have been developed over the years ,16,17. TUrban morphology can affect the quality of urban life and pleasantness to live. Overcrowding, congestion, air pollution, and lack of green space are some of the negative attributes of urban development. There is, however, an increasing focus in linking urban form and sustainable city development. These efforts can be summarised into two competing models of sustainable urban form: (1) compact cities based on ecological footprints; and (2) green cities based on more open type of urban structure . Urban dUrban compactness is often perceived through high population density, mixed-use, and efficient transport ,26. AnalLand use planning may affect human behaviour. It has been proven that more varied land use patterns encourage walking or biking while reducing driving ,33,34. TThe physical layout of an area, including the size and designated land uses, is often shaped by street typology which affects walkability and accessibility. Street patterns or the measurement of geometric accessibility at the street-building level of representation have evident usefulness for urban analysis ,40,41. HHong Kong has a compact urban built form consisting of high-rise and high density dwellings and mixed land uses. This high density high-rise built form is considered by some researchers to be a model of sustainable transport development but Hong Kong has also been criticized for its severe lack of green and open spaces for quality living conditions . This pa2 [Hong Kong lies in the southern coast of China beneath the Pearl River Delta. Located between latitudes 22°08′ N and 22°35′ N and longitudes 113°49′ E and 114°31′ E, it has more than 200 islands and occupies a total land area of 1104.41 km2 . Its maj2 . Around Because of historical development and new town planning initiatives, the morphological characteristics of new towns in the urban-rural fringe  are significantly different from urban development in earlier periods. Recent studies have shown that the environmental performance of neighborhoods is important to the health and well-being of their residents . As manyThe study identified a total of 89 neighborhoods representing different degrees of urbanization . The spaThe study made use of official data from the Survey and Mapping Office of the Lands Department of Hong Kong, including digital topographic map series (B5000 and B10000), digital orthophotos (DOP 5000), building data (BG1000), and road centerline files (RG1000) for 2011. Other data for cross-validation comprised SPOT-5 panchromatic image of 2.5-m resolution and multispectral image of 10-m resolution for the year 2010, as well as the outline zoning map series  from the Hong Kong Planning Department. These data were used to extract various urban morphological metrics described below. Urban morphological metrics selected for the study should describe spatial characteristics based on size, composition, and intensification of the built-up area . The fivThe number of road intersection and road density are useful measures to describe urban typology ,58. The Building volume within a neighborhood is a measure of building densification. It was estimated by summing products of all building footprints and their corresponding building heights. Ground floor building footprints were retrieved from the B5000 building feature layer while building heights were obtained from the BG1000 building data.LUM index for each neighborhood was calculated using the formula expressed below:N is the number of compatible land use types; k is the type of land use; and p is the proportion of a specific type of land use within a neighborhood.A land use map is an important layer for understanding the relationships between developed and natural areas. Hong Kong has seven major designated land uses: commercial, greenery, industrial, institutional, mixed, open area, and residential. The greenery classification includes the following uses: agriculture, conservation, grassland, country and urban parks, greenbelt, and recreation. Since digital land use maps of Hong Kong are not readily available, the layer was derived by combining data from multiple sources, including B5000, SPOT-5 images, and OZP. The percentage of each type of land uses within an 800 m × 800 m neighborhood was processed using GIS-based functions. The To address the issue of land use compatibility amid diversity, the study excluded industrial land use in the computation of LUM scores because of its negative effects, such as poor air quality or higher crime ,38. In aFive morphological metrics were computed for each neighborhood. Each metric recorded in different measurement units was converted into standardized scores to allow for fair comparison. The unity-based normalization process, as shown below, was applied to bring all values into the range :The standardized metric scores were sorted and grouped by four geographic regions of Hong Kong. Although textual or tabular presentation is excellent in conveying exact values, they are less effective in communicating an overall impression and for comparative analysis . This stp ≤ 0.05) between the means of all five morphological metrics. Post hoc analysis using various tests  was used to conduct other than just pairwise comparisons to determine which specific groups differed from each other for each morphological metric (not shown here). The results found that neighborhoods within the four geographic regions  exhibit different morphological characteristics based on the five metrics. The results also indicate varying degrees of regional differences in the urban built form.One-way analysis of variance (ANOVA) was applied to determine whether the mean normalized scores are statistically significantly different from each other. The study examines physical constructs of urban sustainability based on morphology. Although sustainability is a complex issue involving multiple concerns, the physical form of cities including the way people live in them and travel around them constitutes an important element of consideration. The compact city arguments have focused on increasing the density of urban development, improving accessibility, encouraging mixed land uses, and enhancing green space. These components can be assessed in an objective manner using modern geospatial technologies but they must be considered in light of the limits to growth. The study made use of neighborhoods located in the core and peripheral areas of Hong Kong to examine their morphological qualities based on five metrics—road intersection, road density, building volume, greenery, and LUM. These metrics do overlap, to some degree, and it is difficult to completely isolate individual factors. For example, the extent of the road network and the building footprint in an area are roughly equal in their negative contribution to the extent of green space.Despite apparent simplicity of the morphological metrics, the study demonstrates the feasibility of deriving these measures and making sense of the quantitative results. Descriptive statistics  are usefThe box plots  enable cCities are ranked or rated by many ways, such as population, gross domestic product, quality of life, cost of living, and crime. The visualization tools described in this paper serve as an initiative to a broader and deeper exploration in the multidimensional realm of sustainable urban forms. Although a myriad of indicators do exist to compare performance between urban areas, visualization makes comparing cities with various attributes easy and straightforward  even thoA major limitation of the urban morphological methodology concerns a lack of research in the applicability thresholds for best practice in sustainable development. This study assumes that increasing values in morphological metrics will enhance urban sustainability. That is to say increasing density, improved accessibility, intense LUM, and more green space have positive impacts on urban sustainability. However, the various morphological metrics have negative influences on each other within a unit of space. For example, increasing built density will take away lands for green space, as illustrated by KLN in this study. Further investigation is thus needed to establish thresholds of having the maximum expected utility of different morphological metrics in urban development. In particular, how much green space is needed to mitigate the effects of building at high density? Noting that the issue of urban sustainability is more than the physical form, future study should consider also environmental concerns, social acceptability, and economic viability.It is important to have quantitative criteria for sustainable urban development that can be applied in other cities. The study introduces five morphological characteristics that can be derived objectively from aerial images of a city. There remain, however, many questions about urban sustainability. Are more compact, higher density, and mixed urban forms more environmentally sound and more efficient for transport? How much urban green space do people need in their neighborhood to be healthy and happy? With increasingly intense debates in policy and practice about sustainability, this paper offers partial insight on some morphological metrics that can be applied universally and used to inform policy planning. It provides food for thought on quantifiable measures that can be used as evidence for urban planners, designers, as well as decision and policy makers to support their proposals towards more sustainable urban living.


In the Netherlands, most patients with severe mental illness (SMI) receive flexible assertive community treatment (FACT) provided by multidisciplinary community mental health teams. SMI patients with comorbid posttraumatic stress disorder (PTSD) are sometimes offered evidence-based trauma-focused treatment like eye movement desensitization reprocessing or prolonged exposure. There is a large amount of evidence for the effectiveness of narrative exposure therapy (NET) within various vulnerable patient groups with repeated interpersonal trauma. Some FACT-teams provide NET for patients with comorbid PTSD, which is promising, but has not been specifically studied in SMI patients.The primary aim is to evaluate NET in SMI patients with comorbid PTSD associated with repeated interpersonal trauma to get insight into whether (1) PTSD and dissociative symptoms changes and (2) changes occur in the present SMI symptoms, care needs, quality of life, global functioning, and care consumption. The second aim is to gain insight into patients’ experiences with NET and to identify influencing factors on treatment results.n=25) with comorbid PTSD and receiving NET. The quantitative study parameters will be existence and severity of PTSD, dissociative, and SMI symptoms; care needs; quality of life; global functioning; and care consumption. In a longitudinal analysis, outcomes will be analyzed using mixed models to estimate the difference in means between baseline and repeated measurements. The qualitative study parameters will be experiences with NET and perceived factors for success or failure. Integration of quantitative and qualitative results will be focused on interpreting how qualitative results enhance the understanding of quantitative outcomes.This study will have a mixed methods convergent design consisting of quantitative repeated measures and qualitative semi-structured in-depth interviews based on Grounded Theory. The study population will include adult SMI outpatients  patients have been exposed to repeated violence and 30% is suffering from PTSD.Narrative exposure therapy (NET) is designed for PTSD related to repeated trauma and proved effective in refugees and other vulnerable patient groups.NET is provided to SMI patients with PTSD and the first clinical outcomes are promising.This study will analyze symptom changes after NET in relation to patients’ experiences with this treatment. Despite the large attention in research for trauma and posttraumatic stress disorder (PTSD), the interest in the prevalence and treatment options for trauma and PTSD in severely mentally ill (SMI) populations is scarce, albeit growing. Research results show that documentation of trauma and trauma symptoms is exceptionally low in medical records of SMI patients. Improved recognition is needed to provide adequate treatment and meaningful services to this vulnerable population  is a relatively new trauma-focused treatment. It has been shown effective in vulnerable groups like refugees and other patients with a history of repeated trauma exposure including patients with borderline personality disorder (BPD) or major depression and comorbid PTSD. NET appeared to be well tolerated in these groups  the PTSD and present dissociative symptoms changes and (2) changes occur in the present SMI symptoms, care needs, quality of life, global functioning, and care consumption. The second aim is to gain insight into patients’ experiences with NET and to identify influencing factors on treatment results in terms of symptom changes, care needs, and quality of life.This study uses a mixed methods convergent design: a quantitative repeated measures design and qualitative methods consisting of a Grounded Theory design. The aim of a mixed methods design is to integrate quantitative and qualitative components to obtain additional knowledge  SMI patients receiving flexible assertive community treatment (FACT). SMI is defined as the presence of schizophrenia-spectrum disorder, mood disorder, or personality disorder and decreased global functioning, which is operationalized by a Global Assessment of Functioning (GAF)-score <60 during 2 or more years  and with comorbid PTSD are offered NET by trained FACT-team therapists. Participants will be recruited from all FACT-teams from 10 community mental health teams at a large mental health institute in the east Netherlands. Inclusion will start at the beginning of 2016 and will last to the end of 2017.Potential participants will obtain oral and written information about the study from their treating psychiatrist and the primary investigator. They will be asked to sign an informed consent form if they are willing to participate.In order to be eligible to participate in this study, a patient must meet the following criteria for the existence of SMI: (1) a diagnosis of schizophrenia (DSM-5 295.90), or schizoaffective disorder (DSM-5 295.70), bipolar disorder type I (DSM-5 296.40–46 or 296.50–56) or type II (DSM-5 296.89), or major depressive disorder (DSM-5 296.20–26 or 296.30–36) APA,  accordinA potential patient who meets any of the following criteria will be excluded from participation in this study: (1) the provision of other trauma-focused treatment in the past year, (2) the existence of an antisocial personality disorder, (3) the existence of a dissociative identity disorder, and (4) the provision of involuntary treatment following the Dutch Mental Health Law.Participants can leave the study at any time for any reason if they wish to do so without any consequences. In case participants do leave the study, a maximum of five leaving participants will be replaced before the end of 2017. Patients who do not complete their NET will stay in the study, unless they want to leave the study. Withdrawal will be monitored and analyzed.We expect to be able to include 25 participants within 2 years. This number of participants will be sufficient to quantify the clinical changes as assessed by the diagnostic instruments used in this population. For qualitative in-depth analysis, the number of 25 participants will be sufficient and enables integral analysis by comparing quantitative and qualitative results within each individual and the whole group.Schauer, Neuner, and Elbert  describeThe provision of NET is outlined as follows: Session 1: psycho-education; Session 2: the lifeline which is symbolized by a rope with a coiled end, stones (traumatic events) and flowers (positive life experiences) in time sequences; Session 3: start of the narration beginning at birth and continuing through to the first traumatic event; Session 4 and subsequent sessions: rereading of the narrative collected in previous sessions and continuing the narration of subsequent life and traumatic events; and final session: rereading and signing the whole document. The average number of the weekly 90-min sessions varies from 6 to 16 , a trained and supervised research assistant will collect demographic information from the electronic record and assess baseline measurements of all variables. These variables include trauma history, PTSD diagnosis and symptoms, dissociative symptoms, SMI diagnosis and symptoms, care needs, quality of life and global functioning. At post-treatment 1 month after NET (T1) and after 7 months follow-up (T2), clinical outcomes including PTSD symptoms, dissociative symptoms, SMI symptoms, care needs, quality of life, and global functioning are assessed again see .Care consumption and prescribed psychiatric medications will be collected via the electronic record. These data will be analyzed for the following period: 3 months before T0 up to and including T2.Demographic variables include gender, age, marital status, level of completed education, number and duration of traumatic event types , primary SMI diagnosis, duration of illness, prescribed medication, and experiences with forced hospitalization and seclusion. These variables are largely collected via the electronic record and based on the inclusion interview outcomes.Care consumption is defined as the number and time duration in minutes of contacts with FACT-team members and prescribed psychiatric medications (type and doses).The LEC is developed concurrently with the CAPS to facilitate the diagnosis of PTSD and is a measure of exposure to 17 potentially traumatic events. The LEC is evaluated in college undergraduates and combat veterans by Gray, Litz, Hsu, and Lombardo . In thisDissociative symptoms are measured using the Dissociative Experiences Scale (DES), which consists of 28 items and records the severity of dissociative symptoms. The total score for the DES can range from 0 to 100. A total score over 40 suggests a dissociative disorder . It can be used by clinicians after a brief training session  has been developed for assessing the effectiveness of mental health services for patients with SMI. It covers a wide range of areas and has good criterion and concurrent validity  is commonly used for comprehensive needs assessment in mental health services. It is a valid, reliable, and usable measuring instrument to assess the care need of SMI patients .To investigate participants’ experiences with NET and to identify possible influencing factors for success or failure of NET, participants will be interviewed. Sensitizing concepts are (1) experiences during NET, (2) symptom changes, (3) care needs, (4) quality of life and daily life functioning, and (5) influencing factors and meaning. Based on these concepts, the following topics are derived and listed: ad 1: therapeutic relationship, lifeline, narration, exposure, and the treatment effects in daily life; ad 2: experienced symptoms; ad 3: perceived care needs; ad 4: perceived quality of life and effects on daily functioning; and ad 5: experienced success or failure and significance for meaningfulness in daily life  measures. To analyze the clinical outcomes of the NET, mixed models will be used in a longitudinal analysis to estimate the effect within the individual and the whole group, taking into account the repeated measures.The qualitative data analysis forms a cyclic process, with the interim analyzes modifying subsequent interviews. This procedure is well known as the constant comparative method. The texts of the interviews will be transcribed literally and then entered in the ATLAS.ti computer program for qualitative text analysis  purposive sampling confined to SMI patients who have recently received NET treatment for comorbid PTSD, (2) a neutral attitude in asking questions and in orally checking the findings with the respondent, (3) researcher triangulation: minimization of researcher bias by independent coding and analyzing interviews by two researchers, (4) member check in order to assess the accuracy of the representation of the participant's subjectivity, (5) peer debriefing with the whole research group during data collection and analysis, (6) peer debriefing with two independent NET therapists and two FACT-team members who care for the participants, (7) transparency and reproducibility through careful documentation of all steps of the research process. Interviews are tape recorded and verbatim transcribed. The raw material is saved and stored in its entirety to be available for verification purposes.Integration of the quantitative and qualitative results will be focused on interpreting how the qualitative results enhance the understanding of the quantitative outcomes. The quantitative and qualitative results of the experienced symptoms , perceived care needs, and quality of life will be compared within each individual. Additional, this will be analyzed at group level. Finally, congruent and discrepant findings will be interpreted.The study will be conducted with ethical principles that are consistent with the Declaration of Helsinki, amended by the 59th WMA General Assembly, Seoul, October 2008. The ethical approval for conducting the “NET for PTSD in SMI patients” study was provided by the Committee on Research Involving Human Subjects, Arnhem-Nijmegen (number 1843-2015).NET has been shown to be effective in vulnerable groups, and first clinical results in SMI patients with comorbid PTSD receiving FACT have been promising. To evaluate and improve clinical practice, only relying on quantitative measures might not suffice as it lacks sensitivity for this specific population. Moreover, the mixed methods approach further enriches the quantitative data with qualitative interviews addressing patients’ perspectives on effectiveness, barriers, and facilitating factors.This study protocol is registered in The Netherlands National Trial Register (NTR) with number NTR5714.


Ecological approaches to health behavior change require effective engagement from and coordination of activities among diverse community stakeholders. We identified facilitators of and barriers to implementation experienced by project leaders and key stakeholders involved in the Imperial County, California, Childhood Obesity Research Demonstration project, a multilevel, multisector intervention to prevent and control childhood obesity.A total of 74 semistructured interviews were conducted with project leaders (n = 6) and key stakeholders (n = 68) representing multiple levels of influence in the health care, early care and education, and school sectors. Interviews, informed by the Multilevel Implementation Framework, were conducted in 2013, approximately 12 months after year-one project implementation, and were transcribed, coded, and summarized.Respondents emphasized the importance of engaging parents and of ensuring support from senior leaders of participating organizations. In schools, obtaining teacher buy-in was described as particularly important, given lower perceived compatibility of the intervention with organizational priorities. From a program planning perspective, key facilitators of implementation in all 3 sectors included taking a participatory approach to the development of program materials, gradually introducing intervention activities, and minimizing staff burden. Barriers to implementation were staff turnover, limited local control over food provided by external vendors or school district policies, and limited availability of supportive resources within the broader community.Project leaders and stakeholders in all sectors reported similar facilitators of and barriers to implementation, suggesting the possibility for synergy in intervention planning efforts. Approximately one-third of US children are overweight or obese . Rates aPreliminary evidence suggests that multisector, multilevel approaches can promote health behavior change and prevent child weight gain ,4. HowevWe conducted semistructured interviews to identify facilitators of and barriers to implementation experienced by project leaders and stakeholders involved in a multisector, multilevel intervention for childhood obesity prevention and control. Participating stakeholders were located in 3 sectors with high potential to affect childhood obesity — health care, early care and education, and schools — and represented multiple levels of influence within their respective organizations . Findings contribute to knowledge about how to more effectively coordinate and implement social ecological approaches for obesity prevention and control.Data were drawn from the evaluation of the Imperial County, California, Childhood Obesity Research Demonstration project (CA-CORD) . Rates oA multiple holistic case study design was used, with participating organizations as the unit of analysis . Of the All interviews were conducted in 2013, approximately 12 months after year-one implementation of CA-CORD intervention activities. Interviews were conducted by trained interviewers in respondents’ language of choice (English or Spanish) using a semistructured interview guide tailored to respondents’ role in the organization. Interview questions (available from the authors upon request) were informed by the Multilevel Implementation Framework (MIF) , a conceOn average, interviews lasted from 30 to 60 minutes. With respondents’ permission, most  were recorded. For the remaining interviews (n = 4), notes were used in place of a recording.All recordings were transcribed verbatim. Interviews conducted in Spanish were translated into English by a certified translator. Final transcripts and interview notes were imported into the qualitative software NVivo 10.0  for analysis. We used template analysis , in whicThree community health care clinics, 13 early care and education centers, and 11 schools agreed to participate in the study. On average, respondents from these organizations were aged 45 years and had been with their organization for 8 years. Most were female (86%) and Latino/Hispanic (69%). All respondents reported facilitators of and barriers to implementing CA-CORD. We summarized major themes according to key MIF constructs  and provPrevious experience promoting healthy behaviors varied across sectors. In the clinic setting, providers and staff reported distributing educational materials to families but otherwise did not have prior experience promoting healthy behaviors among pediatric patients. For these providers and staff, CA-CORD was viewed as providing important, additional resources that supported their work with children and families. By contrast, respondents in most early care and education centers (10 of 13) and all schools (11 of 11) had prior experience implementing programs to promote healthy behavior, such as Head Start’s I Am Moving, I Am Learning initiative . For staIn general, respondents in the health care and early care and education sectors described CA-CORD as highly compatible with organizational priorities  as significantly affecting implementation, because it affected whether healthy behaviors were reinforced in the home (quotations 15 and 16). Although some respondents reported ongoing efforts to engage parents , most simply identified lack of parental engagement as a barrier to improving targeted health behaviors. In the health care setting, several respondents identified income and language barriers as contributing to lack of parent engagement in CA-CORD (quotation 17).In 2 of the 3 sectors (early care and education and school), respondents also identified child engagement as affecting implementation. For example, several teachers and providers noted that they could not force resistant children to participate in SPARK exercises or to try healthy foods (quotation 18). However, in some centers and schools, highly engaged children enhanced teachers’ and providers’ enthusiasm for the project and also spurred behavior change in teachers.Although CA-CORD project staff identified many initiatives intended to promote healthy behaviors that were taking place in the broader community, most frontline staff were either not aware of them or felt they were still not sufficient. Several respondents expressed frustration that their efforts to promote healthy behaviors were not reinforced by others in the community, either because of limited resources or general lack of support . Additional facilitators to implementation included the use of a participatory approach by CA-CORD project staff and the decision to gradually introduce intervention activities in a way that would minimally disrupt existing work schedules (quotation 23).In all sectors, staff turnover was described as a barrier to implementation. In the health care sector, turnover of community health workers contributed to project costs and delayed implementation of educational workshops for families. In the school sector, turnover of principals and other administrative personnel negatively affected leadership support for CA-CORD and necessitated additional effort by CA-CORD staff to re-engage staff at the affected schools. In the early care and education sector, participating centers were all part of large agencies that purposely rotated staff annually. This movement of early care and education providers, supervisors, and even directors was a barrier that had to be taken into account when planning and implementing CA-CORD activities.Theoretical constructs identified in the MIF were useful for summarizing the major facilitators and barriers experienced by key stakeholders in implementing CA-CORD. Perceptions of the strengths of the external support system and of the importance of parent engagement were remarkably congruent across sectors and consistent with previous research indicating the importance of robust academic–community partnerships and family engagement for health behavior change in rural communities . RespondSeveral sector-specific issues were also identified. In the school sector, lower perceived compatibility of obesity prevention and control activities with organizational priorities contributed to variable leadership support and greater emphasis on the importance of obtaining teachers’ buy-in and support for CA-CORD. Strict scheduling in the school sector also meant that planning for CA-CORD activities needed to be completed by the end of the previous academic year. In the early care and education sector, where centers were often smaller or reliant upon relationships with external vendors to provide services, space constraints and limited control over foods served to children limited staff ability to implement CA-CORD as intended.In general, however, similarity in the facilitators of and barriers to implementation identified by project leaders and key stakeholders suggest the possibility of common ground in collaborative efforts to develop and sustain social ecological approaches to prevent and control obesity. In particular, findings reinforce the importance of taking a participatory approach during the planning process and of ensuring that proposed changes are introduced in a time frame and manner compatible with stakeholders’ work processes and priorities. Specific actions taken by the CA-CORD team to facilitate implementation included conducting formative assessments to assess organizations’ receptivity to proposed project activities and engaging community members to better understand organizations’ different needs and priorities. Study findings also indicate that the support of senior leaders is necessary but not sufficient for program success; strategies for cultivating buy-in of staff at multiple levels within participating organizations should be considered.This study had several limitations. First, implementation is often a dynamic, nonlinear process . These dDespite these limitations, this study contributes to the literature by capturing the perceptions of project leaders and key stakeholders regarding facilitators and barriers experienced in implementing multilevel approaches to childhood obesity prevention and control. Congruity in perceptions of certain facilitators and barriers represents not only critical points to consider during intervention planning, but also key areas in which stakeholders could fruitfully collaborate in developing and implementing social ecological approaches to obesity prevention and control.


The Global Hepatitis Health Sector Strategy is aiming for “elimination of viral hepatitis as a public health threat” by 2030 , while eWe here present HBV within the framework for neglected tropical diseases (NTDs)  in orderhttps://doi.org/10.6084/m9.figshare.5242303.v1). For adults with chronic infection and evidence of ongoing liver damage, a daily dose of suppressive antiviral therapy using nucleot(s)ide analogues (Robust preventive vaccines have been rolled out in Africa since 1995 as a component of the Expanded Programme on Immunization (EPI). Traditionally, most vaccine campaigns have relied upon monovalent HBV vaccines  can be improved through a combination of routine antenatal screening, antiviral drugs during the latter stages of pregnancy, and HBV vaccination to the baby starting at birth. Where resources permit, HBV immunoglobulin (HBIG) can further reduce the risk of vertical transmission.Despite the efficacy of these strategies in managing or preventing individual cases, these interventions do not currently offer a route to global HBV eradication, due to a shortage of investment and resources, the large pool of undiagnosed cases, lack of routine diagnostic screening, the high cost of IFN and HBIG, the lack of a curative therapy, substantial gaps in drug and vaccine coverage, and the potential for increasing drug resistance .We have applied the WHO criteria for NTDs to HBV  and refeAlthough HBV is endemic globally, the bulk of morbidity and mortality is now borne by low-/middle-income countries in tropical and subtropical regions ,13. In AHBV is part of a cycle of poverty, with a high burden of morbidity and mortality in young adults. The economic burden on individual families can be particularly catastrophic in low- and middle-income settings , althougWe already have an armamentarium of strategies with which to tackle HBV prevention and treatment . In ordeCompared with other blood-borne viruses, namely, HIV and hepatitis C virus, which infect substantially lower numbers , HBV hasEven for an organism that is not officially recognized as an NTD, there is much to be learnt from the NTD paradigm that could accelerate progress in tackling HBV. The ethos of combining several public health strategies and integrating care for different diseases is captured by the approach advocated for NTDs  and is aIn the following section, we use suggested interventions for NTDs to discuss briefly how these are pertinent to reducing—and ultimately eliminating—HBV infection as a public health threat.Based on the significant numbers of individuals lost at every step of the “cascade” from diagnosis through to successful treatment and prevention , enhanceThe role and significance of stigma associated with HBV infection in Africa is largely unreported in the literature. However, individual testimony leaves no doubt that this is a significant barrier to diagnosis and clinical care [Although antiviral therapy for HBV is generally regarded as treatment rather than prevention, in the majority of cases, it renders individuals aviremic, preventing onward transmission. Antiviral therapy for HBV  should bPMTCT can progressively become a realistic goal by expanding access to antenatal diagnostics, simple treatment interventions such as maternal tenofovir during trimester 3, and HBV vaccination for all babies, with the first dose delivered at birth . VaccinaAlthough this category of interventions is conventionally applied to reducing food- and waterborne infections, we here broaden our interpretation to include other aspects of prophylaxis. Safety and security of medical supplies has increasingly improved to reduce nosocomial transmission of blood-borne viruses over recent decades ; case 3.Elimination of HBV infection has gained status within international health and development agendas but is a complex clinical and public health challenge that currently lacks proportionate multilateral commitment from pharma, government, commissioners, funders, and the research community. The many parallels with other NTDs are clearly exemplified by vulnerable populations of the African subcontinent. By viewing HBV—as well as its partner in coinfection, HDV—within the NTD framework, we can improve approaches to reducing the burden of disease and move towards eventual elimination.S1 Supporting InformationThis is in line with aims stated within Sustainable Development Goals (SDGs) . Complem(PDF)Click here for additional data file.


Inclusion of ecosystem services (ES) information into national-scale development and climate adaptation planning has yet to become common practice, despite demand from decision makers. Identifying where ES originate and to whom the benefits flow–under current and future climate conditions–is especially critical in rapidly developing countries, where the risk of ES loss is high. Here, using Myanmar as a case study, we assess where and how ecosystems provide key benefits to the country’s people and infrastructure. We model the supply of and demand for sediment retention, dry-season baseflows, flood risk reduction and coastal storm protection from multiple beneficiaries. We find that locations currently providing the greatest amount of services are likely to remain important under the range of climate conditions considered, demonstrating their importance in planning for climate resilience. Overlap between priority areas for ES provision and biodiversity conservation is higher than expected by chance overall, but the areas important for multiple ES are underrepresented in currently designated protected areas and Key Biodiversity Areas. Our results are contributing to development planning in Myanmar, and our approach could be extended to other contexts where there is demand for national-scale natural capital information to shape development plans and policies. Attaining economic development goals while securing the natural capital and ecosystem service (ES) benefits that underpin current and future human well-being remains a major societal challenge. With the effects of climate change increasingly evident—and especially impacting developing countries–the challenge is even greater –3. The aWhile the science and tools to support these efforts are advancing rapidly, substantial gaps remain between the promise of ES-based approaches and their application in common practice. ES assessments routinely focus on ecosystem properties and processes without considering whether and for whom actual benefits are produced . FurtherHere we provide a practical example from Myanmar to demonstrate how natural capital and climate change information can be integrated with data on the location and dependence of people and infrastructure on ES in order to contribute to development planning. Myanmar provides an excellent opportunity to advance natural capital assessment approaches and integrate their results into development policy and planning. After decades of restrictive military rule that both limited economic development and influenced the rate and nature of natural resource exploitation, the country now faces a unique crossroads: unlike so many countries that have prioritized economic development, but at great cost to their natural wealth, Myanmar may still have time to choose a path that allows for economic development while preserving ecosystems and the critical services they provide to the country’s citizens and its economy.Myanmar’s development needs are immense: The country currently ranks 148 out of 188 in Human Development Index , and morImproving understanding of Myanmar’s natural capital stocks and the ES benefits they provide is particularly relevant in the context of climate change. A recent report ranked Myanmar the second most historically vulnerable country to extreme weather events, due largely to the heavy toll of Cyclone Nargis in 2008, which killed upwards of 130,000 people in one of the deadliest tropical cyclones in history . ExtremeRecognizing the role of natural capital in the country’s prosperity and the security of its people, the Myanmar government is developing a number of strategies, procedures, rules and policies to improve environmental conservation in the country, including an overarching environmental policy aimed at mainstreaming environment and climate resilience into development planning and implementation . NaturalIn this context, there is a critical and immediate need for national-scale information on natural capital and the benefits it provides–both for local livelihoods and the larger economy–to contribute to planning the country’s national development pathway. Here we map and quantify how Myanmar’s natural capital provides key benefits to the country’s people and infrastructure, both under baseline climate conditions and a range of projected future climate conditions. This assessment resulted from a 2014 request by then-president of Myanmar, U Thein Sein, after seeing early outputs from this study at a sub-national scale. Specifically, we investigate at a national scale: 1) where natural ecosystems in Myanmar have the greatest potential to provide benefits in the form of four ES: sediment retention, regulation of dry-season water availability, flood risk reduction, and coastal storm protection; 2) where, given the locations of people and infrastructure that rely on these services, natural ecosystems are currently providing the greatest benefits; and 3) which beneficiaries are most susceptible to losing ES benefits from loss of natural vegetation.To understand the degree to which these conclusions are sensitive to climate change, we assess whether the source and magnitude of benefits, as well as the susceptibility of beneficiaries, change under future climate scenarios. We use downscaled temperature and precipitation projections from 21 General Circulation Models (GCMs) , and regMyanmar is the largest country in mainland Southeast Asia. The country has a tropical monsoon climate, with three main seasons–cool (Nov.-Feb.), hot (Mar.-May) and wet (Jun.-Oct.). Myanmar contains a diversity of ecosystems , which hIn Myanmar, climate extremes have increased in frequency and intensity in recent decades, and are resulting in impacts like soil erosion and soil fertility loss, declining water availability and decreased river flows, inland flooding, and above-average storm surges, among many others . These iWe focus on evaluating four ES: sediment retention for drinking water quality and reservoir function, regulation of dry-season baseflows for drinking water provision, inland flood risk reduction for flood-prone villages and coastal protection for coastal populations. These services were chosen based on their relevance in Myanmar to people, infrastructure and climate resilience, as well as on the availability of data and models required to evaluate them at a national scale.We modeled the supply of these services under baseline climate conditions and under the bounds of a range of possible future climate conditions. We then integrated measures of biophysical supply with information on the location and number of beneficiaries to determine where ES provision is greatest, as well as to understand which beneficiaries would be most impacted by ES losses. Finally, we compared hotspots of ES provision with other, established priority areas for conservation–specifically, currently-protected areas and Key Biodiversity Areas–to determine where and the degree to which conservation has the potential to contribute to multiple objectives. We provide additional details about each step in the following sections.To map and quantify the biophysical supply of the focal ES, we used the InVEST 3.2.0 Sediment Delivery Ratio (SDR), Seasonal Water Yield (SWY) and Coastal Vulnerability (CV) models  See S1 AThe SDR model estimates soil loss and sediment export in a watershed . It reliThe SWY model estimates the amount of runoff production and relative contribution to baseflow of different parts of the landscape. Based on monthly precipitation, reference evapotranspiration, and LULC runoff properties, the model computes two indices representing quickflow and baseflow. Quickflow represents the amount of precipitation that is converted to direct runoff, entering streams soon after a rain event, and is computed based on the NRCS curve number method . To asseBaseflow represents the amount of precipitation that enters streams through subsurface flow, both during and between rain events, and is computed based on a local water balance and hydrologic routing. The index used in this study represents baseflow over the entire year. For both the flow retention and the baseflow indices, results are presented as the difference between the current landscape and the hypothetical alternate landscape in which all natural vegetation has been converted to agriculture.The CV model produces a qualitative estimate of how changes to natural habitats can affect coastal communities’ exposure to storm-induced erosion and flooding . By consThe current LULC map  used forFor the hypothetical scenario in which natural vegetation is converted to agriculture, all LULC classes not already included in agriculture/urban/bare were changed to agriculture, assuming the district-specific mix of crops. See We used downscaled estimates of temperature, precipitation and sea level under baseline climate conditions  as well as projections of future climate conditions. To represent the uncertainty in climate projections, we used the bounds of a range of future climate conditions, rather than a single average estimate.th percentile of numerically ranked model results for RCP 4.5 was defined as a low estimate for changes in climate, while the 75th percentile of numerically ranked model results for RCP 8.5 was defined as a high estimate. These points in the model output distribution represent a range of likely future climates. Because the 25th and 75th percentiles are defined separately for each calendar month and gridcell, different GCMs can occupy the 25th and 75th percentiles in different months and locations. This approach broadens the range of possible outcomes compared to selecting a single GCM based on the spatially and temporally averaged 25th and 75th percentiles of the distribution.Baseline and future climate conditions for temperature and precipitation were developed from the NASA Earth Exchange Global Daily Downscaled Projections (NEX-GDDP) dataset . The resolution of both the observed and the projected products is .25 degrees by .25 degrees. For temperature and precipitation , monthly means of long-term average climatology were projected for the 2040 (2031–2050) time period for each 0.25 degree gridcell and calendar month. The combination of 21 climate models and two climate forcing scenarios, or Representative Concentration Pathways (RCPs) , yieldedth percentile of the combined RCP 4.5 and 8.5 numerically ranked model outcomes, and the high estimate was derived from the 75th percentile of the combined numerically ranked RCP 4.5 and 8.5 outcomes. The spatial resolution of the sea level rise was 1.0 degree.Sea-level rise was projected for the 2050s (2050–2059) time period. Twenty-four models were used from Coupled Model Intercomparison Project 5 (CMIP5) to account for thermal expansion of the ocean and dynamically-driven changes in relative ocean height, with other data sources and methods accounting for land-based ice loss and changes in land water storage ,25. Due The low and high ends of the range of climate change estimates, along with baseline climate, were translated into inputs for the InVEST models. See There are a few limitations that need to be considered when interpreting the climate information and projections. First, the combination of limited historical climate data and a highly spatially heterogeneous climate associated with complex topography and coastlines may in turn affect the skill of the climate projections, which by necessity given the data shortages are based upon a modeled representation of baseline climate (and therefore subject to any limitations within the NEX-GDDP dataset). Second, while the projections presented here are designed to capture a range of possible outcomes, as with all climate projections, deep uncertainties render it impossible to develop truly probabilistic projections Finally, these climate scenarios were not translated into climate change-induced projected changes in LULC; further changes in ES provision are likely depending on future land use change, driven by the direct response of vegetation to climate change or human responses to shifting rainfall and temperature increases, but were not modeled due to a lack of national-scale information at sufficient resolution.We used data on the location and needs of people and infrastructure to assess the provision of ES benefits. We considered two benefits from sediment retention: drinking water purification and reservoir function. In the case of drinking water purification, the beneficiaries included households reliant on surface water for drinking. We determined the number of households per township using surface water for drinking based on the 2014 Myanmar Population and Housing Census . BecauseFor inland flood risk reduction, we focused on villages that were affected by flooding in 2015 , with thWe used a serviceshed-based approach to spatially link ES supply to beneficiaries ,44. A seWe translated the biophysical metrics of ES supply from the InVEST models into importance for ES provision by weighting supply by the number of beneficiaries receiving a particular service from a particular place ,44. For To understand the susceptibility of townships to the loss of ES benefits, we calculated the percent change in sediment loads, dry-season baseflows, inland flood risk index and coastal vulnerability between the current landscape and the alternate land use scenario, for both baseline climate conditions and under the range of climate change estimates.et al. [To understand the degree to which areas important for providing the focal ES coincide with biodiversity conservation priorities, we examined the overlap between Key Biodiversity Areas (KBAs) , protectet al. . We defiThe biophysical supply of ES, indicating the potential to provide ES benefits, varies within Myanmar and along its coastline as a function of climate and topography, along with properties of the current vegetation and the assumed alternative land use  generallDemand for service also varies spatially, depending on the nature of the service and the beneficiaries considered  and seasPatterns of service provision, indicating the areas of natural vegetation that provide the greatest biophysical amount of service to the greatest number of beneficiaries, depend on both the location of supply and demand for each service and are unique for each service considered  = 1.2%) at the low end, but increase by 23.3% (SD = 3.3%) at the high end of the range of likely climate change. In addition, the amount of sediment retained upstream decreased an average of 3.4% (SD = 1.2%) under the low estimate and increased 23.3% (SD = 3.4%) under the high estimate.Because the CV model used to assess coastal protection services is a relative ranking model and projected SLR was consistent along Myanmar’s coastline, the relative importance of coastal habitats did not change between SLR scenarios relative to baseline climate conditions , and so Regardless of climate change scenario, the parts of the landscape that currently provide the greatest amounts of services under baseline climate conditions are likely to remain important under the climate change scenarios considered here . We consHotspots of current service provision  vary by The designated KBAs cover 16.3% and existing PAs cover 7.4% of Myanmar’s land area, with over 99% of PAs also falling within a KBA. Overall, overlap between ES hotspots, KBAs and existing PAs was also greater than expected simply from chance : the areOur results confirm that biophysical measures of ES supply alone are inadequate for determining the areas that deliver the greatest ES benefits to people or infrastructure , results are also available online to the public at Because regional- and state-level land use planning and climate change adaptation planning will play an important role in Myanmar’s development trajectory, refining and updating this national assessment to provide information relevant to decision-making at these levels will also be important. This is especially critical given that national ES priorities based on total population are heavily influenced by the country’s largest urban centers and may not reflect regional priorities or the needs of rural populations . AchieviFinally, assessment of additional ES, and their response to land use change and climate change, would be a valuable step for future work, at both the national and sub-national levels. The services assessed here were particularly limited by the availability of spatial data, both ecological and socio-economic. The societal and economic value of many other ES such as non-timber forest products, nursery and breeding habitat contributing to fisheries, and wild insect pollination contributing to crop production are likely quite high , but a lIn interpreting the maps provided in this study, several points should be noted. First, the outputs of the biophysical models are best used to assess relative spatial or temporal differences. Given that the uncertainties around future estimates of climate change have large effects on biophysical predictions, a robust interpretation of results consists in identifying areas that are consistently identified as hotspots of services. Second, the weighting approach used to combine ES supply and demand is subject to limitations of multi-criteria analyses ,66. FinaThe current decade has seen growing attention to the impacts of climate change on ES. However, existing studies are frequently disconnected from decision-making contexts and only rarely assess the robustness of decision-making outcomes such as policies or management strategies to sources of uncertainty, including climate change scenarios . The intIn the context of development planning, delivering assessments on policy-relevant temporal and spatial scales that can guide decisions that will be robust to climate change is critical. This is particularly important in rapidly developing countries where the stakes are highest both for human well-being and biodiversity. Towards this goal and based on our experiences developing a national assessment for Myanmar, we suggest several directions for furthering the integration of natural capital assessments and climate change scenarios.Advances in data and modeling would provide a more precise and nuanced understanding of future changes in ES provision with climate change. In particular, future assessments would benefit from: i) assessing the impacts of climate change on ES through changes in vegetation and land management; ii) accounting for the impacts of extreme weather events on natural capital and ES; iii) better baseline data to improve projections; and iv) improved accounting for and communication of uncertainty. Integration of climate information into ES assessments would be enhanced by the capacity to model a greater diversity of linkages between climate, ecosystems and ES. The ability to assess impacts of climate change on ES through changes in vegetation and land management, as previously discussed, as well as improved accounting for the impacts of extreme weather events, rather than relying on annual or monthly climate data, would be especially valuable. These efforts would benefit from more comprehensive observed baseline climate and land use data, requiring investment, integration of local expert knowledge, local capacity building, and collaboration across countries and sectors. Finally, in line with recognized challenges for ES assessments in general , a more Our assessment process also highlighted trade-offs among analysis complexity, knowledge ownership by stakeholders and decision-making relevance. More sophisticated, dynamic models would provide a more precise characterization of the effects of climate change on natural capital and ES provision. However, this inherently increases data requirements and analytical complexity, resulting in proportionate difficulty in developing local capacity to replicate and build on assessments, potentially affecting the impact of assessments on planning decisions. Balancing this trade-off between complexity, feasibility and utility can be difficult, and requires consideration of the ultimate aims of producing integrated ES and climate assessments: is it to provide a foundation for locally-based knowledge production, shape stakeholder thinking, inform a specific policy or decision, or some combination? Different answers require different approaches  and may As our experiences here illustrate, however, even under conditions of limited data and rapid timelines, it is possible to produce initial, policy-relevant assessments of natural capital and ES benefits to people and infrastructure under future climate scenarios that can set the stage for decision-making and more in-depth research.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.S1 Data(ZIP)Click here for additional data file.S2 Data(ZIP)Click here for additional data file.S3 Data(ZIP)Click here for additional data file.S4 Data(ZIP)Click here for additional data file.


Background: Dietary intake of macronutrient and foods is considered crucial to decrease the risk of diet-related non-communicable diseases. Methods: The aim of this study was to describe the intake of major food groups and macronutrients in a random sample of 1838 southern Italian adults. Results: No significant differences of macronutrient consumption between sexes were found. By contrast, younger individuals had significantly higher intake of animal protein than older ones. Men reported consuming significantly more total processed meats and less eggs than women; egg consumption significantly increased by age groups. Significantly lower intake of fruit in the younger age group compared to older ones was found. Various patterns of correlation between food groups were described. More than half of individuals reached the suggested recommendations for carbohydrate and fiber intake, and about two-thirds met the recommendations for total protein and cholesterol intake, while only a minority met for total fat intake. Total and plant protein, monounsaturated and omega-6 fatty acids, were significantly inversely related with BMI (body mass index), while trans fatty acids and cholesterol were directly correlated. A direct association with unprocessed meats and an inverse association with processed meats was also found. Conclusions: The overall findings suggest that relatively healthy dietary habits are common in southern Italy. Over the last decades, great efforts have been done to identify a nutritionally balanced diet that might help reduce the risk of chronic non-communicable diseases. There is convincing evidence that dietary factors, alongside with physical activity and abstinence from unhealthy lifestyle behaviors (such as smoking habits), play a crucial role in prolonging the lifespan and ameliorating human health ,2. AdequResearch in nutritional epidemiology produced over the last years investigated the association between macronutrients/major food groups, and the most common chronic non-communicable diseases . As prevNational and international organizations are dealing with current evidence on the association between diet and health. Experts boards continuously draft and update dietary guidelines and recommendations in order to prevent, on a large population scale, common non-communicable diseases. However, data on actual food consumption in cohort studies is often underrated and scarcely described. The aim of the present study was to describe the intake of major food groups and macronutrients in a sample of southern Italian adults, and to analyze the differences in consumption between sexes and age groups. Additionally, the study aimed to explore the correlation between the variables investigated and the association with weight status of participants.A sample of 2044 men and women aged 18 or more was collected between 2014 and 2016 in the main districts of the city of Catania, southern Italy, to build the Mediterranean healthy eating, ageing, and lifestyle (MEAL) cohort. A detailed description of the study protocol is published elsewhere . BrieflyData was collected by a face-to-face computer-assisted personal interview using tablet computers. In order to visualize the response options, participants were provided of a paper copy of the questionnaire, however, final answers were filled in by the interviewer directly on the digital device (tablet computer). The demographic and anthropometric data were collected according to standard procedures . RegardiConsiglio per la ricerca in agricoltura e l’analisi dell’economia agraria) [n = 107) as well as missing items for the purposes of this study (n = 99) were excluded from the analyses, leaving a total of 1838 individuals included in the analysis.A food frequency questionnaire (FFQ) previously validated for the Sicilian population was administered to collect information on food consumption ,25. The agraria) . Nutrienagraria) . FFQs wiLivelli di Assunzione di Riferimento di Nutrienti” (LARN) [To investigate agreement with dietary recommendations, we used the European proposed values for macronutrient intake of the European Food Safety Agency (EFSA)  and thos” (LARN) , while f” (LARN) .t test and ANOVA for continuous variables distributed normally, and Mann–Whitney U test and Kruskal–Wallis test for variables not normally distributed. Correlations among major food groups were tested through calculation of Pearson’s or Spearman’s correlation coefficients, depending on the distribution of the variable. Linear association between variables of interest and BMI levels were tested through linear regression analyses. All reported P values were based on two-sided tests and compared to a significance level of 5%. SPSS 17  software was used for all the statistical calculations.Frequencies are presented as absolute numbers and percentages; continuous variables are presented as means and standard errors, medians and ranges. Differences between groups for continuous variables were compared with Student’s The description of consumption of major food group from animal source is shown in The correlation between intake of all major food groups is shown in The present study provided updated information on intake of major food groups and macronutrients and their association with weight status in a sample of southern Italian adults. We found that a large proportion of individuals had adequate intake of protein, fiber, fats, fruit and vegetable, meat, and pulses according to national and international recommendations. These results suggest that the investigated population has generally healthy dietary choices; however, investigating major food group consumption and comparison with other reports is crucial to better understand dietary priorities for future strategies to improve dietary habits and overall health.Despite the importance of monitoring dietary intakes at population level, previous studies investigating macronutrient and food consumption are scarce. A recent report of Global Burden of Diseases Nutrition and Chronic Diseases Expert Group aimed to describe consumption of major food groups worldwide and at national level . DespiteGlobal and national reports on macronutrient intake have underlined dramatic diversity across nations and the need for inform policies to improve global health. Our estimates for dietary fats are slightly “healthier” than those previously reported in the Italian population  ; howeverIn this study, we found a correlation between certain macronutrients and food groups with BMI levels of the participants. Mostly in line with expectations, among dietary proteins, only plant protein intake was inversely correlated with BMI, while among dietary fats, monounsaturated and omega-6 fatty acids were inversely correlated, whereas trans fatty acids and cholesterol were directly correlated. However, these results did not entirely fit with correlations obtained with major food groups, as processed and unprocessed meats were indirectly and directly correlated with BMI levels, respectively. A possible reason for such unexpected findings may be the relative good quality of processed meat in southern Italy, which according the results of individual questions of the FFQ, we found it mostly referred to cured meat rather than fast foods (data not shown). Another explanation is the relatively low magnitude of the correlation for protein and meat products, which in fact might be spurious. Regarding the findings on dietary fats, we hypothesize that a major contributor to monounsaturated fatty acid intake was olive oil, highly consumed in this cohort as reported in previous studies . GeneralThe results presented in this study should be considered in light of methodological limitations. The use of FFQs is a widely-consolidated methodology, but they are also known to only provide estimates and not true intake, as they are subject to recall bias and over- and underestimation, depending on the number of food items included and social desirability bias, respectively. However, comparative reports used similar methodology and results are generally in line with literature and expected findings.In conclusion, the present study provided updated information on macronutrient and major food group intake in a southern Italian adult population, taking into account specific subgroup of macronutrients rarely reported in current literature. The overall findings suggest that relatively healthy dietary habits are common in southern Italy, in up to two-thirds of the sample investigated. Further in-depth studies are needed to better understand whether findings related to foods may translate in equally adequate micronutrient intake in this cohort. However, further efforts should be made to improve diet quality of the remaining population in order to prevent non-communicable diseases.