With the booming development of evacuation simulation software, developing an extensive database in indoor scenarios for evacuation models is imperative. In this paper, we conduct a qualitative and quantitative analysis of the collected videotapes and aim to provide a complete and unitary database of pedestrians’ earthquake emergency response behaviors in indoor scenarios, including human-environment interactions. Using the qualitative analysis method, we extract keyword groups and keywords that code the response modes of pedestrians and construct a general decision flowchart using chronological organization. Using the quantitative analysis method, we analyze data on the delay time, evacuation speed, evacuation route and emergency exit choices. Furthermore, we study the effect of classroom layout on emergency evacuation. The database for indoor scenarios provides reliable input parameters and allows the construction of real and effective constraints for use in software and mathematical models. The database can also be used to validate the accuracy of evacuation models. For example, the 2014 Ms 6.4 Ludian earthquake caused 617 deaths and injured 3,143 people, and 112 people went missing (as of 3 p.m. on August 8th); the 2014 Ms 6.6 Jinggu earthquake caused 1 death and injured 323 people (as of 4 a.m. on October 8th); the 2013 Ms 6.6 Zhangxian earthquake caused 89 deaths and injured 628 people, and 5 people went missing (as of 8 p.m. on July 22nd); and the 2013 Ms 7.0 Lushan earthquake caused 196 deaths and injured 11,470 people, and 21 people went missing (as of 2 p.m. on April 24th) (China Earthquake Administration: http://www.cea.gov.cn/). Given the ongoing social and economic development and the accumulation of wealth, society is becoming more vulnerable to natural disasters, such as earthquakes. The casualties and property losses caused by earthquake are becoming increasingly serious [China is an earthquake-prone country. It is also among the countries that have suffered the most from a serious earthquake. Earthquake and its secondary disasters cause serious casualties and property losses, and the social impact of earthquake disaster ranks first among the different types of natural disasters. From January 2012 to May 2017, 30 earthquakes with a magnitude greater than Ms 6.0 have occurred in mainland China , which could be used to analyze the decision-making process of pedestrian evacuation and the pattern of evacuation behavior .Individual characteristics. Due to the differences in physiological and psychological characteristics, people of different genders tend to make different decisions and adopt different behaviors ,19.Pre-earthquake phase. Pre-earthquake phase refers to the state of pedestrians before the earthquake occurs, which includes location (the position of the pedestrians), social context (the pedestrians are with whom?), and action (what are they doing when the earthquake occurs?). For example, pedestrians who are moving cannot easily feel slight shaking. In contrast, pedestrians who are still can easily feel slight shaking and take protective action. The pre-earthquake phase will have a certain impact on pedestrians’ emergency response decisions .Pedestrian response phase. People will display different self-protection behaviors with different degrees of ground shaking. Their behaviors and choices would be affected by the environment and other people around them.Delay time includes recognition time and response time. Recognition time is the time from feeling the ground shaking to confirming the earthquake occurrence; response time is the time from the first response to taking the first protection action. Based on the particularity of earthquake disasters and the characteristics of Chinese people, self-protection actions include evacuation or hiding oneself. Thus, delay time not only refers to the time between earthquake occurrence and evacuation but also to the time between earthquake occurrence and hiding oneself.2).Evacuation speed. Some studies have previously investigated earthquake evacuation speed . In thisEvacuation route choices. The physical environment of evacuation route can affect the evacuation efficiency –23. In tEmergency exit choices. The choice of emergency exit will be connected with the evacuation route and affect the evacuation efficiency .One of the innovation in this paper is the analysis of the influence of seismic intensity on pedestrian evacuation. In this study, we employ the Chinese seismic intensity scale (CSIS) to represent earthquake intensity. This intensity scale is the national standard used in the People’s Republic of China . When anThe collection and organization of qualitative and quantitative data is the first step in characterizing the EERB of pedestrians for use in simulations. In this paper, collected videotapes are treated as the research object and used to construct the database of EERB. This database will be valuable in developing, evaluating and validating different types of earthquake evacuation simulators, and it can be used to verify the accuracy of model results .The following principles were followed to select videotapes that have recorded real earthquake events in mainland China . Each viThe videotapes used should satisfy the following criteria:contain at least one person;include confirmed information on the time and location of the earthquake;record people with different personal characteristics ;display different scenes ;reflect different social contexts ;reflect different seismic intensities (I-IX); andreflect earthquakes occurring in different years (2008–2016).The selected videotapes satisfy these criteria and are representative.https://data.qdr.syr.edu/dataset.xhtml?persistentId=doi:10.5064/F651PANT). We summarize the general characteristics and conditions experienced by the selected more than one hundred individuals, specifically seismic intensity according to the CSIS  provides a platform that can be used to analyze the EERB of each individual [The Transana software package  provides a quantitative method for analyzing entire emergency responses. For each evaluated experimental data, we provide the minimum and maximum values, average value, median, arithmetic mean and standard deviation. In this paper, the used method was previously provided by other studies [The Tracker software package  throughout his or her entire emergency evacuation process is as follows:The definition of the average evacuation speed , ind(2)⋯ind(j)⋯ind(N)}. The duration of the entire emergency evacuation process of an individual (j) is Tj, the step size is L,j) is {t(1), t(2)⋯t(i)⋯t(k(j))}, i∈{1,2,⋯k(j)}. At time point t(i), the instantaneous speed of an individual is j) during the entire emergency evacuation process is given by the following:The average speed of an individual (t' (i) around t(i):According to z (i), the average instantaneous evacuation speed (At time point tz (i), the total number of individuals who are evacuating is M (i), and the corresponding set is {indeva (1), indeva (2)⋯indeva (j)⋯indeva (M (i))}, where eva denotes the evacuation status. The time required for all individuals to evacuate out of the room in the videotape is Tz, the step size is L, and the set of time points used in calculating the instantaneous speeds of individuals is {tz (1), tz (2)⋯tz (i)⋯tz (k)},z (i), the instantaneous evacuation speed of each individual is M(i)}, i ∈ {1,2,⋯k}.At time point tz (i), the function isAt tThis paper makes the following contributions and discusses the following differences between this new study and previous studies.Little research has been conducted on the emergency responses of crowds during earthquake disasters. Models used in the study of earthquake emergency responses represent a complex nonlinear physical problem . Due to In this paper, we used Transana software to build a Keyword database of pedestrian evacuation . This keyword database is used to analyze the decision-making process of pedestrian evacuation and the pattern of evacuation behavior.In the analysis of Delay time, the influence of seismic intensity on the delay time of pedestrians is analyzed. Then, we construct a seismic intensity-gender matrix of the average delay time. From this matrix, we can determine the average delay time for men and women under different seismic intensities.2).In the analysis of Evacuation speed, we discuss the correlation between evacuation speed and seismic intensity in a location   5) propoSeismic intensity is one of the factors that exerts a paramount influence on the delay time. In this paper, we discuss only the correlation between the delay time and the seismic intensity in terms of gender. The data of delay time are divided into six categories, based on seismic intensity used in the CSIS .Based on the data in Furthermore, this paper has also studied the relationship between delay time and gender. We have created a Figure with two boxplots of the delay time: one for male and one for female. As shown in This article has used the Mann-Whitney U-test to investigate the impact of gender on delay time . Based oBased on the analysis presented above, we construct a seismic intensity-gender matrix of the average delay time . From thEvacuation speed is a crucial parameter used in evacuation models. It is directly related to whether crowds can safely evacuate to designated areas within a specified time. Currently, few quantitative studies investigate the speed of earthquake evacuation. This lack of research is because earthquakes are not repeatable, and it is difficult to reconstruct pre-earthquake conditions after an earthquake. Moreover, post-earthquake scenes are complex, and available analytical data are limited.In this paper, the evacuation scenarios we discuss are indoor scenarios with a large number of individuals. The data distribution of instantaneous evacuation speed follows a log-normal curve, which is consistent with the findings of previous studies in indoor scenarios with a high number of individuals .2).According to previous studies, evacuation speed is affected by many factors, such as seismic attributes, building characteristics and individual characteristics. Each of these three factors can also be divided into several aspects. In this paper, we discuss only the correlation between evacuation speed and seismic intensity in a location (density: person/m2) on evacuation speeds, the more crowded a location, the slower the evacuation speed [In terms of the effects of location . Each student in the classroom is marked as a point mass with a different color and shape, and the point mass center is located at the students’ shoulder level. The position of each student is noted in every four frames from the moment they leave their seat. Thus, all students are traced until they reach the emergency exit.The classroom layout and evacuation trajectories are shown in As shown in Based on the above results, we can infer that the student’s route choice is affected by the following factors. As shown in To better understand the effects of classroom layout on evacuation speed, the evacuation is divided into four stages .From 18.00–21.07 s, the students stop hiding and begin evacuating. At 19.00 s, 10 students have already begun evacuating, and their average instantaneous speed is 0.77 m/s. Because the crowd density along routes is low, the 10 students can evacuate relatively quickly. At this time, the other students are still hiding, and they are excluded from the calculation of the average instantaneous speed. As time progresses, an increasing number of students begin to evacuate. At 21.07 s, 45 students have already begun to evacuate. Due to the large number of students and the narrowness of the evacuation routes, an increasing number of students form congestion in the routes. The students who comprise this congestion have been included in the calculation of the average instantaneous speed, resulting in a decrease in this speed.From 21.07–34.93 s: At 22.93 s, all students have begun evacuating, and four students have escaped the classroom. During this stage, the total number of students in the classroom decreases from 51 to 18. Two of the evacuation routes are always crowded with students, whose instantaneous speeds are very low (approximately 0.50 m/s). Then, these students are included in the calculation of the average instantaneous speed. During this stage, the number of students along the routes is approximately constant. The students in the back can use the route only after the students in the front have left. During this stage, the average instantaneous speed is low, between 0.49 and 0.62 m/s.From 34.93–39.47 s: During this stage, the number of students causing congestion along the routes gradually decreases. That is, the number of students who reduce the instantaneous speed decreases. Therefore, the average instantaneous evacuation speed increases over time from 0.55 to 0.80 m/s.From 39.47–42.93 s: During this stage, the total number of students in the classroom decreases from 7 to 0, and the remaining students are not crowded along routes. Therefore, the average instantaneous evacuation speed is relatively steady between 0.70 and 0.80 m/s.In this paper, we analyze the students’ emergency exit choices in Class 3 of Grade 7 in the Middle School of Tangshan Yucai . In this example, the position of each student is noted every three frames from the moment the student leaves his seat.The classroom layout and evacuation trajectories are shown in Based on the above research, we can conclude that the student’s exit choice is affected by the following factors. Eqs  and 7)  7) have In To understand the impact of classroom layout on evacuation speed, we again divide the evacuation process into four stages. In contrast with the classroom in the No. 2 Middle School of Ganqika, both Exits 1 and 2 of the classroom can be used for the evacuation, and the evacuation routes are relatively wide  and two exits, the students do not cause congestion along the routes, and the instantaneous speed of students is less affected by the environment and other people. These students have a high instantaneous speed s up to 1.14 m/s. As the number of students in the routes increases, the average instantaneous speed also increases. This quantity ranges from 0.82 to 1.14 m/s.From 5.40–7.30 s: During this stage, the total number of students in the classroom decreases from 11 to 3, and the number of students along routes gradually declines. That is, the number of students who contribute to increasing the instantaneous evacuation speed decreases. Therefore, the average instantaneous evacuation speed decreases and ranges from 1.23 to 0.99 m/s.From 7.30–8.50 s: The remaining two students in the classroom are near the front door. During this stage, these two students are evacuating from the classroom to the hallway of the building. Therefore, the average instantaneous evacuation speed is lower than that of the classroom. The speed, however, is relatively stable and ranges from 0.83 to 0.99 m/s.Based on Due to the narrowness of evacuation routes, the large number of students and the smaller number of exits, the average evacuation speeds noted in the second and third stages are slower than those of the first and fourth stages in the No. 2 Middle School of Ganqika. In contrast, the average evacuation speeds in the second and third stages are quicker than those of the first and fourth stages in the Tangshan Yucai Middle School .Quantifying the EERB of pedestrians during an earthquake emergency is of the utmost importance when developing models. In this work, based on analysis of the earthquake evacuation data of more than one hundred individuals, we construct a complete and unitary (though not exhaustive) database that encompasses the qualitative and quantitative aspects of the EERB of pedestrians for evacuation simulation software and could be used to verify the accuracy of simulation results. The constructed database is composed of the following seven parts: individual characteristics, pre-earthquake status, pedestrian response behaviors, delay time, evacuation speed, and evacuation route and emergency exit choices.The qualitative data of the individual characteristics, pre-earthquake status and pedestrian response behaviors comprise the keywords and keyword groups, which provide a foundation for further study of the codification of earthquake emergency response modes under different seismic intensities (I-IX). In this paper, the evacuation scenarios that we discuss are indoor scenarios, and evacuation and hiding under safety places are the main first protective behaviors.The delay time data follow the log-normal distribution. Our analysis on delay time in earthquake conditions is the first in the literature. Then, we construct a seismic intensity-gender matrix of the average delay time. The average delay time decreases as the intensity increases.The instantaneous evacuation speed data follow a log-normal distribution. Then, we construct the seismic intensity-location matrix of average evacuation speed. The average evacuation speed increases with increasing seismic intensity and decreases with increasing population density.The route choices of pedestrians are primarily affected by the geometric distance between the pedestrian and the nearest emergency exit, the average width of the selected route, pedestrians’ daily habits and the passing capacity of the chosen route. To understand the effects of classroom layout on evacuation speed, the evacuation process of students is divided into four stages.The emergency exit choices of students are mainly affected by their teacher’s guidance, the geometric distance between the student and the nearest emergency exit, the students’ daily habits and the number of other students between the student and the nearest emergency exit.The constructed database could be valuable in evaluating the results of evacuation simulation software programs and may provide reliable basic data for EERB models in indoor scenarios. In future research, the number of videos used in this article and analyses on the EERB should be expanded; a study of pedestrians’ earthquake evacuation in outdoor scenes should be performed; and the earthquake emergency response modes under different seismic intensities (I-IX) should be studied.In subsequent studies, the machine learning method will be used to construct a decision tree of earthquake emergency responses. Using the decision tree, the decision rules that can predict the emergency response decisions of individuals in future earthquakes are extracted. Based on the constructed database and decision rules, computer simulation technology can be used to further study how to optimize the spaces and configurations of classrooms and how to design earthquake emergency response procedures.S1 File(XLSX)Click here for additional data file.S2 FileNotations.(DOCX)Click here for additional data file.


This study describes how teachers’ nature of science (NOS) views changed throughout an innovative Continuing Professional Development (CPD) program that provided sustained support throughout the process in a collaborative and reflective environment and activities that are consistent with the current curriculum and NOS tenets integrated within. Eighteen in-service science teachers enrolled in a yearlong nature of science, Continuing Professional Development (NOS-CPD) program. Data were collected by pre/post-interviews using the Views of Nature of Science-Form C (VNOS-C) questionnaire, and a post-interview using an open-ended questionnaire developed by researchers to uncover teacher reactions to the NOS-CPD program.The results indicated that the NOS-CPD program improved the teachers’ NOS views more effectively than previously reported short-term teacher development programs, and thus, the findings should be useful for future studies in support of the professional development of teachers.The article concludes with practical advice for implementing NOS-focused, in-service teacher development programs. The transformational change agent says: “Here is the standard, which I know is impossible, so let’s stand together and learn our way into a higher level of performance.”Robert Quinn Equipping individuals with adequate knowledge and understanding of science and technology has become one of the main goals of national education programs  Numerous studies have tested methods for improving students’ NOS views. Although these studies show that NOS instruction can be made more effective, the studies indicate that there is room for still the improvement of students’ understanding of NOS. Moreover, NOS studies suggest that some science teachers have naive conceptions about NOS and numerous misconceptions  in-service middle school science teachers (teaching grades 5 through 8) volunteered to participate in this study. These teachers worked in 15 different schools in Turkey. They regularly attended project meetings and fulfilled all participation requirements. Thirteen of 18 (72.2%) participating teachers had previously taken a short-term course or training about the history of science and philosophy of science or NOS.The data were collected through interviews and analyzed using content analysis. Participant’s NOS understandings were assessed through face-to-face interviews at the beginning and end of the second stage. These interviews were semi-structured based on VNOS-C questions as developed by Abd-El-Khalick . Althougnaive, eclectic, and informed. Table Analyses of the interviews were carried out in several steps. First, interviews were transcribed. Second, these transcripts were transferred to a qualitative data analysis program. Thirdly, teachers’ statements were grouped regarding NOS themes. At the 4th stage of the analysis, teachers’ statements about related themes were classified as A rubric was used that developed by Irez , defininAn improvement was observed in all participant teachers’ NOS views at the end of the innovative NOS-CPD program. Teacher’s naive views about NOS themes decreased whereas their informed views increased Table . On the For the themes specifically targeted by the program, the percent of teachers who had naive views about these themes decreased whereas the percent of teachers with informed increased Table .Table 4Ppost-interview)It is hard to talk about a universal method in general as scientists might have different methods even though they are working on the same subject. In my opinion, every scientist has his own method. So it is not possible that every scientist follows the same steps in the scientific method. They might use their imagination and creativity at every stage, however they might use it more at some stages. For example, they might use their imagination/creativity less while recording data whereas they use it a lot when making an observation and maybe more when making a deduction. Still, imagination and creativity are present at every stage. The needs of a society, personal needs, religious opinion and even the languages spoken have an effect on scientific studies. I think law is a proved theory. I would give a very good answer to that question before; I kept the cliché sentence ‘theories are developed, proven and turn into law’ in my mind for years. However, I do think different now. There might be a mutual interaction. A law might be explained by more than one theory. (Duru, One of the teachers sharing a conscious opinion after the program while she had naive views regarding the “nature of scientific theories and laws” theme before, clearly underlined her opinion regarding this subject:Our primary research question asked in what ways and to what extent does teachers NOS views change in response to an innovative NOS-CPD program that provided sustained support? In response, our research findings showed that the innovative NOS-CPD program improved teachers’ NOS knowledge and understanding in general. For the themes specifically targeted by the program, the percent of teachers who had naive views about all these themes decreased whereas the percent of teachers with informed increased. As a result of the innovative NOS-CPD program, the NOS theme in which the furthest progress was made is “scientific method.” Another theme in which a high level of progress was made is the “imagination and creativity in science” theme. The improvement achieved in “nature of scientific theories and laws” theme as a result of the innovative NOS-CPD program was less than expected. It is more difficult to ensure improvement in some NOS themes than others even if the direct-reflective teaching method is used. “Nature of scientific theories and laws” is one of those (Koseoglu et al. Our subquestion asked to what extent was our program more effective than short-term professional development programs? In response, our research findings showed that the innovative NOS-CPD program is more successful than short-term programs improving teachers’ views of the NOS themes, especially which are difficult to change as scientific method or the nature of scientific theory and laws. When we looked at the literature, studies have generally demonstrated that short-term professional development programs are difficult to change teachers’ views on such NOS themes (Dogan et al. Learning to teach is a slow process and note easy. Therefore, it should be taken into account that teachers may have difficulty changing their previous knowledge and misconceptions, and professional development programs should be designed for a long time with this prediction Hayes . In addiThe effect of the factors mentioned above in the development of teachers’ NOS views is quite obvious in the literature. However, the main problem for teachers is that they have difficulty integrating what they learn in professional development programs into their classroom practices. It is thought that the use of formative assessment procedures during the teaching process and reinforcement of teaching with discourse analysis and support of teachers through feedback during the process will also improve the performances of the teachers in the classroom. We have also shown that the innovative NOS-CPD program that incorporates these features improved the teachers’ classroom practices. There were other issues that could be reported in this paper, but this paper focused especially on teacher’ NOS views. It is recommended that a professional development program in this context should investigate and report on the effect of teachers, especially on classroom practices.Last of all, as Guskey  emphasiz


The majority of people with spinal cord injury (SCI) in the United States are not meeting the recommended guidelines for regular physical activity. Behavior change techniques  that are framed within the principles of the social cognitive theory (self-efficacy and self-regulation) have the potential to enhance physical activity behavior.The aim of the study was to develop and test the usability of an electronic learning (e-learning) program for improving social cognitive factors related to physical activity behavior among people with SCI.The program was created through an iterative process of development and refinement, using a modification of a similar methodology used to develop evidence-informed guidelines in health promotion for people with disabilities . The study included 4 phases: (1) initial product creation, (2) national survey, (3) expert review, and (4) usability testing. Usability testing included both quantitative and qualitative data collection and analyses.The review of the program by an expert panel (n=5) and the results from a national survey (n=142) led to several refinements. Usability testing demonstrated that the program could be completed in a timely manner (<30 min). Participants reported 5 themes: (1) the program improves social cognitions related to physical activity participation; (2) reflection of physical activity behavior; (3) positive perceptions of the quality of the program; (4) positive perceptions of the program operation and effectiveness; and (5) recommendations for improvement. Each item was incorporated into a revised program version 1.0.This study incorporated an evidence-based framework for developing a brief 30-min e-learning program for increasing the physical activity behavior among people with SCI. The Exercise Strategies Through Optimized Relevant Interactive E-learning Storytelling (e-STORIES) program could be completed in a timely manner and was reported by participants as valuable and useful for enhancing intent-to-perform physical activity in individuals with SCI. The program has the potential to be applied in a variety of settings, but feasibility testing is required before implementing in a larger trial. Regular physical activity participation is a core component of the postrehabilitative care among people with spinal cord injury (SCI). Over 30 years of research has indicated that people with SCI can increase one or more aspects of their physical and mental health through participation in physical activity ,2. PhysiIndividuals with SCI are often overwhelmed by a multitude of barriers  that preInterventions aimed at increasing LTPA in people with neurological disabilities have been found to be more effective when framed within a theory of behavior change . In partOne method that may be effective for communicating physical activity information is through story-based communications -18. Perrnarrative style [Preliminary data suggest that storytelling might be an effective strategy for conveying physical activity information to people with SCI ,21. Furtve style . Within ve style , 3 key nve style ,17: (1) ve style . HoweverE-learning technologies, combined with health behavior theory and narrative style, have the potential to provide educational opportunities to teach people how to overcome barriers to LTPA. E-learning authoring software  can be used to deliver easily accessible, interactive, and personalized educational programs. With the guidance of a narrative, individuals can be the narrators of their own e-learning storyline that adapts to their responses from programmed questions and queries. E-learning narratives can be combined with behavior change activities and engaging, visually attractive content  to modify SCT determinants, enhancing the likelihood of an individual engaging in LTPA. Although there are long-term behavioral coaching programs that can increase engagement in LTPA , there aThe aim of this study was to develop and test the usability of a brief e-learning program that embedded SCI narratives in a story-based approach, with the goal of improving SCT constructs that are related to LTPA. Program development included immersive involvement by people with SCI and input from an expert panel of researchers. This paper describes the development and usability of the program e-STORIES (Exercise Strategies Through Optimized Relevant Interactive E-learning Storytelling).develop, feedback, revise, and repeat  framework . GRAIDs peat see .Initial development of the computer-based program involved 4 elements: literature review, storyboard creation, theory and intervention alignment, and creation of the infrastructure for the program.A systematic review of peer-reviewed publications was conducted using the search terms: “spinal cord injury” AND “physical activity” AND “behavior change” AND “self-management.” The study inclusion criteria included studies that were (1) peer-reviewed, (2) conducted within the past 2 years (2016-2018), (3) classified as a review paper, and (4) indexed in PubMed, Cumulative Index to Nursing and Allied Health Literature, or Scopus. The search for review papers returned a total of 10 articles and no duplicates. After screening these articles for eligibility criteria there was only 1 article remaining. Other articles were removed owing to not being a systematic review or not targeting SCI population.The single systematic review of physical activity self-management interventions for people with SCI was used to identify behavioral LTPA interventions and strategies to aid in content development for the e-STORIES program . This reThe first stage of development was to create a storyboard that outlined the flow of the program, content suggestions, and scripts, as well as naming the project and designing a logo. The storyboard displayed the flow of the e-learning intervention and whether the information would be delivered by audio, text, pictures, animation, video, or some combinations of these media. The storyboard also helped with the construction of the pathways for tailored survey responses .SCT is based on the interplay between the behavioral factors, personal factors, and environmental factors . The intStoryline 360, developed by Articulate Global Inc, is an e-learning authoring tool that was used to create the e-STORIES program. This software allowed the program to be interactive and instructional through multimedia that included digital movies, pictures, sound files, animation, graphics, and other electronic files. After a story board was created, the basic outline of the program was developed in Articulate’s Storyline 360. The outline included (1) program introduction, (2) assessment of theory constructs, (3) LTPA behavior change activities, and (4) printed copy of the participant’s results.The second phase of the study included a survey of individuals with SCI that was delivered on the Web using Qualtrics. The survey aimed to collect descriptive information on the physical activity readiness and identification with SCI narratives related to LTPA, to inform and revise the program. Participants were asked to indicate which of the following best described their current level of physical activity: (a) Yes, I have been doing LTPA regularly for more than 6 months; (b) Yes, I have been doing LTPA regularly for less than 6 months; (c) No, but I intend to start doing LTPA regularly in the next 30 days; (d) No, but I intend to start doing LTPA regularly in the next 6 months; or (e) No, and I do NOT intend to start doing LTPA regularly in the next 6 months [A description of each of the three SCI LTPA narrative styles was developed from the literature ,20: (1) People with SCI were recruited through one of 12 SCI-related support groups or organization pages on a social media platform. The eligibility criteria included participants who (1) were aged 18 years or above, (2) had a diagnosis of SCI, (3) had the ability to use hands and arms to exercise, and (4) had the ability to converse in English and complete the survey forms.P<.05.Using a measure of physical activity readiness, participants were categorized as physical activity nonintenders, intenders, or actors , to asseversions 0.2 and 0.3.An expert panel reviewed each component of the e-learning program for quality and accuracy using Articulate’s 360 Review, which allowed them to review the program online and add comments. The panel included an exercise psychologist, an exercise physiologist, a rehabilitation scientist, an information specialist, and a clinician who had several decades of experience in exercise research in SCI. After completing the review, each expert provided a summary of suggested revisions. This feedback led to several revisions, including textual, audio, and video changes and adding features to better guide participants. This phase included program The usability testing incorporated a nested mixed-methods design , where the qualitative component was embedded within a primarily quantitative study design. In other words, the usability study included a qualitative interview within a design that emphasized the core fundamentals of usability testing. Quantitative and qualitative aspects were treated with equal value. On the basis of the best practice recommendations for usability testing , a mixedBelief systems in the mixed-methods studies are critical as they influence all aspects of a study, including the design, analyses, and even the presentation of the results . SeparatThis study aimed to enroll 12 inactive people with SCI to satisfy the best practice recommendations for usability testing . People Participants were briefed about the study and provided the written consent forms. After obtaining the consent, participants’ demographics and clinical characteristics were recorded. Participants were then instructed to complete 16 usability tasks which involved navigating through and completing the entirety of the program and responding to the interactive questions. A research assistant took written notes while observing the participants perform the usability tasks and recorded the time taken by the participants to complete the entire e-learning program . This was followed by a one-on-one interview conducted in a private and comfortable setting within the research laboratory. Examples of the interview questions included: “Describe to me some positive experiences of the program,” “Describe to me some negative experiences or issues you experienced with the program,” and “Tell me your overall thoughts about the program.” The interview was recorded by an audio device, which was later transcribed for qualitative analysis.Usability was defined in terms of effectiveness , efficiency , usefulness , and satisfaction . Usefulness and satisfaction were explored through qualitative means, whereas effectiveness and efficiency were examined through quantitative metrics.Effectiveness was measured as the number of slides on which participants experienced an issue or problem, divided by the total slides that were completed without issues, which resulted in a single percentage value. The research team set an a priori benchmark of acceptable effectiveness at 90% .Relative efficiency was measured by the time required to complete the entire module, which included the 16 tasks. The research team established a benchmark of acceptable efficiency at 30 min, which was 8 min longer than it took the lead researcher to complete the module. The program was developed to be brief so that it could be used during clinic visits  or at a baseline visit for someone starting an exercise intervention.Researchers assessed the usefulness and satisfaction through participants’ qualitative feedback from the face-to-face interviews. Each interview included open-ended questions that sought to gain insight into the participants’ overall perceptions of the module, their likes and dislikes regarding module features and content, whether they would use the module if it was provided to them in the clinic, and whether they perceived the information as valuable. One member of the research team conducted the interviews. The interviewer had 2 years of experience with qualitative research that involved usability testing of exercise technology.Participant characteristics and quantitative usability data were descriptively reported. Qualitative data were analyzed using latent deductive thematic analysis  . ThematiA total of 154 people with SCI contributed to the development of the program. The national survey was completed by 142 participants, and 12 people enrolled in and completed the usability testing.P=.18) in physical activity readiness across the narrative groups. The open-ended questions were compiled into a list and redundancies removed to provide a list of suggestions to include in the program. Overall, the analysis of the national survey data resulted in the addition of video content of active people with SCI who shared their stories, videos of adapted exercises and sports, and emphasis of health benefits associated with LTPA.Participant characteristics for the national survey are shown in The following summarizes the revisions completed after the expert review: a statement about pain and exercising as a person with SCI was changed; some videos were re-recorded to improvequality; volume was increased on several audio clips; minor text edits were made; option was added in narratives for participants to use their own words or phrase; and examples of goals and next steps were provided.version 0.4 led to several minor revisions that were incorporated within the final program version 1.0. In total, participants experienced 29 usability issues. The issues were related to (1) operating action prompts during a task , (2) operation errors , (3) verbal clarity , and (4) video resolution . Usability testing of program The mean effectiveness score was 86% . This value was slightly lower than our a priori benchmark of 90%, indicating that minor changes were required to reduce operation issues.The mean time to complete the program was 28 min 20 seconds , which was lower than our a priori benchmark of 30 min.The analysts identified 5 themes regarding the usability of the program: (1) the program promoted reflection/introspection of physical activity behavior; (2) the program improved social cognitions related to physical activity participation; (3) the participants had positive perceptions of the quality of the program; (4) the participants had positive perceptions of program operation and effectiveness; and (5) participant recommendations for improvement. These themes and their subthemes and supporting quotes are shown in Participants reported that the program promoted valuable thoughts of self-reflection regarding physical activity behavior. The program provided relevant and encouraging information to establish reasonable outcome expectations of LTPA and to progress from a focus on the injury to resuming normal daily activities as reported by participant 1: “It definitely gets you from being focused on the actual injury to getting back into life, getting that groove back into life.”Participants reported that the program improves social cognitions related to physical activity participation such as self-regulation. The program increased the participants’ confidence to plan and schedule PA through behavior change techniques that included goal setting, demonstration of the behavior, and how to plan physical activity around barriers that prevent participation. Participants further noted that the content provided meaningful and relevant information, with an uplifting and motivating tone:It gets you to thinking. It gets you out of the doom and gloom process, and into the hopefulness, the looking forward to...And that's why I see it as being a major help in that area.Participant 2Participants reported high levels of satisfaction with the program design, including the animations and general flow of the slides. Participants further described the program as self-explanatory, intuitive, easy to operate, and engaging. However, the participants also had recommendations for improving the usability of the program. Participants noted that minor changes in the form of visual cues or instructional prompts and a back button could assist navigation and clarity in areas of the program that caused confusion.41 slides  did not support tailoring the presentation of SCI narratives based on the participant’s physical activity readiness. Findings demonstrated no significant differences among the SCI narratives and the physical activity readiness. However, only 8.3% (12/142) of the people identified with the chaos narrative, which likely affected the analyses. This finding is consistent with previous research which reported that less people with SCI identified with the chaos narrative when compared with the cure and quest narratives in LTPA studies ,17. NeveAlthough usability results suggested that the e-STORIES program could potentially improve self-efficacy and self-regulatory skills to perform physical activity, further research is required to explore whether the program can be successfully implemented in pragmatic, real-world settings. One such setting is within the waiting area of a rehabilitation hospital for SCI patients, where the patient could discuss the e-STORIES results with their physician, as people with SCI perceive doctors as a trusted and credible source of PA information . In addiexercise is medicine and exercise is progressive redemption, which were not presented in this study.This project had a few limitations. Although the sample size for usability testing met 1 minimum recommendation, the sample limited our understanding of usability within various subgroups of people with SCI. Only people with paraplegia enrolled in the study, and these individuals were, on average, middle-aged. This limitation supports the need to test the program with larger heterogeneous samples of people with SCI, particularly individuals who are in the acute or subacute stage postinjury, a period when the program could be highly valuable as noted by several study participants. Another limitation was the low number of individuals in the chaos narrative, reducing the power to detect differences in readiness among the narratives. Finally, although only 3 narratives were presented in the program , it is important to note that there have been several other narratives concerning LTPA among people with SCI in the literature , such ase-STORIES is a brief, online program developed through an iterative process that was informed by the life experiences of more than 150 people with SCI, including the creator of the program (JW). The usability study demonstrated that people with SCI perceived the e-STORIES program as valuable, useful, effective, and of high quality. However, feasibility testing is required before the implementation of the program in a larger trial.


This research tried to compare the level of farmers’ livelihood vulnerability to flooding in Sukoharjo and Klaten. Farmers are the most susceptible caused by climate change. The data used in this research are primary data, collected by interviewing 61 respondents who are farmers in the Sonorejo Village, Sukoharjo Regency and 72 respondents in the Jiwo Wetan Village, Klaten Regency. This data obtained by using non-probability sampling technique with purposive methods. Meanwhile mapping for hazard level was analysed by using Geographic Information System (GIS). Descriptive statistic was used for the livelihood vulnerability index’s (LVI) and the LVI-Intergovernmental Panel on Climate Change’s (IPCC) index calculation. The results show that the farmers’ livelihood vulnerability in the Sonorejo Village is medium level because of climate change based on the LVI index value at 0.363 and LVI-IPCC index value at 0.044. Meanwhile, the Jiwo Wetan Village has a lower index in LVI at 0.344 and LVI-IPCC index value at 0.038. Areas with similar physical characteristic and most of its community have a dependence on agriculture tend relatively the same level of vulnerability. The increase in emissions of greenhouse gases (GHG) leads to an increase in temperature of the earth and causes global climate change. This is one of the key elements in the system of metabolism and physiology of plants; the global climate change has a major impact on the agricultural sector. According to the Agricultural Research and Development Agency BBSDLP , the agrAn extreme climate change causes a great impact on the agricultural sector. The climate change severely leads to changes in pattern, and the level of precipitation affects the initial time of planting and growing period. The alteration in level of precipitation affects the time and seasons, cropping patterns, land degradation, destruction of crops and productivity, planted and harvested acreage, and the damage to biodiversity, especially crops that is relatively sensitive to water availability  and interview conducted with the Head of Village and the Head of Sonorejo’s Farmers Group Association (Gapoktan), wetland that is mostly prone to flood is located in the eastern part of the Sonorejo Village, namely, Langsur and Ngiser, that is directly adjacent to the Bulakrejo and Sukoharjo Village. The land altitude in those areas is lower than the surrounding areas, and the water drains (drainage) are not functioning properly, resulting to the flooding in the field.The research area in Klaten Regency also has characteristics similar to the sample area in Sukoharjo Regency. The altitude of the Jiwo Wetan Region is lower than other areas around it. When the Dengkeng River overflows, the overflow leads in the terrain in the south of the village. If the inundation does not pass, then the water goes to the rice fields and settlements of the Jiwo Wetan Village.The majority of the population in the Sonorejo and Jiwo Wetan villages rely on agriculture, especially crops and paddy rice. This condition causes the vulnerability on the livelihoods of farmers and their households. This study aims to deepen the understanding of the vulnerability of people’s livelihoods in flood-prone areas in paddy field in the Sonorejo Village and Jiwo Wetan Village, which are based on the results of the mapping with GIS and livelihood vulnerability index (LVI). The benefit of this research is to find out whether areas that have the same level of hazard and the same dependence on agriculture will have the same level of vulnerability.Geographic Information System is used as a tool to find the area that is prone to flood. Thereafter, the analysis of the vulnerability of households’ farming based on flood occurrence will be conducted by using LVI calculations, which is based on the primary data obtained. Furthermore, the results are described as follows.The utilisation of GIS has been done to identify areas of potential disasters. Wood and Good  identifyVulnerability is one of the factors that determines whether people have risks to their livelihoods or not. According to IPPC , the vulSocio-demographic profile (SDP)Livelihood strategies (LS)Health (H)Food (F)Water (W)Social networks (SN)Natural disasters (ND) and climate variabilityAccording to Hahn et al. , LVI comThe Life Expectancy Index . The di index reflects the value of the sub-components that are indexed by i. Based on these equations, the LVI grades can be obtained by using the following equation:d represents the index value for the susceptibility in area, d, measured by seven major components. WMi represents the number of sub-components that reflect to the main component, which is equally contributed to the overall LVI  for area d (Sonorejo Village); Mdi represents a main component for area d, which is indexed by I; WMi represents the quality of the main component; n represents the number of the main components of each contributing factor. The combination of these three contributing factors is calculated using the following equation:d represents the LVI index in area d expressed by using the framework of the vulnerability of the IPCC; e represents the score of area d ; a represents adaptive capacity score of area d  and s represents sensitive score of area d . The scale of LVI-IPCC range between (−1) and (−0.4) is not vulnerable; (−0.41) and (0.3) is vulnerable or moderate and (0.31) and (1) is very vulnerable.Livelihood Vulnerability Index-Intergovernmental Panel on Climate Change (IPCC) index is an alternative method used when calculating LVI according to the IPCC definition of vulnerability. Respect for the dignity of research participants was prioritised. Anonymity of individuals and organisations participating in the research were ensured.The high intensity of rainfall in the Sonorejo Village causes the rice fields in the area vulnerable to flooding. Based on the mapping of flood-prone rice fields in the Sonorejo Village, the areas most prone to flooding in lowland rice fields are Langsur and Ngiser. Meanwhile, the region that has the same characteristic with the Sonorejo Village is the Jiwo Wetan Village in Klaten Regency. The Sonorejo and Jiwo Wetan villages have an annual flood risk; the frequency of flooding is 4 to 6 times each year. In 2017, farmers in the Jiwo Wetan Village have accepted agricultural insurance claims because their agricultural land was damaged by floods (i.e. 75%).The curvature of the river is the ratio between the valleys and the length of the river. The river in the eastern of Sonorejo Village is a meandering river that flows over gently sloping ground that begins to curve back and forth across the landscape. Meandering river has asymmetric channels. The deepest part of the channel is found outside of each bend. The water flows faster in these deeper fragments and grinds down material from the riverbank. The water flows more gently in the shallow areas near the inside of each bend. The slower flow of water cannot carry much residue and deposits its load on a series of point bars. Meandering rivers erode residue from the outer curve of each meander bend and deposit it on an inner curve further downstream.The characteristics in the Jiwo Wetan Village area have similarity with the Sonorejo Village. Although the meandering is not like in Sonorejo, yet Jiwo Wetan is potentially flooding because the south of the village is the terrain of the Pegunungan Seribu, Yogyakarta. When rainfall is high, rainwater flows into the Dengkeng River and has the potential to increase the vulnerability of the area in Jiwo Wetan Klaten.Slope in the Sonorejo Village, Sukoharjo sub-district, shows that most areas in the Sonorejo Village are flat with slope level ranging between 2% and 6%, which leads to the conclusion theoretically that the Sonorejo Village is highly susceptible to flooding. Slope in the Jiwo Wetan Village, Klaten Regency, is approximately 2% – 7%.Land use index is determined by a map of land use and land use information on RBI topographic maps. The data collected are then contributed to the mapping of land use. The result shows that the Sonorejo and Jiwo Wetan villages are classified into three categories of land use, that is housing, irrigated fields and farming.Flood is a condition of overflowing of a large amount of water. Based on Based on Livelihood vulnerability index consists of seven main components, namely, SDP, LS, H, F, W, SN and ND and climate variability, and each consists of several indicators or sub-components. Each sub-component is measured by different scales that should be standardised to convert it into an index and combine it as a whole with the composite index.The result of the standardisation of each sub-component, which is obtained by a survey of 61 families in the Sonorejo Village and 72 respondents in the Jiwo Wetan Village, is presented in Based on the level of vulnerability classification conducted by Hahn et al. , it is kThe socio-demographic index of the Sonorejo Village is 0.235 and the Jiwo Wetan Village is 0.145. The proportion of the population of non-productive age, education pursued by the head of the family and the limitations of family members are still at a moderate level. The percentation of women as family heads is 0.115, while in the Jiwo Wetan Village it is higher at 0.368. This index shows that families led by a woman will be more vulnerable than households led by a man.The livelihood strategy index from the Sonorejo Village is 0.392, while in the Jiwo Wetan Village it is 0.499. The index of household sub-components that are based on the agricultural sector in Sonorejo sub-district is 0.607, while in the Jiwo Wetan Village it is 0.645. This shows that family dependence on the agricultural sector is more susceptible to climate change than families who do not only rely on the agricultural sector. Besides farming they also work outside the city and other economic sectors.The comparison of the health index numbers shown by the Sonorejo Village is 0.263, while in the Jiwo Wetan Village it is 0.245. In the health sub-component, the distance between health facilities and the number of families who have members with chronic diseases shows a moderate number. Based on the health degree vulnerability index, it can be concluded that the residents in the Sonorejo and Jiwo Wetan villages are not very vulnerable to climate change. Geographically, the Sonorejo and Jiwo Wetan villages are not isolated from health service centres.Based on the survey results, several families in the Sonorejo and Jiwo Wetan villages have the same characteristics in terms of food components. If the level of vulnerability in the Sonorejo Village is 0.426, then in Jiwo Wetan Village it is not significantly different at 0.445. This is because of changes in rainfall patterns and high rainfall as a result of climate change that causes flooding or inundation in the paddy fields of Sonorejo and Jiwo Wetan villages, resulting in crop failure and a decrease in rice productivity. As a result, farm households that get the main food source from their own crops become vulnerable to climate change. Based on the food sub-component index, households whose main source of food comes from their own crops do not store it for use when unpredictable conditions are the most vulnerable to climate change.Households in the Sonorejo Village in the water component showed a relatively moderate level of vulnerability with an index number of 0.274. As many as 78.7% of families in the Sonorejo Village use natural water sources to meet their daily water needs with consistent water availability , while 8.19% or five families are recorded as not having a consistent water source. This is because their water sources sometimes have a salty or cloudy taste, so they have to find other water sources to meet their family’s water needs. The level of vulnerability in water resources in the Sonorejo Village is higher than in the Jiwo Wetan Village. Water problems in the Jiwo Wetan Village will appear during the dry season, but not significantly.The Social Network Indicator in the Sonorejo Village shows that most of the people in the Sonorejo Village did not request assistance from the local or local government during the past year (as many as 65.57% or 40 households). While in the Jiwo Wetan Village, the majority of the population also did not ask for government assistance except because of the agricultural insurance premium subsidy programme. Based on the results of the survey conducted, in Sonorejo Village the agricultural insurance programmes are still at the socialisation stage, while in the village area Jiwo Wetan has implemented the programme. The agricultural insurance programme in the Jiwo Wetan Village has given claims to farmers who have experienced crop failure.The index number of ND and climate variability in the Sonorejo Village is 0.495; this figure shows that farmers in Sonorejo sub-district are very vulnerable to floods because of their location adjacent to Langsur River and lower terrain than other regions in Sonorejo sub-district. Based on the average number of floods reported in the past 6 years, as many as 85% of families did not get a warning or notification that there would be heavy rain or flooding. However, for the Jiwo Wetan region 0.445 is lower than in Sonorejo. This information is important considering the population of Jiwo Wetan when the rainy season almost always suffers from flooding because it is topographically bordered by the Dengkeng River and Pegunungan Seribu.d is a formula to measure the level of vulnerability of a community or community using the IPCC framework; Ed is a score calculation from community or community exposure; Ad is the calculation of the score from the capacity of a community or community and Sd is the calculation of the sensitivity of a community or community.Livelihood vulnerability index/LVI-IPCC is a measure of vulnerability of farmer households in disaster-prone areas with three measurement indicators, namely, exposure, sensitivity and adaptive capacity. The formula LVI calculation formula based on the IPCC is:Livelihood Vulnerability Index-Intergovernmental Panel on Climate Change is an alternative method for making the alleged vulnerabilities of communities relative to the effect of climate change developed from LVI. The Final IPCC weighted LVI scores range between (−1) and (−0.4) is not vulnerable, (−0.41) and (0.3) is vulnerable or moderate and (0.31) and (1) is the most vulnerable .The overall value of LVI-IPCC indicated that the vulnerability of farmers’ livelihoods to flood in the Sonorejo Village goes in the category of vulnerable or moderate by 0.044 on index figure. Although Jiwo Wetan has a lower LVI than Sonorejo, LVI Jiwo Wetan is still classified as vulnerable. LVI Score in Jiwo Wetan is −0.032. The agricultural insurance programme is proven to reduce losses for farmers in Jiwo Wetan. If the social network score in Sonorejo reaches 0.482, then in Jiwo Wetan it is at the level of 0.245.According to the mapping result using GIS, rice field in the Sonorejo Village, especially in Langsur and Ngiser, has high level of vulnerability to flood because of its lower altitude than other areas.The results of the research show that farmers in the Sonorejo Village is vulnerable to climate change by 0.363 and 0.044 index calculated by using the LVI and LVI-IPCC approach, respectively. In Jiwo Wetan, LVI is lower than in Sonorejo Village (0.275) and LVI-IPCC is also lower than in Sonorejo Village (−0.032).The LVI index measurement results show that two regions that have the same characteristics also have different levels of vulnerability. Strengthening population capacity can be done by expanding the agricultural insurance network. Although agricultural insurance still depends on government subsidies, this policy eases the burden on farmers who experience crop failure.


The cost of conventional serological testing for toxoplasmosis discourages universal adoption of prenatal monthly screening programs to prevent congenital toxoplasmosis. Point-of-care (POC) technology may constitute a cost-effective approach.Toxoplasma POC tests against gold-standard testing performed at Palo Alto Medical Foundation Toxoplasma Serology Laboratory (PAMF-TSL). The POC tests included the following: Toxo IgG/IgM Rapid Test (Biopanda) and the OnSite Toxo IgG/IgM Combo-Rapid-test that detect IgG and IgM separately, and the Toxoplasma ICT-IgG-IgM-bk (LDBIO) that detects either or both immunoglobulin IgG/IgM in combination. Samples were selected from PAMF-TSL biobank (n = 210) and Centers for Disease Control and Prevention Toxoplasma 1998 Human Serum Panel (n = 100). Based on PAMF-TSL testing, Toxoplasma-infection status was classified in 4 categories: acute infections (n = 85), chronic infections (n = 85), false-positive Toxoplasma IgM (n = 60), and seronegative (n = 80). The POC testing was performed in duplicate following manufacturer’s instructions by investigators blinded to PAMF-TSL results. Sensitivity and specificity were calculated.We evaluated the diagnostic accuracy of 3 Toxoplasma IgG, sensitivity was 100%  for all 3 POC kits; specificity was also comparable at 96.3% , 97.5% , and 98.8% . However, sensitivity for detection of Toxoplasma IgM varied significantly across POC tests: Biopanda, 62.2% ; OnSite, 28% ; and LDBIO combined IgG/IgM, 100% . Diagnostic accuracy was significantly higher for the LDBIO POC kit. The POC kits did not exhibit cross-reactivity for false-positive Toxoplasma-IgM sera.A total of 1860 POC tests were performed. For detection of Toxoplasma-IgG antibodies. The LDBIO-POC test exhibited 100% sensitivity for the combined detection of IgG/IgM in acute and chronic Toxoplasma infection. Biopanda and Onsite POC tests exhibited poor sensitivity for Toxoplasma-IgM detection.The 3 evaluated POC kits revealed optimal sensitivity for  Toxoplasma gondii, the causative agent of toxoplasmosis, is an obligate intracellular protozoan of worldwide distribution that infects one third of the world’s human population  http://www.pamf.org/serology/), the reference laboratory for study and diagnosis of toxoplasmosis in the United States.In this study, we sought to evaluate diagnostic accuracy for 3 Toxoplasma 1998 Human Serum Panel (CDC-HSP) (Toxoplasma antibody test kits (https://www.cdc.gov/dpdx/toxoplasmosis/index.html) and were submitted to investigators in a blinded fashion. All serum samples were previously tested at PAMF-TSL by gold-standard Toxoplasma-IgG method (Sabin-Feldman Dye test [DT]), double-sandwich immunoglobulin (Ig)M enzyme-linked immunosorbent assay, and additional confirmatory tests available only at PAMF-TSL.A total of 310 patient serum samples tested at PAMF-TSL were included: 210 were obtained from the PAMF-TSL biobank, and 100 from the Centers for Disease Control and Prevention (CDC) CDC-HSP) . The PAMToxoplasma infection  (n = 50); (2) chronic-Toxoplasma infection (Toxoplasma-IgG+/IgM−) (n = 50); (3) seronegative samples  (n = 50); and (4) false-positive (FP) Toxoplasma-IgM (Toxoplasma-IgG−/IgM+) (n = 60) [Toxoplasma-IgM serum samples were considered samples that tested repeatedly positive by IgM-enzyme-linked immunosorbent assay ([ELISA] at least in 2 separate test dates separated ≥3 weeks apart) but failed to show IgG seroconversion (when tested by DT) at follow-up testing at PAMF-TSL. In addition to IgM-ELISA and Toxoplasma-IgG DT, all of these samples were also tested with additional diagnostic tests, including differential agglutination (AC/HS), Toxoplasma-IgA, and Toxoplasma-IgE, and were all negative. Moreover, final interpretation of serological results from PAMF-TSL’s consulting physician (J.G.M.) stated that the serologic test results for these samples were compatible with FP Toxoplasma-IgM.The PAMF-TSL samples (n = 210) were divided into 4 different groups: (1) acute-(n = 60) . False-pToxoplasma infection, 35 to have chronic infection, and 30 uninfected. The POC testing results for CDC-HSP samples were returned to the CDC for data analysis and calculation of IgG and IgM diagnostic sensitivity and specificity for each POC kit.Of 100 CDC-HSP samples, 35 were established to have acute Toxoplasma-IgG and Toxoplasma-IgM antibodies in 2 different testing bands (IgG and IgM). For the LDBIO POC kit, test band (T band) simultaneously detects Toxoplasma-IgG and Toxoplasma-IgM not allowing their differentiation (Three POC kits were included: (1) Toxo IgG/IgM Rapid Test  (Biopanda POC test); (2) OnSite Toxo IgG/IgM Combo Rapid Test  (OnSite POC test); and (3) Toxoplasma ICT IgG-IgM  (LDBIO POC test). All 3 POC kits are based on a lateral-flow immunochromatography method that uses a nitrocellulose membrane strip containing a test (T) and control (C) band. For the Biopanda POC and OnSite POC tests, their cassette arrangement allows detection and differentiation of ntiation . The POCToxoplasma-IgG testing was performed using Sabin-Feldman IgG DT, the gold-standard method for Toxoplasma-IgG detection in the United States. The DT is a very sensitive and specific test in which live tachyzoites are lysed in the presence of complement and T gondii-specific IgG derived from patients’ samples. Toxoplasma-IgM testing was performed using a laboratory-developed, double-sandwich IgM-ELISA that uses sonicated T gondii antigen prepared from live tachyzoites (www.pamf.org/serology/clinicianguide.html). When indicated , additional tests such as Toxoplasma-IgG avidity, differential agglutination (AC/HS), Toxoplasma-IgA, and Toxoplasma-IgE, were performed by PAMF-TSL +true negative [TN]) among all tests performed  , as suggA total of 1860 POC tests (310 samples × 3 POC kits × 2 [duplicate testing of each POC kit]) were performed.Toxoplasma-IgG detection were done for 170 sera (85 from PAMF-TSL biobank and 85 from CDC-HSP). Sensitivity was 100% for all 3 POC kits . Specificity for Toxoplasma-IgG detection was comparable among all 3 POC kits: 96.3% , 97.5% , and 98.8% , for Biopanda, OnSite, and LDBIO POC tests, respectively . The IgG titers from patients with acute Toxoplasma infection were significantly higher compared with patients with chronic Toxoplasma infection . Of note, all 3 POC kits showed optimal sensitivity for IgG detection across all tiers of IgG DT titers. Diagnostic performance for all POC kits according to infection status is shown in Detailed serological results for Toxoplasma-IgM was performed for 82 (instead of 85) Toxoplasma-IgM-positive serum samples because 3 of 35 positive Toxoplasma-IgM samples from the CDC-HSP serum panel were dilutions of 3 true Toxoplasma-IgM-positives specimens, and their corresponding PAMF-TSL IgM-ELISA results were <2.0 . Therefore, these 3 samples were excluded from sensitivity calculation in results reported to us by the CDC , OnSite-POC test 28% , and LDBIO-POC test for combined IgG/IgM detection 100%  . Specificity for Toxoplasma-IgM was significantly lower for Biopanda compared with OnSite and LDBIO POC tests: 88.5% , 97.6% , and 98.8% , respectively  (P < .0001 for both Biopanda vs LDBIO POC test and OnSite vs LDBIO POC test).Sensitivity for C tests) . DiagnosToxoplasma-IgM samples (nonspecific IgM) .All 3 POC kits showed negative results for IgM (0 of 60) when tested against FP fic IgM) . In 3 ofThere were instances when Biopanda and OnSite POC cassettes displayed poorly visualized testing bands  . AmbiguoToxoplasma IgG and IgM antibodies using a large number of sera from US patients tested by PAMF-TSL reference gold-standard IgG and IgM tests. There are 2 major conclusions from our study. First, all POC tests  demonstrated optimal analytical sensitivity and specificity for Toxoplasma-IgG testing irrespectively of Toxoplasma-infection status (acute vs chronic infection) and IgG titers. Second, except for LDBIO POC test that detects IgG-IgM in one testing band and therefore showed 100% diagnostic sensitivity for acute Toxoplasma infection, Biopanda and OnSite POC tests showed poor diagnostic sensitivity for Toxoplasma-IgM detection . Notably, no POC tests showed cross-reactivity with sera from patients with FP Toxoplasma-IgM results. Hence, our results support use of the LDBIO-POC platform as a simple, low-cost, and rapid diagnostic tool capable of efficiently detecting Toxoplasma-IgG and/or Toxoplasma-IgM antibodies. Our study also supports the LDBIO-POC test as an initial serological screening test in programs for universal Toxoplasma prenatal testing.We report the diagnostic performance of 3 POC tests for detection of Toxoplasma-IgM detection noted for the 2 POC tests that were designed to detect IgG and IgM separately deserves further discussion. There are some technical differences between these 3 POC tests. The Biopanda and OnSite POC tests use recombinant T gondii antigens for binding to specific anti-Toxoplasma antibodies , whereas the LDBIO POC test uses as antigen whole-cell lysates of tachyzoites from the T gondii RH Sabin Type I strain. Additional mechanistic differences on lateral flow assays design may also account for the higher diagnostic performance observed with the LDBIO POC kit  and 4.5% (28 of 620) of the tests performed by Biopanda and OnSite, respectively. The above, added to an excessive number of FP results (11.5% for Biopanda IgM), represents a significant drawback that, in clinical practice, may lead to confusion and unnecessary confirmatory testing at expenses of increasing testing cost and patient’s anxiety. The failure of the Biopanda (62.2% sensitivity) and OnSite POC tests (28% sensitivity) to optimally detect Toxoplasma IgM represents a serious handicap for the implementation of such POC tests in universal screening programs during pregnancy.The underperforming diagnostic accuracy for  kit see . Biopand M band, . False-nToxoplasma-IgG and Toxoplasma-IgM antibodies combined in a single testing band (T band); therefore, independent calculation of IgM sensitivity and specificity for this POC test, without taking into account the presence of IgG, was not possible . Our team, led by McLeod et al demonstrated 100% sensitivity and specificity for the LDBIO POC test when tested against 180 sera from United States patients, including seropositive individuals with diverse T gondii serotypes previously tested at PAMF-TSL [Toxoplasma-IgG II Western blot analysis and Platelia Toxo-IgM (Bio-Rad) for IgG and IgM detection, respectively. In Mahinc et al’s [T gondii strain and across a wide range of Toxoplasma-IgG antibody titers [The LDBIO Toxoplasma POC kit showed robust performance in our study, with 100% sensitivity for the combined detection of IgG and IgM detection and low rate of FP IgG/IgM POC test results . Of note, the LDBIO reports possible  to 3. Thetection . To dateetection  evaluatePAMF-TSL . Mahinc  et al’s  study, t et al’s . In lighy titers . If costToxoplasma infection and FP IgM results, we did not include sera from patients with early T gondii infection (early seroconversion) to assess for IgM diagnostic accuracy in the absence of Toxoplasma IgG. These sera are scarce given lack of routine prenatal screening for Toxoplasma infection in the United States, impeding access to patients with documented seroconversion at early stages of infection. Therefore, in our study, IgM titers from patients with acute Toxoplasma infection were remarkably high . As a result, POC analytical performance for IgM detection at lower IgM titers remains unknown, and we encourage investigators to address this issue in future prospective studies. Reassuringly, Mahinc et al [Toxoplasma IgM (16 of 17 positive).Our study has some limitations. Despite large sample size and inclusion of sera from acute and chronic nc et al  tested sToxoplasma serology testing, the estimated PPVs and NPVs were representative of a group of tested samples with 68% IgG and 33% IgM seropositivity. Positive predicted values and NPVs vary according to the prevalence of the disease or condition in a determined population, and thus the PPVs and NPVs for a pragmatic cohorts with different IgG and IgM seropositivity rates would be very different; eg, for a population with 1% IgM seropositivity, a POC test with sensitivity and specificity for IgM detection of 62.2% and 88.5%, respectively, would have a PPV of only 5.2%, and a NPV of 99.6% and a POC test with 28% and 97.6% sensitivity and specificity, respectively, would have a PPV of 10.5% and NPV of 99.26%.Because our study evaluated the diagnostic accuracy of POC kits compared with reference laboratory methods for Toxoplasma diagnostics. As such, our results have notable implications for obstetricians, pediatricians, neonatologists, infectious diseases specialists, and others including policy makers in public health. As a neglected disease, CT represents a significant burden to healthcare systems around the world, with 190000 infants per annum affected worldwide carrying 1.2 million disability-adjusted life years [Toxoplasma diagnostics holds enormous promise given its critical elements such as rapid turnaround time, simplicity, low cost, and completion of testing during same clinical encounter [Our study was a proof-of-concept study and the first to directly compare 3 commercial POC tests for fe years . Integrancounter . Howeverncounter . In thisncounter , can recncounter . Despitencounter . Work isToxoplasma infection during gestation  would always require confirmatory testing with conventional laboratory-based methods to confirm the diagnosis and guide clinical management. Moreover, positive POC test results at the first prenatal care visit (either IgG+/IgM− or positive for the combined IgG/IgM detection) also require confirmatory testing, to confirm that these reflect chronic infection, acquired before gestation. Pregnant women found to be chronically infected early in gestation would not need additional monthly screening for the rest of their pregnancy because they are not at risk of transmitting the infection to their fetus, unless severely immunocompromised and not on prophylactic therapy. Despite the need for confirmatory testing for positive results, POC test-based prenatal screening programs are still cost saving because they significantly limit the number of women who will need such confirmatory testing .Positive POC test results indicating acquisition of an acute Toxoplasma-IgG detection across different Toxoplasma-infection states. However, the LDBIO POC test showed 100% sensitivity for the combined detection of IgG/IgM in acute and chronic Toxoplasma infection, whereas Biopanda and OnSite POC tests showed poor diagnostic sensitivity for Toxoplasma IgM. An accurate, low-cost, and reliable POC diagnostic test for Toxoplasma infection can benefit patients and mitigate the cost of serological testing in universal prenatal screening programs for Toxoplasma infections.In conclusion, we demonstrated that all 3 POC tests  showed optimal diagnostic sensitivity and specificity for Open Forum Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.Supplementary materials are available at ofy215_suppl_supplementary_materialClick here for additional data file.Financial support. This work was funded by the E.W, AI Thrasher Foundation  and the Mann Cornwell, Rooney, Morel, Taub, and Engel families.Potential conflicts of interest. R. M. and J. G. M. performed a literature review for Sanofi-Pasteur during the time this manuscript was prepared; no compensation was received for this review. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.


The potential factors associated with trainees’ perception of the program and willingness to become a doctor after the exposure to the SRT program were assessed by multiple linear and logistic regression models. Compared to WM trainees (n = 1853), TCM trainees (n = 261) would be more likely to become doctors if there were no SRT program (p = 0.003). Both individual and program-wide  factors contributed to trainees’ perception, overall satisfaction, and willingness. Only specialty played an independent role in the associations with all three outcome variables. Inequality of characteristics between TCM and WM trainees reduced TCM trainees’ willingness to become a doctor after the exposure to the SRT program.A standardized residency training program (SRT) was launched in Shanghai in 2010, for both Western Medicine (WM) and Traditional Chinese Medicine (TCM). This study aimed to assess whether the program impacted trainees’ willingness to become a doctor and whether the program had different effects among WM and TCM trainees. A structured questionnaire was distributed to 2114 trainees to assess their perceptions and satisfaction with the program and their willingness to become a doctor after the exposure to the program. The trainees’ characteristics were compared between WM and TCM specialties using X Despite the significant growth of Western Medicine (WM), Traditional Chinese Medicine (TCM) still plays an important role in Chinese health care . In ChinHowever, it is uncertain whether China has sufficient TCM doctors to fulfill these ambitious goals. Over the past decade, a trend of declining interest among medical graduates in pursuing careers in clinical practice has persisted . From 20China is reforming its medical education to alleviate the doctor shortage. One focus of current reforms is the residency training program. Medical education in China consists of medical school, graduate medical education, and continuing education . The resThis new SRT program has many innovative initiatives compared to the previous residency training program (non-SRT program) . First, Preliminary evaluations for Shanghai’s SRT program focused on assessing resident trainees’ clinical skills ,11,12. RThis study hypothesizes that the implementation of the SRT program may have a negative impact on residents’ willingness to practice medicine. This research aims to find out whether the SRT program has an impact on residents’ willingness to practice medicine, especially focusing on the difference between WM and TCM residents. Additionally, we hope to find out the factors related to change of the willingness and accordingly make suggestions to promote the SRT program and help reduce the influence.The study has been approved by the Medical Ethical Committee at Fudan University (registration number: IRB00002408 & FWA00002399). The number for the study is IRB#2013-10-0468. Written informed consent was obtained from all participants.The study is a cross-sectional study to evaluate the trainees’ attitudes toward the SRT program. Invitations for the study were made to all trainees who enrolled in the Shanghai SRT program in 2013. Data on trainees’ attitudes, their satisfaction toward the SRT program, and the change in their willingness to become a doctor after the exposure to the SRT program were collected in June 2014.By 2013, 44 hospitals had met the requirements for training bases and held the qualifications to carry out the SRT program, including 32 tertiary institutions, 7 secondary institutions, and 5 TCM-specialized institutions. This study included all 2283 trainees in these 44 hospitals under 27 specialties in the Shanghai SRT program. A structured questionnaire was used to investigate trainees’ attitudes toward the SRT program and their willingness to become a doctor after the exposure to the SRT program. In 2014, just before the end of the first study-year, the questionnaires were distributed to the residents online. Residents signed the online informed consent before filling in the questionnaire. The data were collected anonymously. Of all included trainees, 2114 completed the questionnaire survey. The response rate was 92.60%.Questions included domains of perception of the SRT program, overall satisfaction toward the SRT program, and willingness to become a doctor after or without the current SRT program. Perception of the SRT program was assessed by the question, “How do you consider the necessity of Shanghai SRT program?” in a five-point Likert scale ranging from 1 (very unnecessary) to 5 (very necessary). Overall satisfaction toward the SRT program was also assessed using a five-point Likert scale ranging from 1 (very unsatisfied) to 5 (very satisfied). Two items in the questionnaire were used to assess the trainees’ willingness to become a clinical doctor: “How strong is your willingness to become a clinical doctor under the new SRT program?”  and “How strong would be your willingness to become a clinical doctor if there were no SRT program?” . Scores were assigned to the possible answers for the two questions regarding trainees’ willingness to become a clinical doctor  ,16. The p < 0.05 was used to indicate significant associations.First, frequency tables and cross-tabulations were used to explore the characteristics of the study population. Trainees were compared in groups of TCM specialties and WM specialties. 8 TCM sub-specialties  were categorized into TCM specialties, and 19 WM sub-specialties  were categorized into WM specialties. Chi-square tests were used to test the differences of characteristics between the two groups. Second, we used a multiple linear regression model to explore factors associated with trainees’ perception of and satisfaction toward the SRT program. We used a multiple logistic regression model to explore whether the factors would increase residents’ willingness to practice medicine or not. Trainees’ gender, graduation region, educational level, clinical work experience, physician’s license acquisition, and background  were considered as the potential factors in the models. The univariate models included each potential factor separately. The multivariate models included all the potential factors. Data preparation and statistical analyses were performed using IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. A significance level of Among 2114 trainees, 261 were trained in TCM specialties (12.3%) and 1853 were trained in WM specialties (87.7%). The mean age of trainees was 26.55 ± 2.36.Compared to WM-specialty trainees, TCM-specialty trainees were more likely to be female (72.0%), graduate from Shanghai region (57.9%), and have a bachelor’s or master’s degree (95.4%). About 40.6% of TCM-specialty trainees had clinical experience before they enrolled in the SRT program, while in WM-specialty trainees, 36.9% of them had clinical experience. In both WM and TCM specialties, around half of the trainees had already received their physician’s licenses before they enrolled in the SRT program. There were no significant differences in clinical experiences and physician’s licenses between TCM-specialty trainees and WM-specialty trainees .p < 0.001). Around a quarter of TCM-specialty trainees would have increased willingness to practice clinical medicine if there were no SRT program, while only 17% of WM-specialty trainees would have increased willingness if there were no SRT program (p = 0.003).Among WM-specialty trainees, 10.5% of them considered the SRT program very necessary for their medical training, while only 6.1% of TCM-specialty trainees considered it very necessary . About 5p < 0.05), while its association with trainees’ overall satisfaction toward the SRT program was not significant (p = 0.547).In univariate models, gender was not significantly associated with any outcome variables . Traineep = 0.036). Compared with trainees without a physician’s license, those who had already acquired one had a higher chance of increased willingness if there were no SRT program . The graduation region was associated with trainees’ perception of the SRT program (p < 0.001) and the change in willingness after the exposure to the SRT program (p < 0.001). Trainees’ educational level was associated with the perception of the SRT program (p < 0.001 for master’s degree and p = 0.003 for doctorate) and overall satisfaction toward the SRT program (p = 0.003 for master’s degree and p = 0.016 for doctorate). Trainees’ specialty was associated with all three outcomes in the multivariate models. Compared with TCM-specialty trainees, WM-specialty trainees had a better perception of the SRT program (p = 0.004) and higher overall satisfaction toward the SRT program (p < 0.001). Compared with TCM-specialty trainees, WM-specialty trainees were less likely to show an increase in willingness if there were no SRT program , which means that TCM-specialty trainees would be more likely to become a clinical doctor if there were no SRT program for them.In multivariate models, the clinical working experience was not significantly associated with any outcome variables . TraineeThe present study suggested that after the exposure to SRT program, perception of the SRT program, overall satisfaction toward the SRT program, and change in willingness to become a clinical doctor varied consistently between WM and TCM specialties. We found that WM-specialty trainees tended to view the Shanghai SRT program more favorably than TCM-specialty trainees did. Correspondingly, TCM-specialty trainees would show a more significant increase in willingness if there were no SRT program. Other individual  and program-wide  factors were not consistently associated with all outcome variables.We found significant differences in gender, education background, and graduation region between TCM-specialty trainees and WM-specialty trainees, which may result from different career expectations. The situations of gender inequality and lower educational level of TCM trainees were not limited to the Shanghai area, but rather a common phenomenon across China TCM-specialty programs. There are more female TCM-specialty trainees than male trainees . In factTCM-specialty trainees consistently rated the Shanghai SRT program more negatively than WM-specialty trainees, after adjusting for all potential factors of outcome variables. This suggested that TCM-specialty trainees were less satisfied with the newest residency training program. This may be because TCM-specialty trainees experienced more significant changes in the training system. Before the SRT program in Shanghai, TCM-specialty graduates were usually locked down at positions in the TCM institutions and trained mostly in TCM examination methods. The current SRT program is the first standardized training program requiring TCM-specialty trainees to practice traditional examination methods as well as multiple clinical skills . The curIn the univariate model, all potential factors except gender were associated with trainees’ perception of, overall satisfaction toward the SRT program, and change in willingness to become a doctor after the exposure to SRT program. Senior trainees, trainees who graduated from the Shanghai region, trainees with a higher educational level, and trainees with a physician’s license or work experience had lower satisfaction toward the SRT program and would be more inclined to become a doctor if there were no SRT program. This suggested that trainees with more skills or advantages when they enrolled in the SRT program were less in favor of standardized training. Trainees with more advantages may feel that the SRT program prolonged their path to secure positions in medical institutions. Besides, the graduation region was associated with the perception of the SRT program and an increase in willingness. There was existing evidence showing that trainees dropped out of the SRT program to land a job outside Shanghai ,23. The Besides, a TCM general practitioner (GP) training was launched in the SRT program . This feData in this paper was collected at the end of the first year after the implementation of the SRT program. The possible reason for the low perception and satisfaction could be the immature institutions and measures, residents’ ignorance of policies and requirements of the SRT program. In the current study, it was found that the perception and satisfaction improved with the promotion of the SRT program . The SRTThis study still has several limitations. First, the career development of the present trainees after the SRT program was not known when the project was launched. There is no existing information to illustrate the trainees’ choices after the SRT program. Future studies are recommended to further explore trainees’ career development. Comparison between trainees’ actual career choices and their change in willingness after the exposure to SRT program would give a more comprehensive understanding of the effect of the SRT program in terms of manpower resources in the TCM-specialty. Second, the present study is the first large-scale study assessing trainees’ perception of and satisfaction toward the Shanghai SRT program, but certain subgroups in the TCM specialty were still relatively small. The project was conducted cross-sectionally on trainees of the class of 2013. Comparisons between trainees from each year or a longitudinal satisfaction evaluation need to be addressed by future research.Inequality of gender, educational level, and graduation region existed between TCM-specialty trainees and WM-specialty trainees in the Shanghai SRT program. The inequality contributed to trainees’ perception of and satisfaction with the SRT program, and thus reduced TCM-specialty trainees’ willingness to become a doctor after the exposure to the SRT program. This research highlighted that specialty difference between TCM and WM played an important and independent role in the associations with trainees’ perception of the SRT program, satisfaction toward the SRT program, and their change in willingness to become a doctor after the exposure to SRT program. Policymaking regarding the SRT program needs to take into consideration the risk that certain groups’ willingness to practice medicine could be reduced by this training program. Future policies are needed to enhance the connection between medical education and a systematic residency training program, which will lead to less inequality between trainees with different backgrounds.