The Peruvian Andean region is a main center of plant domestication of the world. There, several tuber species were domesticated and the area lodges one of the most important reservoirs of their varieties and wild relatives. It is also the setting of traditional cultures using and conserving them. However, crop genetic erosion has been reported in the region since several decades ago; therefore, understanding factors influencing both loss and maintenance of crop variation is relevant to design conservation policies. Previous researches have examined factors influencing agrobiodiversity conservation in the region but additional case studies are recognized to be still necessary for a deeper understanding of causes of genetic erosion and for policy design to prevent and remedy it. Our study focused on analyzing (1) variation in richness of traditional varieties of tubers cultivated among households, (2) changes in varieties richness occurred in four consecutive agricultural cycles, and (3) ecological, social, and cultural factors influencing loss and conservation of varieties.Richness of farmer varieties of tuber species cultivated by 28 peasant households was monitored in communities of Cajamarca and Huánuco, Peru during four consecutive agricultural cycles (from 2001 to 2005). In-depth interviews were conducted with 12 of the households with higher reputation as conservationists, in order to document farmers' perception of tubers qualities in ecological, social, economic, technological and culinary aspects and how these influence their decisions of conservation priorities. Traditional varieties were identified according to their local names, which were then confronted among farmers and with scientific catalogues in order to identify synonyms. Based on the information documented, indexes of ecological and socio-cultural factors affecting agricultural practices were designed, and their linear correlations and multivariate relations with varieties richness managed per household were analyzed in order to explore factors with higher influence on conservation of crop variation.A total of 1483 and 507 farmer varieties of tuber species were found in the whole sample and period studied in Huánuco and Cajamarca, respectively. Significantly more varieties managed per household per year were recorded in Huánuco (146.39 ± 12.02) than in Cajamarca (44.55 ± 9.26), and marked differences in number of varieties per year were documented among households within each region . Correlation and multivariate analyses identified that the extent of agricultural area managed by households, cultural identity, practicing of traditional agricultural techniques, and level of self-sufficiency, are meaningful factors influencing higher varieties richness maintained by households. Yield and culinary attributes were considered by people as main features for selecting and deciding which varieties are priorities for conservation.Maintenance and promotion of indigenous Andean culture is crucial for ensuring conservation of both traditional agroecological systems and agrobiodiversity. Policies supporting Andean culture  are therefore directly connected with conservation of traditional farmer varieties. Promotion of seed availability and interchange are effective actions for maintaining and developing diversity, but using and valuing native tubers at regional, national and international levels are fundamental motivations to enhance policies and processes in this direction. The Andean region of Peru is one of the main centers of domestication and diversification of crop plants of the world -3. The gSolanum ajanhuiri, S. chaucha, S. curtilobum, S. juzepzuckii, S. phureja, S. stenotomum, and S. tuberosum [Oxalis tuberosa) with at least 50 technically described varieties, "olluco" (Ullucus tuberosus) with 50 to 70 clones, and "mashua" (Tropaeolum tuberosum) with nearly 100 described varieties [chakitaqlla in Quechua , with auberosum , "oca" . This project was conducted from 2001 to 2006, and became one of the most important Peruvian efforts of in situ conservation of agrobiodiversity. It was an inter-institutional program documenting and promoting conservation of agrobiodiversity of Andean and Amazonian regions of Peru. The "in situ project" recorded nearly 9000 names used by local peoples for designating native variants of several crop species of tubers [By the end of the 1980s and early 1990s several initiatives for f tubers . We basef tubers .in situ project" documented differences in richness of traditional farmer varieties among households and regions, and identified that some varieties remained constant in parcels  whereas others changed from cycle to cycle.By monitoring numerous production units during the agricultural cycles from 2001 to 2005, the "in situ project" resulted in a great amount of information that has been only partially used for in situ conservation programs and public policies but that potentially may have more substantial contribution. Some institutions and scholars have made attempts to systematize and analyze the information but there is still much to do, especially for identifying the main factors influencing loss, maintenance, and generation of varieties richness by households. This latter task is particularly important for designing strategies of in situ conservation, and our study aspires to contribute in this direction. Based on information generated by the "in situ project", the main questions guiding our current research were: How different the traditional farmer varieties richness is among regions and households?, what factors influence such differences?, what factors determine that certain traditional varieties remain constant (are "not replaceable") whereas others are more commonly lost or substituted by others (are "replaceable")?The research effort of the "We hypothesized that: (1) differences in traditional farmer varieties richness are associated to ecological, technological and socioeconomic variations of the contexts where agriculture takes place; particularly, we supposed that aspects such as the range of environments in which households practice agriculture, the weight of traditional culture influencing strategies of risk management and use of traditional technologies, as well as the degree of dependence of their subsistence on their own agricultural products should be meaningful factors determining in direct proportion higher crop variation; (2) traditional varieties would be "not replaceable" or "replaceable" depending on their role in households subsistence, and their performance in particular environments, technological and cultural contexts of production. Our study aimed at exploring these hypotheses in a sample of households from Huánuco and Cajamarca, looking for identifying factors influencing both loss and conservation of these plant genetic resources.in situ project". We aspire to contribute to make more relevant use of the information obtained by the "in situ project" to design strategies and policies of in situ conservation of genetic resources.Exploring these hypotheses was also considered useful for constructing methods to analyze the great amount of data generated by the "Our study was conducted in the highest elevation zone of mountain agroecosystems of Cajamarca (Northern Sierra region) and Huánuco , Peru. In Cajamarca our study covered elevations from 3100 to 4150 m in the watersheds of Chugzen, Muyoc and Shitamalca, Province of San Marcos. In Huánuco our study covered elevations from 3100 to 4300 m in the watershed of Mito, Province of Huánuco Figure . Both stPeople of the study area inhabit small and dispersed settlements of difficult access. Most of the population live in poverty and extreme poverty conditions , with high levels of illiteracy and strong migration to cities ,27. HousTraditional farmer varieties of potato, oca, olluco and mashua, recognized and named by farmers, were annually recorded during four sequential agricultural cycles (from 2001 to 2005), in parcels cultivated by a sample of 28 peasant households. Traditional farmer varieties are units of variation recognized and named by local people based on multiple morphological, physiological, phenological, and ecological features, as well as technological and culinary attributes . Traditional farmer varieties are not equivalent to varieties characterized by botanists and agronomists through standardized morphotype descriptors, e.g. ,30.Further in-depth studies were conducted with 12 households (6 from Cajamarca and 6 from Huánuco), which were selected based on their reputation as crop diversity conservationists according to the high number of local varieties they manage, as documented by the Centro IDEAS  and IDMATraditional farmer varieties of tuber crop species were recorded every agricultural cycle during the study period. After obtaining name inventories and photographic material of traditional farmer varieties, a careful process of nomenclature depuration was conducted through workshops in order to corroborate the varieties identity and to identify synonyms. Such process was conducted with people of the households studied, consulting to them doubts about the varieties identity by confronting plant materials and images of different tubers with similar names and similar tubers receiving different names. The process was supported with complementary reviews of common names registered in the most complete database of potato landraces collection available for Peru . Also, iVariation of crops managed by the peasant households studied was determined calculating the richness of traditional farmer varieties recognized at household and regional levels per agricultural cycle and for the whole period studied. Taxa identified as wild relatives of potatoes, oca, olluco and mashua were inventoried in all study sites.An integrated multi-factor approach to analyze motives of management and maintenance of diversity of varieties in farmers' fields was conducted, inspired in ideas by Zimmerer ,15 and BInformation on environmental conditions  in which peasants cultivate native tubers and on the spatial organization of parcels  were recorded in the field. People's perception about threats associated to climate (frosts and amount of rain), pests, availability of soil and water and their management solutions was documented through interviews. We also explored people's perception on the presence of wild relatives in the surrounding areas of crop fields and their relation to crops. Influence of spatial distribution of parcels was analyzed by recording the traditional varieties richness in relation to the total surface of parcels that each farmer dedicated to cultivation of tubers. We considered the distribution of parcels in three altitudinal floors , we conducted interviews about the reasons why households consider replaceable or not a traditional variety and how the not replaceable variants are maintained and recovered.Interviews were conducted to obtain information on: (i) tools and practices representing traditional agriculture, including traditional techniques and mutual help, (ii) land area cultivated with native tubers, and (iii) strategies for maintaining seed flow among households, including data on effort invested in searching seeds, and mechanisms of seeds attainment. With this information we constructed an index of traditional agricultural management  was constructed to analyze the relation between the monetary value of production destined to direct consumption and incomes earn by households. The index of family size (IFS) was designed to evaluate the relation between number of members of households and the maximum number of members in households. The index of hand labor (IHL) analyzed the relation between number of households members older than 12 years old  and the maximum number of members with this age in households.Linear regressions between traditional varieties richness of native tubers as dependent variable of 10 independent variables Table  were perp < 0.0001), and marked differences in number of varieties per year among households within each region   than in Cajamarca , predominating the traditional farmer varieties of potato in both richness and cultivated area  and the Andean potato weevil or "gorgojo de los Andes" (Premnotrypes spp.). Frosts are also considered a principal factor affecting agriculture. In addition, the farmers interviewed said that delay in starting of the rainy season contribute to decrease ponds and soil humidity and addressed problems of soil erosion and decreasing fertility.According to farmers' perception, the most severe pests threatening agriculture in Cajamarca and Huánuco are the potato blanch or "According to farmers' perception, distribution and abundance of wild relatives are decreasing in great part of their territories. They consider that this situation is mainly due to damage caused by skunks which unbury tubers looking for insect larvae for feeding; also, because of over-grazing of domestic animals, accidental and intentional burning of vegetation, and drought. Some people also referred to decreasing of vegetation cover caused by deforestation and land use change, especially because of agriculture expansion.potreros, majadeos, guaneos), grazing land management, regulating slash and burn agricultural systems (rozo y quema) and grassland burning practices. They are adopting appropriate technologies of conservation of soil , water  and vegetation cover, mainly through management of agroforestry systems. The perspective of these measures is to guarantee an adequate habitat for native tuber crops, their varieties and wild relatives.In order to face environmental degradation, farmers are trying to recover traditional strategies and practices, like rotation and lying at rest of soils, production of livestock manure in particular areas , agricultural rituals and festivities such as allpa pagamanchi or alpata garapashun , the jircata garaicushun or cerrugpag ofrendapag (offering to the mountain), and agricultural calendar such as the quillata or goillarta, or observaman (astronomic "reading") or señalcuna plantacuna and animalcuna mañucusheque climangpag , iii) age of learning native tubers agriculture (younger: 12-18 years old), iv) stimulating and teaching children agricultural practices, v) management of a greater variation of native tubers  was significant in both regions Table . All farrs Table . Our stuchakitaqlla, not using chemical inputs, and practicing traditional seed storing), mutual help (yanamanchi or ayni), and seed interchange (rukan semilla), as important characteristics for conserving farmer varieties richness  allowed identifying that in Huánuco most farmers participating in the study managed genetic resources orienting their production systems to direct consumption of products more clearly than farmers from Cajamarca Table . The higDifferences in family size were found among the households studied. With the exception of younger families, most households cover their requirements of hand labor by their own family members Table . Signifiin situ management of traditional varieties richness associated to the regions analyzed  and self-sufficiency. In Cajamarca, households' management strategy is mainly influenced by number and altitudinal distribution of parcels, family size and hand labor.Cluster and principal components analyses clearly showed two groups of households which represent general patterns of strategies for d Figure . The mosd Figure  and 8. IThese analyses allowed distinguishing the farmers managing more traditional varieties within each group: Mr. Huaccha  in Cajamarca and Mr. Fernández  in Huánuco. Common aspects in these farmers are intermediate levels of the index of cultural identity (ICI) and high values of the index of traditional agricultural management (ITAM). The cases of these farmers support the information that indigenous culture favors maintenance of greater genetic resources diversity.papa seca (dry potato) in Cajamarca and tocosh (a kind of fermented potato) and chuño (a frozen dehydrated potato) in Huánuco. Attributes for preparing these products are recognized specifically in some varieties, most of them remaining constant in seed stocks. Mr. Sánchez was the only one person addressing the conservation of traditional varieties diversity itself as the main reason for maintaining them.Farmers' decisions for managing diverse traditional varieties of tubers take into account utilitarian, technical and cultural attributes of the varieties Figure . The reain situ conservation of agrobiodiversity documented in this study are carried out by households that are part of rural communities that maintain features of the classic Andean agriculture [Patterns of iculture  such as:According to Monroe , the capin situ conservation of genetic resources. The risk can be even greater than what has been discussed in this study since most households in the villages studied conserve less variation than the households analyzed.In general, we found that although the households studied maintain high diversity of traditional varieties of native tubers, some ecological and socio-cultural factors affect such task. Pests, climate change, and degradation of soils are all considered by farmers among the main unfavorable ecological factors limiting maintenance of traditional varieties diversity. In accordance with this perception, other studies ,45 foundOur study found that the pattern of organization of the cultivated land area, characterized by using more parcels as possible in different altitudinal zones, favors the management of a greater variation of native tubers. Maintaining such actions is highly important for managing the current expressions of risk.We also found that households with clearer signs of traditional Andean culture and traditional characteristics in agricultural management were those conserving more tuber varieties. Factors negatively affecting the indigenous Andean culture therefore represent general risks for conservation of traditional agricultural systems and agrobiodiversity. For instance, cultural discrimination influences changes in language, customs, food and use patterns of natural resources; migration and formal education may impact on young farmers' cultural identity and rooting to their communities -49, inflin situ conservation of agrobiodiversity. For some of them, markets determine high risk and frequently are direct cause of loss of native crops diversity since commercial systems generally favor a narrow spectrum of varieties [The progressive loss of traditional techniques and agriculture intensification influence the loss of traditional farmer varieties diversity. A trend of expansion of the modern agriculture and livestock oriented predominantly to commercialization can be observed in both regions, and it may have unfavorable consequences for conservation of the genetic resources diversity. Trade of native traditional variaties is a controversial topic among actors promoting arieties , but alsarieties , marketsarieties . Howeverin situ conservation of genetic resources. Holistic approaches and integrated analyses of these factors and processes are required.Our current information does not intend concluding linear cause-effect relations among the factors analyzed. Crop variation conservation is a complex issue influenced by socio-ecological factors like the ones analyzed in this study. Therefore, loss of variation associated to one particular factor may have consequences on other factors and on cultural patterns. This illustrates that partial examination of effects of environmental, cultural or socio-economic factors on crop variation offer insufficient information of the processes influencing in situ conservation of Andean tuber crops occurring in the studied areas. However, some aspects also indicate vulnerability of the system; these are for instance the marked asymmetry in number of varieties managed by households  may be effective in accomplishing in situ conservation tasks, particularly if these efforts are sustained for long time periods as priority issue of public policies.The trend of increasing traditional variaties richness recorded during the period studied in both regions and in all households monitored is apparently related to actions of the "Richness of traditional farmer varieties of native tubers was generally high in the conservationist households studied, but risks of varieties loss do exist associated to: a) unfavorable changes in ecological and socio-cultural contexts of their use and management, b) marked asymmetry in varieties richness managed by households, and c) a high number of unique varieties managed by single or few households.Differences in traditional varieties richness managed by households were identified to be related to the extent of cultivated land area, degree of cultural identity, differences in the way of practicing traditional agricultural techniques, and levels of self-sufficiency of households. In Cajamarca differences were also related to altitudinal range of plots distribution, and family size.Food quality, good productivity and culinary attributes, were main criteria considered by people for managing and selecting their tuber varieties, and influence decisions on which varieties are priority to remain constant.in situ project" on factors influencing peasant strategies of in situ conservation of genetic resources. Both quantitative and qualitative methods are required to conduct researches to support policies, actions and their monitoring for sustainable management of genetic resources. Proposals against genetic erosion risks require holistic research and action approaches for enhancing in situ conservation of crop variation and wild relatives.The indexes designed in this study may contribute to more general analyses of the information generated by the "Maintenance and promotion of indigenous Andean culture is crucial for ensuring maintenance of both traditional agroecological systems and agrobiodiversity. Policies supporting and respecting Andean culture through educational, cultural and economic programs are therefore directly connected with conservation of traditional farmer varieties. Promotion of seed availability and interchange are effective actions for maintaining and developing diversity, but using and valuing native tubers at regional, national and international levels are fundamental motivations to enhance processes in this direction.in situ project" is undoubtedly an important source of information and methodological experience. Our current analysis of a small sample of villages and farmers suggests particular pathways for systematizing and analyzing the valuable information generated by that project. But more formal reflections and actions from all the actors of the project are required for continuing constructing a vigorous program for conservation of plant genetic resources in one of the main centers of domestication of plants of the world.Public policies are relevant for concerting visions to support planning and strategic actions oriented to the integral management of agrobiodiversity. In Peru, a favorable context currently exists for public policy in agrobiodiversity conservation issues. The Plan Nacional del Ambiente  and the Programa Nacional de Agrobiodiversidad  are strategic instruments for recording and inventorying genetic resources, as well as identifying zones of agrobiodiversity at local, regional and national levels. Construction of public policies requires support from different sectors of the Peruvian society . Contributions in methods for recording, monitoring, systematizing and using field information are required. The experience of the "CCTA: Coordinadora de Ciencia y Tecnología en los Andes; CENTRO IDEAS: Centro de Investigación, Documentación, Educación, Asesoría y Servicios; CIECO: Centro de Investigaciones en Ecosistemas. Universidad Nacional Autónoma de México; CIP: Centro Internacional de la Papa; IDMA: Instituto de Desarrollo y Medio Ambiente; IN SITU PROJECT: In situ conservation of native crops and their wild relatives in Peru; INCAGRO: Programa para la Innovación y Competitividad del Agro Peruano; IIAP: Instituto de Investigación de la Amazonía Peruana; INEI: Instituto Nacional de Estadística e Informática; PNUD: Programa de las Naciones Unidas para el Desarrollo; PRATEC: Proyecto Andino de Tecnologías Campesinas; PROYECTO IN SITU: Proyecto Conservación In situ de Cultivos Nativos y sus Parientes Silvestres en el Perú; SENAMHI: Servicio Nacional de Meteorología e Hidrología; UNALM: Universidad Nacional Agraria La Molina.The authors declare that they have no competing interests.DVM conceived, designed and coordinated the study, carried out the analyses and helped to draft the manuscript. AC made substantial contributions to theoretical background, conception and design of the study, data analysis and interpretation of results, and drafted the manuscript. JTG participated in the conception and design of the study, analysis and interpretation of data and helped to draft the manuscript. ACS participated in the design of the study, carried out the statistical analyses and helped to draft the manuscript. All authors read and approved the final manuscript.in situ project, combining ecological, ethnobiological, inter-cultutral and participatory research approaches.DVM. MSc (Biology) at the Universidad Autónoma de México (UNAM), consultant of CCTA and researcher at the Centro de Investigaciones de Zonas Áridas, UNALM. Participant at the AC. Biologist at UNAM, Mexico, PhD at the University of Reading, UK. Researcher at the Centro de Investigaciones en Ecosistemas, UNAM. Coordinator of the Laboratory of Ecology and Evolution of Plant Resources, advising and conducting researches with ethnoecological, ecological and evolutionary approaches to the study of plant management and domestication.JTG. Lecturer at the Faculty of Biology, UNALM, Researcher and Director of the Centro de Investigaciones de Zonas Áridas, UNALM, and consultant of CCTA. Coordinator of researches in ecology of arid zones and mountainous ecosystems, and ethnobiology in relation to plant genetic resources.in situ project, encharged of managing and analyzing databases of the project.ACS. Specialist in ecological economy, researcher of the Centro de Investigaciones de Zonas Áridas, UNALM, and consultant of CCTA. Participant at the


The global trade in wildlife provides disease transmission mechanisms that not only cause human disease outbreaks but also threaten livestock, international trade, rural livelihoods, native wildlife populations, and the health of ecosystems. Outbreaks resulting from wildlife trade have caused hundreds of billions of dollars of economic damage globally. Rather than attempting to eradicate pathogens or the wild species that may harbor them, a practical approach would include decreasing the contact rate among species, including humans, at the interface created by the wildlife trade. Since wildlife marketing functions as a system of scale-free networks with major hubs, these points provide control opportunities to maximize the effects of regulatory efforts. Threats to global health and risk factors for emerging infectious diseases run the gamut from climate change to poverty to security issues, but few are as immediately manageable as the global trade in wildlife. Trade in wildlife provides disease transmission mechanisms at levels that not only cause human disease outbreaks but also threaten livestock, international trade, rural livelihoods, native wildlife populations, and the health of ecosystems. Quantifying the global wildlife trade is almost impossible since it ranges in scale from local barter to major international routes, and much is conducted illegally or through informal networks. Some estimates indicate that ≈40,000 live primates, 4 million live birds, 640,000 live reptiles, and 350 million live tropical fish are traded globally each year . Live wiIn lieu of precise trade data, we conservatively estimated that in East and Southeast Asia, tens of millions of wild animals are shipped each year regionally and from around the world for food or use in traditional medicine. The estimate for trade and local and regional consumption of wild animal meat in Central Africa alone is >1 billion kg per year , and estHunters, middle marketers, and consumers experience some type of contact as each animal is traded. Other wildlife in the trade is temporarily exposed, and domestic animals and wild scavengers in villages and market areas consume the remnants and wastes from the traded and potentially traded wildlife. These numbers combined suggest that at least some multiple of 1 billion direct and indirect contacts among wildlife, humans, and domestic animals result from the wildlife trade annually. The increasingly global scope of this trade, coupled with rapid modern transportation and the fact that markets serve as network hubs rather than as product endpoints, dramatically increases the movement and potential cross-species transmission of the infectious agents that every animal naturally hosts.Since 1980, >35 new infectious diseases have emerged in humans , ≈1 everThe inadvertent movement of infectious agents due to the wildlife trade is not limited to human pathogens but also affects pathogens of domestic animals and native wildlife. H5N1 type A influenza virus was recently isolated from 2 mountain hawk eagles illegally imported to Belgium from Thailand . A paramMany diseases are transmitted through the same species of parasites carried by imported animals. For example, from November 1994 to January 1995, US Department of Agriculture personnel inspected 349 reptile shipments from 22 countries containing 117,690 animals. Ticks were removed from animals in 97 shipments, and infested shipments included 54,376 animals (The possibility of emerging infectious diseases spreading between persons and animals is rising, fueled by human activities ranging from the handling of bushmeat and the trade in exotic animals to the destruction or disturbance of wild habitat –25. In aIn addition to the direct health effects of the pathogens on persons and animals, animal-related disease outbreaks have caused hundreds of billions of dollars of economic damage globally, destabilizing trade and producing devastating effects on human livelihoods. The rash of emerging or reemerging livestock disease outbreaks around the world since the mid 1990s, including bovine spongiform encephalopathy, foot-and-mouth disease, avian influenza, swine fever, and other diseases, has cost the world's economies $80 billion . In earlRather than attempting to eradicate pathogens or the wild species that may harbor them, a practical approach to decrease the risk for the spread of infectious diseases would include decreasing contact among species. Closing down retail poultry markets in Hong Kong for 1 day per month reduced the rate of H9N2 avian influenza virus in market birds . Little


In 2002, the Chinese government launched a new rural health financing policy to provide health insurance  for its rural population. NCMS, jointly financed by governments and individual households, aims to protect households from impoverishment due to catastrophic health expenditure. In 2011, NCMS covered more than 96% of the rural population. We have systematically searched and reviewed available evidence to estimate the effects of NCMS on health outcomes and on alleviating catastrophic health expenditure.PubMed, Web of Science with Conference Proceedings, ProQuest Digital Dissertations, CMCI, CNKI, and VIP were searched. We also obtained literature from colleague communications. Quasi-experimental studies regarding the effect of NCMS on health outcomes and catastrophic health expenditure were included. Two independent reviewers screened the literature, extracted the data, and assessed the study quality.Fifteen studies out of the 6123 studies in the literature fulfilled criteria and were included in this review. Twelve studies identified the relationship between NCMS and health outcomes, among which six studies measured sickness or injury in the past four weeks, four measured sickness or injury in the past two weeks, and five measured self-reported health status. Four studies focused on the relationship between NCMS and alleviating catastrophic health expenditure. However, the results from these studies were in conflict: individual studies indicated that NCMS had positive, negative, or no effect on health outcomes and/or the incidence of catastrophic health payments, respectively.We still have no clear evidence that NCMS improves the health outcomes and decreases the alleviating catastrophic health expenditure of the China’s rural population. In addition, the heterogeneity among individual studies reminds us that provider payment method reforms, benefit package and information systems around NCMS should be improved in the future. Under China’s planned economy, almost all rural residents were covered by the Cooperative Medical Scheme (CMS). Moreover it was believed that the program helped to reduce China’s mortality rate during the 1960s and 1970s In 2002, the Chinese government launched a new rural health financing policy to provide health insurance (NCMS) for its rural population. NCMS is financed by the combined contributions from central and local governments, as well as from individual households. NCMS aims to protect households from becoming impoverished due to catastrophic health expenditure One concern with NCMS is that its financing is too small to make a significant impact on either health outcomes and/or reducing catastrophic health expenditure. At its inception, the minimum financial requirement is 50 RMB  per person. In 2009, the average financial requirement per person reached 113.37 RMB Most of the studies show that the impact of NCMS is limited Although the main objective of NCMS is to prevent rural residents from being impoverished by medical expenses, the 2003 to 2005 longitudinal study by the Chinese Ministry of Health and the World Bank indicated that inpatient cost per case increased by 30% after people were insured A literature of nearly 5000 items cover the effect of NCMS on health outcomes and/or catastrophic heal expenditure between the national pilot in 2003 to the end of 2010. There is, however, no systematic review on this topic. Many studies used counterfactual analysis to compare catastrophic payments before and after NCMS reimbursements. One cannot draw causal inference about the effect of the NCMS on health outcomes/catastrophic health expenditure The objective of a systematic review was to determine the impact of New Cooperative Medical Scheme (NCMS) on health outcomes and/or catastrophic health expenditure in China.Types of studiesQuantitative studies, mainly quasi-experiment studies, which estimate the causal effects of NCMS on health outcomes and on reducing catastrophic health expenditure in China. In the absence of findings from randomized controlled trials, well designed and implemented quasi-experimental studies could estimate causal effects of health insurance Types of participantsRural residents.Types of interventionNCMS.ComparisonNCMS vs. non-NCMS. The control group included internal control (the subjects were in the NCMS implemented county but did not enrolled in the NCMS), and external control (the subjects were not in the NCMS implemented county).Types of outcomes measurementHealth outcomes: prevalence of sickness or injury in the last two or four weeks, and the proportion of self-reported health, and mortality;Catastrophic health expenditure and its threshold Catastrophic health expenditure: Payment is considered catastrophic when a household has to cut its basic living expenses over one year in order to afford the medical expenses of its household member(s) LanguagesPublications in both Chinese and English were included.Exclusion criteriaBecause we are interested in whether NCMS improves health outcomes and/or reduces the household catastrophic health expenditure, we exclude literature on NCMS regulation, financing, supervision of the NCMS fund, capacity of healthcare facilities, participation proportions, and establishing impact or performance evaluation indicators. In addition, regarding the effect of NCMS, we also exclude health service utilization, patient’s satisfaction with NCMS, inpatient and outpatient reimbursement proportions, determinants of participation and sustainability, and the insured’s benefit proportion.This review excluded the studies without individual or household data.This review excluded the studies that: (1) used prevalence of chronic disease as indicators of health outcomes; (2) used medical care financed by borrowing or selling assets as indicators of catastrophic health expenditure; (3) used self-comparison before and after reimbursement by NCMS as indicators of catastrophic health expenditure; (4) compared NCMS and other health insurance on health outcomes and catastrophic health expenditure. These studies commonly evaluated the effect of NCMS on health outcomes and reduced catastrophic health expenditure.We searched the following databases: CNKI ; Chongqing VIP database (a full text issues database of China), CMCI on Chinese Biomedical Literature; PubMed; ISI Web of Science with Conference Proceedings; ProQuest Dissertations and thesis. Books and working papers were obtained from communication with colleagues. We included Chinese and English literature published between January 2003 and December 2010. The search combined the following two categories of terms:The terms describing NCMS: (a) New Cooperative Medical Scheme; (b) New Cooperative Medical System; (c) New Rural Cooperative Medical Scheme; (d) New Rural Cooperative Medical System.The terms describing outcome: (a) health; (b) cost; (c) expenditure; (d) catastrophic.Our detailed search strategy is in Primary, selected studies were based on the inclusion criteria described above. An EndNote database containing the search results was used to keep track of references identified through the electronic database search (to be screened for inclusion).Screening of literature proceeded at two levels. At level 1 screening, two reviewers (Hong Guo and Xiaoyun Liang) independently performed an assessment of the identified records by reading the title/abstract. The pre-developed inclusion questions for level 1 were based on the inclusion criteria listed in At level 2 screening, two reviewers (Hong Guo and Xiaoyun Liang) independently evaluated the full text of each record promoted from level 1 screening for inclusion. They used a pre-developed inclusion form . DiffereWhen there was more than one record of the same study, we included all potential eligible records according to the inclusion criteria, but used the most relevant one as the main record.Two reviewers independently extracted data from the published sources using the pre-designed data extraction form.After independent extraction of data, two reviewers compared their forms, and resolved any discrepancies by the consulting experts.Two reviewers independently assessed the quality of the selected studies using quality assessment criteria for quasi-experiment study adapted from Loevinsohn (1990) From each included study, we abstracted information about author, year data were collected, study design, sample site and data source, sample size, measures of the type of dependant variable , statistical analysis, and findings relevant to the effects of NCMS on health outcomes/catastrophic health expenditure. The primary comparison of the effects of insurance was explored: differences between rural population with and without NCMS, and control groups included internal controls and external controls. Substantial variation of methods among individual studies precluded formal meta-analyses. Therefore, results are presented in narrative form.In total, 6123 studies were identified: 4107 from CNKI; 1329 from Chongqing VIP database; 598 from CMCI; 24 from PubMed; 57 from ISI; 6 from ProQuest; and 2 from colleague communication . There wOf the included fifteen studies, twelve studies reported health outcomes As Of the twelve studies measuring health outcomes, six P<0.001) Of the six studies examining the effect of NCMS on sickness or injury in the past four weeks, Lei and Lin Of the four studies examining the effect of NCMS on sickness or injury in the past two weeks, Feng used a probit model to analyze cross-sectional data and estimated that NCMS reduced sickness or injury in the past two weeks by 5.3% P<0.1) of self-reported health after NCMS Of the five studies examining the effect of NCMS on self-reported health, scaled as “very good”, “good”, “fair”, “poor” and “very poor”, three panel studies used the DD method and/or PSM estimation and showed no improvement or very limited improvement  indicate that there is no sufficient and clear evidence to support the hypothesis that NCMS improves the health outcomes of rural population and/or decreases the catastrophic health expenditure of rural households.Hadley On the other hand, one determinant for catastrophic health expenditure identified by Xu et al. For health intervention strategies, as Peters et al. stated, some of the success factors, such as strong leadership, good management systems, clear accountabilities, and incentives to support performance, could lead to improve health service delivery in low- and middle-income countries Several factors complicate the findings of this systematic review. Firstly, health outcomes measurement played a critical role in the relationship between NCMS and health outcomes. Health outcomes in the current study include prevalence of sickness or injury in the last two or four weeks, proportion of self-reported health, and mortality. Due to the moral hazard problem, the insured are inclined to be diagnosed with more conditions and use more treatment, while the uninsured may be more likely to die without treatment. In this case, mortality measured as a health outcome could reflect the real effects of NCMS. However, no eligible studies in this systematic review  measured mortality as a health outcome. According to a very recent paper by Chen and Jin Secondly, selection from voluntary NCMS participation leads to biased comparison groups among cross-sectional studies, and endogeneity of NCMS resulted in underestimation or overestimation of its effect on health outcome. Therefore, main conclusion was supported by the findings of panel studies with regression analysis controlling selection bias and endogeneity in this systematic review.At the same time, several limitations need to be borne in mind in interpreting our findings. Firstly, the number of eligible studies was only fifteen although there is a growing body of literature on NCMS. Moreover, as a social experiment in universal insurance coverage, there is increasingly less chance of finding a non-NCMS control group, which means that very few relevant studies could be considered in a future update of this systematic review. Secondly, although the included studies cover most of mainland China, methodological limitations, such as the lack of controlling confounders, constrain making generalizations across the rural population. This is consistent with the argument many researchers make–health insurance is an endogenous variable, and studies vary in the degree they address this endogeneity problem The NCMS revenue sharply increased annually from 3.0 billion RMB in 2004 to 130.8 billion RMB in 2010 Firstly, payment method reform is an alternative to control unnecessary medical cost and improve the health service quality. In the recent decades Chinese doctors earned money on a fee-for-service basis, and it is essential to alter their incentives in order to make NCMS reach its goals. Pilot reform for the provider payment method has been tried in some areas. For example, in Lufeng county of Yunnan province they changed from fee-for-service to per bed-diem in county hospitals and township health centers. This resulted in a positive change in health provider behaviors and reduced out-of-pocket payments for patients Secondly, NCMS benefit package should fit into the disease profile and health expenditure pattern of the population Lastly, information systems including electronic medical records in health facilities and its interlinkage across health facilities are essential to real-time expense reimbursement, further reform fee-for-service payment method to comprehensive but effective payment methods such as diagnosis-related groups (DRGs) payment.In spite of methodological limitations of individual studies included, our study still provides evidence-based assessment on the effect of NCMS. The construction of an effective NCMS needs its own evolved design. China is developing a more comprehensive health system, and its effort in the rural health system is not isolated. Improvements in the health care of its rural population plays a significant role in its effort to construct a “harmonious society” Checklist S1PRISMA Flowchart Checklist.(DOC)Click here for additional data file.Table S1Database for literature search.(DOC)Click here for additional data file.Appendix S1Detailed search strategy.(DOC)Click here for additional data file.Appendix S2Inclusion form level 1 screening.(DOC)Click here for additional data file.Appendix S3Inclusion form level 2 screening.(DOC)Click here for additional data file.Appendix S4Quality assessment criteria for quasi-experiment study.(DOC)Click here for additional data file.


Unhealthy diet and low levels of physical activity are common behavioural factors in the aetiology of many non-communicable diseases. Recent years have witnessed an upsurge of policy and research interest in the use of taxes and other economic instruments to improve population health.To assemble, configure and analyse empirical research studies available to inform the public health case for using economic instruments to promote dietary and physical activity behaviour change.We conducted a systematic scoping review of evidence for the effects of specific interventions to change, or general exposure to variations in, prices or income on dietary and physical activity behaviours and corollary outcomes. Systematic electronic searches and parallel snowball searches retrieved >1 million study records. Text mining technologies were used to prioritise title-abstract records for screening. Eligible studies were selected, classified and analysed in terms of key characteristics and principal findings, using a narrative, configuring synthesis focused on implications for policy and further research.We identified 880 eligible studies, including 192 intervention studies and 768 studies that incorporated evidence for prices or income as correlates or determinants of target outcomes. Current evidence for the effects of economic instruments and exposures on diet and physical activity is limited in quality and equivocal in terms of its policy implications. Direct evidence for the effects of economic instruments is heavily skewed towards impacts on diet, with a relative lack of evidence for impacts on physical activity.The evidence-based case for using economic instruments to promote dietary and physical activity behaviour change may be less compelling than some proponents have claimed. Future research should include measurement of people’s actual behavioural responses using study designs capable of generating reliable causal inferences regarding intervention effects. Policy implementation needs to be carefully aligned with evaluation planning and design. In 2008, non-communicable diseases (NCDs) caused 36 million (63%) of global deaths and 2.8 million people died as a consequence of being overweight or obese . A largeThe term ‘economic instruments’ encompasses fiscal or legislative government policies designed to change the relative prices of goods or services or people’s disposable income, and promotional practices used by retailers to change the relative prices of goods and services. Recent years have witnessed an upsurge of policy and research interest in the potential use of economic instruments to shape markets for specific goods and services in ways that incentivise healthier behaviours -8. This Extant research evidence largely corroborates the public health case for using economic instruments to discourage purchasing and use of tobacco and alcohol products -16. HoweThe specific objectives of this scoping review were to assemble and conduct a configuring synthesis of empirical research evidence for the effects of economic instruments to change, or general exposure to changes in, prices or income on diet- and physical activity-related behaviours and corollary health-related outcomes. Evidence from intervention studies of the effects of economic instruments can be regarded as providing direct evidence, whilst evidence from studies that include assessment of the effects of general exposure to changes in prices or income can be regarded as providing supplementary, indirect evidence for the potential effects of economic instruments that are intended to operate via such price or income mechanisms.The methods applied in this systematic scoping review, including provisional study eligibility criteria, were pre-specified and documented in a protocol developed by all members of the review team  . Whilst In parallel, scoping reviews are characterised by evidence synthesis strategies that focus on configuring or mapping evidence for effects ,23, rathFinal eligibility criteria for selecting studies into this scoping review wereEmpirical primary studies and reviews of any design . Reviews were included if at least one of their included primary studies met other eligibility criteria. No restrictions for publication status, year or language were applied in searches.Human participants of any age, with no restrictions for demographic, socio-economic, or clinical characteristics. Animal studies were excluded.Economic instruments (direct evidence) – Price promotions, taxes (including tax exemptions), supply-side subsidies , direct unit pricing legislation, or transfer payments (see Interventions S1 for a definition of each instrument). These interventions alter remunerative incentives by changing prices, except for transfer payments, which alter people’s budget constraints by changing their income. No restrictions were applied for type of comparator. Studies of personal financial incentives – defined as rewards or penalties with a monetary value, provided directly to individuals contingent on performance of specific behaviours or achievement of specific outcomes – were excluded due to our focus on population- rather than individual-level interventions. Exposures (indirect evidence) – Exposure to variation in prices of final consumer products or services and/or individual or household income (i.e. studies of prices or income as correlates or determinants of target outcomes).i. Purchasing of food, non-alcoholic beverages or physical activity-related products or services; ii. other diet- or physical activity-related behaviours ; iii. proximal consequences of such behaviours , such as food, energy or nutrient intake, energy expenditure and physical fitness; and iv. distal consequences of such behaviours , namely modifiable physiological or metabolic risk factors for NCDs, such as body weight, blood cholesterol, blood glucose and blood pressure. Studies that did not report outcomes in at least one of these categories (i-iv) were excluded. For example, studies reporting measures of morbidity or mortality associated with NCDs  were excluded if they did not also report outcomes in at least one eligible category (i-iv). No restrictions were applied for type of measurement instrument or scale.Methods for locating and selecting eligible studies are described in detail elsewhere ,28 and sWe designed systematic search strategies for MEDLINE (Ovid SP), EMBASE (Ovid SP) and PsycINFO (Ovid SP). These search strategies were necessarily highly sensitive, due to the following factors: our intention to progressively refine pre-specified, provisional eligibility criteria; our decision to impose few eligibility restrictions for types of participants, comparators, study designs or publication characteristics; the fact that search terms based on target intervention concepts were unlikely to be specific to titles, abstracts or indexing of eligible study reports; target outcomes encompassed multiple sets of health behaviours, proximal consequences of such behaviours, and the full range of physiological and metabolic risk factors for NCDs. We tested draft search strategies for their sensitivity to retrieve a reference set of 45 records of potentially eligible study reports, assembled using non-systematic internet searches and contacts with topic experts in the author team. We refined search strategies until they retrieved 100% of the reference set records indexed in each database, with a concurrent aim to minimise search yields so far as possible. The process of testing and refining draft search strategies confirmed that we could not achieve greater specificity without sacrificing sensitivity to retrieve eligible reference set records. We then adapted final versions for eight other electronic literature databases, based on close inspection of thesauri, scope notes and search syntax for each database.Final systematic search strategies were executed between 11 July and 11 August 2011 in 11 relevant electronic literature databases from inception to present: MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), EconLit (EBSCO), SPORTDiscus with Full Text (EBSCO), Applied Social Sciences Index and Abstracts (CSA Illumina), Cochrane Database of Systematic Reviews (Wiley Online Library), Database of Abstracts of Reviews of Effects (Wiley Online Library), Health Technology Assessment Database (Wiley Online Library), NHS Economic Evaluation Database (Wiley Online Library), and Database of Promoting Health Effectiveness Reviews (EPPI Centre). Full details of systematic search strategies, search dates and yields are provided as Supporting Information files (Search Strategies S1 and All retrieved study records (title-abstract records) were exported to Endnote X4 reference management software and imported into EPPI Reviewer 4 systematic review software . We nextA preceding stage to application of text mining technologies involved manual screening of a random sample of title-abstract records to estimate a baseline inclusion rate (BIR). The BIR is an a priori estimate of the proportion of retrieved title-abstract records expected to be assessed as provisionally eligible. Our estimated BIR was 0.00348, indicating that ≈0.3%, or ≈3,669 of >1 million, retrieved records could be expected to be assessed as provisionally eligible. This estimate was used as a target to monitor the overall progress of title-abstract screening. Sequential sets of title-abstract records were then prioritised using text mining and assigned for manual screening. One reviewer (IS) undertook all screening assignments prioritised by text mining. Final eligibility criteria were confirmed at the end of the title-abstract screening stage, in consultation with the multi-disciplinary review team and with reference to a purposive sample of provisionally eligible, or borderline eligible, full-text study reports. Provisional eligibility decisions were reviewed against final eligibility criteria.Corresponding full-text reports were sought for all title-abstract records assessed as provisionally eligible via electronic library resources of three universities . Full-text screening and eligibility assessment was performed by one reviewer (IS). Full-text reports located using snowball searches were also assessed against final eligibility criteria by one reviewer (IS). Further duplicates were identified manually and removed at this stage. Multiple reports of the same study were linked into a single study.All included studies were classified by behavioural domain , study type  and population (including a focus on high income country (HIC)  populatiDue to the large number of included studies, the review team decided at this stage to prioritise studies of the effects of economic instruments (i.e. direct evidence for intervention effects) that included a focus on HIC populations or population subgroups for further, more detailed data collection and analysis. Data were collected from the latter set of studies using a pre-specified data extraction form, based in Microsoft Excel, which had been pilot-tested on a random sample of ten included studies. In addition to study characteristics collected from all included studies, we collected further information relating to primary study design , interventions (specific sub-types for each broad type of economic instrument), outcomes (details of specific measures within each broad category i-iv), and relevant principal findings and conclusions, the latter two being transcribed verbatim from full-text study reports. All data collection was undertaken and checked by one reviewer (IS). We did not plan or conduct assessments of risk of bias in included studies .We did not plan or conduct statistical meta-analysis of the results of included studies. Summary statistics (frequencies and percentages) were calculated to inform development of a configuring synthesis of included studies in terms of their key characteristics and findings. This included developing narrative statements to summarise the evidence base for each broad type of intervention, based on the study characteristics data and transcribed principal findings and conclusions collected from the relevant subset of primary studies. It was important to base these summary statements on evidence from primary studies, rather than review articles, to avoid the risk of ‘multiple-counting’ of evidence derived from sets of primary studies that overlapped between included reviews. The cumulative evidence base was analysed and interpreted iteratively as the review proceeded through discussions involving all members of the multi-disciplinary review team .Based on full-text screening, 774 study reports met final eligibility criteria and were selected for inclusion in the review, whilst the remaining 196 were excluded for reasons shown in The final set of 880 eligible studies comprised 192 studies of the effects of economic instruments  and 768 studies (including 86 intervention studies) that included evidence for prices or income as correlates or determinants of target outcomes . In this article, our predominant focus is on summarising evidence from the 181 intervention studies that included a focus on HICs and were prioritised for detailed data collection and analysis (intervention studies – direct evidence). We also briefly describe the body of 610 studies that included evidence for prices or income as correlates or determinants of target outcomes (studies of exposures – indirect evidence) and included a focus on HICs.Table S2 (a Supporting Information file) summarises key characteristics of the 181 studies of the effects of economic instruments that included a focus on HIC populations or population subgroups. Although a substantial body of evidence for the effects of taxes or supply-side subsidies on specific foods, drinks or nutrients (food-related taxes or subsidies) was identified, few studies measured behavioural responses to real interventions using experimental or robust quasi-experimental study designs. This is largely attributable to the fact that relatively few governments or legislatures outside the US have implemented such interventions to date . InsteadStudies of food-related taxes or subsidies collectively assessed a large and diverse set of specific outcomes. For example, the impacts of such taxes have been modelled in terms of ≈800 specific measures across included primary studies, only ≈5% of which were assessed in more than one study. Modelled tax rates were small compared with those typically applied to tobacco or alcohol products and were generally predicted to have small-to-moderate beneficial effects on purchasing, or negligible effects on body weight. Several authors concluded that higher tax or subsidy rates than those considered in their studies might need to be imposed to have a meaningful impact on target outcomes. Although most studies of food-related taxes modelled compensatory purchasing, whereby consumers substitute within or between taxed and untaxed sets of products, the range of substitute or complementary products incorporated into analyses was inevitably limited relative to the vast array of potential alternative food and beverage products available to consumers. For example, Andreyeva and colleagues highlighted that their prediction that estimated tax-induced reductions in SSB purchasing “could translate into losses in average body weight [of] up to 5 lbs/year... is certainly an upper bound given potential substitution to other caloric beverages and foods” and that “reliable estimates of the cross-price elasticities necessary to quantify the extent of possible substitution and the net impact on caloric intake are not available.” . FurtherThe largest subset of studies of transfer payments involved analyses of large, observational datasets to investigate the impacts of US nutrition and federal food assistance programs (63 primary studies and 13 reviews), principally the Supplemental Nutrition Assistance Program (SNAP – formerly known as the Food Stamp Program). SNAP provides financial assistance for food purchasing to people and families on low or no incomes by income transfer via an Electronic Benefit Transfer (debit card) system. Use of SNAP benefits is generally restricted to the purchase of foods or food products for consumption at home, such as breads and cereals, fruits and vegetables, meats, fish and poultry and dairy products . StudiesIn summary, our analysis indicates that the public health case for using economic instruments to promote dietary behaviour change depends largely on evidence from US studies; from studies that vary in the degree to which they support causal inferences; and from studies modelling predicted  behavioural responses, which inevitably rely on simplifications and a variety of more or less credible assumptions. Moreover, there is a general lack of evidence to inform the case for or against the use of economic instruments to promote physical activity see . OverallFurther specific types of eligible interventions were encountered in three studies that included investigation of the effects of cigarette taxes -58  incorporated assessments of distributions of effects by population sub-groups, such assessments were less frequently conducted for other intervention types. In addition, many included studies of economic instruments that are reliant on behaviour change as the pathway for modifying physiological or metabolic risk factors did not assess intermediate behavioural endpoints at all.610 studies conducted in HICs incorporated evidence for price or income levels as correlates or determinants of target outcomes. This body of evidence bears indirectly on the public health case for using economic instruments because such instruments are proposed to operate via price and income mechanisms to influence the target behaviours  over depth  . NeverthSecond, the large absolute number of included studies (N=880) necessitated prioritisation of studies that included a focus on HIC populations for data collection and analysis (N=791), with the subset of intervention studies in HIC populations (N=181) prioritised for further, more detailed data collection and analysis. With limited scope to collect and analyse data from studies of general exposure to changes in prices or income in HIC populations, results derived from these studies should be viewed with caution. Furthermore, we did not generate any results pertaining to the effects of interventions or exposures on diet- or physical activity-related behaviours and corollary outcomes in LMIC populations. We have, however, assembled a large body of studies that comprise this evidence base for LMIC populations, which could, in principle, be synthesised in future systematic reviews.In this scoping review, we did not plan to conduct formal risk-of-bias assessments, nor aggregative synthesis  of the results of included studies. The scope for conducting formal risk-of-bias assessments was, in any case, limited by a lack of established methods for conducting such assessments on quasi-experimental and non-experimental study designs. The lack of formal aggregative synthesis of the results of included studies, which means we do not (and did not set out to) present pooled effect-sizes for economic instruments in terms of target outcomes, reflects differences between the objectives and characteristics of scoping reviews and those of systematic reviews, outlined in the introduction to this article. Clearly, reliable estimates of intervention effect-sizes are an important component of the basis for policy formulation, and meta-analysis of evidence for the effects of economic instruments will therefore form an important component of the design of subsequent systematic reviews that follow the preliminary, configuring synthesis performed in this systematic scoping review.Finally, a further limitation of this scoping review was that a single reviewer completed the large majority of screening at the study selection stage. Whilst initial development of the scoping review protocol and judgements concerning potential revisions to provisional eligibility criteria and application of final eligibility criteria were based on discussions involving the wider review team and collective examination of examples drawn from the emerging body of eligible and borderline eligible studies, this limitation should be acknowledged. The ‘gold standard’ approach involves assessments of study eligibility being undertaken by at least two reviewers working independently, in order to reduce the possibility that eligible study reports will be discarded due to human error .Our findings have exposed a complex, limited and largely equivocal evidence base, suggesting that the public health case for using economic instruments to promote dietary and physical activity behaviour change may be less compelling than some proponents have claimed. This conclusion provides an important counterpoint to what are, in our view, overly optimistic claims made by some authors of individual primary studies and reviews for the use of economic instruments to improve population health behaviour. It implies a need for caution in the development of public health policies intended to alter economic environmental stimuli to incentivise health-enhancing dietary and physical activity behaviour change at population level. In particular, policy implementation needs to be carefully aligned with evaluation planning and design.Bibliographies S1Bibliographic details of included studies, excluded studies, and studies not assessed.(DOCX)Click here for additional data file.Checklist S1PRISMA checklist.(DOCX)Click here for additional data file.Interventions S1Defintions of interventions.(DOCX)Click here for additional data file.Protocol S1Protocol for the systematic scoping review.(DOCX)Click here for additional data file.Search Strategies S1Search strategies used in electronic searches.(DOCX)Click here for additional data file.Table S1Electronic search dates and yields, by database.(DOCX)Click here for additional data file.Table S2Characteristics of included studies.(DOCX)Click here for additional data file.Table S3Brief summaries of evidence by intervention type.(DOCX)Click here for additional data file.


Structural change in both the habitat and reef-associated fish assemblages within spatially managed coral reefs can provide key insights into the benefits and limitations of Marine Protected Areas (MPAs). While MPA zoning effects on particular target species are well reported, we are yet to fully resolve the various affects of spatial management on the structure of coral reef communities over decadal time scales. Here, we document mixed affects of MPA zoning on fish density, biomass and species richness over the 21 years since establishment of the Saba Marine Park (SMP). Although we found significantly greater biomass and species richness of reef-associated fishes within shallow habitats (5 meters depth) closed to fishing, this did not hold for deeper (15 m) habitats, and there was a widespread decline (38% decrease) in live hard coral cover and a 68% loss of carnivorous reef fishes across all zones of the SMP from the 1990s to 2008. Given the importance of live coral for the maintenance and replenishment of reef fishes, and the likely role of chronic disturbance in driving coral decline across the region, we explore how local spatial management can help protect coral reef ecosystems within the context of large-scale environmental pressures and disturbances outside the purview of local MPA management. Marine Protected Areas (MPAs) are often used as a spatial management tool to balance harvesting pressures against the need to conserve biodiversity and maintain key ecosystem processes Effects of spatial management on coral reef ecosystems can often take considerable time to be fully realised. For species targeted by fishing, up to six-fold increases in fish density and biomass have been documented within no-take areas, but in many cases this has taken 10 or more years to occur Understanding the critical role that certain reef fishes play in ecosystem function and how they respond to changing habitat quality can provide key insights into the causes and consequences of long-term change in coral reef communities In this study we examined the structure of a coral reef community following 21 years since the establishment of an isolated Caribbean MPA on Saba Island, Netherland Antilles. Combining published data with new recordings via the same methodology in a meta-analysis, our aims were threefold: (1) examine whether spatial protection has had an overall effect on the coral reef community since inception of the SMP, (2) explore temporal consistency in the affects of zoning (if any) on various components of the SMP coral reef community, and (3) examine the present distribution and abundance of herbivorous and carnivorous fish families and species across zones open and closed to fishing. In our discussion, we explore both the benefits and limitations of MPA-based local management of coral reefs in this region, and highlight the importance of effective monitoring for identifying and acting on coral reef vulnerability.2, with a no-take area of 4.29 km2 (approximately 33% of the SMP) Underwater visual censuses (UVCs) of fish abundance and habitat variables were conducted within the Saba Marine Park (SMP) surrounding Saba island , Netherland Antilles  using nob described by Bonsack and Harper 2) following Higgins and Thompson 2 and large χ2) suggests that mean differences varied more across years than expected by random error alone (i.e. there was significant change in the magnitude and/or direction of the mean difference among zones from survey to survey). Further graphical examination of temporal trends in the density and biomass of “carnivorous” and “herbivorous” fishes (by merging family-level data according to the prior classification of Roberts 10(x+1) transformed to minimize departures from normality and homoscedasticity. Statistical analyses and presentations were made with SPSS , RevMan  and Sigmaplot .UVCs were made with the stationary point-count method  and temporal trends suggesting changes have occurred among survey years , Fig. 3.us 15 m,  and Sparide 5 m, , and theum 15 m,  and H. fum 15 m, . By contlineatum , carnivois fulva  and piscmahogoni .Despite effective spatial protection of the Saba Marine Park (SMP) by local managers for 21 years, we found no significant difference in overall fish density between open (fished) and closed (no-take) zones. While we did find marginally higher biomass of certain fish species in zones closed to fishing, this was generally restricted to shallow habitats and was tempered by an apparent decline in live hard coral cover between 1991–1995 and 2008. Notably, we found historically low carnivorous fish density across all zones in 2008, which was offset by marginal increases in their biomass, and slight increases in the density and biomass of herbivorous fishes. Such shifts in the habitat composition and trophic structure of the coral reef communities around Saba are cause for concern, as even subtle changes in community composition may have significant ecological consequences, and may indicate altered ecosystem resistance and resilience Evaluating whether spatial management of coral reefs is effective in meeting the intended goals of an MPA must be done in the context of time since establishment and zoning compliance. Overfishing has been a key explanation for regional declines in carnivorous fishes on Caribbean coral reefs with and without MPAs Shifts in the availability of live coral habitat could be a major driver of change in the reef-associated fish communities of Saba. Historical losses of live hard coral cover, such as the 38% decrease from 1995 to 2008 recorded for Saba, have been documented for coral reefs throughout the world and have often been attributed to factors such as thermal bleaching, hurricanes, pests and disease e.g. . Saba anSparisoma viride, which plays a pivotal role in the bioerosion and sculpturing of reefs to facilitate the removal of dead coral skeleton and prime the reef for new coral recruits Sparisoma viride, to bolster reef resistance to regime shifts in the face of large-scale disturbances.Losses in live coral alongside changes in fish community structure can have serious consequences for the health of coral reefs and their capacity to resist and rebound from disturbance events. Around Saba, we found 68% less carnivorous fish across all sites and zones of the SMP in 2008 relative to the 1990s, offset by only marginal increases in their biomass, and slight increases in herbivorous fish across the same period. There was no clear evidence that zoning has played a role in these trophic-level trends, as we found that all families tended to display greater biomass in closed zones across all survey years, with relatively light variability across survey years. The notable exceptions, however, was that in 2008 a substantially greater biomass of herbivorous scarids were recorded in closed zones, while there was markedly lower biomass of carnivorous haemulids. Such dynamic shifts in community trophic structure can produce wider ecosystem effects through trophic cascades, such as the urchin overgrazing of the benthos on reefs bereft of predatory fishes e.g. , which eLong-term change within the coral reef communities of Saba and other parts of the Caribbean highlight the effective scope and limitations of local-scale spatial management, and point to the need for targeted strategies that bolster coral reefs against large-scale threats


Physical inactivity has major impacts on health and productivity. Our aim was to estimate the health and economic benefits of reducing the prevalence of physical inactivity in the 2008 Australian adult population. The economic benefits were estimated as 'opportunity cost savings', which represent resources utilized in the treatment of preventable disease that are potentially available for re-direction to another purpose from fewer incident cases of disease occurring in communities.Simulation models were developed to show the effect of a 10% feasible, reduction target for physical inactivity from current Australian levels (70%). Lifetime cohort health benefits were estimated as fewer incident cases of inactivity-related diseases; deaths; and Disability Adjusted Life Years (DALYs) by age and sex. Opportunity costs were estimated as health sector cost impacts, as well as paid and unpaid production gains and leisure impacts from fewer disease events associated with reduced physical inactivity. Workforce production gains were estimated by comparing surveyed participation and absenteeism rates of physically active and inactive adults, and valued using the friction cost approach. The impact of an improvement in health status on unpaid household production and leisure time were modeled from time use survey data, as applied to the exposed and non-exposed population subgroups and valued by suitable proxy. Potential costs associated with interventions to increase physical activity were not included. Multivariable uncertainty analyses and univariate sensitivity analyses were undertaken to provide information on the strength of the conclusions.A 10% reduction in physical inactivity would result in 6,000 fewer incident cases of disease, 2,000 fewer deaths, 25,000 fewer DALYs and provide gains in working days , days of home-based production  while conferring a AUD96 million reduction in health sector costs. Lifetime potential opportunity cost savings in workforce production (AUD12 million), home-based production (AUD71 million) and leisure-based production (AUD79 million) was estimated .Opportunity cost savings and health benefits conservatively estimated from a reduction in population-level physical inactivity may be substantial. The largest savings will benefit individuals in the form of unpaid production and leisure gains, followed by the health sector, business and government. Physical activity, which is increasingly being engineered out of our working and social lives, is important to maintaining health. Physical activity enhances muscle strength, aerobic capacity and psychological well-being, while moderating health risk factors such as obesity, high cholesterol and hypertension . PhysicaA sedentary lifestyle has been associated with a greater risk of all-cause mortality . InactivFew authors have quantified the economic costs of physical inactivity and the value of increasing participation in physical activity to levels that produce health benefits. In studies from Canada, Switzerland, the United Kingdom (UK) and United States (US), annual direct healthcare costs attributable to physical inactivity ranged from 1.5% to 3% of total direct health costs . RegularThe aim of this study was to quantify the health and economic benefits that could be achieved following a feasible reduction (as opposed to a complete elimination) of physical inactivity in the Australian adult population. This study was part of a larger study funded by the Victorian health promotion foundation  whereby the benefits of feasible reductions in the prevalence of alcohol, physical inactivity, high body mass index, tobacco smoking, inadequate consumption of fruit and vegetables, and intimate partner violence were estimated .To estimate the health and economic benefits to society, the impact of an absolute reduction in the prevalence of physical inactivity levels for the 2008 Australian population was measured as reduced incident cases of preventable physical inactivity-related diseases, deaths and disability adjusted life years (DALYs). Relevant diseases affected included cardiovascular disease, cancers, fractures and depression.The initial step was to agree on a feasible target reduction in the prevalence of physical inactivity. The feasible reduction targets selected for physical inactivity in Australia were based on expert consensus via discussions with the study-specific Advisory Committee and consultation with health promotion experts coupled with a review of the broader intervention-based literature. The evidence from the literature indicated that health benefits should accrue when the prevalence of physical inactivity is reduced by 5% to 10%. In the systematic review of Kahn et al. , there wThe comparator groups analyzed were the exposed Australian population of inactive people (defined as sedentary or low activity category that did not meet recommended activity levels), and the non-exposed active population (defined as moderate to high activity that met or exceeded recommended activity levels).The net difference in mortality, incident morbidity and consequent health sector costs and the impact on paid and unpaid production and leisure between the current prevalence of physical inactivity and the two target prevalence levels for the 2008 Australian adult population was then estimated with population-based simulation models developed in Excel . Cost data from other years were adjusted to 2008 by applying health price inflators . A 3% diThe Workforce Production Gains model developed by Magnus et al  was adapThe Household Production and Leisure Time model was developed to estimate the net difference in the economic value of hours of lost leisure and household production associated with diseases attributable to physical inactivity. The model incorporated surveyed time allocations of both working and non-working adults by gender and age. Household production was defined as the hours spent performing non-paid household duties such as cooking, shopping, cleaning, child care and maintenance. These were valued at 'replacement cost', whereby the duties unable to be performed due to illness were purchased commercially. Unit prices for household production were based on the average 2008 wage rates for domestic services and child care. Leisure time comprised social and community interaction, together with recreation and leisure activities only. Leisure time was valued using the 'opportunity cost method', applying one third of the average 2008 weekly earnings for men and women . The NatTo estimate changes in health sector costs, the attributable portion of total health sector costs to diseases associated with physical inactivity were estimated using Population Attributable Fractions (PAF) . A PAF iThe most up-to-date Australian data sources were used. The current estimates for the prevalence of physical inactivity overall 70%) by age and gender were obtained from the 2004/5 NHS 0% by age. RespondDemographic data, employment status, and health-related actions of physically inactive and active adults were also obtained from the 2004/5 NHS dataset Table . PAFs, hMultivariable probabilistic uncertainty analyses were undertaken using @RISK software version 4.5 for Excel . Input variables were modeled as known distributions rather than single values where uncertainty existed (e.g. each surveyed parameter and life-years remaining). Uncertainty in wages, participation rates and absenteeism were captured in the reported survey standard errors ,38,39. Mhttp://www.vichealth.vic.gov.au/~/media/ResourceCentre/PublicationsandResources/Knowledge/Research%20Report_FINAL_July09.ashx and are also reported in the publication on tobacco smoking and the combined analysis of the six risk factors [Comprehensive details on our methods are provided in the full technical report  availabl factors ,41.Table If the prevalence of physical inactivity in the adult Australian population was reduced by 10%, the estimated 45,000 annual new cases of physical inactivity-related disease could be reduced by 6,000 (13%); the 13,000 annual deaths attributed to physical inactivity could be reduced by 2,000 deaths (15%); and the 174,000 DALYs lost from physical activity could be reduced by about 25,000 (14%) , AUD12 million in workforce production (FCA), AUD71 million in home based production and AUD79 million in leisure based production Table . This reThe primary finding of this study is that a feasible reduction in prevalence of physical inactivity can lead to total potential opportunity cost savings of AUD258 million, with 37% of the savings arising in the health sector. The largest savings would benefit individuals, followed by the health sector, business and government. These savings would be much larger if all physical inactivity was eliminated , but our aim was to estimate savings that were realistic and relevant to the setting of future public health campaigns and disease prevention strategies.A novel and important aspect of the present study was the inclusion of benefits for workforce, household production and leisure time associated with reduced physical inactivity. The choice of appropriate methods for quantifying and valuing household production and leisure time continue to be debated . Neverthannual health sector cost attributable to incident cases of physical inactivity at AUD672 million . While the results are not directly comparable given fundamental methodological differences, both studies provide a valuable contribution to the literature regarding the potential economic benefits of reducing physical inactivity in Australia.It is difficult to compare these estimates of potential savings with earlier literature. The only previous Australian study to identify health sector costs associated with physical inactivity estimated them at AUD377 million . The larincident cases of disease attributable to physical inactivity for the 2008 population would be reduced. Thus, future reductions in disease risk among those already ill (e.g. benefits gained from reducing inactivity in people with existing cardiovascular disease) were not incorporated in these analyses. Furthermore, the impact on health sector costs for reduced mortality is not easily modeled, since death-related costs occur during a lifetime, rather than at the point of death. The more conservative FCA estimates of workforce production gains over the HCA were preferred by the investigators of this present study, and represented less than 10% of the HCA estimates.Other strengths of this work were the conservative approach taken and the use of best available data. It was assumed that only The reliance on self-reported cross-sectional data is a limitation, since such data are less reliable than objective measurement data, because people can exaggerate, fail to remember, or misunderstand questions. The direction of reporting bias is not always clear. In addition, other concurrent risk factors and socioeconomic status, not controlled for in this analysis, could be a source of overestimation. It is also possible that people increase their level of activity following the onset of an illness . Assuming causality in the absence of rigorous longitudinal data means that the results must be regarded as broadly indicative of what might be achieved. A further limitation is that forecasted gains will occur over time. A quantitative assessment of when opportunity cost savings and health status benefits would be achieved was not undertaken. This approach is rare because of the subsequent additional levels of uncertainty, making estimates less reliable. However, there is some evidence that the time lag between increased physical activity and observed benefits is relatively short. Blair demonstrated that increasing activity reduced all cause mortality within two years, which was half the time required to observe benefits from smoking cessation .The selection of targets for risk factor prevalence reduction is an important policy decision. It is possible that a 10% reduction in physical inactivity prevalence is an overly ambitious goal in the current Australian climate of increasing levels of obesity, with modern technology eliminating the need for many physical pursuits. However, this bold target could be justified as feasible given the high prevalence of inactivity.Lastly, opportunity cost savings need to be carefully interpreted. These savings will only be achieved by the adoption of effective interventions that will invariably have implementation and time costs attached to them. Including intervention costs and effects was beyond the scope of this study and it was assumed that acceptable effective interventions exist to achieve the target reductions in physical inactivity. Opportunity cost savings are not estimates of immediately realizable financial savings; they are estimates of resources consumed in current practice that could be made available for other purposes, such as investing in public health programs. Future, well-designed epidemiological and clinical research studies are needed to provide better evidence to underpin decision analytic modeling for health promotion, and for prioritizing specific interventions to achieve reductions in inactivity.Investment in disease prevention and health promotion in Australia is dwarfed by avoidable spending on disease treatment. The findings of this project contribute important new knowledge about the major impact of physical inactivity on the productivity of individuals in both the paid and unpaid sectors, as well as health sector expenditure. The findings from this study reinforce the argument that greater investment in risk factor reduction strategies is required and economically justified, particularly in ageing populations.The authors declare that they have no competing interests.AM, DC and RC conceptualized the project. AM, DC, TC and LS conducted literature reviews. AM and DC developed the economic models. DP performed the data analyses. DC and TC wrote the initial draft of the paper. All authors reviewed and contributed to drafts of the paper. All authors have read and approved the final manuscript.DC: Head Translational Public Health Unit, Stroke and Ageing Research Centre, Monash University, Victoria. Head: Public Health. National Stroke Research Institute, Heidelberg Heights, Victoria, Australia. Honorary Research Fellow: Department of Medicine, The University of Melbourne, Australia and Deakin Health Economics, Strategic Research Centre Population Health, Faculty of Health, Deakin University, Burwood Deakin University and The University of Melbourne, Parkville, 3010.TC: Post-doctoral Research Fellow. National Stroke Research Institute, Heidelberg 3084, Victoria, AustraliaLS: Research Fellow. Deakin Health Economics, Strategic Research Centre Population Health, Faculty of Health, Deakin University, Burwood, 3125, Victoria, AustraliaDP: Research Fellow, Melbourne School of Population Health, The University of Melbourne, 3010, Parkville, Victoria, Australia.RC: Founding Chair, Deakin Health Economics, Strategic Research Centre Population Health, Faculty of Health, Deakin University, Burwood, 3125, Victoria, AustraliaAM: Senior Research Fellow, Deakin Health Economics, Strategic Research Centre Population Health, Faculty of Health, Deakin University, Burwood, 3125, Victoria, Australia


Diet is thought to play an important role in cancer risk. This paper summarizes dietary recommendations for cancer prevention and compares these recommendations to the dietary behaviors of U.S. youth ages 8-18.We identified cancer prevention-related dietary recommendations from key health organizations and assessed dietary consumption patterns among youth using published statistics from the National Health and Nutrition Examination Survey, the national Youth Risk Behavior Survey, and other supplemental sources.Cancer prevention guidelines recommend a diet rich in fruits, vegetables, and whole grains, recommend limiting sugary foods and beverages, red and processed meats, sodium, and alcohol, and recommend avoiding foods contaminated with carcinogens. However, youth typically do not meet the daily recommendations for fruit, vegetable, or whole grain consumption and are over-consuming energy-dense, sugary and salty foods.A large discrepancy exists between expert recommendations about diet and cancer and actual dietary practices among young people and points to the need for more research to better promote the translation of science into practice. Future research should focus on developing and evaluating policies and interventions at the community, state and national levels for aligning the diets of youth with the evolving scientific evidence regarding cancer prevention. The consensus among scientists in the field of cancer control is that diet plays an important but not fully understood role in modifying cancer risk and that certain changes in the American diet could have a beneficial impact on cancer occurrence -6. HowevWe used a targeted approach to identify the most recent cancer prevention-related dietary recommendations of key organizations, including the American Academy of Pediatrics (AAP), American Cancer Society (ACS), American Heart Association (AHA), American Institute for Cancer Research (AICR), International Agency for Research on Cancer (IARC), U.S. Department of Health and Human Services (HHS), U.S. Department of Agriculture (USDA), World Cancer Research Fund International (WCRF), and World Health Organization (WHO). We used National Institutes of Health (NIH) PubMed and the National Guideline Clearinghouse to search for additional information on dietary recommendations published from 2000 to present.Fourth National Report on Human Exposure to Environmental Chemicals, a CDC publication which uses blood and urine samples collected as part of NHANES to assess exposure of the U.S. population to chemicals in the environment  provide fruit and vegetable recommendations based on caloric requirements  among children ages 6-11 years and 12 - 19 years were 7.08 (5.66-8.84) and 8.55 (7.34-9.97) respectively [AICR recommends avoiding the use of any source of water that may be contaminated with arsenic Table . Arsenicectively .Dietary guidelines for cancer prevention are similar across prominent public health organizations. In spite of a general scientific consensus on the importance of a healthy diet for cancer prevention, the actual diets of a large proportion of America's youth are not aligned with these dietary recommendations. Pre-adolescents and adolescents tend to fall short of recommendations for fruit, vegetable, and whole grain consumption. Furthermore, an unhealthy proportion of their diet is composed of energy-dense foods that are high in fat (such as red and processed meats), refined sugar (such as refined grains and SSBs), and/or salt.Improving dietary behaviors poses many challenges. Among youth, dietary behaviors are influenced by numerous factors at multiple levels: individual, interpersonal, community, and society levels . IdentifWhen assessing the dietary behaviors among youth related to cancer prevention, we face several limitations. First, dietary intake data from both NHANES and YRBS rely heavily on self-reported information, which can be subject to bias and error. NHANES dietary intake data are collected via multiple 24-hour dietary recalls which may be less prone to error than other dietary recall methods . NHANES Cancer etiology and cancer risk assessment are dynamic fields of scientific investigation, and our understanding about the role of diet in cancer occurrence is continually evolving. As a result, the dietary recommendations for cancer prevention examined in this review may change over time. For example, although the consumption of fruits and vegetables has long been associated with lower risks for certain types of cancers, recent research suggests that the consumption of fruits and vegetables may not be as protective against cancer as had been previously assumed ,63. The This review illustrates discrepancies between expert recommendations about diet and cancer and actual dietary practices among youth and points to the need for more research to better promote the translation of science into practice. Data from the 2003 Health Information National Trends Survey (HINTS) suggests that at least half of the general population in the U.S. is aware that a healthy diet may reduce one's cancer risk . AlthougThe authors declare that they have no competing interests.DH participated in the conception and design of the paper, carried out the initial literature review, and contributed to drafting and critically revising the manuscript. MW participated in the conception and design of the paper and contributed to drafting and critically revising the manuscript. Both authors have read and approved the final manuscript.