Integrated survey methodologies provide process-driven framework for marine renewable energy environmental impact assessment.

Environmental interactions of marine renewable energy developments vary from fine-scale direct (e.g. potential collision) to indirect wide-scale hydrodynamic changes altering oceanographic features. Current UK Environmental Impact Assessment (EIA) and associated Habitats Regulations Appraisal (HRA) guidelines have limited focus on underlying processes affecting distribution and movements (hence vulnerability) of top predators. This study integrates multi-trophic ship survey (active acoustics and observer data) with an upward-facing seabed platform and 3-dimensional hydrodynamic model as a process-driven framework to investigate predator-prey linkages between seabirds and fish schools. Observer-only data highlighted the need to measure physical drivers of variance in species abundances and distributions. Active acoustics indicated that in situ (preferable to modelled) data were needed to identify temporal changes in hydrodynamics to predict prey and consequently top predator presence. Revising methods to identify key habitats and environmental covariates within current regulatory frameworks will enable more robust and transferable EIA and HRA processes and outputs, and at larger scales for cumulative and strategic-level assessments, enabling future modelling of ecosystem impacts from both climate change and renewable energy extraction.

A proactive financial navigation intervention in patients with newly diagnosed gastric and gastroesophageal junction adenocarcinoma.

PURPOSE: Many cancer patients and caregivers experience financial hardship, leading to poor outcomes. Gastric and gastroesophageal junction (GEJ) cancer patients are particularly at risk for financial hardship given the intensity of treatment. This pilot randomized study among gastric/GEJ cancer patients and caregivers tested a proactive financial navigation (FN) intervention to obtain a signal of efficacy to inform a larger, more rigorous randomized study. METHODS: We tested a 3-month proactive FN intervention among gastric/GEJ cancer patients and caregivers compared to usual care. Caregiver participation was optional. The primary endpoint was incidence of financial hardship, defined as follows: accrual of debt, income decline of ≥ 20%, or taking loans to pay for treatment. Data from participant surveys and documentation by partner organizations delivering the FN intervention was analyzed and outcomes were compared between study arms. RESULTS: Nineteen patients and 12 caregivers consented. Primary FN resources provided included insurance navigation, budget planning, and help with out-of-pocket medical expenses. Usual care patients were more likely to experience financial hardship (50% vs 40%) and declines in quality of life (37.5% vs 0%) compared to intervention patients. Caregivers in both arms reported increased financial stress and poorer quality of life over the study period. CONCLUSIONS: Proactive financial navigation has potentially positive impacts on financial hardship and quality of life for cancer patients and more large-scale randomized interventions should be conducted to rigorously explore the impact of similar interventions. Interventions that have the potential to lessen caregiver financial stress and burden need further exploration. TRIAL REGISTRATION: TRN: NCT03986502, June 14, 2019.

Quantification of circulating HBV RNA expressed from intrahepatic cccDNA in untreated and NUC treated patients with chronic hepatitis B.

OBJECTIVE: A convenient, reproducible biomarker of hepatitis B virus (HBV) covalently closed circular DNA (cccDNA) transcriptional activity is lacking. We measured circulating HBV RNA (cirB-RNA) in untreated and nucleos(t)ide analogues (NUC) treated chronic hepatitis B (CHB) patients to define its correlation with intrahepatic viral markers and HBV core-related antigen (HBcrAg). DESIGN: Paired liver biopsy and serum samples were collected from 122 untreated and 30 NUC-treated CHB patients. We measured cirB-RNA, HBV DNA, hepatitis B surface antigen (HBsAg), HBcrAg and alanine aminotransferase levels. cirB-RNA was quantified using an investigational HBV RNA assay for use on the cobas 6800 system. The test detects a region spanning the HBV canonical polyadenylation site. cccDNA and 3.5 kb RNA in liver tissue were assessed by quantitative PCR and droplet digital PCR. RESULTS: cirB-RNA was detectable in 100% of HBeAg(+) chronic hepatitis (CH), 57% and 14% of HBeAg(-) CH and chronic infection untreated patients and 47% of NUC-treated patients. cirB-RNA undetectability was associated with lower intrahepatic cccDNA transcriptional activity, as well as serum HBcrAg, but no significant differences in HBsAg, in both untreated and treated patients. In untreated HBeAg(-) patients, cirB-RNA correlated with intrahepatic 3.5 kb RNA and cccDNA transcriptional activity, serum HBV DNA and HBcrAg, but not with HBsAg or total cccDNA levels. Combined undetectability of both cirB-RNA and HBcrAg detection in untreated HBeAg(-) patients identified a subgroup with the lowest levels of intrahepatic transcriptionally active cccDNA. CONCLUSION: Our results support the usefulness of quantification of circulating HBV RNA expressed from cccDNA as an indicator of intrahepatic active viral reservoir in both untreated and NUC-treated CHB patients. TRIAL REGISTRATION NUMBER: NCT02602847.

Pupil dilation evaluation of two mydriatic dosing profiles delivered by the Optejet®.

Aim: To compare pupil dilation achieved by a single microdose versus two microdoses of tropicamide-phenylephrine fixed combination (TR-PH FC) delivered by the Optejet®. Patients & methods: In this assessor-masked, crossover, noninferiority study, 60 volunteers underwent two treatment visits and received either one (∼8 µl) or two sprays (∼16 µl) of TR-PH FC to both eyes in randomly assigned order. Results: At 35 min postdose, mean change in pupil diameter was 4.6 mm and 4.9 mm following one or two sprays, respectively. The estimated treatment group difference was -0.249 mm (standard error: 0.036; 95% CI: -0.320, -0.177). No adverse events were reported. Conclusion: A single microdose was noninferior to two microdoses of TR-PH FC and achieved clinically significant mydriasis in a timely manner. Clinical Trial Registration: NCT04907474 (ClinicalTrials.gov).

Pupil dilation efficacy and efficiency were evaluated using microdosing via the Optejet^®. The Optejet^® is a new ophthalmologic drug device that utilizes piezoelectric technology to deliver a fine, controlled, horizontal microdroplet spray with precise volume (∼8 µl), spray pattern and velocity. A single spray versus two sprays of tropicamide-phenylephrine fixed combination (TR-PH FC) were administered to both eyes anesthetic free. Efficacy and safety were evaluated at specific time intervals. The primary end point was the mean change in pupil diameter at 35 min compared with baseline. At 35 min, clinically relevant dilation was observed, with a mean change of 4.55 mm ± 0.68 for one spray and 4.88 ± 0.60 for two sprays. The treatment group difference of one spray of TR-PH FC was noninferior to two sprays (p < 0.001). Rapid dilation was observed at 15 min, and the proportions of eyes that achieved a pupil diameter of ≥6.0 mm were 74% and 83% of patients at 15 min with one spray and two sprays, respectively. The mydriatic agent was well tolerated with the delivery system even in the absence of topical anesthetic, with no ocular or system adverse events reported. Mydriasis is a vital component of routine eye healthcare, and the current standard-of-care mydriatic eye drops potentially have limitations, including contamination, spillage and burning/stinging. Delivery of a mydriatic with the Optejet^® may improve patient care flow in the clinical office setting.

Performance of the cobas® HBV RNA automated investigational assay for the detection and quantification of circulating HBV RNA in chronic HBV patients.

BACKGROUND: The amount of HBV RNA in peripheral blood may reflect HBV covalently closed circular DNA (cccDNA) transcriptional activity within infected hepatocytes. Quantification of circulating HBV RNA (cirB-RNA) is thus a promising biomarker for monitoring antiviral treatment. OBJECTIVES: We evaluated the performance of an automated, prototype quantitative HBV RNA assay for use on the Roche cobas® 6800/8800 systems. STUDY DESIGN: The sensitivity, specificity, linearity, and potential interference by HBV DNA of the cobas® HBV RNA assay were assessed using synthetic HBV armored RNA and clinical specimens. RESULTS: cobas® HBV RNA results were linear between 10 and 107 copies/mL in clinical samples of several HBV genotypes, and up to 109 copies/mL with synthetic RNA. Precision and reproducibility were excellent, with standard deviation below 0.15 log10 copies/mL and coefficients of variation below 5% throughout the linear range. The presence of HBV DNA had minimal (<0.3 log10 copies/mL) impact on HBV RNA quantification at DNA:RNA ratios of up to approximately one million. In a panel of 36 untreated patient samples, cirB-RNA concentrations were approximately 200-fold lower than HBV DNA. cirB-RNA was detected in all 13 HBeAg-positive patients (mean 6.0 log10 copies/mL), and in 20 of 23 HBeAg-negative patients (mean of quantifiable samples 2.2 log10 copies/mL). Finally, cirB-RNA was detected in 12 of 20 nucleoside analog-treated patients (mean of quantifiable samples 3.4 log10 copies/mL). CONCLUSIONS: The cobas® 6800/8800 investigational HBV RNA assay is a high throughput, sensitive and inclusive assay to evaluate the clinical relevance of cirB-RNA quantification in patients with chronic hepatitis B.

Insertional activation of STAT3 and LCK by HIV-1 proviruses in T cell lymphomas.

Retroviruses cause cancers in animals by integrating in or near oncogenes. Although HIV-1 infection increases the risk of cancer, most of the risk is associated with immunodeficiency and coinfection by oncogenic virus (Epstein-Barr virus, Kaposi sarcoma herpesvirus, and human papillomavirus). HIV-1 proviruses integrated in some oncogenes cause clonal expansion of infected T cells in vivo; however, the infected cells are not transformed, and it is generally believed that HIV-1 does not cause cancer directly. We show that HIV-1 proviruses integrated in the first introns of signal transducer and activator of transcription 3 (STAT3) and lymphocyte-specific protein tyrosine kinase (LCK) can play an important role in the development of T cell lymphomas. The development of these cancers appears to be a multistep process involving additional nonviral mutations, which could help explain why T cell lymphomas are rare in persons with HIV-1 infection.

Fishing within offshore wind farms in the North Sea: Stakeholder perspectives for multi-use from Scotland and Germany.

Offshore wind power generation requires large areas of sea to accommodate its activities, with increasing claims for exclusive access. As a result, pressure is placed on other established maritime uses, such as commercial fisheries. The latter sector has often been taking a back seat in the thrust to move energy production offshore, thus leading to disagreements and conflicts among the different stakeholder groups. In recognition of the latter, there has been a growing international interest in exploring the combination of multiple maritime activities in the same area (multi-use; MU), including the re-instatement of fishing activities within, or in close proximity to, offshore wind farms (OWFs). We summarise local stakeholder perspectives from two sub-national case studies (East coast of Scotland and Germany's North Sea EEZ) to scope the feasibility of combining multiple uses of the sea, such as offshore wind farms and commercial fisheries. We combined a desk-based review with 15 semi-structured qualitative interviews with key knowledge holders from both industries, regulators, and academia to aggregate key results. Drivers, barriers and resulting effects (positive and negative) for potential multi-use of fisheries and OWFs are listed and ranked (57 factors in total). Factors are of economic, social, policy, legal, and technical nature. To date, in both case study areas, the offshore wind industry has shown little interest in multi-use solutions, unless clear added value is demonstrated and no risks to their operations are involved. In contrast, the commercial fishing sector is proactive towards multi-use projects and acts as a driving force for MU developments. We provide a range of management recommendations, based on stakeholder input, to support progress towards robust decision making in relation to multi-use solutions, including required policy and regulatory framework improvements, good practice guidance, empirical studies, capacity building of stakeholders and improvements of the consultation process. Our findings represent a comprehensive depiction of the current state and key stakeholder aspirations for multi-use solutions combining fisheries and OWFs. We believe that the pathways towards robust decision making in relation to multi-use solutions suggested here are transferable to other international locations.

A review of the UK and British Channel Islands practical tidal stream energy resource.

This review provides a critical, multi-faceted assessment of the practical contribution tidal stream energy can make to the UK and British Channel Islands future energy mix. Evidence is presented that broadly supports the latest national-scale practical resource estimate, of 34 TWh/year, equivalent to 11% of the UK's current annual electricity demand. The size of the practical resource depends in part on the economic competitiveness of projects. In the UK, 124 MW of prospective tidal stream capacity is currently eligible to bid for subsidy support (MeyGen 1C, 80 MW; PTEC, 30 MW; and Morlais, 14 MW). It is estimated that the installation of this 124 MW would serve to drive down the levelized cost of energy (LCoE), through learning, from its current level of around 240 £ / MWh to below 150 £ / MWh , based on a mid-range technology learning rate of 17%. Doing so would make tidal stream cost competitive with technologies such as combined cycle gas turbines, biomass and anaerobic digestion. Installing this 124 MW by 2031 would put tidal stream on a trajectory to install the estimated 11.5 GW needed to generate 34 TWh/year by 2050. The cyclic, predictable nature of tidal stream power shows potential to provide additional, whole-system cost benefits. These include reductions in balancing expenditure that are not considered in conventional LCoE estimates. The practical resource is also dependent on environmental constraints. To date, no collisions between animals and turbines have been detected, and only small changes in habitat have been measured. The impacts of large arrays on stratification and predator-prey interaction are projected to be an order of magnitude less than those from climate change, highlighting opportunities for risk retirement. Ongoing field measurements will be important as arrays scale up, given the uncertainty in some environmental and ecological impact models. Based on the findings presented in this review, we recommend that an updated national-scale practical resource study is undertaken that implements high-fidelity, site-specific modelling, with improved model validation from the wide range of field measurements that are now available from the major sites. Quantifying the sensitivity of the practical resource to constraints will be important to establish opportunities for constraint retirement. Quantification of whole-system benefits is necessary to fully understand the value of tidal stream in the energy system.

Ecological costs of climate change on marine predator-prey population distributions by 2050.

Identifying and quantifying the effects of climate change that alter the habitat overlap of marine predators and their prey population distributions is of great importance for the sustainable management of populations. This study uses Bayesian joint models with integrated nested Laplace approximation (INLA) to predict future spatial density distributions in the form of common spatial trends of predator-prey overlap in 2050 under the "business-as-usual, worst-case" climate change scenario. This was done for combinations of six mobile marine predator species (gray seal, harbor seal, harbor porpoise, common guillemot, black-legged kittiwake, and northern gannet) and two of their common prey species (herring and sandeels). A range of five explanatory variables that cover both physical and biological aspects of critical marine habitat were used as follows: bottom temperature, stratification, depth-averaged speed, net primary production, and maximum subsurface chlorophyll. Four different methods were explored to quantify relative ecological cost/benefits of climate change to the common spatial trends of predator-prey density distributions. All but one future joint model showed significant decreases in overall spatial percentage change. The most dramatic loss in predator-prey population overlap was shown by harbor seals with large declines in the common spatial trend for both prey species. On the positive side, both gannets and guillemots are projected to have localized regions with increased overlap with sandeels. Most joint predator-prey models showed large changes in centroid location, however the direction of change in centroids was not simply northwards, but mostly ranged from northwest to northeast. This approach can be very useful in informing the design of spatial management policies under climate change by using the potential differences in ecological costs to weigh up the trade-offs in decisions involving issues of large-scale spatial use of our oceans, such as marine protected areas, commercial fishing, and large-scale marine renewable developments.

Taking movement data to new depths: Inferring prey availability and patch profitability from seabird foraging behavior.

Detailed information acquired using tracking technology has the potential to provide accurate pictures of the types of movements and behaviors performed by animals. To date, such data have not been widely exploited to provide inferred information about the foraging habitat. We collected data using multiple sensors (GPS, time depth recorders, and accelerometers) from two species of diving seabirds, razorbills (Alca torda, N = 5, from Fair Isle, UK) and common guillemots (Uria aalge, N = 2 from Fair Isle and N = 2 from Colonsay, UK). We used a clustering algorithm to identify pursuit and catching events and the time spent pursuing and catching underwater, which we then used as indicators for inferring prey encounters throughout the water column and responses to changes in prey availability of the areas visited at two levels: individual dives and groups of dives. For each individual dive (N = 661 for guillemots, 6214 for razorbills), we modeled the number of pursuit and catching events, in relation to dive depth, duration, and type of dive performed (benthic vs. pelagic). For groups of dives (N = 58 for guillemots, 156 for razorbills), we modeled the total time spent pursuing and catching in relation to time spent underwater. Razorbills performed only pelagic dives, most likely exploiting prey available at shallow depths as indicated by the vertical distribution of pursuit and catching events. In contrast, guillemots were more flexible in their behavior, switching between benthic and pelagic dives. Capture attempt rates indicated that they were exploiting deep prey aggregations. The study highlights how novel analysis of movement data can give new insights into how animals exploit food patches, offering a unique opportunity to comprehend the behavioral ecology behind different movement patterns and understand how animals might respond to changes in prey distributions.

Bayesian joint models with INLA exploring marine mobile predator-prey and competitor species habitat overlap.

Understanding spatial physical habitat selection driven by competition and/or predator-prey interactions of mobile marine species is a fundamental goal of spatial ecology. However, spatial counts or density data for highly mobile animals often (1) include excess zeros, (2) have spatial correlation, and (3) have highly nonlinear relationships with physical habitat variables, which results in the need for complex joint spatial models. In this paper, we test the use of Bayesian hierarchical hurdle and zero-inflated joint models with integrated nested Laplace approximation (INLA), to fit complex joint models to spatial patterns of eight mobile marine species (grey seal, harbor seal, harbor porpoise, common guillemot, black-legged kittiwake, northern gannet, herring, and sandeels). For each joint model, we specified nonlinear smoothed effect of physical habitat covariates and selected either competing species or predator-prey interactions. Out of a range of six ecologically important physical and biologic variables that are predicted to change with climate change and large-scale energy extraction, we identified the most important habitat variables for each species and present the relationships between these bio/physical variables and species distributions. In particular, we found that net primary production played a significant role in determining habitat preferences of all the selected mobile marine species. We have shown that the INLA method is well-suited for modeling spatially correlated data with excessive zeros and is an efficient approach to fit complex joint spatial models with nonlinear effects of covariates. Our approach has demonstrated its ability to define joint habitat selection for both competing and prey-predator species that can be relevant to numerous issues in the management and conservation of mobile marine species.

A never-before opportunity to strengthen investment and action on adolescent contraception, and what we must do to make full use of it.

BACKGROUND: Increasingly, the health and rights of adolescents are being recognized and prioritized on the global agenda. This presents us with a "never-before" opportunity to address adolescent contraception. This is timely, as there are enormous numbers of adolescents who are currently unable to obtain and use contraceptives. From research evidence and programmatic experience, it is clear that we need to do things differently to meet their needs/fulfil their rights. MAIN BODY: In this commentary, we call for action in several key areas to address adolescents' persistent inability to obtain and use contraceptives. We must move away from one-size-fits-all approaches, from a 'condoms-only' mind set, from separate services for adolescents, from ignoring the appeal of pharmacies and shops, and from one-off-training to make health workers adolescent friendly. Our efforts to expand access to quality contraceptive services to adolescents must be combined with efforts to build their desire and ability to use them, and to do so consistently. In order for these changes to be made, action must be taken on several levels. This includes the formulation of sound national policies and strategies, robust programme implementation with monitoring, regular programmatic reviews, and implementation research. Further, high-quality collection, analysis, and dissemination of data must underlie all of our efforts. As we move ahead, we must also recognize and draw lessons from positive examples of large scale and sustained programmes in countries that have led the way in increasing contraceptive use by adolescents. CONCLUSION: This unprecedented moment in history gives us a real opportunity to bring about transformational change, particularly when there is so much at stake.

The use of an unsupervised learning approach for characterizing latent behaviors in accelerometer data.

The recent increase in data accuracy from high resolution accelerometers offers substantial potential for improved understanding and prediction of animal movements. However, current approaches used for analysing these multivariable datasets typically require existing knowledge of the behaviors of the animals to inform the behavioral classification process. These methods are thus not well-suited for the many cases where limited knowledge of the different behaviors performed exist. Here, we introduce the use of an unsupervised learning algorithm. To illustrate the method's capability we analyse data collected using a combination of GPS and Accelerometers on two seabird species: razorbills (Alca torda) and common guillemots (Uria aalge). We applied the unsupervised learning algorithm Expectation Maximization to characterize latent behavioral states both above and below water at both individual and group level. The application of this flexible approach yielded significant new insights into the foraging strategies of the two study species, both above and below the surface of the water. In addition to general behavioral modes such as flying, floating, as well as descending and ascending phases within the water column, this approach allowed an exploration of previously unstudied and important behaviors such as searching and prey chasing/capture events. We propose that this unsupervised learning approach provides an ideal tool for the systematic analysis of such complex multivariable movement data that are increasingly being obtained with accelerometer tags across species. In particular, we recommend its application in cases where we have limited current knowledge of the behaviors performed and existing supervised learning approaches may have limited utility.

Modelling foraging movements of diving predators: a theoretical study exploring the effect of heterogeneous landscapes on foraging efficiency.

Foraging in the marine environment presents particular challenges for air-breathing predators. Information about prey capture rates, the strategies that diving predators use to maximise prey encounter rates and foraging success are still largely unknown and difficult to observe. As well, with the growing awareness of potential climate change impacts and the increasing interest in the development of renewable sources it is unknown how the foraging activity of diving predators such as seabirds will respond to both the presence of underwater structures and the potential corresponding changes in prey distributions. Motivated by this issue we developed a theoretical model to gain general understanding of how the foraging efficiency of diving predators may vary according to landscape structure and foraging strategy. Our theoretical model highlights that animal movements, intervals between prey capture and foraging efficiency are likely to critically depend on the distribution of the prey resource and the size and distribution of introduced underwater structures. For multiple prey loaders, changes in prey distribution affected the searching time necessary to catch a set amount of prey which in turn affected the foraging efficiency. The spatial aggregation of prey around small devices (∼ 9 × 9 m) created a valuable habitat for a successful foraging activity resulting in shorter intervals between prey captures and higher foraging efficiency. The presence of large devices (∼ 24 × 24 m) however represented an obstacle for predator movement, thus increasing the intervals between prey captures. In contrast, for single prey loaders the introduction of spatial aggregation of the resources did not represent an advantage suggesting that their foraging efficiency is more strongly affected by other factors such as the timing to find the first prey item which was found to occur faster in the presence of large devices. The development of this theoretical model represents a useful starting point to understand the energetic reasons for a range of potential predator responses to spatial heterogeneity and environmental uncertainties in terms of search behaviour and predator-prey interactions. We highlight future directions that integrated empirical and modelling studies should take to improve our ability to predict how diving predators will be impacted by the deployment of manmade structures in the marine environment.

Sanitation and health.

As one article in a four-part PLoS Medicine series on water and sanitation, David Trouba and colleagues discuss the importance of improved sanitation to health and the role that the health sector can play in its advocacy.

Interventions to improve disposal of human excreta for preventing diarrhoea.

BACKGROUND: Diarrhoeal diseases are a leading cause of mortality and morbidity, especially among young children in low-income countries, and are associated with exposure to human excreta. OBJECTIVES: To assess the effectiveness of interventions to improve the disposal of human excreta for preventing diarrhoeal diseases. SEARCH STRATEGY: We searched the Cochrane Infectious Disease Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in The Cochrane Library; MEDLINE; EMBASE; LILACS; the metaRegister of Controlled Trials (mRCT); and Chinese-language databases available under the Wan Fang portal, and the China National Knowledge Infrastructure (CNKI-CAJ). We also handsearched relevant conference proceedings, and contacted researchers and organizations working in the field, as well as checking references from identified studies. SELECTION CRITERIA: Randomized, quasi-randomized, and non-randomized controlled trials (RCTs) were selected, comparing interventions aimed at improving the disposal of human excreta to reduce direct or indirect human contact with no such intervention. Cluster (eg at the level of household or community) controlled trials were included. DATA COLLECTION AND ANALYSIS: We determined study eligibility, extracted data, and assessed methodological quality in accordance with the methods prescribed by the protocol. We described the results and summarized the information in tables. Due to substantial heterogeneity among the studies in terms of study design and type of intervention, no pooled effects were calculated. MAIN RESULTS: Thirteen studies from six countries covering over 33,400 children and adults in rural, urban, and school settings met the review's inclusion criteria. In all studies the intervention was allocated at the community level. While the studies reported a wide range of effects, 11 of the 13 studies found the intervention was protective against diarrhoea. Differences in study populations and settings, in baseline sanitation levels, water, and hygiene practices, in types of interventions, study methodologies, compliance and coverage levels, and in case definitions and outcome surveillance limit the comparability of results of the studies included in this review. The validity of most individual study results are further compromised by the non-random allocation of the intervention among study clusters, an insufficient number of clusters, the lack of adjustment for clustering, unclear loss to follow-up, potential for reporting bias and other methodological shortcomings. AUTHORS' CONCLUSIONS: This review provides some evidence that interventions to improve excreta disposal are effective in preventing diarrhoeal disease. However, this conclusion is based primarily on the consistency of the evidence of beneficial effects. The quality of the evidence is generally poor and does not allow for quantification of any such effect. The wide range of estimates of the effects of the intervention may be due to clinical and methodological heterogeneity among the studies, as well as to other important differences, including exposure levels, types of interventions, and different degrees of observer and respondent bias. Rigorous studies in multiple settings are needed to clarify the potential effectiveness of excreta disposal on diarrhoea.

Water distribution systems as living ecosystems: impact on taste and odor.

Six waters from different U.S. cities with known diverse taste and odor (TO) evaluations were selected for additional microbial characterization. All waters were subjected to microbial and cultural analyses, and four of the waters were further analyzed by cloning and sequencing of community 16S rRNA. The purpose of the study was to evaluate water distribution systems as living ecosystems, and the impact of these ecosystems on TO. All waters had total bacterial counts of at least 10(3) per ml. The water with lowest TO ranking had 10(6) total counts per ml. Community DNA sequence analysis identified diverse bacterial communities representing five different phyla and over forty genera. Included in this diversity were heterotrophic and autotrophic species that were both aerobic or anaerobic. Additionally, waters with the lowest TO evaluations contained significant sulfide concentrations, as well as bacteria associated with both the oxidation and reduction of inorganic sulfur compounds. Low redox conditions could have resulted in the reduced sulfur compounds and concomitant TO related problems, and an increase in redox could help alleviate these problems. Overall, data show that water distribution systems contain living ecosystems that evolve based on specific environments within particular distribution systems that impact water TO.

Marketing hygiene behaviours: the impact of different communication channels on reported handwashing behaviour of women in Ghana.

In 2003-04, a National Handwashing Campaign utilizing mass media and community events took place in Ghana. This article describes the results of the evaluation of the campaign in a sample of 497 women with children <5 years. The unifying message across all communication channels was that hands were not 'truly' clean unless washed with soap. The campaign reached 82% of the study population. Sixty-two per cent of women knew the campaign song, 44% were exposed to one channel and 36% to two or more. Overall, TV and radio had greater reach and impact on reported handwashing than community events, while exposure to both a mass media channel and an event yielded the greatest effect, resulting in a 30% increase in reported handwashing with soap after visiting the toilet or cleaning a child's bottom. Our evaluation questions wide-held belief that community events are more effective agents of behaviour change than mass media commercials, at least in the case of hygiene promotion. However, failure of mass media to reach the entire target audience, particularly in specific regions and lower socio-economic groups, and the additive effect of exposure, underscores the need to implement integrated communication programmes utilizing a variety of complementary channels.

Hard to handle: understanding mothers' handwashing behaviour in Ghana.

While handwashing with soap (HWWS) has been identified as a major pathway to reducing the risk of diarrhoeal diseases, and respiratory infections, rates of HWWS remain low across the globe. The current study, a national survey of Ghanaian mothers, found that as few as 4% of mothers engaged in HWWS after defecation, and only 2% after cleaning a child's bottom. In a multivariate analysis, we explored the determinants of handwashing at these key junctures, with and without soap. After defecation, mother's education, knowledge of important times to handwash with soap, the age of her children, and a measure of the quality of child care were all associated with handwashing (in any form). However, only the latter two variables also predicted soap use amongst handwashers. After cleaning a child's bottom, education, knowledge of important times to handwash with soap, and child care quality were associated with handwashing (in any form), yet only one variable, a measure of disgust sensitivity, showed any possible relationship with soap use. While this study has several important limitations, failure to explain much of the observed variance, despite a large range of potential determinants explored, suggests that we need to continue complementing quantitative surveys with in-depth qualitative studies if we are to better understand the motivations for, and constraints to, HWWS in community settings.

Health in our hands, but not in our heads: understanding hygiene motivation in Ghana.

Each year more than 2 million children die from diarrhoeal diseases; the same number again die from acute respiratory infections. The simple hygiene behaviour of washing hands with soap represents an effective way of preventing the transmission of many of these infections. However, rates of handwashing across the globe are low, presenting a challenge for health promotion programmes. Behaviour change is not easy, and past efforts based upon health education have met with limited success. New approaches are needed. We propose that much can be learnt from the world of consumer marketing. Rather than base communications programmes for behaviour change on increasing knowledge, marketers aim to respond to the inner desires and motivations of their target audiences. This study used consumer research to investigate the factors motivating handwashing with soap in order to inform a national communications campaign for Ghana. It revealed that the strongest motivators for handwashing with soap were related to nurturance, social acceptance and disgust of faeces and latrines, especially their smell. Protection from disease is mentioned as a driving force, but was not a key motivator of handwashing behaviour. The ways in which these findings have been translated into a handwash promotion campaign are discussed.