Investigation of the environmental influences on human behavioral phenotypes is important for our understanding of the causation of psychiatric disorders. However, there are complexities associated with the assessment of environmental influences on behavior.in press) provide evidence in support of four stable and robust temperament clusters. Using these temperament clusters, as well as independent temperament dimensions for comparison, we conducted a data-driven analysis to assess the influence of a broad set of life course measures, assessed pre-natally, in infancy, and during adolescence, on adult temperament.We conducted a series of analyses using a prospective, longitudinal study of a nationally representative birth cohort from Finland (the Northern Finland 1966 Birth Cohort). Participants included a total of 3,761 male and female cohort members who were living in Finland at the age of 16 years and who had complete temperament scores. Our initial analyses (Wessman et al., Measures of early environment, neurobehavioral development, and adolescent behavior significantly predict adult temperament, classified by both cluster membership and temperament dimensions. Specifically, our results suggest that a relatively consistent set of life course measures are associated with adult temperament profiles, including maternal education, characteristics of the family’s location and residence, adolescent academic performance, and adolescent smoking.Our finding that a consistent set of life course measures predict temperament clusters indicate that these clusters represent distinct developmental temperament trajectories and that information about a subset of life course measures has implications for adult health outcomes. Understanding the causation of psychiatric disorders will require dissection of the specific genetic and environmental determinants of disease susceptibility. Yet the two components of this task differ enormously in their feasibility. The genetic variations contributing to such susceptibility, although mostly still unknown, are knowable. Aspects of genetic variation are fixed throughout life, and increasingly straightforward to assay; most will likely be identified within the decade, after routine genome re-sequencing provides comprehensive catalogs of genome variants.Investigation of the environmental influences on human behavioral phenotypes poses more fundamental questions. The environment encompasses a vast array of different components, some of which are distinct and objectively measurable – for example exposure to particular toxins – while others are generally poorly defined and their severity only assessed subjectively – such as stressful life events Longitudinal birth-cohorts uniquely provide such a framework. They offer the opportunity to assess the influence of multiple early environmental factors on the development of neurobehavioral profiles. Such cohorts also enable examination of the relationship between these profiles and overt expression of psychiatric illness and adult temperament while avoiding problems associated with sampling and recall bias. The Northern Finland 1966 Birth Cohort (NFBC 1966) is well suited to address these types of questions, as more than 10,000 individuals born in the year 1966 in the two most northern provinces of Finland have been followed over the course of their life, starting from before birth, until age 31. The NFBC 1966 database permits longitudinal analyses of sociodemographic characteristics, neurodevelopment, and quantitative neurobehavioral measures Another example is the Dunedin Multidisciplinary Health and Development Study, from which a number of early childhood factors have been identified that predict the risk of developing post-traumatic stress disorder clusters comprised of multiple temperament dimensions capture more information about individual differences and risk profiles in press).Temperament is considered a candidate endophenotype for a wide range of psychiatric disorders, reflecting common genetic factors shared across diagnostic categories In the second of this pair of analyses (presented here), we set out to further examine whether the temperament patterns seen in adulthood are consistent across the developmental trajectory. Specifically, we examined the relationship between prospective measures capturing the early environment, neurobehavioral development, and adolescent behavior (obtained from the extensive life course data available in NFBC 1966) and temperament clusters assessed in adulthood. Temperament, in our series of analyses, therefore represents a critical phenotype for examining the development of individual differences associated with adult health outcome. By conducting a data-driven investigation to uncover relationships between life course measures and adult temperamental profiles in this rich, longitudinal birth cohort, our approach is in contrast to many analyses of early environmental influences on temperament in longitudinal birth cohorts. First, conducting an exploratory analysis with a range of life course variables enabled us to comprehensively examine all variables, in order to identify suitable targets for future research, rather than limit our focus to a single known predictor. Second, by comparing the relationship between these life course variables and temperament profiles to the relationship between these variables and individual temperament scales, we were able to compare these different  approaches to representing temperament. Although our data-driven approach did not involve testing a series of hypotheses about each prospective measure, we did hypothesize that:in press); andWe would identify early life course measures that could predict temperament clusters, just as we identified health and outcome correlates of temperament in adulthood in Wessman et al. . The analysis does, however, identify specific measures that are associated with the development of temperament features.The Northern Finland 1966 Birth Cohort (NFBC 1966) is a longitudinal birth cohort, initially comprised of all 12,058 individuals live-born in 1966 from the two northernmost provinces of Finland, Oulu and Lapland When cohort members were 31-years old, all subjects who were alive at the time and had a known address were asked to complete a subset (107 items) of Cloninger’s Temperament and Character Inventory (TCI) version 9 questionnaire for measurement of four dimensions of temperament  and their respective subscales The current study sample contains cohort members who were living in Finland at the age of 16 years, who completed the TCI at the age of 31, who were not mentally retarded, and who provided informed consent . All subjects included in the present study gave written consent for their data to be used. The study was approved by the Ethics Committee of the Faculty of Medicine, University of Oulu.a priori hypotheses. Rather, we took advantage of the multitude of life course variables available in the NFBC 1966 database and selected those for analysis of association with temperament at age 31 if sufficient information was available about the nature of the variable  and more than 50% of cohort members had data available for that variable As this was an exploratory analysis to identify any life course measure associated with adult temperament, we did not restrict our choice of variables based on th to 28th gestational week  in 1982 . The folk-means method, of TCI scores was previously conducted, and the characterization of the clusters (Clusters I–IV) is reported in Wessman et al. (in press). Briefly, k-means clustering was conducted on the 12 TCI subscale scores, separately for each sex .Cluster analysis, using the in press), and apply to both males and females. For females, Clusters I, II, III and IV include 26%, 25%, 28% and 21% of the subjects, whereas for males these numbers are 26%, 22%, 30% and 22%. Cluster I individuals are characterized by high persistence (P), low extravagance (NS3), anticipatory worry (HA1) and fatigability (HA4). Cluster II individuals are characterized by very low fear of uncertainty (HA2), shyness (HA3) and very high exploratory excitability (NS1), impulsiveness (NS2), extravagance (NS3), disorderliness (NS4), as well as above average persistence (P) and attachment (RD3). Although Cluster III individuals show relatively average temperament scores, these individuals are characterized by low persistence (P) but high dependence (RD4) and extravagance (NS3). Cluster IV individuals are characterized by particularly high levels of high anticipatory worry (HA1), fear of uncertainty (HA2), shyness (HA3), fatigability (HA4), paired with low exploratory excitability (NS1) and attachment (RD3). As such, individuals from Cluster I can be described as stable, persistent and not very impulsive; from Cluster II as outgoing, energetic and impulsive; from Cluster III as not extreme on any trait dimension; and from Cluster IV as shy, pessimistic, and with a preference for routine and privacy.The resulting clusters obtained from these prior analyses are described briefly here . The p-values for contingency table analyses of categorical variables were determined using an MCMC approximation to Fisher’s Exact Test . A total of 54 independent early life variables were tested for differences between the 4 clusters, separately for both sexes.In the present analyses, we attempted, using a multivariate analysis, to identify life course measures that were significantly associated with membership in the above four clusters (I–IV). To reduce the number of variables for consideration in the multivariate models, we first conducted a series of univariate analyses, separately by sex, in order to examine differences between temperament clusters in early life variables. These univariate analyses consisted of one-way analyses of variance for continuous variables and chi-square tests for categorical variables, and were conducted using R statistical software (R 2.9.2) (p<0.05 uncorrected level), we identified the set of variables that jointly predicted group membership in each of the clusters, and for each sex, separately, while controlling for all significant predictor variables. Models with the lowest AIC were chosen as the final model.After initial univariate analyses, we conducted four stepwise logistic regression analyses for each sex. The outcome in these logistic regression analyses was an indicator variable for membership in one of the four clusters. By entering all variables that significantly predicted cluster differences in univariate analyses , and for each sex, we used linear models (rather than logistic models used for temperament clusters) to predict the temperament values as a function of each life course variable.p<0.05 uncorrected level), we identified the set of variables that predict temperament dimension scores while controlling for all significant predictor variables, for each sex separately. Models with the lowest AIC were chosen as the final model.After initial univariate analyses, we conducted four stepwise linear regression analyses. By entering all variables that significantly predicted dimension scores in univariate analyses  or twice a week or more , as compared to female adolescents who reported never smoking in adolescence  increase, while the odds of being in Cluster III  and IV  decrease, with increasing grades. The odds of being in Cluster II increase with increasing physical education grades for females, while the odds of being in Cluster IV decreases with increasing physical education grades for males. Finally, with increasing smoking reported by females in adolescence, the odds of either Cluster II or III membership increases, but the odds of either Cluster I or IV membership decreases. The presentation of 2 values from the logistic models .This is the first report to demonstrate that life course measures (assessed as early as before birth) significantly predict adult temperament (assessed at age 31). Although some prior evidence has suggested specific developmental pathways with implications for psychopathology leading from early environment to adult temperament, such evidence derives from studies using limited age ranges or retrospective data. In the series of analyses reported here, we first observed that stable and robust clusters of temperament differ on a number of variables that were assessed at age 31 in the NFBC 1966, including lifestyle, working capacity, socioeconomics status, and mental health . Although it has previously been demonstrated that children and adolescents characterized by differences in temperament prospectively assessed measures.In support of our first hypothesis – that we would identify early life course measures that predict adult temperament clusters – we were able to demonstrate that life course measures assessed as early as the prenatal period are associated with membership in distinct clusters organized according to temperament in adulthood, and that these differences seen across the life course are consistent with differences between clusters seen in habits, socioeconomic status, and health in adulthood  The comprehensive assessment of life course measures in this cohort therefore allows for the elucidation of a set of correlates that potentially play an important role in the development of individual differences in temperament. The set of variables that consistently predicts adult temperament across the four clusters reflects the growth environment  or the early, emerging temperament of cohort members (such as academic performance). The variables related to the growth environment may reflect the background of emerging temperament. Alternatively, as the development of temperament is under genetic control, these variables may interact via mechanisms of genetic correlation, as the genetic background of the parents (with whom the offspring shares genes) affects the growth environment.in press). We argue here that these temperament clusters capture more information about the development of temperament profiles than the scales alone.Overall our findings suggest that a suite of life course measures predicts membership across temperament clusters. While these measures may be either shared between temperament clusters  or unique to a given cluster (number of words spoken at age one), the measures that predict temperament dimensions are unique to particular temperament scales. In the accompanying report, we demonstrate that these temperament clusters are significantly related to adult outcome across a number of lifestyle and health domains and that the proportion of variables significantly associated with clusters is similar to the proportion of variables significantly associated with any subscale, suggesting that these clusters capture as much information about adult outcome as individual scale scores alone  we conducted a cluster analysis of temperament sub-scales using the NFBC 1966, which provided evidence in favor of four stable and robust clusters of temperament, which were similar between genders and which we labeled Clusters I–IV. We next examined the association between these temperament clusters and a broad range of measures of health and well being that were assessed in adulthood. Our results demonstrate clear patterns of association between temperament clusters and health, life events, and well-being: Cluster I individuals are characterized by healthy life habits, stable life features, and a decreased risk for mental illness; Cluster II individuals report high physical fitness, education and annual income, higher smoking and alcohol use, in addition to high scores on a hypomania personality scale; Cluster III individuals are not characterized by extreme characteristics in lifestyle or health; and Cluster IV individuals are characterized by the lowest scores in most areas of health and well-being, and are at increased risk for physical and mental illness. In summary, the analyses in Wessman et al. (in press) characterized the health and well-being profiles of these four temperament clusters, using data collected only in adulthood.In our first set of analyses , considered independently at the first stage of univariate analyses, and carried forward to the second stage of multivariate analyses if significant. Although there is potentially some overlap in some of the items, we chose to analyze all variables that were available, if they were sufficiently described and if more than 50% of cohort members had data available for that variable, in order to examine as much as the environmental search space as possible.The primary limitation of this report is that the information available for analysis is constrained by what was collected in the cohort. For example, we did not have a direct index of socioeconomic status available for the families of cohort members, nor did we have a measure of fetal alcohol exposure. In addition, despite the rich dataset collected on this cohort, temperament was only assessed in adulthood. Future work should be aimed at repeated measurement of temperament, as well as socioeconomic status and family characteristics, health conditions, developmental milestones, education and behavior, across the life course.We also did not have equal sample sizes for males and females, which complicates interpretation of differences in results across sexes. The NFBC 1966 began with a cohort of 12,058 live births; here, our analyses were conducted on a total of approximately 1,400 of those individuals. While it has previously been demonstrated that study participation is lower in individuals with a psychiatric illness as compared to those without, participation does not vary across specific disorders Finally, as we have already stated, our analysis does not allow us to make conclusions about causality, but identifies specific measures that are associated with the development of temperament features. In addition, it is also possible that associations reported here are indirect, such that an additional, unmeasured variable is responsible for their association. Additional comprehensive and longitudinal cohorts will be critical to uncovering the mechanisms underlying temperament and the development of psychopathology.Early environment, neurobehavioral development, and adolescent behavior significantly predict adult temperament. Although all multivariate models account for less than 10% of the variation in outcome classifications (both cluster membership and temperament dimension), our results highlight a consistent set of life course measures that predict temperament clusters. Of note, we were able to replicate previous associations between early life variables  and adult temperament, even when considering a large set of life course measures. These results contribute to our understanding of how individual differences in life course correlates are related to individual differences in adult temperament, and support the utility of conducting data-driven research to both uncover novel, and replicate previously reported, associations.Our results demonstrate significant relationships between life course measures and temperament clusters, particularly in females. There is substantial evidence that risk factors for later psychopathology include parental psychopathology, low socioeconomic status, prenatal stress and the experience of negative life events, maternal smoking, a low maternal age and education Table S1Differences in early life measures between female temperament clusters.(DOC)Click here for additional data file.Table S2Differences in early life measures between male temperament clusters.(DOC)Click here for additional data file.Table S3Differences in average grades in adolescence between temperament clusters for females and males.(DOC)Click here for additional data file.Table S4Early life measures predicting individual temperament dimensions, as measured by the Temperament and Character Inventory, which survived correction for females.(DOC)Click here for additional data file.Table S5Early life measures predicting individual temperament dimensions, as measured by the Temperament and Character Inventory, which survived correction for males.(DOC)Click here for additional data file.Table S6Early life measures predicting group membership of each female temperament cluster separately.(DOC)Click here for additional data file.Table S7Early life measures predicting group membership of each male temperament cluster separately.(DOC)Click here for additional data file.Table S8Early life measures predicting temperament dimension scores for females.(DOC)Click here for additional data file.Table S9Early life measures predicting temperament dimension scores for males.(DOC)Click here for additional data file.


Obesity is a serious public health problem, especially in some minority communities, and it has been associated with an increased risk of cardiovascular diseases. While obesity is a serious health concern in both American Indian and Mexican American populations, the relationship between obesity and cardiac autonomic control in these two populations is not well understood. The present study in a selected sample of American Indians and Mexican Americans assessed associations between obesity, blood pressure (BP), and cardiovascular autonomic control. Cardiovascular autonomic control, systolic and diastolic mean BP, and body mass index were obtained from one hundred thirty-two American Indian and Mexican American men and women who are literate in English and are residing legally in San Diego County. Men had a significant greater systolic and diastolic BP and were more likely to develop systolic prehypertension and hypertension than women. Obese participants showed greater mean heart rate (HR) and systolic and diastolic BP than nonobese participants. Obese men also exhibited greater cardiac sympathetic activity and lower cardiovagal control than obese women. These results suggest that obesity and gender differences in cardiovascular autonomic control may contribute to risk for cardiovascular disorders in this sample of American Indians and Mexican Americans. The prevalence of obesity in American Indians is high and is generally associated with insulin resistance and diabetes –3, but gObesity has been associated with an increased risk of cardiovascular diseases including hypertension, arrhythmias, coronary artery disease, and stroke . AmericaEvaluation of noninvasive cardiovascular autonomic control based on measures of heart rate variability (HRV) is playing an important role elucidating the role of the autonomic nervous system (ANS) in several neurological, cardiovascular, and psychiatric disorders see –12). HRV. HRV12])DB), requires participants to breathe at a rate of 6 breaths per minute (bpm) over a short interval (<90 sec). The estimate of cardiovagal control is based on the mean HR range. These clinical methods have been used to assess cardiovascular autonomic control in patients with autonomic disorders ).isorders , 24, 25.We have previously reported the presence of several cardiovascular risk factors including obesity and alcohol abuse and dependence in a community sample of American Indians and Mexican Americans residing in San Diego County e.g., , 26–29).–29.26–29n = 49) who were of at least one-sixteenth American Indian heritage were targeted for study participation and were recruited from eight geographically contiguous Indian reservations with a total population of ~3000 individuals. Participants who were mobile and without serious medical illness and between the ages of 18 and 72 years were recruited by using a combination of a venue-based method for sampling hard-to-reach populations and a respondent-driven procedure, as reported previously ).s et al.  and Umets et al.  using 8 s et al. ).American Indians and Mexican Americans have an increase in some risk factors for cardiovascular disease such as alcohol and tobacco use . We haveThe results of this study should be interpreted in the context of several limitations. First, while previous studies have shown the validity of CSI as an index of sympathetic activity , 23, 67,These results suggest that obesity and gender differences in cardiovascular autonomic control may contribute to risk for cardiovascular disorders in this sample of American Indians and Mexican Americans.


They are also the first to demonstrate that the abundance of eDNA, as measured by qPCR, correlates positively with population abundance estimated with traditional tools. Finally, Thomsen et al. (2012) demonstrate that next-generation sequencing of eDNA can quantify species richness. Overall, Thomsen et al. (2012) provide a revolutionary roadmap for using eDNA for detection of species, estimates of relative abundance and quantification of biodiversity.Three mantras often guide species and ecosystem management: (i) for preventing invasions by harmful species, ‘early detection and rapid response’; (ii) for conserving imperilled native species, ‘protection of biodiversity hotspots’; and (iii) for assessing biosecurity risk, ‘an ounce of prevention equals a pound of cure.’ However, these and other management goals are elusive when traditional sampling tools  have poor detection limits, are too slow or are not feasible. One visionary solution is to use an organism’s DNA in the environment (eDNA), rather than the organism itself, as the target of detection. In this issue  Yet theSpecifically, results from qPCR provide an index of population size, which is a very important advance over PCR (The application by Some prominent early applications of environmental DNA have involved the detection of faecal pollution (We believe that However, one of the striking gaps in this rapidly growing field is the dearth of knowledge about how field and laboratory protocols influence the detection of eDNA . ExperimEnvironmental DNA analysis is already an essential and influential tool in water quality monitoring, the early detection of invasive and other harmful species and the surveillance of imperilled species. With further refinements and comparisons of field and laboratory protocols, eDNA analysis will provide more information on taxonomic diversity and population abundance and find wider applications in environmental science research.


A systematic review of the literature on the effects of water and sanitation in schools was performed. The goal was to characterize the impacts of water and sanitation inadequacies in the academic environment. Published peer reviewed literature was screened and articles that documented the provision of water and sanitation at schools were considered. Forty-one peer-reviewed papers met the criteria of exploring the effects of the availability of water and/or sanitation facilities in educational establishments. Chosen studies were divided into six fields based on their specific foci: water for drinking, water for handwashing, water for drinking and handwashing, water for sanitation, sanitation for menstruation and combined water and sanitation. The studies provide evidence for an increase in water intake with increased provision of water and increased access to water facilities. Articles also report an increase in absenteeism from schools in developing countries during menses due to inadequate sanitation facilities. Lastly, there is a reported decrease in diarrheal and gastrointestinal diseases with increased access to adequate sanitation facilities in schools. Ensuring ready access to safe drinking water, and hygienic toilets that offer privacy to users has great potential to beneficially impact children’s health. Additional studies that examine the relationship between sanitation provisions in schools are needed to more adequately characterize the impact of water and sanitation on educational achievements. The United Nations Millennium Development Goal 2.A is to “ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling” . The goal of this review is to characterize how inadequacies in water and sanitation in the school environment have the potential to or are impacting the health of children and their attendance in schools. We sought to identify all claimed effects of adequate or inadequate water and sanitation access in the school environment by cataloguing peer-reviewed journal articles on the subject, defining the scope of effects, and highlighting possible future research directions within the field. The school environment represents an important setting because many children’s social habits and behaviors are learned at school. School WASH interventions improve overall sanitation, hygiene and daily water intake in both educational and non-educational environments . AccordiPublished peer reviewed literature was screened and reviewed and peer reviewed journal articles that documented an educational or health effect associated with provision or absence of water and/or sanitation in schools selected. These impacts include an increase or decrease in school attendance, school dropouts, or any type of physical, social or psychological illness. The review was restricted to studies that explicitly explored the effects of the provision or absence of water, sanitation, and related hygiene materials such as soap, towels, and toilet paper in the school environment; studies that only examined the effects of behavior changes were excluded. Dissertations were not included. Articles without abstracts or full texts available were not included. Studies concerning day care centers were excluded. Studies on hand sanitizers were excluded.We categorized ‘water’ interventions as either those for hand washing—including water, wash basins, soap, and drying devices, or for drinking. Studies considering only the impact of fluoride in drinking water were also excluded from the review, as the effects of fluoride on oral health in schools have been widely studied. Sanitation was defined as the availability of facilities to urinate or defecate  or as facilities for women and girls to manage menstruation . Studies on the impact of availability of sanitary napkins were not included. The outcomes targeted by this review included health and educational outcomes. Health effects included in the study encompassed all of the defined social health, mental and physical health topics recognized by the National Institute of Health. Educational outcomes included school attendance and academic performance. Studies were classified into seven non-exclusive categories: intervention trials, randomized control trials, observational studies, participatory research studies, descriptive studies, cross-sectional studies and outbreak investigations. Studies were also organized by economic status and field topic in order to better organize the results of the search.The following major scientific, electronic databases were searched during the months of October through December 2010: PubMed, Embase, Web of Science, the Cochrane Library, Science Direct, and Google. In March 2012 a follow-up scan for subsequently published papers was conducted and five articles that met the inclusion criteria were added to the review.Schools and Water or Sanitation, Gender and Water or Sanitation, Girls and Water or Sanitation, Menstruation and Water or Sanitation, School Absenteeism and Water or Sanitation, School Health Policies and Water or Sanitation, WASH  and Schools. All references in the bibliographies of included documents were also systematically searched for relevant documents. The study was restricted to documents for which an abstract and article in English was available. The primary search was based on the keywords: The search included no time or location restrictions. Studies not written in English, or without an English translation available, were not included in this review. A secondary reviewer completed the review independently. Consensus was reached between primary and secondary reviewers in all cases of initial disagreement. The primary search identified 3,485 publications whose titles discussed water provision, water quality or sanitation facilities in schools. The majority of these references came from scientific databases , with the majority from PubMed . The secondary screening based on abstract identified 471 relevant references. Thirty-nine articles met the inclusion criteria for the tertiary, full-text, review. Bibliographies of these articles revealed an additional six articles. Four of the 39 included studies were excluded from the library due to duplication in multiple papers; in these cases the most comprehensive article from each of these studies was included. Forty-one papers were included in the initial systematic review. Six more studies were added after the initial review, making forty-seven included studies used in data analysis (n = 47) .Of the forty-seven papers, eleven addressed drinking water (23%), seven addressed water for handwashing (15%), five addressed providing water for drinking and handwashing (11%), six addressed sanitation (13%); four papers addressed sanitation related to menstruation facilities (8%); and fourteen addressed providing water and sanitation combined in schools (30%) .Many of the studies utilized more than one source of data. Twelve of the forty-seven studies included an experimental intervention (25%); twelve studies used interviews, questionnaires, or focus group and site observation (25%); fourteen studies were analyses of publicly-available data or questionnaires (30%); two studies performed solely site observations (4%); and nine studies included microbiological analyses of student stool samples, observations of sites and/or a questionnaire (19%). The forty-seven included studies comprised nine intervention trials (19%); four randomized control trials (9%); one observational study (2%); one participatory research study (2%); four descriptive studies (9%); twenty-six cross-sectional studies (55%); and two outbreak investigations (4%) . CharactThe health, cognitive and educational outcomes catalogued in the studies were: infectious diseases  (n = 20); gastrointestinal issues including constipation, incontinence, and urinary tract infections related to avoidance (n = 7); physical harm, (n = 2); dehydration (n = 6); obesity (n = 2); neuro-cognitive impacts including mental performance (n = 7); psychological outcomes such as shame or discomfort to use the toilet (n = 5); and absenteeism (n = 8). Seven studies documented outcomes of schools failing to serve as role models on hygiene  (n = 7). Educational outcomes included educational achievements and school attendance, while eight studies report absenteeism, only one study analyzed academic performance as an educational outcome  Figure .vs. developed regions, as classified by the United Nations Statistical Division. However, the studies revealed similarities in reported inadequacies in facilities and in the stated benefits of provision of water and sanitation services [Studies were grouped into categories to more effectively describe the results. Articles were also analyzed to determine the differences in responses in developing services . This caservices ,12,26. Eleven studies investigated drinking water provision and five examined both water for drinking and for handwashing combined ,18,19,20Two survey studies in schools in the United Kingdom documented inadequate water facilities such as water fountains potentially leading to inadequate hydration ,10. Theset al., in 2006 tested the blood lead levels in students in a Washington State school after reports of lead levels above USEPA guidelines [In relation to water quality, four studies concerned lead in drinking-water fountains in schools in the United States ,8,9,15. Seven studies examined handwashing in schools while five studies examined both water for drinking and for handwashing combined ,29,30,31et al., in Colombia, indicate that children with access to handwashing materials were three times as likely to consistently wash their hands before eating and after toilet usage. In addition, those who reported proper handwashing  were statistically significantly less likely to report illness such as gastrointestinal and respiratory symptoms, and 20% less likely to be absent [Schools with scarce supplies for handwashing—such as water provision, soap, or towels—reported less handwashing ,30. Scare absent . These set al., performed a quasi-blinded handwashing study and found no significant change in rates of communicable illness or absenteeism despite sustained handwashing behavior after six months [et al., conducted an experimental handwashing study in China in which the intervention groups experienced statistically significant lower rates of illness and of absenteeism [et al., conducted a handwashing and education intervention in Cairo, Egypt and reported statistically significant declines in absences caused by illnesses such as diarrhea, conjunctivitis and laboratory confirmed cases of influenza [Three randomized control trials targeted at increasing provision of water for handwashing in Israel, China and Egypt reported dissimilar findings ,29,31. Ienteeism . Talaat et al., performed interventions at seventeen Kenyan schools which provided handwashing and drinking water treatment sources and education of teachers [et al., found a statistically significant decrease in visits to the school nurse for diarrheal diseases in response to their interventions in Kenya which involved providing drinking water treatment and handwashing stations [Three of the six studies that investigated the combined effects of drinking water provision as well as water for handwashing reported decreased absenteeism and illness rates due to inadequate sanitation materials and facilities ,18,19,20teachers . They foteachers . Migele Six studies met the pre-defined search criteria for sanitation ,35,36,37et al., in Sweden also documented avoidance of toilets observed as smelly, unclean and lacking privacy [Samwel and Gabizon highlight the need to build sustainable toilet facilities indoors in rural areas in Eastern European nations due to avoidance of outdoor toilets located far from the school buildings . Outdoor privacy ,34.Overcrowding in schools was also associated with the avoidance of toilets. Students were reported to avoid using the toilet due to the anxiety of waiting in line during recess or lack of privacy .The avoiThere was only one study that examined academic performance as an educational outcome, a study assessing the condition of school sanitation facilities in New York City by Duran-Narucki . The stuFour studies focusing on the provision of water and sanitation facilities for menstruation management in the school environment met the search criteria ,22,23,24All four studies documented female discomfort in the school environment during menses due to inadequacies in the assurance of privacy, disposal of materials for menstruation, or sufficient school water and sanitation facilities. Economically developed countries may have sanitation facilities that enable females to privately manage menses due to an abundant supply of clean water, privacy, affordable sanitary materials and undergarments and may also have supportive female teachers and school nurses for managing menses . HoweverFourteen studies focus on the combined effects of water and sanitation in schools ,48,49,50et al., documented that students who used toilets for defecation in a primary school in the United Kingdom were statistically significantly more likely to develop Hepatitis A due to inadequate sanitation facilities [et al., studied sanitation in the Pacific Islands and reported a decrease in the risk for helminthic infections when children have increased access to water for handwashing and relieving wastes [Three studies reported inadequate water and sanitation facilities in schools through surveys and commentaries ,43,45. Scilities . On invecilities . Hughes g wastes ; reportig wastes .The school environment is an important sector to explore due to the social and health influences schools have on children . In addiet al., in Israel found no significant changes in rates of illness or absenteeism, while similar studies in China and Egypt noted significant changes in rates of illness [In comparing the efficacy of interventions conducted in developing and developed settings, and between regions within these categories, differences in results may be partly explained by varying baseline rates of disease. In similar studies on provision of water for handwashing, Rosen  illness ,33,35. Aet al., have shown a decrease in absenteeism among girls after water and hygiene interventions [The scope of our review with respect to water and sanitation facilities related to management of menstruation in schools was limited. Our criteria excluded papers related to the availability of sanitary napkins in schools. Though there is a large body of evidence within this field, and the outcomes related to it are critical in understanding the role of menstruation on school performance and absenteeism, it was outside the scope of this review. The available evidence supports the claim that a lack of water and sanitation facilities to manage menstruation in schools leads to discomfort and avoidance of school during menstruation. Freeman ventions . This isventions . The relventions . Measureet al., found a significant increase in household water treatment practices that was sustained over one year after their intervention in Kenya [This review revealed areas for future research. Future studies should examine the relationship between drinking water and sanitation provision in schools. It has been suggested in the literature that a link may exist between unwillingness to drink water at school in order to avoid using unsanitary school toilets . This inin Kenya . Howeverin Kenya . High quPotential errors in study identification and inclusion were mitigated by including a secondary reviewer. As studies were limited in number, used diverse methods and metrics and were conducted in various countries, findings may not be generalizable. No attempt was made to weight the value of the findings of studies according to study quality. The World Health Organization has issued guidelines for water, sanitation, and hygiene implementation in schools in low cost settings . ImplemeThis review identified the health and educational effects of water and sanitation in schools. The goal of the review was to catalogue and characterize existing studies in the field. The review concluded that studies document higher rates of infectious, gastrointestinal, neuro-cognitive and psychological illnesses where school children were exposed to inadequate water and sanitation facilities. Potential areas for future research were identified. The evidence of widespread inadequate facilities suggests that greater resources and attention need to be invested in this field by school management, bureaucrats and multilateral and civil society organizations.The overall reasoning behind attention to water and sanitation in schools is logical. Respiratory and gastrointestinal diseases are one of the leading causes of death for children globally . The evi


The 58th World Health Assembly and 56th WHO Regional Committee for Africa adopted resolutions urging Member States to ensure that health financing systems included a method for prepayment to foster financial risk sharing among the population and avoid catastrophic health-care expenditure. The Regional Committee asked countries to strengthen or develop comprehensive health financing policies. This paper presents the findings of a survey conducted among senior staff of selected Eritrean ministries and agencies to elicit views on some of the elements likely to be part of a national health financing policy.This is a descriptive study. A questionnaire was prepared and sent to 19 senior staff (Directors) in the Ministry of Health, Labour Department, Civil Service Administration, Eritrean Confederation of Workers, National Insurance Corporation of Eritrea and Ministry of Local Government. The respondents were selected by the Ministry of Health as key informants.The key findings were as follows: the response rate was 84.2% (16/19); 37.5% (6/16) and 18.8% said that the vision of Eritrean National Health Financing Policy (NHFP) should include the phrases ‘equitable and accessible quality health services’ and ‘improve efficiency or reduce waste’ respectively; over 68% indicated that NHFP should include securing adequate funding, ensuring efficiency, ensuring equitable financial access, protection from financial catastrophe, and ensuring provider payment mechanisms create positive incentives to service providers; over 80% mentioned community participation, efficiency, transparency, country ownership, equity in access, and evidence-based decision making as core values of NHFP; over 62.5% confirmed that NHFP components should consist of stewardship (oversight), revenue collection, revenue pooling and risk management, resource allocation and purchasing of health services, health economics research, and development of human resources for health; over 68.8% indicated cost-sharing, taxation and social health insurance as preferred revenue collection mechanisms; and 68.75% indicated their preferred provider payment mechanism to be a global (lump sum) budget.This study succeeded in gathering the preliminary views of senior staff of selected Eritrean ministries and agencies regarding the likely elements of the NHFP, i.e. the vision, objectives, components, provider payment mechanisms, and health financing agency and its governance. In addition to stakeholder surveys, it would be helpful to inform the development of the NHFP with other pieces of evidence, including cost-effectiveness analysis of health services and interventions, financial feasibility analysis of financing options, a survey of the political and professional acceptability of financing options, national health accounts, and equity analyses. Nakfa 240 per capita per month [Eritrea is situated in the Horn of Africa , and hadThe country has six health regions  and 54 health districts. The health infrastructure comprises 369 health facilities, including 13 tertiary hospitals, 13 secondary hospitals and 343 primary level facilities  .The total per capita expenditure on health in Eritrea was US$10 in 2008. About 44.9% of total health expenditure came from general government expenditure, the remaining 55.1% coming from private expenditure in the form of household out-of-pocket payments. The external resources for health made up 60.8% of total expenditure on health in 2008; i.e. channelled through public and private sectors . TherefoOver reliance on direct out-of-pocket payments for health care may expose households to the risk of financial catastrophe ,9. In orIn 2006, Eritrean Ministry of Health developed its National Health Policy (NHP) whose vision is :“…the improvement of the health status of Eritrean people by creating an enabling environment for the provision of sustainable quality health care that is acceptable, affordable and accessible to all citizens” (p.15).Three of the objectives of the NHP are related to health financing: (a) ensure that quality health services are available, accessible and affordable to all the people in the country; (b) introduce a health-financing scheme that protects the people from catastrophic expenditures and ensures sustainability of the system; and (c) implement the concept of hospital autonomy .In view of global and regional developments, and the development of the 2006 NHP, the Ministry of Health realized that its first health financing policy, which was developed in 1996 and subsequently revised in 1998, needed to be revisited . Whilst The Ministry of Health requested external technical support to start the process of developing a comprehensive National Health Financing Policy (NHFP) that explores the three functions of health financing: revenue collection, revenue pooling and risk management, and resource allocation and strategic purchasing. The preparatory support focused on the review of existing in-country literature on health systems with a focus on health financing, an analysis of health expenditure trends, and a rapid key informant survey to get preliminary views from relevant government ministries on the extended process of policy formulation.This paper presents the findings of the preliminary key informant survey conducted among senior staff of selected Eritrean ministries and agencies to elicit views on some of the elements likely to be included in a national health financing policy.et al.[Figure et al.. That frAccording to WHO  stewardsRevenue collection is the process through which the health system receives money, primarily from households, businesses, the ministry of finance and donors (in the form of grants and loans) . Murray Pooling has been defined by Gorret and Schieber as the accumulation and management of revenues so that members of the pool share collective health risks, and thus protect themselves from large, unpredictable health expenditures .Purchasing refers to the mechanisms used to pay for health services from public, private-not-for-profit and private-for-profit providers . The metEritrea national health financing policy questionnaire for government Ministries and Partners’ was drawn up  leadership to focus the interview process on senior staff (Directors) in the MOH, Labour Department, Civil Service Administration, Eritrean Confederation of Workers (ENWC), National Insurance Corporation of Eritrea (NICE) and the Ministry of Local Government (MOLG). The reason for the restricted focus was the limited time available, and an understanding was reached with the MOH that broader consultations would take place at a later date. In this sense the people to be interviewed or consulted were purposely chosen by the MOH. A total of 19 key informants were interviewed or consulted. Out of those, 16 completed the questionnaire. Those who completed the questionnaire included 14 senior officials from the MOH; the Vice-Chairman of ENWC; and the General Manager of NICE.Prior to completion of the questionnaires, the research team briefed the interviewees on the purpose of the survey and explained in detail the objectives and functions of health financing. This was done to ensure a basic understanding of the health financing framework.The survey was very limited in scope and did not include, for example, the MOF, health development partners in the country, and representatives of other stakeholder groups, such as civil society organizations, non-governmental organizations and the private sector.In your opinion, what are the key health financing related challenges facing Eritrea today?’ The challenges mentioned by the respondents included: lack of a comprehensive NHFP; lack of a health planning office; shortage (insufficiency) of financial and human resources; increasing cost of medication; increased health awareness and demand for medical services; majority of population lives below the poverty line; lack of health insurance; lack of experience in operating a revolving fund; hospitals have no experience in retaining and managing user fees; poor referral mechanism; dearth of administrative and monitoring capacities; absence of sector-wide approaches for coordinating partner contributions; and inefficient use of available resources. The challenges most frequently mentioned included: lack of a comprehensive NHFP (5/16); and shortages (insufficiency) of financial resources (4/16) and human resources (3/16).About 84% 16/19) of the respondents completed the questionnaire. Table 6/19 of tIn your opinion, what are the existing local opportunities that Eritrea could leverage to strengthen the health financing system?’ The respondents outlined a number of opportunities for strengthening the Eritrean health financing system, namely: high government commitment to good governance and accountability; high community participation in development activities; infrastructure ; immediate need for reform of the hospital services and Government plans for making hospitals autonomous; cost-sharing programme; about 20% of the population are public servants with defined remuneration (payroll); willingness to pay for any good service; and absence of corruption in the public system. The high government commitment to good governance and accountability (4/16); high community participation in development activities (4/16); and willingness to pay for any good quality service (4/16) were the most frequently cited opportunities.Table What key words or phrases would you like to see in the vision of the Eritrean National Health Financing Policy?’ The three most frequently mentioned phrases were: ‘equitable and accessible health services’ (6/16); ‘quality (plus continuous service improvement)’ (4/16); and ‘improve efficiency and reduce waste’ (3/16).Table Which of the following should be included as the objectives of the Eritrean NHFP?’ A total of nine possible objectives were mentioned in the questionnaire, the following six being mentioned by more than 68% of the respondents:Table (a). To secure a level of funding needed to achieve desired health goals and the objectives stated in the National Health Policy in a sustainable manner (15/16);(b). To ensure efficiency in the allocation and use of health sector resources (14/16);(c). To ensure equitable financial access to quality health services (13/16);(d). To ensure that partner support for the implementation of the NHP is aligned, harmonized and coordinated (12/16);(e). To ensure that people are protected from financial catastrophe and impoverishment as a result of using health services (11/16); and(f). To ensure that the provider payment mechanisms chosen create positive incentives for providing quality preventive and curative services, responding to non-medical legitimate expectations of service users, and containing the cost of health care (11/16).Which of the following core values should guide the implementation of the NHFP?’ A total of 11 possible core values or guiding principles were mentioned. Community participation, efficiency, transparency, country ownership, equity of access, evidence-based decision making and partnerships were mentioned by more than 80% of the respondents.Figure In your opinion, which of the following should constitute the key components of the NHFP of Eritrea?’ The responses are summarized in Figure Sixteen people responded to the question: ‘Taking into account the political, cultural and socioeconomic context of Eritrea, which of the following revenue collection mechanisms should Eritrea use?’ The revenue collection mechanisms mentioned included: cost sharing through user fees; tax funded national health services; private health insurance; social health insurance; community health insurance and combinations of those mechanisms. However, the majority of the respondents thought that the preferred revenue collection mechanisms would be cost-sharing through user fees (15/16), tax funded national health services (13/16) and social health insurance (11/16).Figure Taking into account political, cultural and socioeconomic context of Eritrea, which of the following provider payment mechanisms should Eritrea use?’ Figure Sixteen people responded to the question: ‘In your opinion, which department of the Ministry of Health should be responsible for the implementation of the NHFP? Why?’ The responses were as follows: Department of Administration and Finance (5/12); Department of Health Services (4/12); Health Systems Management Unit (HSMU) (1/12); Department of Clinical Services (1/12); and Departments of Health Services plus Department of Administration and Finance plus Planning Office (1/12). The respondents recognized that whichever department or unit takes the lead; it will have to collaborate with all other departments in the MOH. Of the eight people who gave reasons for their answers, five said that preferred Department/Unit was more related to the objectives of the NHFP; two indicated that the HSMU was responsible for NHFP development, implementation and monitoring; and one said that the Department of Clinical Services had better and closer contact with the service provider institutions.Twelve people responded to the question asking: ‘In your opinion, what kind of agency should be established to manage complex links between risk management and both revenue pooling and purchasing of health services? Why?’ Eighty one per cent of the respondents felt that a parastatal (government corporation) should be established to manage complex links between risk management, revenue pooling and purchasing of health services, while 3% felt that it should be handled by a quasi-government agency. None of the respondents said that a private agency would be appropriate. Eight of the respondents who gave a reason for their choice indicated: that Eritrea’s stage of development is appropriate for a parastatal (3/8); that parastatal or quasi-government agency status gives better autonomy as well as security (3/8); that a parastatal or quasi-government agency is appropriate because government primarily looks after the health of its people and will convince others to accept it (1/8); and that a parastatal or quasi-government agency is more appropriate for price and quality control.Sixteen people responded to the question: ‘Who should be members of the health financing agency board of directors?’ As shown in Table All sixteen respondents addressed the question: ‘Who should chair health financing agency board meetings?’ Sixty-per cent (9/15) answered Ministry of Health; 27% (4/15) answered Ministry of Finance; 7% answered Minister of National Development; and 7% answered Minister of Labour and Human Welfare (pension head).Fifteen people responded to the question: ‘Who should be the secretary of the health financing agency board?’ Seven entities were named as possible sources of candidates. Thirty-three per cent answered Minister of Health, 25% (3/12) Minister of Finance, and 8% (1/12) either Minister of National Development, Chair of Sector-Wide approach (SWAp), Representative of the private health care providers, Chairperson or Director of National Insurance Corporation of Eritrea.Twelve people responded to the question: ‘Kindly feel free to make other suggestions related to the development of the Eritrean NHFP.’ Five suggestions were made. First, there is a need for statements regarding hospital autonomy and its implementation. Second, in-depth training of those people who are going to handle or implement the NHFP is essential. Third, as the private sector is not well developed at present the national health financing policy is expected to be developed with the focus mainly on public sector health care provision. Fourth, there is a need to ensure wider participation and consultation of relevant authorities and knowledgeable professionals. And last, since health financing is an integral part of social security, the health financing agency board ought to be chaired by the Social Security Division in the Ministry of Labour and Human Welfare (MoLHW).Finally, five people responded to the statement ‘There were seven key findings:First, 37.5% (6/16) and 18.8% of the respondents said that the phrases ‘equitable and accessible quality health services’ and ‘improve efficiency or reduce waste’ should be included in the vision of Eritrean health financing policy (NHFP).Second, over 68% of the respondents indicated that the objectives of the NHFP should include securing adequate funding, ensuring efficiency, ensuring equitable financial access, protection from financial catastrophe, and ensuring provider payment mechanisms create positive incentives to service providers.Third, over 80% of the respondents posited that core values of NHFP should include community participation, efficiency, transparency, country ownership, equity in access, and evidence-based decision making.Fourth, over 62.5% of the respondents stated that the NHFP components should include stewardship (oversight), revenue collection, revenue pooling and risk management, resource allocation and purchasing of health services, health economics research, and development of human resources for health.Fifth, over 68.8% of the respondents suggested cost-sharing, taxation and social health insurance as preferred revenue collection mechanisms.Sixth, 68.75% said that their preferred provider payment mechanism is a global (lumpsum) budget.Seventh, 81% of the respondents opined that a parastatal (Government Corporation) should be established to manage complex links between risk management and both revenue pooling and purchasing of health services.As already mentioned, the majority of respondents indicated that the NHFP vision statement should include the phrases ‘equitable and accessible quality health services’ and ‘improve efficiency or reduce waste’. Thus, a possible vision statement might read: ‘access of all population to needed essential package of quality promotion, prevention, treatment, and rehabilitation health services at an affordable cost and without waste’. This is close to the 58th World Health Assembly definition of universal health coverage (UHC) .The objectives cited as important by most respondents included: securing adequate funding; ensuring efficiency; ensuring equitable financial access; and protection from financial catastrophe. Securing adequate funding presumes the existence of a costed health sector strategic plan, estimates of available funding and any funding gap, and a resource mobilization strategy for bridging that gap. It is also important to note that ensuring efficiency entails the allocation and use of resources without waste, while equity in financing is dependent on household contributions to the funding of the health system being made according to ability to pay. Finally, protection from financial catastrophe requires payment long before health care is needed, and the pooling of resources to allow for the sharing of risk.According to the majority of respondents the core values of the NHFP should include: community participation; efficiency; transparency; country ownership; equity in access; and evidence-based decision making.Community participation requires recognizing communities as key partners in the planning, financing, implementation, monitoring and evaluation of health programmes and services . PracticEfficiency requires minimizing the opportunity cost of attaining a given output or maximizing the output for a given opportunity cost . In shorTransparency refers to openness in decision making and resource allocation. It may entail the strengthening of the parliamentary role in discussion and the adoption of national development strategies and/or budgets. In addition, it may involve: transparent results-oriented reporting and assessment frameworks; diagnostic reviews and use of the information derived from those reviews; and publishing of audit reports for public consumption ,23.Country ownership is about exercising leadership in the development and implementation of national development strategies through broad consultative processes . With reEquity in access requires that people in equal health need be treated equally regardless of their ability to pay or other irrelevant criteria  and that people in unequal need be treated appropriately  .Finally, evidence-based decision-making demands the use of relevant information when making health-care decisions at the level of policy, strategy, programme, system, planning, implementation, monitoring and evaluation .According to majority of the respondents, the NHFP should include stewardship, revenue collection, revenue pooling and risk management, resource allocation and purchasing of health services, health economics research, and the development of human resources for health financing.Stewardship in health financing involves oversight of all the other components of the NHFP. Therefore, the development of a health financing policy and strategy, legislation, management of health financing system and audit all have implications for stewardship.The revenue collection mechanisms preferred by most our respondents included cost-sharing via taxation and social health insurance. Currently, the Eritrean health system is financed primarily through household out-of-pocket payments (OOP), tax revenues and donor funding. Therefore, it seems that the respondents envisage a shift from cost-sharing through OOP to prepayment through a mix of general taxation and compulsory contributions to health insurance. Although the contexts are very different, economically developing countries such as Eritrea may draw lessons from developed countries such as Austria, Belgium, Costa Rica, Germany and Luxemburg that have all made significant strides towards UHC via social health insurance .According to Carrin and James , a numbepurchasing, the majority of our respondents said that a global budget was their preferred provider payment mechanism. Culyer defines global budget as a method of reimbursing health service providers by establishing rates of payment in advance which are paid regardless of the costs in actual individual cases [Regarding al cases . Accordial cases . TherefoHealth economics research entails reinforcing capacities for health financing evidence generation, dissemination and utilization in decision-making. Examples of pertinent health financing evidence include: costing; economic evaluation of services and interventions; economic viability analysis of health financing mechanisms; allocative and technical efficiency analyses and productivity trend analyses of health facilities; national and sub-national health accounts; and health financing equity analyses [analyses ,32.development of human resources for health financing concerns the strengthening of financial management skills, including competencies in health accounting, auditing, actuarial science, health economics, budgeting, planning, monitoring and evaluation [The aluation . These cThe respondents felt that a parastatal (Government Corporation) agency should be established to manage the complex links between risk management and both revenue pooling and purchasing of health services. Instead of setting up a new agency, The National Insurance Corporation of Eritrea (NICE) capacities could be reinforced to ensure the proper coordination of the three health financing functions. The governance (board of directors) arrangements of the agency should include representation from all relevant stakeholders mentioned by the majority of the respondents, e.g. relevant ministries, the Eritrean Confederation of Workers, the Association of Employers, the General-Manager of NICE, representatives of the medical and nursing associations of Eritrea, and representatives of agricultural workers and other non-unionized workers.The rapid key informant survey succeeded in gathering the preliminary views of senior staff of selected Eritrean ministries and agencies regarding elements likely to be an essential part of the NHFP, that is to say the vision, objectives, components, provider payment mechanisms, and health financing agency and its governance. The findings may be of help to the Ministry of Health in further refining the data collection instrument to be used in a more representative stakeholder survey.In addition to an exhaustive stakeholder survey, there will be a need for a national health accounts study, a financial feasibility analysis of health financing options, an assessment of the political and professional acceptability of financing options, and equity analysis.The authors declare that they have no competing interests.JMK, EZ and JA contributed to the study design, analysis and writing of various sections of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-698X/12/16/prepubAPPENDIX 1. Questionnaire for Government Ministries and Partners.Click here for file


Plasmodiumrelictum has contributed to the extinction of many endemic avian species. While the ecology of invasive malaria is reasonably understood, the ecology of endemic haemosporidian infection in mainland systems is poorly understood, even though it is the rule rather than the exception. We develop a mathematical model to explore and identify the ecological factors that most influence transmission of the common avian parasite, Leucocytozoonfringillinarum (Apicomplexa). The model was parameterized from White-crowned Sparrow  and S. silvestre / craigi black fly populations breeding in an alpine ecosystem. We identify and examine the importance of altricial nestlings, the seasonal relapse of infected birds for parasite persistence across breeding seasons, and potential impacts of seasonal changes in black fly emergence on parasite prevalence in a high elevation temperate system. We also use the model to identify and estimate the parameters most influencing transmission dynamics. Our analysis found that relapse of adult birds and young of the year birds were crucial for parasite persistence across multiple seasons. However, distinguishing between nude nestlings and feathered young of the year was unnecessary. Finally, due to model sensitivity to many black fly parameters, parasite prevalence and sparrow recruitment may be most affected by seasonal changes in environmental temperature driving shifts in black fly emergence and gonotrophic cycles.Most of our knowledge about avian haemosporidian parasites comes from the Hawaiian archipelago, where recently introduced  Plasmodiumrelictum and the mosquito Culexquinquefaciatus in Hawaii in 1826, in conjunction with habitat degradation and invasive predators, led to the endangerment and extinction of many endemic bird species , and 4) is linked to transmission of Lfringillinarum.  in other systems , and 2) the timing of the emergence and peak of susceptible vectors occurs before birds begin to develop chronic infections.In contrast, infection prevalences in both populations were insensitive to changes in parameters associated with chronically infectious birds  and the probability of transmission from an infectious black fly to a nude nestling (bN). Nestlings are without feathers for a relatively brief window of time during the breeding season, and an increase in the probability of transmission during this interval may not significantly affect overall infection in both the bird and black fly population. This contrasts with results from models for St. Louis encephalitis virus [However, distinguishing between nude nestlings and feathered first year birds in the transmission system is unnecessary, as shown by the insensitivity of both avian and black fly prevalence to the daily rate nestlings acquire feathers  earlier in the season, to a point, significantly increased the degree of overlap between infectious black flies (infected from feeding on relapsing infectious adult sparrows) and susceptible first year birds . In conar birds . Shiftinbirds r, , as has P. falciparum [Prelictum.  [λF) may not necessarily increase parasite prevalence , temperevalence  and 3 inWith this multi-year model, we present an in depth look at the ecological, parasite, and host factors that are important for parasite transmission outside of the well-described Hawaiian Island bird malaria system. We conclude that seasonal relapse is crucial for parasite transmission across years. Further, parasite prevalence in the bird population is highly sensitive to the timing of black fly emergence, seasonal bird relapse, and the production of susceptible first year birds. Thus, changes in environmental temperature due to inter-seasonal variation in overwinter snowpack and black fly ecology could be critical determinants of parasite prevalence and sparrow recruitment from year to year.Lfringillinarum.  live in a system comprised of multiple vertebrate hosts, potentially multiple black fly vectors, and other blood parasite species. For example, we have found a range of other bird species infected with the same morphospecies of Lfringillinarum. , as well as the presence of other co-infecting blood parasite species  on these sites [Further research and better precision of model parameters are needed to improve some of our model predictions. White-crowned sparrows and se sites . How mulse sites , sex [13se sites ,76, and se sites ,77,78. Fse sites ), variatse sites .Text S1Description of field methods for capturing birds, black flies, and sampling parasite prevalence throughout each breeding season.Details on parameterizing the nestling hatch and black fly emergence function are also included.(DOC)Click here for additional data file.Text S2Compartmental diagram and differential equations associated with the single season model.(DOC)Click here for additional data file.Text S3Differential equations for the multi-season model.(DOC)Click here for additional data file.Text S4Includes a table of the distributions assumed for each model parameter as well as detailed descriptions on choice of parameter distributions, minimum, maximum, and mean values.(DOC)Click here for additional data file.Text S5Parameter plots of the parameters avian and black fly infection prevalence were most sensitive to as indicated in the sensitivity analysis.(DOC)Click here for additional data file.


Racial/ethnic minority groups have higher risks for disease resulting from obesity.The University of California, Los Angeles, and the Los Angeles County Department of Public Health partnered with community organizations to disseminate culturally targeted physical activity and nutrition-based interventions in worksites.We conducted community dialogues with people from 59 government and nonprofit health and social service agencies to develop wellness strategies for implementation in worksites. Strategies included structured group exercise breaks and serving healthy refreshments at organizational functions. During the first 2 years, we subcontracted with 6 community-based organizations (primary partners) who disseminated these wellness strategies to 29 organizations within their own professional networks (secondary worksites) through peer modeling and social support. We analyzed data from the first 2 years of the project to evaluate our dissemination approach.Primary partners had difficulty recruiting organizations in their professional network as secondary partners to adopt wellness strategies. Within their own organizations, primary partners reported significant increases in implementation in 2 of the 6 core organizational strategies for promoting physical activity and healthy eating. Twelve secondary worksites that completed organizational assessments on 2 occasions reported significant increases in implementation in 4 of the 6 core organizational strategies.Dissemination of organizational wellness strategies by trained community organizations through their existing networks (train-the-trainer) was only marginally successful. Therefore, we discontinued this dissemination approach and focused on recruiting leaders of organizational networks. More than one-third of adults and nearly one-fifth of children in the United States are obese, placing them at greater risk for heart disease, diabetes, and other chronic diseases ,2. PeoplThe Centers for Disease Control and Prevention (CDC) created Racial and Ethnic Approaches to Community Health Across the US (REACH US) , a natioIntervening at key community institutions such as worksites, churches, and schools can have a profound effect on obesity prevention, because these institutions represent contexts for engaging captive audiences to make changes in social and cultural norms, enhance awareness, build necessary skills, and make structural shifts to support desired behavior change . EmployeWe describe our approach to disseminating wellness strategies at worksites in Los Angeles and Orange counties from 2007 to 2009, the first 2 years of CEED. We present results of a midpoint process evaluation that reshaped our approach to dissemination during the next 2 years.With the support of a National Institutes of Health disparities grant, and before we received CEED funding, we conducted a series of community dialogues with 188 representatives of 59 different government and nonprofit health and social service organizations. We presented wellness strategies that were practice- or evidence-based to these representatives, who then identified those strategies that could realistically be implemented in their organizations during work hours . The 6 cIn the first 2 years of CEED, we subcontracted with 6 community-based health and social service organizations as primary partners, organizations with a history of successful outreach activities in the target communities. Given the racial and ethnic diversity of Los Angeles County, we partnered with organizations that served the largest local minority populations, including Latinos, African Americans, and Asians and Pacific Islanders. For this discussion, we refer to these partners as Agencies A through F. Agency A is a community health center that provides services to low-income families, particularly Asians and Pacific Islanders. Agency B empowers black women to take responsibility for their health and to advocate for changes in policies that adversely affect their health. Agency C, located in a majority-Latino neighborhood, develops and preserves affordable housing; advocates for childcare, quality education, and health care access; and promotes economic development and progressive public policy. Agency D trains Latino community health workers to be leaders in fostering wellness through provision of quality preventive services and educational programs. Agency E enables African Americans and other racial/ethnic minority groups to attain economic self-reliance, parity, power, and civil rights through advocacy activities and the provision of programs and services. Agency F addresses the needs of underserved, predominantly Latino, families by providing information at worksites that encourages healthy lifestyles and timely and appropriate use of health care services.The number of employees at each organization ranges from fewer than 10 to approximately 300. The racial/ethnic composition of the employees reflects that of the agency's clientele. Five of the community partner organizations are in Los Angeles County and 1 is in Orange County. One of the organizations has been in existence for 85 years, and all others, between 15 and 25 years.Primary partners received financial support and technical assistance to implement selected policy and practice changes within their own organizations and to participate in the worksite wellness assessments associated with CEED. Each primary partner also agreed to recruit and train 5 to 13 organizations (secondary partners), depending on their capacity, from their network of collaborators willing to implement selected policy and practice changes. The goal of this "train-the-trainer" model was to disseminate the 6 core organizational strategies to the larger community through diverse organizations offering peer modeling and social support. The director of each primary partner agency and the principal investigator at UCLA (A.Y.) signed a memorandum of understanding that outlined the scope of work.UCLA staff provided technical assistance to all primary sites in person and by telephone and e-mail, including at least 2 site visits per year. Other trainings and events were made available for both primary and secondary partners, including Instant Recess trainings on how to lead and implement regular structured group activity breaks , 1 workshop on use of evidence-based strategies, the California REACH conference, and an annual community cancer prevention symposium. In addition, designated peer leaders at each worksite attended the Program Champion training, a program designed to build skills in advancing fitness-promoting practices and policies at the workplace.A coalition advisory board comprising members from the Los Angeles County Department of Public Health, academia, and 10 community agencies was convened in the first year. The advisory board meets quarterly. Its goal is to provide oversight to CEED to assure cultural relevance, appropriateness, and responsiveness of the interventions; to support dissemination efforts; and to ensure the establishment of an authentic partnership between the community partners, UCLA, and the Los Angeles County Department of Public Health. The advisory board chose its own name , identified its guiding principles, and established ground rules for meetings. Members determined that 4 central elements of community-based participatory research would shape the coalition: partnership, participation, equity, and social change.We asked staff at each community organization to complete a worksite wellness assessment (WWA) to identify current practice and policy support for health promotion activities before initiating any CEED activities (baseline) and again at 6 and 12 months after the organization's enrollment. The assessment tool was adapted for an earlier REACH project from the New York State Department of Health Heart Check, a validated instrument assessing organizational characteristics that support heart-healthy behaviors  with demonstrated sensitivity in detecting preintervention and postintervention changes -19. The Each site was asked to return 3 WWAs, to be completed by 1 representative each from upper management, middle management, and nonmanagement or line staff. We chose different levels of the organizational hierarchy to capture and compare the range of perspectives of both the decision makers and line staff. Initially, the WWA comprised a 13-page self-administered questionnaire for line staff and a 15-page questionnaire for upper management. During the first assessment period (2007 to 2008) we noticed that many assessments were only partially completed, and our community partners thought that the instruments were too long and cumbersome. Subsequently, we shortened the assessment instrument to 6 pages with the same instrument to be completed by line staff and management, and we made it available online.UCLA staff also conducted 1 environmental audit at each primary partner organization to verify self-reported implementation of wellness strategies. Specifically, staff observed and noted the availability of drinking water and fruit baskets in common areas, contents of vending machines, and incidence of physical activity breaks during work routine. During these site visits, UCLA staff also provided technical assistance as needed.Data from the WWAs were entered into a database in EpiData version 3.1  and then exported to Stata version 10.0  for analysis. Sites varied in how many respondents completed the organization-level questionnaire. Although most WWAs were completed by the same employees at baseline and follow-up, some were completed by different employees. Prevalence estimates were obtained by using Stata's survey data cross-tabulation procedure. For the comparison of baseline and follow-up data, we combined formal and informal policy changes, combined missing values with the "no" categories, and weighted the data based on the number of responses received from each organization. Thus, all worksites made an equal contribution to overall estimates of the proportion of worksites supporting specific nutrition and physical activity-related policies and practices. The significance of the difference in mean prevalence estimates between baseline and 8-month follow-up was obtained by using Stata's survey data mean procedure and Stata's postestimation Wald test to determine whether the follow-up mean was equal to the baseline mean prevalence estimate. CEED was ruled exempt from UCLA Human Subjects Protection Committee review because interventions and assessments were focused at the organizational level, not at the individual level, and UCLA's role was one of training and consultation, not direct-service delivery.The 6 primary community partner organizations agreed to recruit 41 to 53 secondary worksites during the first 2 years . HoweverWe compared the answers to 3 questions from the WWAs completed by members of the primary community partner organizations with answers to the same questions on the 8-month follow-up questionnaire and to findings from the environmental audits . At bothSummary data from the WWAs for primary sites  show thaFor the 6 primary worksites, there were fewer missing data at follow-up than at baseline. This may be due both to more diligent completion of questionnaires and better quality control by UCLA staff. The proportion of organizations who reported "healthier" trends between baseline and follow-up significantly increased for policies regarding healthy food procurement and exercise breaks conducted during work hours. There were no changes with respect to policies regarding nutritious food and beverages at company meetings, the presence of functional water coolers, and the support of standing, stretching, or fidgeting during meetings. Decreased support reported for casual dress attire during work hours was significant.Similar trends were observed in secondary sites . SupportMore primary sites reported exercise breaks during work hours at baseline than did secondary sites. This may be explained by the participation of 2 of the primary sites in a previous pilot study that promoted exercise breaks during work hours, attesting to the sustainability of this approach given adequate implementation support .On the basis of the findings of these process measures, we shortened the WWA and modified the protocol to have the same employee (a senior-level but not director-level manager) complete baseline and follow-up assessments in future years. Informed by the data presented in this report and discussions with our community partners, we decided to discontinue the dissemination strategy employed from 2007 to 2009. Instead of the projected participation of 41 to 53 secondary sites, we enrolled only 29 sites, which completed at least a baseline WWA. In addition, primary sites reported that it took a lot more effort than anticipated to recruit secondary sites. Furthermore, only 12 of the secondary sites completed a follow-up assessment. The 17 sites that did not complete WWAs at follow-up likely did not implement the recommended wellness strategies.Our data do suggest, however, that participating sites were able to incorporate several of the core strategies into worksite routines, especially exercise breaks. According to Luanne Heinen, National Business Group on Health , this is noteworthy in that the typical corporate "pull" physical activity promotion strategies that rely on individual motivation  are being abandoned as costly and ineffective by many corporations  and staff had actively promoted the centerpiece wellness strategy, the 10-minute Instant Recess break, for the past decade by using accelerated funding from the CEED. They have offered workshops, mounted a website, and led recess breaks at many local and national meetings and at any type of gathering that involved sitting for long periods. As a result, many community members and leaders, researchers, and public health practitioners participated in various activity breaks that were built into the agendas of these meetings. These breaks are generally welcomed as an opportunity to relieve stress and restore energy. We have, over time, received increasing numbers of requests from organizations, networks, and public agencies for trainings, materials, and related resources to implement recess breaks. Working with these groups led to the development and adoption of a new dissemination model, the Meta-Volition Model, in which "sparkplugs"  engage self-identified early-adopter leaders who are connected to networks of organizations to encourage them to implement "push" organizational wellness policy and practice changes . On the