To reduce excess dietary sodium consumption, Nigeria’s 2019 National Multi-sectoral Action Plan (NMSAP) for the Prevention and Control of Non-communicable Diseases includes policies based on the World Health Organization SHAKE package. Priority actions and strategies include mandatory sodium limits in processed foods, advertising restrictions, mass-media campaigns, school-based interventions, and improved front-of-package labeling. We conducted a formative qualitative evaluation of stakeholders’ knowledge, and potential barriers as well as effective strategies to implement these NMSAP priority actions.From January 2021 to February 2021, key informant interviews (n = 23) and focus group discussions (n = 5) were conducted with regulators, food producers, consumers, food retailers and restaurant managers, academia, and healthcare workers in Nigeria. Building on RE-AIM and the Consolidated Framework for Implementation Research, we conducted directed content qualitative analysis to identify anticipated implementation outcomes, barriers, and facilitators to implementation of the NMSAP sodium reduction priority actions.Most stakeholders reported high appropriateness of the NMSAP because excess dietary sodium consumption is common in Nigeria and associated with high hypertension prevalence. Participants identified multiple barriers to adoption and acceptability of implementing the priority actions  as well as facilitators to implementation . Key strategies to strengthen NMSAP implementation included consumer education, mandatory and improved front-of-package labeling, legislative initiatives to establish maximum sodium content limits in foods and ingredients, strengthening regulation and enforcement of food advertising restrictions, and integrating nutrition education into school curriculum.We found that implementation and scale-up of the Nigeria NMSAP priority actions are feasible and will require several implementation strategies ranging from community-focused education to strengthening current and planned regulation and enforcement, and improvement of front-of-package labeling quality, consistency, and use. Cardiovascular diseases (CVDs) are the leading cause of death globally, accounting for an estimated 18.6 million lives with over three-quarters of those CVD deaths occurring in low- and middle-income countries . NigeriaEvidence shows that processed and ultra-processed foods are important contributors to sodium intake at the population level –13. A muThe estimated daily salt intake in Nigeria (5.8g/day)  is higheImplementing NMSAP priority actions requires political commitment, program leadership, effective partnerships, community, and manufacturer acceptance as well as adoption, and multipronged action across various sectors . Impleme This study was reviewed and approved by the Ethics Committee of the Federal Capital Territory in Nigeria (FHREC/2020/01/89/11-09-20), Northwestern University (STU00213707) and the University of New South Wales (HC200807).A formative qualitative study was conducted to explore stakeholders’ perceptions on implementation of the NMSAP priority actions on salt reduction. Guides were developed to explore potential barriers and facilitators with suggestions to address these factors and explore implementation outcomes of the NMSAP priority actions. The NMSAP includes policies based on the SHAKE package aims to achieve at least a 30% relative reduction in mean population intake of dietary salt/sodium by 2025. The national target is to specifically reduce salt/sodium consumption to 3 g/day by 2025. Semi-structured interview guides were developed starting with the Consolidated Framework for Implementation Research (CFIR)  and RE-AParticipants were invited through a purposive sampling of identified key actors at the federal, state, or local level who were knowledgeable or influential regarding dietary intake of the Nigerian population and would be involved in various components of the priority actions. Participants were recruited from two states (Kano and Ogun) in Nigeria and the Federal Capital Territory (FCT), Abuja. These states were chosen to align with states where the Nigerian Federal Ministry of Health (FMoH) and the WHO were already working to pilot the implementation of selected NMSAP priority actions. Data were collected through focus group discussions (FGDs) and in-depth interviews (IDIs) between January 2021 and February 2021. Twenty-three IDIs and 5 FGDs (n = 11) were conducted with health professionals (n = 10), federal, state, and local policymakers (n = 9), community leaders (n = 3), food industry (n = 3), international non-governmental organization (n = 3), food retailers/restaurant owners (n = 3), academia (n = 2), and food and drug regulatory body (1).S2 Table).Written informed consent was obtained from all participants before interviews began. Interviews were conducted either face-to-face at participants’ workplace or online via Zoom by four study team members  trained in qualitative methods and working in non-communicable diseases. Among these team members were a cardiologist, family physician, consultant psychiatrist, and social scientist. Field notes were taken during interviews. One author had prior relationships with some stakeholders before the interviews. Interviews lasted for up to 45 minutes with one conducted in Hausa and the remaining ones in English. All stakeholders participated fully, and transcripts were not returned to them for comments. Further details about participant recruitment, interviews, and data management are reported following the Consolidated criteria for Reporting Qualitative research (COREQ) guidelines , followed by local, state, and federal policymakers (26.5%); most worked in the FCT (94.2%).A total of 34 stakeholders participated in the study  whose mean (SD) age was 39.2 (SD) years  lack of knowledge of risks associated with excessive amount of salt in food; 2) customs and cultural tastes for high-salt diets; 3) salt as an inexpensive flavor enhancer prompting liberal use in food preparation; 4) urbanization, globalization, and changes in work dynamics associated with reduced consumption of home-cooked meals and increased consumption of commercially prepared cooked foods, including ultra-processed foods.Table 2 shows the identified potential barriers and facilitators to implementing the first NMSAP priority action, including factors affecting both consumers as well as suppliers and producers of processed foods. Low general awareness on the harmful effects of excess dietary salt intake was noted by many respondents as a barrier to acceptability and perceived appropriateness of NMSAP priority action 1. Respondents mentioned that there was a lack of general knowledge of the level of salt in many commonly consumed foods and seasonings, which was further complicated by lack of knowledge of the recommended daily sodium intake. They also noted that salt was an inexpensive flavor enhancer, thereby making high-salt diets and seasonings more popular, affordable and widely available. Salt’s low cost and corresponding unhealthy diets would further reduce acceptability and adoption of implementing this NMSAP priority action if it resulted in a change in taste or increased cost as mentioned below:Salt is very cheap in Nigeria, so it’s something everywhere. So, we intend to consume and abuse it a lot. When we want to boil our meat to season it, we use salt because we don’t have money for expensive spices. So, we use salt.” “Mistrust in government-led initiatives also emerged as a major barrier which may impact acceptability and effectiveness of NMSAP priority action 1. Participants noted that the Nigerian population may find it difficult to trust any policy developed by the government targeted at salt reduction because of implementation failures of previous and existing food and dietary policies.(I)n our country, when they (the government) say they will do something, it will be taken seriously at first, but later there will be lapses. We don’t know whether it is from those in charge of the policy, or wherever it comes from, only God knows…Our problem is just that if they want to do something, if the government said it is introducing something, they should make every effort to see it to the end. But they will start and then off it goes. …Participants noted potential barriers from food manufacturers and store and restaurant owners, which could reduce adoption. One barrier included potential loss of consumers due to increased cost or change in taste. For instance, some participants mentioned that bread and packaged noodles are important staple foods in Nigeria that have contributed to excess salt consumption. Reducing salt in these foods was perceived to change flavor or reduce consumer consumption, which may threaten supply-side profits from these products.The challenge that we would have as restaurant owner is that your taste is something that people are already familiar with. And there’s a particular way that they expect it to taste. If it doesn’t taste that way, then you are bound to be losing some customers and all of that. Other potential barriers identified by participants which may affect acceptability, adoption, perceived appropriateness, and effectiveness of this priority action included: lack of knowledge on and poor design of nutrition facts labels; reducing consumers ability to choose food based on salt content; lack of availability of low-sodium or other salt substitutes as flavor enhancers ; cultural and social practices to foods and preparation methods which includes excess salt use and intake; existence of multiple sources of salt  which would make the reduction of total intake complex; and non-availability of standard salt measurement in home-cooked meals including those where high-salt seasonings are used.Participants highlighted strategies which could help overcome some barriers. To address lack of knowledge around excessive salt intake and guidance, participants suggested generating evidence on the amount and sources of salt being consumed by Nigerians. These data would be useful to justify this and other salt reduction strategies and could be used for consumer education. Secondly, participants believed that this NMSAP priority action may be more acceptable to overcome the distrust of national-led initiatives by involving healthcare providers as more trusted information sources for dissemination and to informing patients and the general populace on the dangers of unhealthy, high-salt diets.Key informants identified several other strategies to address the potential barriers to implementing NSMAP priority action 1, many of which are already included in the NMSAP overall document . Participants suggested developing and implementing policies that mandate sodium limits across the food industry. This approach would minimize concerns unfairly targeting specific manufacturers because the policy would be broadly applicable and thus would create a level playing field. Participants also suggested that poor implementation of existing food and dietary policies could be tackled through the development of strong government leadership, regulatory processes, and accountability mechanisms. Lack of knowledge on and poor design of nutrition facts labels could be addressed if the government implemented mandatory nutrition labeling standards to improve content and format , including consumer-friendly front-of-package labeling. Reflecting on priority action 3, community mobilization and public education campaigns on the dangers of excess salt intake were identified by many participants to further address lack of population knowledge on the level and the impact of excess salt intake.Table 3). According to the participants, weak advertising regulations in Nigeria made it difficult to control what was advertised on different media platforms, reducing potential adoption, fidelity, and effectiveness of this priority action. Similarly, there was a perception among respondents that not using appropriate communication channels to drive this priority action could potentially impact adoption, fidelity, and effectiveness. Lack of consumer trust in advertising regarding the content of the products being advertised was also noted as a barrier to effectiveness.Six major factors were identified by participants as potential barriers or facilitators, to the implementation of the second NMSAP priority action of changing how companies advertise their foods, especially to children Possible resistance from the food industry due to perceived threats on sales and consequently profits was also identified by participants as a potential barrier that could affect adoption. In contrast, one potential facilitators of implementing this NMSAP priority action is the existence of a favorable and effective advertising strategy to reduce smoking. This experience has created a favorable environment for similar advertising regulations related to excess dietary salt reduction in Nigeria. Moreover, participants stated that there was a large media presence in Nigeria which could facilitate adoption and effectiveness of this NMSAP priority action. Widespread media presence would facilitate rapid implementation and reach of modified advertisements, resulting in better effectiveness.To address limited advertising regulations in Nigeria, participants suggested that the Nigerian national government develop policy regulations on how the food industry advertises its products, including restricting where and when advertising can be done, how much, and how prominent the advertising should be. Also, participants noted that advertising agencies can strengthen advertising regulations by ensuring that the food industry conforms to laws and regulations that govern food advertisements. Similar to other priority actions, respondents identified the need to improve and mandate front-of-package nutrition labeling to help consumers understand what is in the products to increase demand. Other strategies focused on enforcement including sanctions of companies that do not conform to advertising regulations, as well as monitoring and surveillance of food advertisements. Participants mentioned that using a similar approach to tobacco advertising regulations could be an effective strategy to change how companies advertise their foods, especially to children.What tobacco has done is to enact a law that prohibits advertisement to children and anywhere around where children are prone to be available… I think the same can apply to food and beverage industries that are quite high or rich in salt and trans-fat, the same can apply to them as well. According to participants, strategies were also needed to increase the effectiveness of strengthening advertising regulations on food through strategies to strengthen the communication channels. In addition to priority action 3  these included: 1) use of organizations drawn from local community councils to educate and sensitize the public before policy implementation to increase acceptability and effectiveness; and ensuring that advertisements included information about the danger of excess salt in advertised foods. In addition, participants suggested educating the food industry on the need for salt reduction, increasing government advertising support for the food industry  to incentivize change, and involving the food industry in government plans to change advertising approach on salt reduction as strategies to address possible resistance to adoption from the food industry in implementing the second NMSAP priority action. Additional barriers included public lack of awareness of excess salt risks, ideal salt intake levels, poor food labeling, and distrust of some government initiatives. Participants noted some facilitators including public interest in health issues in Nigeria, thus providing a good platform for public campaigns to educate people about foods.Poor internet services, high cost of public health campaigns, high level of illiteracy in Nigeria, and cultural practices which support excess salt consumption were identified as potential barriers that could affect effectiveness, feasibility, acceptability, and perceived appropriateness of the third NSMAP priority action Further, participants highlighted that use of existing government institutions and structures, such as the National Orientation Agency that is tasked with the responsibility of mass awareness campaigns including public health campaigns, to facilitate rapid adoption and effectiveness of this NMSAP priority action.Many participants mentioned that to implement NMSAP priority action 3, public health campaigns should be conducted in local languages and carried out in platforms where different audience could be reached such as traditional media , social media, religious institutions , and public spaces . Participants mentioned that targets of public health campaigns should include both children and parents, as well as religious leaders, traditional rulers, opinion leaders, and ethnic leaders.What I would just want to add to that is that when we are going, when we go below the industry, the stakeholders, the whatever, when we are getting to the lower cadre, we should try to speak to them in their own languages…Let it get to the languages that everybody understands. And then, the message will be passed across. Participants highlighted the need for multi-sectoral collaboration and involvement to promote public health campaigns for implementing this NSMAP priority action. These stakeholders should include local, state, and federal government, local and international NGOs, and government agencies, such as the National Orientation Agency, Ministry of Women Affairs, and Ministry of Education. Use of trusted sources such as religious leaders, ethnic leaders, community health workers, community mobilizers, health professionals, community health volunteers, teachers, and social networks was identified as a key strategy to increase acceptability and effectiveness. Other strategies included: grassroot mobilization to change how people learn about food; use of other influencers such as music and movie stars, celebrities, and politicians to champion salt reduction in public health campaigns; and framing of public health campaign messages in a way that shows the impact of excess salt intake on health  and enlightens consumers on how to limit daily salt intake.This priority action was highlighted as the most important and perhaps most likely to be effective according to respondents. Barriers highlighted by participants included bureaucracy by school authorities and teachers’ lack of knowledge on appropriate salt intake levels, which could affect adoption and feasibility. Conversely, participants stated that children influence their families, which could be leveraged on to facilitate effectiveness of this NMSAP priority action. They emphasized that integration of nutrition education into the school curriculum may have a long-term impact because children generally trust their teachers and believe that what is taught in school is true and could favorably influence the dietary behaviors of their families. Some participants mentioned that there were existing government school feeding and health programs underway in some schools in Nigeria. The successful adoption of such programs could influence acceptance, feasibility, and effectiveness of this NMSAP priority action more broadly.Participants reinforced the need to integrate nutrition education within the school curriculum as a major strategy to ensure feasibility and adoption. Integrating nutrition education into school curriculum would achieve a sustained and prolonged healthful influence on children and increase the likelihood that low salt intake is maintained into adulthood. Participants cautioned that such a nutrition education program should be simple, and easy to understand by children and applied whenever and wherever school food is served.To address the bureaucracy by school authorities, participants suggested the need to work with teachers and the school administrators and to engage the Ministry of Education for the institutionalization of school-based activities and policies on salt reduction in Nigeria. Further, training of chefs in proper nutrition on the need to prepare low-salt meals and training of teachers to be able to teach healthy diets to school-children are key strategies to improving knowledge on salt intake levels among school staff. Since there are existing school nutrition and health programs, these could be leveraged to facilitate the provision of nutritious diets that are low-salt diets, but flavor enhanced to children. Other strategies mentioned by participants included teaching children on the benefits of healthy eating, culinary arts, and health risks associated with poor diet quality and excess salt intake. These messages could be conveyed using social media, poems, debate competition, cartoons, radio jingles, and use of ambassadors and celebrities and during classroom sessions, practical demonstrations of healthy and low-salt diets in schools.Food labeling is included in the NMSAP goal 2, which focuses on promoting healthy diet in Nigeria, and relates to NMSAP priority actions 1–3. Participants noted potential barriers to strengthening food labeling in Nigeria included: absence of nutrition facts label in processed foods; tiny lettering of nutrition facts labels; misleading and deceptive labeling; difficulty of understanding nutrition labeling due to use of technical terms; lack of trust in food labels because labels may not be an accurate reflection of the food content; lack of knowledge on the benefits of reading food labels; and checking food products for other information, such as expiry dates, calories, sugar levels, and Nigerian Agency for Food and Drug Administration and Control code rather than information on salt.They (Nigerian community members) look at all the things that are there but most of them don’t even look at it and see whether they have a large amount of salt in the diet or not. What most Nigerians check is the expiry dates. How many Nigerians even know what the normal amount of salt is? To increase the effectiveness of better food labeling, participants mentioned that providing public health education including how and why to read food labels is an important strategy to improve public awareness and application. Other strategies highlighted by participants included: mandatory labeling of nutrition declaration, which should be done by dialoguing with food companies and giving them enough time to adjust to the policy change on food labeling; creating standards for and enforcing front-of-package food labeling; simplification of labeling; and public education on the amount of salt in ultra-processed foods.By interviewing a range of key stakeholders in the Federal Capital Territory (FCT), Ogun, and Kano states and using implementation science frameworks, this study provides insights on salt-related knowledge, attitudes, and behavior among stakeholders and explores their perspectives on the potential implementation outcomes, barriers, facilitators, and strategies for implementation and scale-up of Nigeria NMSAP priority actions to reduce excess dietary salt intake. While implementation of the four NMSAP priority actions and the strengthening of food labeling will be important to reduce excess salt consumption in Nigeria, there are multifaceted barriers that may affect implementation within and across these priority actions, but which can be addressed through cross-cutting and targeted strategies.The most prominent barriers affecting two or more implementation outcomes included: consumer level barriers , organization barriers , and policy level determinants .These implementation barriers are similar to those identified in previous studies of national salt reduction programs –29.Participants noted that one cross-cutting facilitator of the four NMSAP priority actions and food labeling was the high media presence in Nigeria. Many participants in this study emphasized the important role of media in the implementation and scale-up of the Nigeria’s national salt reduction program. Since there is high media presence in Nigeria, this strategy provides a potential opportunity to use this avenue to widely educate the public on excess salt consumption. The starting point may be involving reporters in salt reduction program to increase media coverage to increase public knowledge and healthy behaviors related to salt and health . EvidencKey strategies suggested by participants in implementing the NMSAP priority actions include strengthening consumer education through multiple sources, front-of-package labeling, legislative initiatives to establish maximum salt content limits in foods and regular monitoring for implementation, mandatory front-of-package labeling schemes and warning labels for high salt foods for publicly procured foods and meals, strengthening regulations and implementation of food advertising, and interventions in public institution settings. Similar multifaceted national strategies to salt reduction have been reported in other countries ,17,27,32Consumer education has been an important strategy for salt reduction globally, which has been mostly led by governments, followed by both government and NGO and food industry, and solely by NGO . ParticiParticipants in this study mentioned front-of-package labeling as an important strategy to reduce excess salt consumption in Nigeria. Evidence shows that front-of-package labeling is effective in improving public understanding and use of food labels and also support informed choices –43. FronKey informants also highlighted the importance of engaging the food industry and other stakeholders including consumers in the design of policy implementation work to reduce dietary salt including the priority actions and improving food labeling. This recommendation reflects other studies recommending a collaborative approach involving stakeholders across government, food industry, and individuals provides an important opportunity for implementing reduced sodium salt interventions . This coParticipants in this study explained the need for government to strengthen and enforce existing food and dietary policies in Nigeria. Even though there are existing dietary policies in Nigeria –47, thesSome participants in this study also mentioned that ultra-processed foods such as packaged noodles and bread are major staple foods that have contributed to excess salt consumption in Nigeria, and this aligns with what previous studies have shown ,49. As aParticipants were very enthusiastic about the policy action of integrating nutrition education into school curriculum as a key strategy to long-term children’s behaviors towards excess salt intake. However, while nutrition knowledge may help students form positive behavior intentions towards healthy eating , there iAlthough this study engaged many stakeholders from government to non-governmental agencies, it has some limitations. First, our study was based on a purposive sample only including three states in Nigeria, and most came from FCT indicating that the results cannot be generalized to the whole of Nigeria. Similarly, the sample was not a representation of Nigerian population as participants had high baseline knowledge about salt intake and its impact on health. For instance, parents were not interviewed in this study. However, work is ongoing to ensure broad stakeholder engagement on this topic, including a November 2021 meeting at the authors’ institute that included >400 participants [This qualitative study provides stakeholder perspectives on implementation and scale-up of the NMSAP efforts to reduce excess dietary sodium consumption in Nigeria. Many cross-cutting barriers and implementation strategies were identified to increase adoption, acceptability, and ultimately effectiveness of the NMSAP priority actions. While some of the participants’ narratives built on existing facilitators, many were targeting known or potential challenges, which will be important to address for the bold and important NMSAP to achieve its goal to reduce the risk of premature mortality from NCDs, including CVD, and to improve the health for all Nigerians.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(DOCX)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.S8 Table(DOCX)Click here for additional data file.


This article details how and why we have developed a flexible and responsive process-based rubric exemplar for teaching, learning, and assessing critical and creative thinking. We hope to contribute to global discussions of and efforts toward instrumentalising the challenge of assessing, but not standardising, creativity in compulsory education. Here, we respond to the key ideas of the four interrelated elements in the critical and creative thinking general capability in the Australian Curriculum learning continuum: inquiring; generating ideas, possibilities, actions; reflecting on thinking processes; and analysing, synthesising and evaluating reasoning and procedures. The rubrics, radical because they privilege process over outcome, have been designed to be used alongside the current NAPLAN tests in Years 5, 7 and 9 to build an Australian-based national creativity measure. We do so to argue the need for local and global measures of creativity in education as the first round of testing and results of the PISA Assessment of Creative Thinking approach and to contribute to the recognition of creative thinking (and doing) as a core twenty-first century literacy alongside literacy and numeracy. We propose that creative inquiry rubrics are radical in their attention to teaching, learning and assessing processes over outcomes. We advocate for a process orientation as an antidote to the continuing standardisation of creativity measures, most recently seen in the incoming PISA creative thinking test OECD, . Within  Grundy, , where t Grundy, , where rAustralian ITE programs are complex programs focussed on learning about teaching practices through the study of curriculum and pedagogy. These programs are developed through well-defined accredited learning designs, underpinned by curriculum, policy, educational theories and pedagogical practices in conjunction with school-based work-integrated learning (WIL) placements to prepare pre-service teachers for success. To achieve this, ITE programs are responsive to multiple reforms: professional regulatory bodies such as the Australian Institute for Teaching and School Leadership (AITSL) and the Australian Curriculum, Assessment and Reporting Authority (ACARA), including recent shifts in the wake of the COVID-19 pandemic, and compliance standards that are enforced through state and commonwealth government authorities. Higher education providers must meet standards from authorities in their home state to enable graduates to register as teachers. University courses are mapped against program standards set by AITSL to ensure that pre-service teachers are classroom ready for the challenging and diverse educational contexts they will encounter.Action Now – Classroom Ready Teachers  Education Declaration The Mitchell Institute's  positionThe Practice Principles for Excellence in Teaching and Learning  in VictoIt began pre-pandemic with designing and developing a PBCI rubric to support and enable ITE students to contribute positively to the creative ecologies in their creative educational ecosystems, including placement schools and future employment sites. By focussing on the inter-relationships between teaching, learning, practices and assessing for Critical and Creative Thinking, we can avoid definitional skirmishes that frequently occur in disciplinary debates and highlight creative thinking skills. Therefore, we make it clear that ITE programs need to demonstrate how they teach, practice and assess Critical and Creative Thinking through an inquiry-based learning model that can be integrated into and across all disciplinary cultures and practices in education . Australian ITE programs should better reflect the changing global educational landscapes that recognise critical and creative thinking as central to learning, teaching and assessment to ensure success-ready graduates in the pandemic and endemic.critical with creative as problematic. Central to the Creative Education Toolkit are the radical rubrics, designed to align with the NAPLAN testing years, scaffolding the skills to participate in and contribute to, developing a robust creative ecology within their future schools.Our collaborative ecological approach offers ITE pre-service teachers experience in considering both the theoretical underpinnings of the Critical and Creative Thinking general capability and practical, implementable strategies for approaching teaching, learning and assessment on their professional experience placements to combat the conflation of Harris' formulation of a creative ecology model includes five domains that address elements in all areas of learning communities. Following Amabile and et al.'s  developmApproaching creativity in education as an ecology . This cyclic program design creates an evaluative feedback loop where pre-service teachers move into the schooling sector with evidence of teaching, practising and assessing the Critical and Creative Thinking general capability as learners themselves.A creative ecology model in ITE prepares teachers as future ready by learning about creative practice through practice  for addressing creative assessment, it was necessary—as a starting point—that we held similar beliefs about the influence of ITE and shared values about the transformative power of creativity. A deep understanding of creativity in education was also common amongst the co-authors, all having employed creative approaches in education at various levels and across multiple learning areas. Approaching this work as both artists and educators was integral to understanding criticality and creativity, inter-, multi- and transdisciplinary and diverse approaches to creativity within the curriculum and beyond.The remainder of this article explains how we as a collaboratory developed these radical rubrics against the Australian Curriculum General Capability against the USA Common Core Standards (CCSS) and the OECD Learning Framework 2030 OECD, , which s…think creatively, develop new products and services, new jobs, new processes and methods, new ways of thinking and living, new enterprises, new sectors, new business models and new social models. Increasingly, innovation springs not from individuals thinking and working alone, but through cooperation and collaboration with others to draw on existing knowledge to create new knowledge. The constructs that underpin the competency include adaptability, creativity, curiosity and open-mindedness. OECD, , p. 5While the Australian standards set grade-specific goals, they do not define how the standards should be taught or which materials should be used to support students, and the supports that effectively enhance creative and critical thinking through CCSS aligned Creativity & Innovation Rubrics  as a core literacy alongside literacy and numeracy, underlining further focus on creativity assessment at a global scale Bouchie, .While we recognise that tensions exist across Australian states between implementing a national curricular capability into localised state agendas responsible for implementation, we have designed this overarching assessment strategy through PBCI rubrics Fig.  useful fThis radical rubric may be used as a capstone or foundational tool in ITE programs to foster assessment of creativity through practice; however, it can also be used individually or collectively within a school- or university-based ecological model. As Moss, et al.  agree, t…highlights the increasing duality of the modern teacher – that of both teacher and learner. It also suggests that 21st century teachers will be unable to navigate the modern educational workplace without the skills and dispositions that enable them to focus on their own learning and improvement. (p. 3)The radical rubrics within the Creative Education Toolkit act as an iterative tool through which learners design, develop and review their inquiry. The rubric as an agentic tool allows the merging of learning experiences with ongoing engagement and collaboration. It offers learners (teacher educators and pre-service teachers and in-service teachers with students) to construct and organise knowledge themselves, engage in detailed research, inquiry, writing and analysis, and communicate effectively to audiences. Leadbeater (2008) argues that the successful reinvention of educational systems worldwide depends on transforming pedagogy and redesigning learning tasks. Promoting learner autonomy and creativity through inquiry learning within ITE programs is part of the solution. The Mitchell Institute  note thiThe next section introduces a radical rubric that promotes teaching, practising and assessing creativity and critical thinking in ways that move beyond binaries such as 'standardised' and 'creative' instead of an imaginative, empathetic and inquiry-focussed interdisciplinary assessment tool. Our 'sleight-of-hand' in offering what may at first seem like a capitulation to standardised assessment is the kind of tool that can serve both or, as Maxine Greene argued, offer an imaginative approach that can work within simple standardisation “to combat standardardization” , p. 380.Rubrics such as this exemplar can be deployed in Years 6, 8 and 10  as part of a networked ecological approach to fostering creativity in educational settings Harris, . Using fThe rubric is described in Fig. Figure The rubric provides illustrations of practice that enable teaching staff to consider potential implementation ideas. Figure The second illustration of practice is included in Fig. This paper has explored how and why our collaboratory developed a flexible and responsive PBCI rubric exemplar for teaching, learning and assessing creativity to work within Harris' Creative Education Toolkit. We began this work by asking, 'how do early career teachers develop and maintain the ability to design interdisciplinary future-focussed creative learning and teaching? Where do early career teachers develop curriculum integration skills and capacities as practitioners?' This is an important time to share our praxis approach as educators worldwide face new post-pandemic challenges requiring teachers to design creative, critical, often-digital, inquiry-based learning encounters for young people. Being radical, creative and critical through a critical praxis model that challenges teaching, learning and assessment education, rather than standardising creativity in education, is needed now more than ever. Our radical rubric design provides a model for cultivating and assessing critical and creative thinking across the ecology. This kind of active feedback-feedforward loop through an inquiry model, also understood as curriculum “as praxis” Grundy, , p. 15 cThe approach outlined in this paper suggests moving creative change in schools and ITE programs away from teacher-driven activities to co-activating problem posing as a collaborative creative practice that initiates and sustains learning through creative inquiry. The radical rubric design effectively and efficiently initiates and cultivates Critical and Creative Thinking as a general capability in ITE (and by extension into schools and classrooms). The model explored in this article is just one of the Toolkit rubrics that we propose as a set of radical interventions, which together establish more processual and accessible creative practices in learners and across whole-school creative ecologies. As such, ITE holds the potential to activate substantial and sustainable critical and creative thinking development in pre-service and early-career teachers and apply generational mindset change in all learners, by effectively developing and evolving creative communities of practice.


Based on the Web of Science core collection database, this paper retrieves 349 research papers on terraced fields published during 1991–2020. Keyword co-occurrence analysis, cluster analysis, and thematic evolutionary analysis were used to identify the evolutionary path of terrace research. The findings were as follows: (1) In the past 20 years, the study of terraced fields has shown an upward trend. The number of annual published papers during 2012–2020 was much more than that during 1991–2011, but papers during 1991–2011 were more academically influential than those during 2012–2020. (2) Regional analysis showed that terrace research in China is the most abundant currently, and is mainly focused on agricultural production, agricultural engineering, cultural tourism, and ecological environment. (3) Keyword co-occurrence analysis showed that terrace landscape, terrace agriculture, terrace abandonment, land use change, soil and water conservation, and sustainable utilization of typical terraces are the main modules of current terrace studies. (4) In a temporal dynamic perspective, terrace research presented 10 main evolutionary paths during 1991–2020, reflecting the trend of terrace research towards sustainable terrace development of ecological agriculture and ecosystem service. (5) Finally, this paper suggests that here is a need to deepen studies on terrace ecosystem services and human well-being based on their structure and processes, to analyze the interaction and comprehensive effect of natural process and humanistic driving forces on terrace abandonment, and to explore the multi-functional benefits and sustainable management of high quality terraced landscape. Terraces refer to cultivated land with terraced distributions, horizontal surfaces, and ridges . TerraceTerraced fields are of great value in broadening agricultural production sources, alleviating soil erosion and degradation ,6, savinAlthough terraced fields are of great value, their utilization is not optimal. Studies show that influenced by agricultural input cost, grain yield, agricultural facilities, labor quantity, and labor opportunity cost ,24,25,26The influence of terraced land abandonment is multifaceted. Although terrace abandonment may benefit biodiversity improvement and soil habitat restoration, its adverse effects cannot be ignored. Research show that terrace abandonment will cause resource waste, ecosystem service value reduction, land cover change, and an overall decline in water resource availability , resultiMore than typical ecological agriculture modes in mountainous areas, terraced fields are also outstanding ecological and cultural landscapes and precious agricultural cultural heritage, which have important enlightenment and reference significance to the sustainable development of agriculture. The second section of this paper introduces data sources and research methods. The third and fourth sections describe quantitative and qualitative scientometric analysis on terraced fields by bibliometrix and VOSviewer software, respectively. The fifth section draws conclusions and describes prospects for future research. This review provides a broader vision of terrace study, which has a positive effect on terrace landscape maintenance, ecological protection, and sustainable development in hilly and mountainous areas.The data in this study were sourced from the world’s largest comprehensive information resource, the Web of Science core collection database of the Institute for Science Information (ISI). This database includes over 8700 core academic journals in various fields of natural sciences, engineering, biomedicine, social sciences, arts, and humanities. In this paper, the core collection of the Web of Science was used as the data source, the SCI-EXPANDED and SSCI databases were indexed, articles were selected as the literature type, and English was set as the language. After screening and removing the duplicated data, 349 papers on terraced fields during 1991–2020 were obtained, and the downloaded data was saved in a text format.R package provides a set of tools for quantitative research in scientific metrology. R-language-based bibliometric software developed by Dr. Aria and others provides support for importing and processing literature information from SCOPUS and WoS, statistically analyzing relevant scientific literature indices, constructing a data matrix, and conducting research and visualization processing on co-citation, coupling, cooperative analysis, and co-word analysis [Bibliometric analysis provides a comprehensive overview of a large body of research literature and further develops previously unevaluated insights by allowing quantitative and objective identification of past and present research topics . The Bibanalysis . It has analysis ,35,36. Vanalysis ,39,40,41Based on the statistical analysis of 349 papers on terraces during 1991–2020 from WoS, the research was divided into two stages. The first stage was the exploration of the period of low yield from 1991 to 2011, which was characterized by the small number of published papers on terraces. In this period, the average number of annual published papers was 7.1 and the average annual number of citations was 23.1. The second stage was the period of increasing production during 2012–2020. The average number of annual published papers had increased to 21.7 and the average annual citations reached 10.9. While the number of published papers in the second stage was approximately three times that of the first stage, the number of citations in the second stage was only half that of the first stage, indicating a greater academic influence in the first stage and a higher research enthusiasm in the second stage. It also indicates that the early pioneering studies from varied perspectives laid a foundation for subsequent terrace research. Based on current research trend, it is expected that terrace research will be further enriched.Studying the role of old agricultural terraces on runoff generation in small Mediterranean mountainous basin” published in 1994 had been cited 122 times by the end of the study period. It was proven in this paper that surface runoff in the Mediterranean mountainous area was related to the spontaneous reorganization of the artificial drainage network in abandoned terraced fields [Land use change effects on abandoned terraced soils in a Mediterranean catchment, NE Spain” published in 2003 had been cited 146 times. In this paper, the different vegetation stages were divided into four main land-use types according to the age of abandonment: cultivated fields , recent abandonment , moderate abandonment  and early abandonment , and variance analysis indicated significant differences in the main soil quality parameters such as soil organic matter (SOM), total nitrogen (N), water holding capacity (WHC), and pH, among the selected environments under different land-use conditions [Land environment and slope gradient as key factors of soil erosion in Mediterranean terraced lands” published in 2007 had been cited 211 times by the end of 2020. The research results showed that the influence of traditional extensive cultivation abandonment on soil sediment losses varied with slope gradient. When slope gradient was steep (25%), soil erosion increased significantly. When slope gradient was very steep (40%), soil sediment losses remained at the same high levels after cultivation abandonment as slope gradient was the main factor controlling soil erosion, although soil and vegetation properties were changing [In the first stage during 1991–2011, there were four small peaks of citations, namely, 1994, 1998, 2003, and 2007 Agriculture (1991–2017);(2)Soil erosion (1991–2017);(3)Agricultural landscape (2005–2017);(4)Land abandonment (2014–2020).The four main single research paths are as follows:According to the study period, paths 1, 2, and 3 are traditional paths, while path 4 is an emerging path. The temporal information shows that early terrace research (1991–2017) focused on agricultural and soil erosion. Traditional terraces were generally built on hillsides to develop cultivated land, regulate water circulation, and maintain soil. The early research paths were consistent with the original development needs for terraced fields. Namely, to control soil and water loss of production land by slope treatment, and to improve soil physical and chemical properties through terrace cultivation to accumulate nutrients needed for crop growth, thus improving agricultural production capacity. Terraced fields play an important role in maintaining slope landscape pattern and tourism development by changing land landscape and increasing regional landscape heterogeneity. Therefore, with the development and improvement of terrace engineering technology, scholars pay more attention to the agricultural landscape value of terraced fields, including landscape pattern change, typical watershed landscape patterns, terraced cultural landscapes, comprehensive evaluation of landscape multifunctional value, and landscape protection. In recent years, due to the decline of agricultural comparative income, the rise of agricultural opportunity cost, and the constraints in terrace engineering design, abandoned terrace fields gradually expanded and became an emerging research focus. The advancement of industrialization and urbanization highlights the intensifying terrace abandonment. Therefore, study of abandoned terraced fields will continue to be a hotspot in future.(1)Cultivation terraces (2005–2013) → sustainability (2014–2017);(2)Ifugao rice terraces (1991–2004) → biodiversity (2005–2013);(3)Ifugao rice terraces (1991–2013) → ecosystem services (2014–2017);(4)Soil erosion (1991~2004) → terraces (2005–2013) → runoff (2014–2017);(5)Soil erosion (1991~2004) → terraces (2005–2017) → terraces landscape (2018–2020);(6)Terraces (2005~2017) → soil and water conservation (2018–2020).The expanded research paths are as follows:The evolutionary process of expanded research paths is more abundant than the single research paths. Path (1) reflects the sustainability goals and research trends of terrace cultivation, including the necessity of terrace sustainable development , sustainThe theme evolution pathways present a terrace research trend from single to diversified and from simple to complex in the past 30 years. Themes have evolved from the initial topics of agriculture, terraces, and soil erosion to sustainable utilization, biodiversity, and ecosystem services. However, research on the classified management of terrace fields is still deficient, and research on terrace historical evolution, value evaluation, eco-environmental effect analysis, and specific management strategies is expected to become popular in the future.This paper conducted quantitative and qualitative analysis on literature of terraced fields from 1991–2020 from the WoS database. The quantitative analysis included article, author, and regional analysis, and the main conclusions were as follows: (1) terrace research presents an increasing trend with fluctuations during 1991–2020; (2) terrace research has attracted scholars from various fields, and is expected to remain a hotspot in the future; and (3) agricultural production, agricultural engineering, cultural tourism, and ecological environment are the main research aspects in China. Qualitative studies included keyword co-occurrence and thematic evolution analysis. The main conclusions were as follows: (1) keyword co-occurrence analysis formed five research clusters focused on terrace geological archaeology, terrace landscape and cultural value, the effectiveness of terrace soil and water conservation, and the utilization and change of terraces, reflecting the main modules of current terrace studies and (2) thematic evolution analysis presented 10 main evolutionary paths of terrace research in a temporal dynamic perspective, which were characterized by single and expanded research paths and included “land abandonment (2014–2020)” and “soil erosion (1991–2004) → terraces (2005–2017) → terraces landscape (2018–2020)”, reflecting the trend of terrace research towards sustainable terrace development of ecological agriculture and ecosystem service. By reflecting terrace research emphases in different periods, thematic evolution analysis provides ideas for analyzing the evolutionary process and mechanism of terraced field research, thus providing a basis for understanding the future research direction of terraced fields. Based on the existing literature, this paper puts forward the key content and direction of terrace research in future.(1) As important agricultural landscapes and cultural heritages, terraced fields have become a model of the coupling between man and nature, and also a unique way for humans to adapt to the mountain ecosystem during their long-term struggle against harsh natural conditions. Terrace ecosystems provide a variety of services for mankind, and their ecosystem structure and processes affect the service supply. However, there is little research on the spatial–temporal matching of terrace ecosystem services in current studies, thus failing to reveal the interaction between multiple services from the service formation mechanism, and research on the evaluation of terrace ecosystem services is also lacking. Therefore, based on the structure and processes of terrace ecosystems, future studies may focus on terrace ecosystem services and human well-being, and carry out quantitative and qualitative evaluation of terrace ecosystem services according to the research environment and purpose.(2) Terrace research shows a comprehensive and diversified trend in terms of research content, research scope, and research scale. However, studies on the driving forces and risk assessment of terrace abandonment are few. In view of the complexity and coupling effect of terrace abandonment, it is necessary to give full play to the multi-disciplinary advantages of natural ecology, sociology, economics, geography, and human policies and to take into account the demands of stakeholders including scientists, decision makers, grass-roots managers, and farmers, thus comprehensively analyzing the interaction and effect of natural process and humanistic driving forces on terrace abandonment.(3) There is a need to study countermeasures to strengthen ecological protection and restoration of terraced fields, and to explore the multi-functional benefits and sustainable management of high-quality terraced landscapes. In fact, under the impact of the modern scientific and technological revolution and the new ways of production and life, terrace ecosystems in most parts of the world are threatened by abandonment and extinction. It is necessary to establish a long-term self-sustaining mechanism of terrace ecosystems through dynamic protection and adaptive management of terrace landscapes, so as to realize the sustainable utilization and development of terraced multi-functional landscapes.


EPH Conferences have an increased focus on the health impacts of climate change. However, until 2021 EPHC abstracts did not address opportunities to challenge government inaction in national and international courts. ASPHER’s European List of Core Competences for the Public Health Professional (2018) only mentions NCDs and data protection law. Yet litigation to address environmental degradation and climate change is well-developed in Europe and beyond. International environmental law was presciently framed as part of global health law by Joaquin Cayon in Laaser U. and Beluli F. A Global Public Health Curriculum. South Eastern European Journal of Public Health (2016).1. Clarify the role of litigation in achieving environmental and climate goals2. Highlight the role of public health practitioners (PHP) in documenting evidence of harms3. Propose ways to build PHP capacity to use litigation to address related public health challengesIn 2021 EUPHA-LAW, EUPHA-ENV, the Faculty of Public Health (FPH) (UK) and partners co-hosted a multi-stakeholder, interdisciplinary, open-access webinar on public health, climate change and litigation with experts from WHO, Greenpeace, ClientEarth, Lancet Countdown and the Groningen Centre for Health Law (GCHL). A related workshop was held at the 14th EPHC. In March 2022, EUPHA-LAW, FPH, GCHL and the University of Liverpool hosted a webinar on climate action in the European Court of Human Rights.  EUPHA-LAW is preparing a toolkit for public health practitioners and a conference on public health litigation in 2023.There is keen interest in the public health community to better understand how litigation can address public health challenges including climate change and environmental degradation. Capacity building is needed.• Climate litigation supported by interdisciplinary collaboration can strengthen government resolve and accountability for action to address environmental and climate commitments.• Litigation can advance public health objectives even without a favourable court decision. Its value also includes the publicity and awareness generated and engagement of multiple stakeholders.


Foundational high-resolution geospatial data products for population, settlements, infrastructure, and boundaries may greatly enhance the efficient planning of resource allocation during health sector interventions. To ensure the relevance and sustainability of such products, government partners must be involved from the beginning in their creation, improvement, and/or management, so they can be successfully applied to public health campaigns, such as malaria control and prevention. As an example, Zambia had an ambitious strategy of reaching the entire population with malaria vector control campaigns by late 2020 or early 2021, but they lacked the requisite accurate and up-to-date data on infrastructure and population distribution. To address this gap, the Geo-Referenced Infrastructure and Demographic Data for Development (GRID3) program, Akros, and other partners developed maps and planning templates to aid Zambia's National Malaria Elimination Program (NMEP) in operationalizing its strategy.  Zambia is a highly endemic malaria country and is among the 20 countries reporting the highest malaria incidence and mortality globally, with the entire population considered at risk of malaria transmission.  The goveThe country's Ministry of Health relies on a range of interventions, including community-based surveillance and vector control measures, to fight the disease. Since 2017, the National Malaria Elimination Program (NMEP) has deployed indoor residual spraying (IRS) as its primary malaria vector control tool, complemented by distribution of long-lasting insecticidal nets (LLINs) . MaximizNMEP had the ambitious strategy of conducting a combined IRS and LLIN campaign to reach the full population with vector control by late 2020 or 2021. The government's “mosaic approach” aimed to conduct IRS campaigns in prioritized zones of all districts, with the mass distribution of LLINs to fill gaps at sub-district level. At the time of the 2020 campaign, Zambia administrative division constituted 10 provinces and 116 districts. According to longstanding Zambian practice, the selection of settlements for IRS within districts was based on criteria of structure density, suitability of construction materials, accessibility, and other aspects of operational feasibility. To ensure every settlement was covered with at least one vector control intervention, joint IRS/LLIN micro planning sessions were conducted in each district nationwide. However, in the beginning of 2020 the required accurate and up-to-date key data on residential structure counts and population distribution, which determine IRS and LLIN resource needs, respectively, were still lacking.Foundational high-resolution geospatial data products are valuable additions to the efficient planning of resource allocation during critical health sector interventions such as malaria control . To ensuThis paper describes the collaborative process of the partnership's ability to: (1) generate high-resolution geospatial data to enhance the efficient planning of resource allocation; (2) incorporate such data to create a planning map template; and (3) implement a map template during micro planning sessions and generate final map products for all districts; and use the Reveal tool, an open-source digital spatial intelligence platform, in a subset of districts to support the planning, execution, and monitoring of intervention activities. The development of these geospatial data products supported more targeted service delivery, a better understanding of health interventions achieved, partial digitization of campaigns, and communication and harmonization of geospatial data across the government and its partners.In April of 2020, the partners listed above initiated a collaborative process led by the Zambia's NMEP to utilize data produced by GRID3 to create micro planning maps for the vector control campaigns in all 116 districts across the 10 provinces. Data utilized for the production of user-friendly planning maps included the high-resolution gridded population estimates, settlement extents showing delineation of settled areas nationwide, and the number of residential structures, settlement names, and administrative district boundaries, as well as locations of landmarks such as health facilities and schools. These detailed maps were used to (1) ensure that all settlements and their populations within a given district were accounted for in service delivery as per the NMEP strategic plan, (2) ensure that there were enough vector control resources  to reach all settlements targeted by either IRS or LLIN across all districts, (3) to improve understanding of the accuracy of reported coverage, and (4) to communicate and harmonize geospatial data across the government and its partners. The following sections describe the production of geospatial data inputs that were used in the creation of the maps.In partnership with Zambia Statistics Agency (ZamStats), formerly the Central Statistical Office), the GRID3 Zambia team produced high-resolution population estimates that rely on household surveys to model population in a Bayesian framework at a spatial resolution of approximately 100m by 100m . GRID3 ZGRID3 obtained existing health facility location data from government sources, including the Ministry of Health (MoH) and ZamStats, to assess coverage and produce a standardized health facility dataset “NSDI Zambia Operational Health Facility Points and Names, Version 01 (Beta)” . AccuratSettlement extents are polygons representing areas where a human settlement is likely, based on the presence of buildings detected in satellite imagery. Settlement extents that show population distribution are a key data input for micro planning maps.  Prior toSettlement extents are not meant to represent the boundaries of an administrative unit or locality. A single settlement extent may be made up of multiple localities, especially in urban areas. Both the settlements' extents and classification are derived solely from building footprints extracted from high-resolution imagery . Data anThe names and GPS point location of settlement names were developed by compiling existing data sources from the government institutions; settlement names were extracted from a 2010 government mapping exercise, during which points of interest (POIs) nationwide were collected by ZamStats. The settlement points were also compared against nearly 12,000 settlement points from the Ministry of Water Development, Sanitation, and Environmental Protection. All available sources were compiled, merged into one layer, and compared against settlement extents derived from the building footprints to ensure a point fell within a settled area .R, this residential structure estimation model was created using GRID3 settlement structure counts and compared against field-verified malaria implementation data collected through the Reveal platform in 2019 and 2020. Predictive factors of the number of residential structures are primarily related to settlement size and structure density, with some regional geographic differences. The model was rebuilt and validated with 2020 field-verified data reporting an absolute total predictive accuracy of 20% of the true value , with the accuracy of the prediction increasing as settlement size decreased. The average absolute difference between predicted and actual residential structure estimates was about one-to-two structures, except for settlements above 400 structures which comprised less than 1% of settlements in the field-verified dataset.Building densities refer to the total number of building points, or structures of all types, within the settlement. To estimate the number of eligible structures for IRS planning, a predictive statistical model was built and applied to the building density to produce a residential structure estimate. Using QGIS, Stata, and To ensure maps are actively used by decision-makers, a map template was developed in consultation with implementors  to aid districts in micro planning. The map templates were designed to: (1) render easier distinction of spatial populations and settlements; (2) maintain legibility of map content when subdividing the full extent of Zambia into regularly-proportioned index grid cells; (3) allow replication, scaling, and use for all 116 districts and for future intervention campaigns. A flexible grid system was devised using harmonized district boundaries to generate the index study areas and nested reference grid cells. Reference grids were used to summarize residential building and population counts, and to create corresponding alphanumeric settlement names for organizational purposes .Each of Zambia's 116 districts was subdivided into a 289-cell static Index Grid using the output of the ArcGIS Grid Index Features Tool as a baseline. This index grid was used to determine the extent of each map page driven by ArcGIS Pro's Map Series feature. Each page was locked to a 4 : 3 (landscape) or 3 : 4 (portrait) aspect to ensure it could be subdivided into equal-area grid cells. Each baseline index cell was 60 km × 80 km, adjusted as necessary depending on the size and shape of the district they subdivided. In order to prevent symbols and labels from being too small to read at A0 printed page size, maps were given a hard constraint of 1 : 1,000,000 scales. After the final index grid was created and cleaned, each page was subdivided into 12 regular, equal-area reference cells.The index grid output, detailed abovementioned, was then used as an input for the second iteration of Grid Index Features. Sub setting each map into a series of nested grids was useful in two ways. First, nested grids allowed for tabular summaries of grid features to be included on the maps. Using the included tables, users can parse, at a glance, summary statistics and how they relate to different subdivisions of the map document. Whereas index grid pages may depict overlapping areas, reference grid cells were clipped to an exclusive study area, which subtracted all nonrelevant space from the analysis. This ensured that summary statistics related to each grid cell were not double-counted among map pages. The sum of these grid cells was used to calculate per-page summary statistics, and the sum of those sums was in turn used to calculate per-district summaries. Tables summarize settlement counts, full district totals, map page totals, and reference grid cell totals, as well as per-settlement summaries of population and building count. Second, dividing each district into low-level grid cells allowed for the creation of an easily distinguishable unique identifier scheme for every settlement that had 25 or more residential structures within it. Each of the 12 reference grid cells contained its own alphanumeric code  to which settlements were assigned, sorted by latitude, and numbered sequentially .Maps were designed to be viewed at A0 poster size, which gave wide latitude to the level of detail that could be included on the map page. Because of the large volume and density of information necessary to include on the map templates for operations planning, readers' attention needed to be managed hierarchically. To keep the information displayed on the maps efficiently , the prihttps://www.openstreetmap.org) were similarly incorporated. Special consideration had to be taken to avoid using hosted base maps with integrated and possibly outdated administrative boundaries, as GRID3 worked closely with the Office of the Surveyor General, Ministry of Local Government, Electoral Commission of Zambia, and Zambia Statistics Agency in order to provide the most accurate and up-to-date boundaries available [A simple terrain hillside was used as the template' s embedded base map in order to provide additional spatial context and inform users of natural barriers to further facilitate planning exercises. Road networks and water features from OpenStreetMaps , Provincial and National staff, who would later be involved in the district-level IRS and ITN campaign micro planning activities for which these mapping tools were being designed. The NMEP vector control team lead this piloting process, with support from Akros and VectorLink, organizing online map use training and feedback sessions. Each district was also reached out separately to maximize feedback on suggested changes.Feedback from the DHO staff in these three districts during the piloting process suggested that the inclusion of maps along withuser guiding documents to enhance resource allocation decisions during micro planning activities and to guide deployment was highly valued. Suggested changes gathered led to map design changes that were incorporated into the final maps, user guides, and training materials. Having the NMEP vector control team lead these feedback sessions ensured the district participants that their efforts would help improve the NMEP micro planning outcomes and thus led to quick highly engaged feedback. During the actual campaign micro planning sessions in Western Province, positive qualitative feedback was collected through six survey questions, collecting responses from 25 participants representing all 16 districts in that province. Survey participants indicated that the maps and population tables were very useful in demonstrating distribution of settlements across the district, how large they were, and how easy/difficult they are to reach . It was reported the process of demarcation and filling out the planning templates using information from the maps was easy to follow in order to calculate the total number of structures targeted for IRS and the population targeted for LLINs. This helped managers to understand if the resource allocation provided by the national level was over estimated  or under estimated (which means some settlements are excluded).Some feedback from provincial and district managers indicated the need for minor changes to the planning templates. For example, a primary challenge experienced during the pilot was the exclusion of health facility catchment area (HFCA) boundaries on the map. This made it difficult to understand which settlements, and therefore population and structure counts, fell within a specific catchment. Given resource planning and implementation monitoring are required at the catchment level for input into the NMEP DHIS2 health information system, being able to accurately map settlements to the correct catchment is very important. Another limitation was that accurate catchment boundaries were not available and adding modelled ones would have led to inaccurate health facility level planning outputs. In addition, the pilot district teams noted the difficulty in understanding the village or area to which each settlement belonged, as there were not enough features (points of interest data) on the GRID3 map to provide “locational context” to the user. Lastly, once targeted demarcations were made on the maps, the counting of the population within the smaller settlements, less than 25 structures, was error-prone, particularly when there were many settlements within the demarcated area.This specific feedback was used to refocus the purpose of the maps from providing health facility planning outputs to providing district-level structure counts targeted for IRS and population counts targeted for LLINs. These counts could then be compared to the district-level resources made available to determine if enough resources were available to cover the entire district and to encourage districts to advocate for more resources (if required). The main map template changes included the addition of village names, schools, water bodies, roads, railways, and forest reserves to help orient users in the field. Index grids were also added to the map and aggregation tables, to help divide the district, encouraging smaller demarcations and easier counting of population and structures on the map. However, as previously mentioned, time did not permit the incorporation of HFCA boundaries; these were added after the 2020 campaigns as an enhancement for future use.Once the map template was finalized, maps were generated from the template for all 116 districts (289 maps at A0 page size) and disseminated through government micro planning workshops. NMEP conducted the annual planning processes at the national level via the NMEP Vector Control Technical Working Group and at the district level through three-day micro planning workshops held in each province, during which it was determined where IRS would be applied and where bednets would be distributed. During the district micro planning process, key staff from the district level vector control teams, guided by provincial and national malaria trainers, used the printed A0 maps to understand the population and residential structure distribution across their district. With an understanding of the malaria burden and operational constraints across their district, they drew IRS as well as LLIN targeting demarcations on the maps to help inform prioritization and resource allocation decisions at sub-district level. Through understanding the location and size of each settlement within their district in relation to health facility sites, access routes, deployment sites, and resource availability for each intervention, map use during micro planning informed decisions on where each intervention (IRS or LLINs) should be implemented. The process outcomes highlighted any settlements that had been left out and if available resources were likely to be enough to cover all the structures within settlements demarcated for IRS and the population within settlements demarcated for LLIN's. In addition, the maps aided in deployment planning for their vector control interventions by clearly demarcating that settlements were planned to receive IRS versus LLIN' s. While the micro planning map user guide document encouraged discussion to resolve any gaps, any resulting changes were not formally documented. Once the IRS targeted areas were demarcated on the paper maps, the targeting demarcations were digitized and used within Reveal to support IRS implementation in 21 districts across the Western and Southern provinces. Reveal displayed the geospatial data on field teams' mobile devices, navigating them to those settlements that were targeted during micro planning and providing a high-resolution satellite imagery view of the village they are in to understand the distribution of structures within the area. The Reveal dashboards provided the digitized campaign “denominator” to accurately monitor and calculate IRS coverage as daily spray reports came in. In 7 of these 21 districts, Reveal technicians were embedded in the spray teams and marked in real time whether structures were found and sprayed. The teams relied on Reveal to (1) navigate to target areas and houses, (2) track whether GRID3 settlements targeted during planning were actually visited in the field, and (3) track health facility catchment level coverage against the GRID3 population denominator. The rest of the 102 districts relied on paper-based maps.This paper outlined the process applied to create map products that served to inform macro- and micro-level planning of malaria campaigns in Zambia. The information gained through the 3-district pilot of these products informed the further scale and deployment of maps across 116 districts in Zambia. Previous to these efforts, household mapping had been undertaken, both through the use of GPS units  and later through desk-top digitization of satellite imagery at the household level . The appThe maps used during the micro planning demarcation process, to understand population down to settlement level, included modeled population counts as opposed to official census population data that were only available down to district level. The modeled population dataset provided the Government of Zambia and partners with estimates of the population across the country, at a very high resolution and based on recent enumeration data. The dataset provides a detailed picture of where people in Zambia live, with the gridded nature of the dataset providing flexibility in calculating the population per settled area. This level of detail allowed the government to effectively plan and implement malaria activities at the sub-administrative level.Delivery of map products occurred both in paper-based format and also through the digital platform, Reveal. A forthcoming publication highlights the process for operationalizing these products. The integration of the GRID3 product with Reveal highlights the potential for end-to-end digitization of the campaign planning and delivery process, applicable to the campaign and also routine health service delivery . GRID3's map product provides base maps of population data, while Reveal operationalizes these base maps to support planning and also the in-field use of the digital maps to guide field teams and monitor their progress in campaign delivery/coverage. Given this recent work, the ongoing and future application of GRID3 products looks promising for the delivery of various health campaigns . Lessons learned during the 2020 implementation informed changes to the now-complete 2021 maps. For example, in 2021, the MoH and funding partners (including PMI and PATH) requested these planning maps be used again across the country, not only to support vector control planning for malaria but also to support other health sector programs (such as routine immunizations and COVID-19 micro planning support).Throughout the process of generating map products for malaria campaigns in Zambia, several limitations have been observed. One of the key limitations was the absence of health facility catchment area boundaries, which are field mapped and endorsed by district health staff and available in a digital format. Given that health interventions in Zambia are planned down to the catchment level, the absence of such operational level boundaries made it difficult for district health teams to assess the need for resources at the unit of geography at which the operational provisions often take place. Health facility catchment area boundaries were later mapped, in early 2021, and included in the micro planning maps to address this limitation in time for the 2021 vector control planning activities.Despite the presumed accuracy of the enumeration data from surveyed locations, used as an input to GRID3's model, modeled datasets remain statistical estimates which are not a replacement for robust, complete enumeration . HoweverThe need for accurate, up-to-date, and accessible geographic data on population distribution is a fundamental requirement necessary to deliver health services to everyone. Without those data, country planning processes and implementation of health services are hindered. This paper summarizes the successful development of paper-based maps incorporating GRID3 data, through a consultative partnership among the MOH, NMEP, and partners. The approach taken here showcases how maps may be developed at scale for micro planning processes to plan for and improve large-scale health campaigns; in this case, IRS and LLINs for malaria control. Future research would be useful to describe the potential cost-savings achieved through the use of geo-enabled planning processes, which is believed to be significant.


Student-run clinics (SRCs) are becoming increasingly popular at medical schools in the United States. These clinics have provided a variety of benefits, including serving disadvantaged populations and providing early clinical exposure for students. There has been no consensus on the impact of SRCs on medical education, specialty selection, and patient care. This review provides a thorough overview of student and patient outcomes as a function of medical students volunteering at SRCs. We queried PubMed for original literature published in English between the years 2000 and 2020. Inclusion criteria included primary research articles evaluating the impact of medical student participation in SRCs on education, specialty selection, and patient care. All articles included in the final review were agreed upon by three reviewers, and the pertinent data were extracted. Of 10,200 initial search results, seven papers were included in this review. These included two studies evaluating medical education, five studies evaluating residency selection, and three studies analyzing patient care. Three studies were included in multiple evaluations. The relationship between volunteering at SRCs and academic performance is unclear. Clinic volunteers had increased retention of empathy compared to non-volunteers. Additionally, clinic volunteers provided satisfactory care as determined by patient-reported outcomes, and were not more likely to pursue primary care specialties. As SRCs are increasing in number, research into the impact on medical students and patients is necessary to understand how these clinics may affect the field of health care. It is important to further evaluate how medical student involvement in SRCs can further improve patient care and outcomes. The implementation of student-run clinics (SRCs) is a growing trend in medical education. Between 2005 and 2014, the number of SRCs doubled among US medical schools, and as of 2014, more than 75% of US medical schools have an SRC [Participation in SRCs is considered extracurricular and students do so on a volunteer basis . Given tStudies on SRCs have analyzed the quality of patient care, including patient satisfaction and clinical outcomes -14. SimiIn this study, we reviewed selected primary studies investigating the impact of medical student participation at SRCs on medical student education and residency selection. The effects of a variety of factors on patient care, medical education, and residency selection have been documented; however, these have not been comprehensively studied in the SRC volunteer population. The goal of this study is to understand how participation in SRCs influences the professional development of medical students in hopes of optimizing the students’ clinical experiences. Furthermore, we hope to elucidate benefits for patients and students, alike, as SRCs continue to be an integral part of health care .MethodsA literature search was conducted using PubMed, along with a secondary review of the references of included articles. The search was for studies to determine the impact of medical SRCs on education, patient care, and residency selection. Search terms, as well as inclusion and exclusion criteria, are described in Table Data ExtractionThe following data from the included studies were extracted: sample size, school location, medical school type , the time frame of data collection, and medical specialties represented at the clinic. Data on student volunteers included were grade point average (GPA), Step 1 and Step 2 Clinical Knowledge (CK) scores, specialty choice, study participant’s medical school year, empathy scores, and patient-reported outcomes.The literature search was organized into three parts based on types of outcomes from SRCs: education, residency selection, and patient care. Specific search terms for each outcome group are displayed in Table ResultsTwo of the seven studies included in the review examined medical student educational outcomes. Stoddard et al. conducted a retrospective review analyzing the impact of SRC participation on medical student grades at the University of Nebraska Medical Center College of Medicine (UNCOM) . UNCOM mVaikunth et al. examined Clinica Esperanza's (an SRC) participation at the University of Tennessee Health Science Center (UTHSC) with no minimum GPA parameters . The stuIn addition to educational outcomes, Vaikunth et al. examined the association between SRC participation and UTHSC student residency selection, specifically primary care . The stuAt the University of Central Florida College of Medicine (UCF COM), 128 first- and second-year medical students completed a survey assessing their “knowledge/skill/self-efficacy/comfort level/interest/attitude regarding the underserved” . BetweenAnother study conducted at the KNIGHTS Clinic in 2017 looked at the effect volunteering had on entering into primary care, as well as the influence gender had on decisions to volunteer at the clinic . The resAn observational study done at the University of Cape Town in South Africa evaluated patient satisfaction and how volunteering at the Students' Health and Welfare Centres Organisation (SHAWCO) affected their desire to go into primary care . The resA 2017 study that was published evaluated the empathy changes for the class of 2015 at Sidney Kimmel Medical College in Philadelphia . At the Rather than examining residency selection outcomes at an individual medical school, Tong et al. investigated the connection between having an SRC at an allopathic medical school and the number of students that go into primary care . In 2005DiscussionPrevious studies have shown that early clinical exposure, such as prior clinical employment, impacts student education , yet litMedical Education and AcademicsOne objective of our study was to assess the effect of SRC involvement on student education outcomes. There is significant evidence that demonstrates an academic advantage for students with early clinical experience -7,28. SpResidency SelectionCurrently, there is a considerable shortage of physicians in the US, which is relatively higher in the primary care specialties . As suchPatient CareThe patient-provider interaction is at the center of the healthcare system, and even more so in the new era of patient-centered practice ; thus, pLimitationsAs with all secondary research, our findings are limited by the search tools utilized and the articles included. While each of the review studies was assessed for feasible methodology and relevant objectives, most contained lower-quality methods; this includes low sample sizes, the use of survey methodology, and no multi-institution studies. Additionally, variables such as education level prior to medical school, work experience, medical college admissions test scores, and personal demographic characteristics were not accounted for. We attempted to mitigate these limitations by aiming to assess general objectives and refraining from implying causation. The lack of granularity in data contained in the included studies only allowed us to draw associations and highlight potential trends. It will be beneficial to conduct more granular, multi-center primary studies, reviews, and meta-analyses to validate our findings. Additionally, a bias toward US-specific medical school performance measures and residency selection processes limited this study.The increasing practice of medical student volunteering in SRCs has led to research regarding the impact of this type of early clinical exposure on patient and student outcomes. We report several potential academic and personal development advantages associated with SRC participation, including increased student GPA, USMLE Step 1 scores, and USMLE Step 2 scores. However, we found no evidence of a correlation between SRC volunteering and residency specialty of choice. Given the possible benefits and relatively low negative effects in SRC utilization, it is important to assess how incorporating these experiences into medical school training can be refined to further improve outcomes.