This study examines people’s response actions in the first 30 min after shaking stopped following earthquakes in Christchurch and Wellington, New Zealand, and Hitachi, Japan. Data collected from 257 respondents in Christchurch, 332 respondents in Hitachi, and 204 respondents in Wellington revealed notable similarities in some response actions immediately after the shaking stopped. In all four events, people were most likely to contact family members and seek additional information about the situation. However, there were notable differences among events in the frequency of resuming previous activities. Actions taken in the first 30 min were weakly related to: demographic variables, earthquake experience, contextual variables, and actions taken during the shaking, but were significantly related to perceived shaking intensity, risk perception and affective responses to the shaking, and damage/infrastructure disruption. These results have important implications for future research and practice because they identify promising avenues for emergency managers to communicate seismic risks and appropriate responses to risk area populations. In the immediate aftermath of an earthquake, many victims’ survival and injury outcomes depend on the response of others who are in the impact area. Conversely, many of those who have survived unscathed must choose whether to resume their previous activities, seek information—about the situation generally or about their loved ones more specifically—or try to cope with the disaster by cleaning up debris or helping other people. It is well known that volunteers and emergent groups are a major source of early search and rescue (SAR) activity . EarthquThere has been a significant amount of research on household preparedness for earthquakes ,9,10,11 There is even less information about people’s behavior in the immediate aftermath of earthquake shaking although SAR activity has been a major focus of most accounts. For example, Noji  reportedOne limitation of previous research on immediate aftermath actions is the lack of a theoretical framework. This need can be filled by Lindell and Perry’s ,26,27 PrRQ1.How did behavior during the immediate aftermath  differ across earthquakes?RQ2.Do demographic variables, such as age, gender, and marital status, affect peoples’ behavior during the immediate aftermath?RQ3.Does earthquake experience and emergency preparedness affect behavior during the immediate aftermath?RQ4.Does physical context, such as being at home, affect behavior during the immediate aftermath?RQ5.Does household context, such as the location of family members, affect behavior during the immediate aftermath?RQ6.Does social context, such as whether the individual is with others, affect behavior during the immediate aftermath?RQ7.Do actions taken during shaking affect behavior during the immediate aftermath?RQ8.What communication channels were used to seek additional information about the situation and to contact separated household and/or family members?To date, most research relevant to the PADM has focused on pre-impact protective actions, especially recommendations to evacuate from hurricanes or shelter in-place from tornadoes. However, there are many different types of actions that might be taken in the immediate aftermath of an earthquake, such as information seeking and actions to protect persons and property. Consequently, it is important to assess the relative prevalence of each type of action. In addition, the choice of different post-impact actions would be expected to depend on the variables identified by the PADM—social and environmental context, environmental cues, social cues, socially transmitted warnings, and personal characteristics such as past experience, personal resources, and demographic characteristics. These considerations lead to eight research questions and three research hypotheses about the prevalence of different post-impact actions and the variables that might explain them.RH1.Perceived shaking intensity, risk perception and affective response are negatively correlated with returning to previous activities, but positively correlated with behaviors such as turning off utilities, contacting household members, cleaning up, and helping others.RH2.Home damage and infrastructure interruption are negatively correlated with returning to previous activities, but positively correlated with behaviors such as turning off utilities, contacting household members, cleaning up, and helping others.RH3.Injuries are positively correlated with helping others but negatively correlated with the other immediate aftermath actions.There is a common tendency for people to label disaster victims as disorganized or panicked and in need of economic, social, and emotional support. Moreover, this tendency usually assumes that such support can only be effectively organized by external actors or organization. Despite these popular stereotypes, however, disaster research conducted since the 1960s has demonstrated that those affected do not merely remain passive “victims,” but rather become active participants in emergent organizations ,30,31,32W 6.3 event that struck at 12:51 local time on 22 February, causing 185 deaths, some 7500 injuries, and USD 11 billion of damage [W 9.0 earthquake struck Japan at 14:46 local time on 11 March. The 3−5 min of severe earthquake shaking (a maximum of MMI VII in Hitachi) and resulting tsunami caused 15,854 deaths, 26,992 injuries, and USD 235 billion of damage throughout northeast Japan. Two years later, in July and August 2013, two earthquakes occurred near Wellington, New Zealand that were widely felt and injured over 100 people. The Cook Strait earthquake, which occurred at the depth of 13 km about 51 km from central Wellington, was a MW 6.5 event that struck at 17:09 and lasted for 7.5 s, producing a maximum of MMI VI in Wellington. The Lake Grassmere earthquake, which occurred at a depth of 8 km about 77 km from central Wellington, was a MW 6.6 event that struck at 14:31 and lasted for 2–3 s, producing a maximum of MMI VI in Wellington. In combination, the 2013 earthquakes caused NZ$ 30 million of insured earthquake damage to residential properties. Although the Tōhoku event had a much greater magnitude than the other three events, the sample of Hitachi residents selected for that event was located much farther away from the earthquake epicenter than the Christchurch or Wellington samples were from their respective epicenters. The local intensities were thus more similar than the source magnitudes.The 2011 Christchurch earthquake was a Mf damage —see FiguFollowing the 2011 Christchurch and Tōhoku earthquakes, researchers from Texas A&M University drafted a questionnaire in collaboration with colleagues from New Zealand  and Japan —see Lindell et al.  for detaFollowing the 2013 Cook Strait and Lake Grassmere earthquakes, Fraser et al.  used theThe questionnaire asked respondents to report the community in which they were located at the time of the earthquake, their physical context , social context , and household context . Respondents were also asked to report their perceptions of shaking intensity .Respondents were next asked to indicate which one action best described their first behavioral response during the shaking: continued what they were doing before the shaking; stopped what they were doing but stayed where they were; dropped, covered under a sturdy piece of furniture such as a table or desk, and held on to it; tried to protect other people nearby; tried to protect property nearby, such as preventing things from falling; immediately left the building they were in; continued driving; pulled over to the side of the road; or other. Each action was coded No = 0 or Yes = 1.Consistent with the Protective Action Decision Model, people’s perceptions of the earthquake threat were assessed by the perceived likelihood of four personal consequences: damage to their homes; injury or death to themselves and their loved ones; disruption of their jobs; and a loss of utilities. The four items were rated on a scale from Not at all = 1 to A very great extent = 5 and summed to form a scale with α = 0.72. Respondents also reported their affective reactions to earthquake shaking on a nine-item subset of the UWIST MAC , each item being measured on a scale from Not at all = 1 to A very great extent = 5. Three items each measured shock , fear , and vigilance .Next, respondents reported what they did in the first 30 min after the shaking stopped. The response options were: returned to what I was doing before the shaking, tried to find out what had happened, turned off utilities , tried to contact household members, cleaned up broken or fallen items, helped people near me, went to a clinic or hospital for treatment, went to my home, went to the home of a friend or relative, went to a public shelter, went somewhere else, and other. Respondents were allowed to check all actions they took and each was coded No = 0 or Yes = 1. In addition, they reported the communication channels they used during that time: none, face-to-face conversation, television, radio, telephone, and Internet (asked only in the Wellington events), with each coded No = 0 or Yes = 1.Respondents were asked to report their earthquake experience prior to the one being studied in terms of four items: whether an earthquake had damaged property in their community, damaged their homes, injured or killed a member of their family, or injured themselves . These four items were averaged to form a scale with α = 0.55. They were also asked to indicate if they had, previous to the earthquake being studied, obtained earthquake information by attending a meeting on the earthquake hazard or receiving a brochure about earthquake hazard . These two items were averaged to form a scale with α = 0.37. Next, they were asked to report their level of household emergency preparedness by indicating whether or not they had a three-day supply of water, a three-day supply of non-perishable food, an emergency kit filled with supplies, a household emergency plan, a battery-powered radio, and a predetermined place to evacuate . These six items were averaged to form a scale with α = 0.63. In addition, they were asked to report whether anyone in their household was killed or injured, how much damage their home experienced , and what types of infrastructure were interrupted —each coded No = 0 or Yes = 1. The seven infrastructure interruption items were averaged to form a scale with α = 0.91.Finally, respondents were asked to report nine demographic characteristics: age; gender; marital status ; the number of people in their household under 18 years, between 18 and 65 years, and over 65 years; whether anyone in their household had a disability requiring assistance; and how long they had lived in the community where they now resided. In Christchurch and Wellington, the respondent’s education level was categorized: no school qualifications; school qualifications such as trade certificate, professional certificate, or diploma; university undergraduate degree (such as university diploma or bachelor’s degree); or university postgraduate degree (such as a Master’s or a Ph.D.). In Hitachi, the response options were: less than ninth grade; ninth to twelfth grade, no diploma; high-school graduate ; some college, no degree; associate degree; bachelor’s degree; or graduate or professional degree. Yearly household income was categorized as less than USD 20,000, between USD 20,000 and 29,999, USD 30,000 and 39,999, or USD 40,000 and 49,999, or USD 50,000 or more, and was translated into the corresponding currency (NZD or JPY) at the prevailing exchange rate. Finally, respondents reported whether they owned or rented the home in which they lived.As in Huang et al. , the equp ≤ 0.001. Thus, one can expect only one correlation coefficient being considered “statistically significant” just by chance alone. Moreover, the large sample size (N = 793) allows even r = 0.11 to be classified as statistically significant even though this accounts for only about 1% of the shared variance. Consequently, only r ≥ 0.15 are discussed below.One potential consequence of the large number of correlations is an inflated experiment-wise error rate. Specifically, one could expect that there would be approximately 39 coefficients that are classified as “statistically significant” at the 5% level just by chance alone. Consequently, the results presented below only list correlations as statistically significant if Across the four earthquakes, respondents’ most frequent activity during the 30 min after shaking stopped was to contact household members (54.3%), followed by seeking further information (42.3%) and resuming previous activities (24.8%). Relatively few people turned off utilities, cleaned up broken or fallen items, helped others, or went elsewhere . However, Regarding RQ2 (Do demographic variables affect behavior during the immediate aftermath?), r = 0.75).As for RQ4 , the results showed that people who were in their own home at the time of earthquake were less likely to contact household members. This result can be explained by the fact that respondents who were at home were highly likely to be together with other household members at the time of the earthquake (The data related to RQ5 (Does household context affect behavior during the immediate aftermath?) reveal that household context did influence people’s actions immediately after the shaking stopped. Respondents who were together with household members were less likely to contact household members; respondents whose household members were present or known to be safe were less likely to contact household members, whereas those with family members absent and safety unknown were more likely to do so.r = 0.17) and those who tried to protect persons were more likely to help others (r = 0.18), but these were the only two significant correlations out of 30 total correlations between actions during the two time periods.Answering RQ6 , the results indicate that the social context  did not seem to affect people’s activities immediately after the shaking stopped. The percentages of people who took each action in the immediate aftermath are very similar across social contexts. Similarly, regarding RQ7 (Do actions taken during shaking affect behavior during the immediate aftermath?), activities during the immediate aftermath were only weakly related to behavior during the shaking. Those who froze were more likely to resume previous activities (r = 0.49) than TV (r = 0.15) or radio (r = 0.19). To contact household members, however, they tended overwhelmingly to use telephones (r = 0.40) and Internet—presumably email (r = 0.22). Those who helped others quite logically tended to use face-to-face communication (r = 0.17). Finally, those who took the largest number of actions tended to use face-to-face communication (r = 0.17), radio (r = 0.18), phone (r = 0.26), and Internet (r = 0.39).Regarding RQ8 , people most frequently used telephone (60.8%), followed by face-to-face conversation (53.7%), Internet , radio (34.7%), and television (13.9%). To obtain information about the situation, people were far more likely to use the Internet (r = 0.18) and fear was positively related to seeking additional information (r = 0.18), contacting household members (r = 0.27), and helping others (r = 0.15). Finally, shock (r = 0.15) and fear (r = 0.29) were positively related to the total number of actions taken, fear was positively related to phone (r = .19), and all three affective variables were related to Internet . Risk perception was positively related to contacting household members (r = 0.22), helping others (r = 0.19), and Internet use (r = 0.41).Partially consistent with RH1 , perceived shaking intensity was positively related to contacting household members , earthquake damage and infrastructure interruption had no significant impacts on people’s behavior in the immediate aftermath. Also contrary to expectations, the results for RH3 (Injuries are positively correlated with helping others but negatively correlated with the other immediate aftermath actions) indicate that injuries were not significantly correlated with immediate aftermath actions.r = 0.34), so they were standardized and added to produce an index of psychological reactions. Similarly, home damage and infrastructure interruption were standardized and added to produce a damage index.To better understand the variables that might be causally related to immediate aftermath behaviors, binary logistic regression analyses examined the effects of the most highly correlated predictor variables. One physical context variable (being in one’s own home) and one household context variable (member absent and safety unknown) were included as single items. Earthquake experience and emergency preparedness were standardized and added to produce an experience/preparedness index. In addition, perceived shaking intensity, shock, fear, and risk perception had moderately strong intercorrelations (average As The study extends the findings of previous research on immediate responses during earthquake shaking by examining actions in the earthquake’s immediate aftermath (the first 30 min after shaking stopped). In addition, it examined the effects of demographic variables; earthquake experience and emergency preparedness; physical, household and social context; and actions taken during shaking on actions in the earthquakes’ immediate aftermath. Finally, it examined the effects of psychological variables , injuries, damage and infrastructure disruption on actions in the immediate aftermath. The present study found a number of similarities to Takuma’s  data on r = 0.02. In some respects, this is unsurprising because responses during earthquake shaking have trivial average correlations with all of the other groups of variables—demographic (average r = 0.00), experience/preparedness (average r = 0.04), contextual (average r = 0.02), and psychological (average r = 0.09). Actions in the immediate aftermath also have trivial average correlations with most groups of variables—demographic (average r = 0.02), experience/preparedness (average r = 0.08), context (average r = 0.02), and injury (average r = 0.03), but they have significant average correlations with the psychological variables (average r = 0.17) and damage (average r = 0.15) when the signs of the correlations for resuming previous activities are reversed (because this is expected to be correlated with lower risk perception and damage). It is difficult to make direct comparisons between the results of the present study and those from previous studies because, as noted earlier, it appears that few studies have examined response actions immediately following earthquake shaking. Thus, the present results will be compared directly to those of previous studies with regard to immediate responses during shaking, and the relevance for actions within the first 30 min after shaking will be drawn from those comparisons. Another major question of this study concerns whether actions during shaking and the immediate aftermath were differentially correlated with some potential predictor variables .Perhaps the most noteworthy finding is that actions in the immediate aftermath have trivial correlations with responses during earthquake shaking—average As for RQ1 (How did behavior during the immediate aftermath differ across earthquakes?), the results showed that, compared to the 2013 Wellington earthquakes, the 2011 earthquakes (Christchurch and Hitachi) had higher percentages of people who turned off utilities and cleaned up broken or fallen items and lower percentages of people who returned to their previous activities. On the other hand, the 2013 Wellington earthquakes produced higher percentages of people who sought information after the shaking stopped, as compared to 2011 earthquakes in Christchurch and Hitachi. These differences may be due to the greater shaking intensity during the Christchurch and Hitachi earthquakes , which would have generated a greater need for people to turn off utilities or clean up debris. Those affected by the former two earthquakes might have been too busy responding to their immediate situations to be concerned about seeking information. In addition, many more people in Hitachi and Christchurch than in Wellington experienced interruption of electric power , TV , telephone , and only 3% of those in Wellington experienced interruption of the Internet. Thus, the lower levels of information seeking in Hitachi and Christchurch is probably due, at least partially, to lack of access.r = −0.25), or seeking information (r = −0.11), but were more likely to turn off utilities (r = 0.11). These results are somewhat different from Friedsam’s [Concerning RQ2 (Do demographic variables affect behavior during the immediate aftermath?), the results reveal that gender was uncorrelated with immediate aftermath actions, whereas Bourque et al.  reportediedsam’s  findingsr = −0.12) and more likely to contact household members (r = 0.14). However, education and marital status have minimal effects on immediate aftermath actions; higher levels of education increase the search for additional information about the situation (r = 0.11) and marital status increases the likelihood of contacting household members (r = 0.11). Overall, these results indicate that demographic variables have quite modest effects on immediate aftermath actions.Income also appears to have a modest effect on immediate aftermath actions; participants with higher incomes were less likely to turn off utilities (r = 0.12) and help others (r = 0.11). These results could be related with previous findings that reported a positive effect of previous experience and preparedness on appropriate immediate responses to extreme events [RQ3 (Do earthquake experience and emergency preparedness affect behavior during the immediate aftermath?) addressed whether the participants’ personal experiences with earthquakes and their subsequent awareness/preparedness predict immediate aftermath behaviors. This study’s results indicate that respondents who had received earthquake information prior to their earthquakes were more likely to turn off utilities (e events . Howeverr = −0.19). It should be noted, however, that those who were at home were very likely to be with other household members (r = 0.75). Therefore, this result should be interpreted with the impacts of household context (RQ5), which addressed whether being together with household members affected people’s immediate aftermath behaviors. It seems that being at home, where participants were likely to be with their families, largely eliminated uncertainty about the safety of other household members but this did not help them to return to their normal activities. Moreover, the results regarding RQ5 (Does household context affect behavior during the immediate aftermath?) revealed that participants were more likely to contact absent household members if they were unsure of the absent members’ safety (r = 0.23), or even if they were known to be safe (r = 0.17). By contrast, those who were safely together with household members were less likely to make contact (r = −0.30) and were more likely to turn off utilities (r = 0.11). These results suggest that knowing the safety of family members can allow people to take other actions during the immediate aftermath but the effect is very weak. This is consistent with the finding that household context did not show significant correlations with immediate response actions.With regard to RQ4 , it is noteworthy that people who were at home at the time of earthquake were less likely to contact household members than those who were elsewhere (r = 0.12), whereas those who were alone were less likely to do so (r = −0.13). These results are somewhat consistent with Goltz et al. [The results for RQ6  revealed that people’s social context  produced differences in immediate aftermath actions. Consistent with previous studies, those who were with children were more likely to help others  and those who tried to protect persons during shaking were more likely to help others afterward (r = 0.18). Both findings indicate a continuity between actions during shaking and immediately afterward. As for RQ8 , the Internet showed the strongest correlation with information-seeking behavior , although there were significant correlations for the other communication channels as well. By contrast, telephone seems to have been the major communication channel for contacting household members (r = 0.40) although the Internet (r = 0.22) and face-to-face communication (r = 0.11) also received significant use. The results concerning the Internet are consistent with recent conclusions about its increasing importance as a source of information and risk communication [Regarding RQ7 (Do actions taken during shaking affect behavior during the immediate aftermath?), the results revealed that actions during and after earthquake shaking had only two significant correlations: those who froze during shaking were more likely to return to previous activities  to moderately strong (r = 0.32). These results are interesting when considered in relation to the correlations between these psychological variables and the immediate responses during the shaking, which were nonsignificant. These findings are consistent with those reported by Ohta and Ohashi [The partial support for RH1  indicates that the higher people’s perceived shaking intensity and risk perceptions, the less likely they were to resume their previous activities and the more likely they were to engage in actions that responded to the shaking. These correlations ranged from weak . Surprisingly, injuries were nonsignificantly correlated with immediate aftermath actions, perhaps because the injuries these respondents experienced were rare and might have been quite minor—slight cuts and bruises rather than major lacerations and fractures.In order to explore the impacts of physical damage and injuries on immediate aftermath actions, RH2  and RH3 (Injuries are positively correlated with helping others but negatively correlated with the other immediate aftermath actions) were tested. The weak support for RH2 showed that the more damage people experienced, the more likely they were to clean up debris in the immediate aftermath . These results indicate that more planning/policy efforts should be made to encourage households to develop plans for communicating with family members when away from the home as well as to facilitate communication among household members in the earthquake aftermath. Both efforts will reduce people’s psychological stress and facilitate an earlier recovery from the disaster.Second, there was only a modest continuity between actions taken during earthquake shaking and those taken during the immediate aftermath; the only two significant correlations were for freezing during shaking with returning to previous activities afterward and protecting persons during shaking and helping others afterward. Moreover, the antecedent demographic, contextual, and psychological variables had only 11 significant correlations with actions during shaking but 29 significant correlations with immediate aftermath actions. This difference in the predictability of earthquake response during the two time periods poses an important challenge for future research, specifically whether there are other variables that can provide better prediction of actions during shaking. A related concern is that earthquake experience, earthquake information, and emergency preparedness had no significant correlations with actions during shaking and only two small correlations with immediate aftermath action. The significant correlation and regression coefficients for turning off utilities suggests that current earthquake information and preparedness have at least one specific effect on people’s earthquake response actions.However, the nonsignificant correlations of earthquake experience, information, and preparedness with actions during shaking suggest that earthquake experience did not teach people what to do in subsequent earthquakes and the available earthquake information and preparedness checklists—if they did address this information—did not provide it in a way that led people to take appropriate action when it was needed during seismic shaking. This suggests that existing hazard awareness programs may need to be examined to see if they can be revised in ways that facilitate transfer of training ,41 from One promising aspect of these results is that they identify promising avenues for emergency managers to communicate seismic risks and appropriate responses to risk area populations. Specifically, the correlation and regression coefficients for the psychological reactions are important because they indicate that these variables contribute significantly to the prediction of all immediate aftermath actions other than turning off utilities. In turn, the psychological reactions are significantly higher among women and younger respondents. Some of these results are quite consistent with previous research, especially the higher level of psychological reactions among women , which hOne limitation of the present study is that it relies on self-report data about people’s actions during and immediately after earthquake shaking. Future research should supplement post-impact survey data with the analysis of behavioral responses during and immediately after earthquake shaking that are captured on closed-circuit television (CCTV) recordings . Such daA second limitation is the modest response rates, which raises questions about the representativeness of the samples. In fact, like many mail surveys, the sample over-represents older, married, home-owning, and more highly educated respondents. It is noteworthy that over-representation of some demographic categories will produce bias in other variables, such as risk perception and hazard adjustment, only to the degree the latter variables are correlated with demographic variables. Such correlations, however, are low in this sample, as well as more generally ,7,16,46.Finally, although this study appears to be unique in reporting data from four different earthquakes, three of them were from a single country and the fourth was from an event that had a substantially greater magnitude than the others. This concern is supported by the significant regression coefficients for the Hitachi dummy code in the regression analysis of all immediate aftermath actions; except for cleaning up debris, the dummy code suggests that there are some important unmeasured variables that differentiate the response to this earthquake from the responses to the New Zealand earthquakes. Thus, future studies need to investigate a broader range of countries when examining the effects of demographic, experiential, and contextual variables on psychological reactions, actions taken during seismic shaking, and immediate aftermath actions. As in the present study, this will raise the possibility that some of the differences between sites in people’s responses might be due to unmeasured variables such as differences in shaking duration, structural seismic resilience, and household seismic preparedness . However, such systematic comparisons among earthquakes are needed to advance the scientific understanding of people’s behavior in such events.


Scientific Reports 10.1038/s41598-017-17436-5, published online 01 February 2018Correction to: The Acknowledgements section in this Article is incomplete.“This work was supported by the National Program for Quality and Safety Risk Assessment of Agricultural Products of China (No. GJFP2016003) and the Agricultural Science and Technology Innovation Program of Chinese Academy of Agricultural Sciences (No. CAAS-ASTIP). We acknowledge Shanghai Personal Biotechnology Co., Ltd.  for their help in sequencing and bioinformatics analysis.”should read:“This work was supported by the National Program for Quality and Safety Risk Assessment of Agricultural Products of China (No. GJFP2016003), the Agricultural Science and Technology Innovation Program of Chinese Academy of Agricultural Sciences (No. CAAS-ASTIP), and the Earmarked Fund for China Agriculture Research System (No. CARS-27). We acknowledge Shanghai Personal Biotechnology Co., Ltd.  for their help in sequencing and bioinformatics analysis.”


A decrease in blood lactate levels (Lac) >10% during the first hours of resuscitation in sepsis is associated with better outcomes, but the mechanisms are unclear. Our objective was to investigate the relationship between the time course of Lac, inflammatory response, and mitochondrial respiration during experimental sepsis.n = 8 each). Animals were categorized according to the decrease in Lac during the first 6 h of resuscitation (early if ≥10% [Lac ≥10%] or late if <10% or increased [Lac <10%]), and systemic hemodynamics, inflammatory parameters, and mitochondrial function were compared between groups. In a second group of animals with fecal peritonitis and 24 h of resuscitation , abdominal regional Lac exchange was measured, and animals were categorized according to the decrease in Lac as in cohort 1.Original data from two previously published studies were reanalyzed. In cohort 1, pigs were randomized to be resuscitated for 48 h starting at 6, 12, and 24 h, respectively, after fecal peritonitis induction (p = 0.022). In cohort 1, systemic hemodynamics were similar in the Lac ≥10% (n = 13) and Lac <10% (n = 11) groups. Plasma interleukin-6 levels increased during unresuscitated sepsis and decreased during resusciation in both groups, but they were lower at study end in the Lac ≥10% group (p = 0.047). Complexes I and II maximal (state 3) and resting (state 4) isolated brain mitochondrial respiration at study end was higher in the Lac ≥10% group than in the Lac <10% group, whereas hepatic, myocardial, and skeletal muscle mitochondrial respiration was similar in both groups. In cohort 2, mesenteric, total hepatic, and renal blood flow at study end was higher in the Lac ≥10% group (n = 7) than in the Lac <10% group (n = 9), despite similar cardiac output. Hepatic lactate influx and uptake in the Lac ≥10% group were approximately 1.5 and 3 times higher, respectively, than in the Lac <10% group (p = 0.066 for both).Overall mortality was 20% (4 of 20) in the Lac ≥10% group and 60% (12 of 20) in the Lac <10% group (A decrease in Lac >10% during early resuscitation (6 h) after abdominal sepsis is associated with lower levels of plasma interleukin-6 and improved brain but not hepatic or muscle mitochondrial respiration. Blood flow redistribution to abdominal organs in animals with early decrease in Lac concentrations increases the potential to both deliver and extract Lac.The online version of this article (doi:10.1186/s13054-017-1691-4) contains supplementary material, which is available to authorized users. Hyperlactatemia and lactic acidosis are widely accepted as strong predictors of multiple-organ dysfunction and death in different populations of critically ill patients –5. MeasuAlthough there are no single or direct interventions available to reverse hyperlactatemia, it has been proposed that Lac could be used as a guide during early resuscitation of patients with sepsis , 9. It hIn the last 2 decades, the assumption that high Lac levels represent a consequence of anaerobic metabolism has been challenged . Other fWe recently demonstrated that treatment delay in fecal peritonitis increased inflammatory markers and Lac concentrations and was associated with impaired cerebral mitochondrial respiration at the end of the resuscitation period . HoweverWe used original data from two previously published studies , 14. TheThe first study (cohort 1) was designed to address the impact of three different treatment delays  on disease severity, development of sepsis-associated organ dysfunction, and mitochondrial function . In the n = 8 per group) were randomized to a sham control group or one of three groups in which resuscitation was started 6, 12, or 24 h after peritonitis induction. The 48-h resuscitation period consisted of broad-spectrum antibiotics  administered every 8 h, volume expansion , vasopressors, and inotropes wherever necessary to reach predefined hemodynamic goals [Fecal peritonitis was induced by peritoneal instillation of 2 g/kg body weight of autologous feces dissolved in 200 ml of 5% glucose solution. Thirty minutes after surgery, baseline (BL) measurements were taken. Then animals (Blood samples were drawn from an indwelling carotid artery catheter for Lac measurement (in millimoles per liter)  at BL and every 6 h during the resuscitation period. Inflammatory markers  were measured in blood samples drawn from the carotid artery at BL, immediately before starting resuscitation maneuvers (BR), and at the end of the experiment as previously described .At BL, BR, and the end of the experiment, tissue samples were taken from the right quadriceps muscle to assess mitochondrial function and skeletal muscle adenosine triphosphate (ATP) content as previously reported . AdditioOxygen consumption by complexes I, II, and IV was measured using high-resolution respirometry  and was expressed as picomoles per second per milligram of mitochondrial protein. State 3 represents active respiration after addition of adenosine diphosphate (ADP), whereas state 4 represents respiration after depletion of ADP. The respiratory control ratio, an indicator of coupling between respiration and ATP phosphorylation, was calculated by dividing state 3 by state 4 respiration rates . The timWith animals in supine position, a midline laparotomy was performed, and the abdominal cavity was exposed . Catheten = 8 each) fluid resuscitation for 24 h or until death, if earlier. Resuscitation started immediately after fecal peritonitis induction. Wherever necessary to reach a pulmonary arterial occlusion pressure >5 mmHg or urinary output >0.5 ml/kg/h, an additional fluid bolus (50 ml of HES) was given as long as stroke volume increased ≥10%. Vasopressors and inotropes were not used [Fecal peritonitis was induced by peritoneal instillation through a peritoneal drainage tube of 1 g/kg body weight of autologous feces dissolved in 200 ml of 5% glucose solution . The intnot used .Hemoglobin and oxygen saturation were analyzed at BL  and every 6 h thereafter . At the same time, blood gases were measured and values corrected for temperature using a blood gas analyzer , and arterial and venous blood Lac levels were measured with a Lac analyzer  .In contrast to cohort 1, where resuscitation was delayed for 6–24 h, resuscitation in cohort 2 started immediately after fecal peritonitis was induced. Therefore, BL for Lac time-course analysis in cohort 2 was considered after 6 h of resuscitation, corresponding to the shortest resuscitation delay in cohort 1 and the time point of maximum Lac levels.Systemic oxygen delivery and consumption were calculated according to standard formulas , 17. HepIn each cohort, animals were classified according to their time course of blood Lac levels: early  vs. late . All data are presented as mean ± SD, or as median with IQR in cases of non-normal distribution (tested by the Kolmogorov-Smirnov test).t test or with the Mann-Whitney U test in cases of non-normal distribution.Proportions between groups were compared with Fisher’s exact test. Survival analysis was performed using the Kaplan-Meier method, and the log-rank test was used for between-group comparisons. Continuous variables  were compared between groups with an independent-samples t tests were performed at the end of the 6-h resuscitation period used for Lac kinetics and at the end of the experiment. In cases of non-normal distribution, time effects within each group were separately assessed by Friedman’s test followed by a Mann-Whitney U test at the end of the 6-h resuscitation period and at the end of the experiment for differences between groups. To account for testing twice, the significance level was reduced from 0.05 to 0.025 (Bonferroni correction). IBM SPSS Statistics version 21.0 software  was used for statistical analyses, and Prism version 6.07 software  was used for graph plotting.Repeated measurements were assessed by analysis of variance using group as a between-subjects factor and time as a within-subjects factor. If a time × group interaction was detected, independent-samples see Additional file Twenty-four domestic pigs of both sexes (mean ± SD weight 40.2 ± 3.8 kg) were analyzed. Of those, 13 of 24 (54.2%) had a decrease in blood Lac levels ≥10% (early or Lac ≥10% group) and 11 of 24 (45.8%) had a decrease in blood Lac levels <10% (late or Lac <10%)   in the Lac ≥10% group and 4 of 11 animals (36.4%) in the Lac <10% group died during the resuscitation period p = 0.08 Doses of administered propofol, midazolam, fentanyl, resuscitation fluids, norepinephrine, and dobutamine, as well as net fluid balance, did not differ between the Lac ≥10% and Lac <10% groups   Table . Plasma 7) Table .Table 3Isee Additional file see Additional file see Additional file Complexes I and II maximal state 3) and resting (state 4) isolated brain mitochondrial respiration at the end of the experiment were higher in the Lac ≥10% group than in the Lac <10% group  were included in the cohort 2 analysis. Of those, 7 of 16 (43.8%) exhibited a decrease in blood Lac levels ≥10% (early group), and 9 of 16 (56.2%) had a decrease in blood Lac levels <10% (late group) (p = 0.006)  in the early Lac ≥10%) group and eight of nine animals (88.9%) in the late (Lac <10%) group died during the resuscitation period  (Table Hepatic Lac delivery (hepatic Lac influx) and uptake in the Lac ≥10% group were approximately 1.5 and 3 times higher, respectively, than in the Lac <10% group at the end of the study, although statistical significance was not reached  was associated with higher absolute and relative (fraction of cardiac output) abdominal blood flows favoring higher hepatic Lac delivery and uptake.Lac and inflammation have been linked recently in different contexts and diseases, including in cancer , asthma The importance of Lac as a mitochondrial substrate was reinforced with the Lac shuttle theory  and, verWhereas mitochondrial respiration was higher in brain biopsies of our Lac ≥10% group animals, it was not in biopsies of heart, liver, and skeletal muscle. On one hand, in sepsis, use of substrates and mitochondrial respiration efficiency vary between organs . On the In our Lac ≥10% group, state 3 as well as state 4 respiration was slightly higher than in our Lac <10% group, indicating mild uncoupling of respiration due to proton leak. Mild uncoupling is not associated with decreasing ATP synthesis rates . Proton Numerically higher hepatic Lac uptake in the Lac ≥10% group of cohort 2 may indicate better-preserved liver function in this group. We cannot judge the effect of increased liver perfusion (and hence Lac delivery) on liver Lac uptake. In a short-term endotoxemic shock model in sheep, exogenous Lac clearance decreased despite maintained liver perfusion . NeverthOur findings must be interpreted with caution, mainly regarding inadvertent attempts to establish cause-and-effect relationships, because this was a hypothesis-generating study. On one hand, the different design of the two analyzed studies is a limitation. On the other hand, mortality trend differences were consistent between the early (Lac ≥10%) and late (Lac <10%) groups when resuscitation followed immediately after the septic insult or was delayed. Thus, another limitation is that we did not measure Lac uptake of the brain and the heart, two organs where mitochondrial Lac use has been demonstrated previously , 24. FurA decrease in blood Lac level ≥10% is associated with lower levels of plasma IL-6 and better brain mitochondrial respiration during the first 6 h of resuscitation after experimental sepsis induced by fecal peritonitis. Increased liver Lac uptake may account at least partially for the differences.


Temporal distribution of earthquakes is key to seismic hazard assessment. However, for most fault systems shortness of large earthquake catalogues makes this assessment difficult. Its unique long earthquake record makes the Dead Sea fault (DSF) exceptional to test earthquake behaviour models. A paleoseismological trench along the southern section of the DSF, revealed twelve surface-rupturing earthquakes during the last 8000 years, of which many correlate with past earthquakes reported in historical chronicles. These data allowed us building a rupture scenario for this area, which includes timing and rupture length for all significant earthquakes during the last two millenaries. Extending this rupture scenario to the entire DSF south of Lebanon, we were able to confirm the temporal-clustering hypothesis. Using rupture length and scaling laws, we have estimated average co-seismic slip for each past earthquake. The cumulated slip was then balanced with long-term tectonic loading to estimate the slip deficit for this part of DSF over the last 1600 years. The seismic-slip budget shows that the slip deficit is similarly high along the fault with a minimum of 2 meters, which suggests that an earthquake cluster might happen over the entire region in the near future. Testing this assumption, however, has long been hampered by the lack of consistent earthquake time series for long-enough fault sections. Moreover, temporal clustering remains a critical issue for seismic hazard models that only started to be addressed in the most recent modelling attempts.Successions of intense periods of seismic activity rupturing significant length of a fault followed by longer periods of seismic quiescence have been documented along several strike-slip faults8 . At that site, the topography associated with the compressional bend traps fine sediments while diverting the Wadi Musa, which is flowing westward from the Jordanian plateau Fig. . The maiThree trench walls were excavated  that are summarized hereafter . The stratigraphy exposed in the trench is quite diverse. Four main units can be distinguished Figs  and S3. Although, deformation is visible throughout most of the trench, it is more pronounced around mark 17, where deformation is mostly characterized by normal displacement and cracks, while evidence of strike-slip motion remains elusive.27. However, the central push-up disrupts the general stratigraphy, making it difficult to unambiguously establish the lateral continuity of these event horizons between the eastern and the western part of the trench. Therefore we also had to rely on 14C dating of charcoals to strengthen the stratigraphic sequence across the trench. Thirty-two charcoals distributed over the three trench walls were dated by accelerator mass spectrometry  ending at the same stratigraphic levelth millenary BC to the 18th century AD  Fig. . As for 35 and archaeological data37, as it was done for the Wadi Araba. Figure Then, historical earthquakes were systematically associated with one or several fault segments in a pattern that ensures consistency with available paleoseismological datath and the 12th–13th centuries AD. A third period might also be identified during the 4th century, although ruptures along the Wadi Araba are missing, either because they were not recognized or that they did not happened . In addition, for the second scenario, specifically for the Jordan Gorge section, we used direct measurements of earthquake displacements instead of modeled values, based on 3D paleoseismic observation40. These displacements are smaller than values derived from scaling laws25. Part of this difference might be explained by the trench location at the end of the fault section. Direct offset observations are also available in the Wadi Araba41, at Tilah an aquaduc is offset by 1.6 ± 0.4 m21 and a water reservoir by 2.2 ± 0.5 m42. These values are consistent with values predicted by scaling laws25. When available, we include earthquake magnitude. For our area, only the magnitude Mw ~6.3 of the 1927 AD event was recorded43. The magnitude Mw ~6.3 is smaller than the magnitude that would be derived from the scaling laws using the rupture length associated to the 1927 event. Hence, in our lower slip scenario we use a slip value consistent with the Mw ~6.3 magnitude, rather than slip directly modeled from rupture length. Eventually, despite the length of the host faults, we considered for the computation that the 1068 AD, 1113/1117 AD event and 1834 AD event were of smaller magnitude, around 6.5–6.9, because the historical reports for these events are vague and suggest limited damage. In general taking into account measured values of displacement participates to lower the stress released per event.The total co-seismic displacement was computed by summing up average displacement associated to each earthquake. The latter was obtained by combining the hypothesized rupture length for each earthquake in the catalogue with the empirical law relating the surface rupture length (L) to the average displacement (AD) for strike-slip earthquakes: log(AD) =−1.7 + 1.04 log(L)We acknowledge that the segmentation we use and the fact that all events rupturing the same section of fault have the same rupture length are oversimplification. However, a sensitivity test shows that for our average fault-section length of 60 km, a variation of 20% of the rupture length would lead to an average change in slip of about 0.24 m, which is not very significant when considering the total cumulative slip. Indeed, because interpretation of historical data in some cases remains arguable, alternative scenarios for lateral extent of historical earthquakes, that would affect the distribution of cumulative slip to some extent, could never be totally ruled out . We favore here a scenario that is consistent with all available data and that minimizes assumptions.46. Hence, for our calculation we used the geodetic rates published for the different fault sections, which are consistent in the limit of uncertainties all along the fault: For the Wadi Araba and the Lisan peninsula segments we used respectively a slip rate of 4.7 ± 0.7 mm/yr, and 5.5 ± 0.3 mm/yr47, for the Jordan valley we used a rate of 4.7 ± 0.5 mm/yr48, and for the Jordan Gorge and the Hula basin segments we used a rate of 4.1 ± 0.8 mm/yr49. On the northern segment of the Jordan valley Hamiel et al.49 suggest that 10% of the seismic moment is released by a 1.5 km-thick surface creeping layer, which contributes to reduce the accumulated constraint. For this segment we calculate an equivalent slip rate of 3.7 mm/yr, which includes the reduction of accumulated seismic moment.In parallel, we computed the accumulated strain due to tectonic loading over the same time period for each fault section. Comparison of geologic and geodetic slip rates along the DSF shows that the slip rate is steady over the Holocenei.e. the largest magnitude and slip per event . This model considers that the conditional probability of a future event can be estimated from the observed recurrence interval alone. However, these probabilities should be considered as indicative and only first-order calculations, as such model does not consider temporal clustering and all segments are considered independently for the computation.Even if all the sections present a similar slip deficit, each segment underwent a different seismic history, which influences the likelihood of an earthquake to occur on each specific segment. Hence, in order to specify the areas where seismic hazard is higher, we computed a probability of earthquake occurrence on each segment following the probabilistic scheme proposed by SavageOur model counts the number of inter-event periods that are shorter than the prediction window  and uses it to establish a probability of earthquake occurrence. The probabilistic model is Manichean, which introduces a bias for the interpretation of the probability; if the observed recurrence time is close but slightly longer than the prediction window, the probability will be rather low. Conversely, if the observed recurrence time is slightly shorter than the prediction window, then the probability will increase significantly. This is the case for example for the central Wadi Araba segment, where the probability of occurrence of an earthquake is substantially (30%) larger for the next 80 years than for the next 50 years Fig. . Hence, The new paleoseismological site of Taybeh enriches the data about the seismic history of the DSF. Moreover, we were able to estimate a slip deficit for the southern part of the fault, which has a critical implication for the assessment of seismic hazard. Indeed independently of any specific scenario considered, all the sections between Aqaba and South Lebanon present a similar slip deficit, which is quite large, at least 2 m, associated to a homogeneously high probability of earthquake occurrence. The irregular seismic activity presented by the earthquake catalogue and the fact that the fault presents a homogeneous slip deficit everywhere support the assumption of temporal clustering.Supplementary material


In 2013, Zimbabwe’s voluntary medical male circumcision (VMMC) program adopted performance-based financing (PBF) to speed progress towards ambitious VMMC targets. The $25 USD PBF intended to encourage low-paid healthcare workers to remain in the public sector and to strengthen the public healthcare system. The majority of the incentive supports healthcare workers (HCWs) who perform VMMC alongside other routine services; a small portion supports province, district, and facility levels.This qualitative study assessed the effect of the PBF on HCW motivation, satisfaction, and professional relationships. The study objectives were to: 1) Gain understanding of the advantages and disadvantages of PBF at the HCW level; 2) Gain understanding of the advantages and disadvantages of PBF at the site level; and 3) Inform scale up, modification, or discontinuation of PBF for the national VMMC program. Sixteen focus groups were conducted: eight with HCWs who received PBF for VMMC and eight with HCWs in the same clinics who did not work in VMMC and, therefore, did not receive PBF. Fourteen key informant interviews ascertained administrator opinion.Findings suggest that PBF appreciably increased motivation among VMMC teams and helped improve facilities where VMMC services are provided. However, PBF appears to contribute to antagonism at the workplace, creating divisiveness that may reach beyond VMMC. PBF may also cause distortion in the healthcare system: HCWs prioritized incentivized VMMC services over other routine duties. To reduce workplace tension and improve the VMMC program, participants suggested increasing HCW training in VMMC to expand PBF beneficiaries and strengthening integration of VMMC services into routine care.In the low-resource, short-staffed context of Zimbabwe, PBF enabled rapid VMMC scale up and achievement of ambitious targets; however, side effects make PBF less advantageous and sustainable than envisioned. Careful consideration is warranted in choosing whether, and how, to implement PBF to prioritize a public health program. Improving healthcare worker performance is a common objective to raise both the quality and quantity of program outcomes. In the field of public health, performance-based financing (PBF) programs are diverse intervention approaches that tie program outcomes to financial incentives for healthcare providers with the aim of increasing delivery of key programmatic services . PBF mayThe literature is mixed on the effects of PBF. Diverse experiences from Haiti , Rwanda This paper seeks to add an additional viewpoint to the lively exchange on this topic by sharing healthcare worker and administrative experiences implementing a PBF intervention for adult voluntary medical male circumcision (VMMC) in Zimbabwe. The Zimbabwean Ministry of Health and Child Care (MOHCC), with assistance from the International Training and Education Center for Health (I-TECH), Department of Global Health, University of Washington and our partners, the Zimbabwe Association of Church-Related Hospitals (ZACH) and the Zimbabwe Community Health Intervention Project (ZiCHIRe), train health care workers and support roll-out of adult VMMC services. Together, this consortium works under the name ZAZIC. ZAZIC implements an integrated VMMC program model, operating hand-in-hand with the MOHCC through the existing healthcare infrastructure with the explicit intention of not only delivering quality VMMC services, but also building local capacity.The MOHCC adopted a PBF model for Zimbabwe’s VMMC program, including all ZAZIC sites, in May, 2013  19] to  to 19] tFrom October, 2014 through September, 2015, ZAZIC conducted a total of 39,840 MCs; the following 12 months, 44,868 were performed, for an annual increase of 13% productivity. These results exceeded the VMMC targets set by the donor in conjunction with the MOHCC in these fiscal years , contribThis qualitative study was designed to assess the effect of the PBF on healthcare worker motivation, satisfaction, and professional relationships at the clinics where VMMC services are provided. We conducted focus groups with two sets of healthcare workers (HCWs): 1) those who receive these PBF incentives for VMMC service-related activities and 2) those who do not receive PBF from VMMC service-related activities in the same clinic. Key informant interviews were also conducted at the provincial, district, and clinic levels to ascertain administrator opinions on these same issues. Data were collected to meet the following study objectives: 1) To gain understanding of the advantages and disadvantages of PBF at the level of diverse HCWs receiving the PBF; 2) To gain understanding of the advantages and disadvantages of PBF at the VMMC site level; and 3) To use the results to inform scale up, modification, or discontinuation of the PBF component of the national VMMC program in Zimbabwe.This study was conducted with the approval of the Medical Research Council of Zimbabwe (MRCZ), the U.S. Centers for Disease Control and Prevention, and the University of Washington internal review board. The written informed consent process was approved as part of the ethical review and was implemented by the study team. As part of this written consent, all participants were informed that their participation was voluntary. Subjects were assured that their employment and participation in the VMMC program would not be affected by their study participation. Once data were translated, transcribed and verified, the audio recordings were deleted. No names were transcribed for analysis.A focus group guide was developed in English, pre-tested and modified based on pilot testing. Although Shona and Ndebele translations were developed, participants chose to conduct all discussions and interviews in English. The interviewer/facilitators were trained in study protocols and pre-tested instruments. Discussion guides led both key informant and focus group participants through a series of questions and probes on their perceptions, attitudes, and experiences within the VMMC program with an emphasis on the effects of PBF on the workplace, including clinic climate, workplace relationships, and overall satisfaction with their jobs.At the time of the study, ZAZIC operated in all 36 VMMC sites that were located in 21 districts spread throughout all 10 Provinces in Zimbabwe. All ZAZIC facilities performing VMMC applied the same PBF model in accordance with MoHCC policy; no sites performed VMMC without the PBF. All sites also employ various demand creation activities  to encourage more VMMC uptake at both static  and outreach VMMC settings  in accordance with national VMMC program efforts. Eight oThe eight sites represented six provinces. Two sites were in one province, leading to five PMD interviews. PMDs granted permission to contact sites in each included province. In selected sites, healthcare workers in VMMC, HIV voluntary counseling and testing programs and primary care were informed about the study by the clinic director. At each site, a convenience sample of health workers, ages 18–65, involved and not involved with the VMMC program were invited to voluntarily participate in focus groups by study team members.PMDs were interviewed individually in selected provinces. In the eight study sites, one interviewer and one note taker conducted key informant interviews (KIIs) with a member of the site leadership. The interviewer and note taker also conducted two focus groups (FGs) per site: one with VMMC team members who received a VMMC-related PBF payment and one with staff in the same facility who did not participate in the VMMC program, and, therefore, do not receive a VMMC-related payment. Both VMMC and non-VMMC team participants were selected by facility manager using a convenience sample of staff available at the time of implementation. A total of 16 FGs were conducted. Each KII and FG was recorded and transcribed with participant consent. Data were collected in October, 2015.Two people listened to every recording for verification of transcription. Qualitative data were entered, coded and analyzed as text documents in Atlas.ti 6.0 by one researcher. Each document was coded based on predetermined themes covered in the interview guides. Additional themes were then coded based on the grounded theory approach–an iterative approach to generating unanticipated thematic concepts and linkages.Most commonly, and by participants in all discussions, the PBF was noted as quite motivational for the staff involved in the program, increasing VMMC quantity. As many outreach locations are in remote areas, VMMC teams travel and work outside routine clinic hours, including over weekends, to implement outreach activities. Those who received the PBF across all locations noted that the money not only inspired them to do the work, but the desire for more money made them more productive, as one MCFGP noted:The payment is not bad at all. It depends on productivity. If we have more clients we get more money. If we have a low output, this will negatively affect us. So the incentives motivate us to work harder so that we get more money.The PBF money also appeared to encourage staff to work outside of their normal work hours. One FGP noted that staff “are going for MC even when we are off duty,” while another added the detail that, “without the payment there is no way I’m going to agree to work until 8 or 10 pm doing the circumcisions.”. Overall, it appears that the VMMC teams would concur with this MCFGP who stated that, “the incentives do contribute in a big way to the way we are motivated to increase the number of clients who are circumcised.” Several participants wished, similar to one MCFGP, the PBF could be extended to other work to further increase motivation: “These incentives that we get from MC really motivate us. If only the government could also do the same for other programmes I think the staff would be really motivated.”Several VMMC staff also noted that the PBF is motivating as a critical supplement to their salaries, remarking similarly to this MCFGP that, “if you know you are going to be paid you work extra hard.” One MCFGP believed that the incentive could help keep staff in their jobs, commenting, “we appreciate the extra dollar we getting. Some people are going to work in the UK for it but we are getting it while working here.” Another MCFGP suggested that the PBF money is critical to offset their low salaries.The economic situation these days is just hard. It’s difficult for me to get a dollar to buy this or that. The way we work and get the incentive actually motivates us because our livelihoods are improved.Non-VMMC staff also recognize the benefits of PBF on healthcare worker motivation. “I think on the incentive part I think it was good for it to be there, so it must continue, at least they are getting something and it’s motivating them. If funds permit, the incentives should continue,” an FGP declared. Another FGP understood that the PBF helps the VMMC work harder as it rewards their effort.I think it’s a good idea for people to get an incentive. If a person gets an incentive he or she will work well. If one works without an incentive he or she will just work half- heartedly just because it’s his or her duty, but if the duty has an incentive one will work very hard. So it’s good for people to get incentives.“they won’t say they are busy or not available or they are in the rural areas but they will come because of the incentive. It would be better if all programs would give incentives because it enhances the programs.”Key informants echoed claims from the focus groups noting that the PBF provided a much-needed salary supplement as “the major advantage is motivation among the staff getting the incentive especially considering that our salaries are very low.” Another KII added that, “people are grateful that they can put something on the table especially looking at the situation we are in where we do not know when our salaries will be coming.” One KII hinted at how the PBF-based motivation may also improve program quality as VMMC teams are more available to clients, noting that, Although the principle recipients of the money are the healthcare workers, themselves, a portion of the VMMC money goes to the hospital. In dozens of discussions, permeating the focus group and key informant dialogues, it was noted that the PBF money can be used to buy diverse commodities for the healthcare sites and not just benefit VMMC teams. One MCFGP noted that, “the money that is given to the institutions when earnings for the month come is that the money is used for providing food for patients admitted at the hospital. So I see it benefiting the hospital.” Others noted additional concrete improvements.At this hospital, they were able to buy some mattresses and repairing some benches even some of the benches you are seeing here, they were repaired by the money from MC. The hospital is in the process of buying more beds and curtains for the hospital with these funds. (MCFGP)The money also appeared useful for transportation issues for both the VMMC team and the hospital overall. A MCFGP commented that, “for us low cost hospitals it’s a good thing because the money goes for vehicle maintenance, so ultimately it benefits the hospital.” One FGP commented that this portion of the PBF actually benefits everyone indirectly: “Everyone benefits because at the end the hospital gets some incentives, and those incentives help patients who are our friends and relatives, so in a way we all benefit.”KIs were especially eager to note the positive effects of the PBF on the institutional level. One noted that the money helps, “to procure drugs and even day to day running of the hospital. So I think we have many advantages as a hospital and as a VMMC team.” Another added that, “we can do some repairs even some repainting and with this money we can go a long way [to] maintain the structure of the clinics.” Another KI more explicitly linked MC performance to the clinic-level improvements, stating that they are to buy some equipment like, “sphygmomanometer, thermometers, sterilizers and whatever depending with the amount of money that we get and the number of MCs conducted. We can do some repairs even some repainting and with this money we can go a long way maintain the structure of the clinics.”A KI summed the positive effect of the PBF beyond the individual level:Also the way it is done ensures that the districts benefit because when they cut more we get more, as individuals, as teams and also as the district. The hospitals also get some funds. Some of those funds are used to upgrade the facilities and also for supporting the team from the district as they go around doing supervisions. When they do the supervisions they do not only check MC but other health services provided…Most importantly the program comes with training of individuals so indirectly we expect to improve things like infection prevention and control, improved surgical techniques for the staff. So those things are very key.Overwhelmingly, in all focus groups and interviews, participants discussed how the PBF creates animosity among staff. Predominantly, the discord was related to how the VMMC program exacerbated the public-sector human resource shortages when the VMMC team leave their routine work to conduct circumcisions. As one KII explained:We don’t have specific personnel for VMMC. The same nurses and doctors who are supposed to perform VMMC are also supposed to perform other duties. So you find that the VMMC program can be demanding sometimes thereby straining the work relationship between the nurses and the doctors. That’s the main challenge.Those performing the circumcisions are well aware of the combined effect of the PBF and understaffing on their workplace relations. Commonly, conversations within the MC teams referred to understaffing in the wards as a result of the MC work. “The MC team members are also responsible for covering various departments in the hospital so when they go out for outreach some departments in the hospital face staff shortages,” noted a MCFGP. Another MCFGP justified the feelings on both sides:Everyone needs money, there is no one who doesn’t need money, whether it’s $100 or $200 or it’s 50 cents. Just an extra coin these days makes a difference. There is bound to be a gap between me and my colleagues when I go out and come back with something extra on top of my salary yet I left others in my department working.For those not involved in the VMMC program, there is obvious disgruntlement with the added workload in the absence of the VMMC team. Repeatedly, FGPs noted similarly to this non-MC worker who stated that when the teams leave to perform MC, “in other departments it creates shortage of manpower at work. If a health worker goes to MC, the one who remains behind does not benefit anything yet he carries the extra load for the person who went to the MC program.” Part of the human resource issue may be connected with the implementation of VMMC in outreach settings as well as in the static sites. One KII explained how performing VMMC outside of the static sites worsened the shortage of staff:The challenge now is it takes out some people from the system like the anesthetists, the theatre nurses and doctors. This is extra work that has come and established staff has to do it. So there becomes an artificial shortage with some people off work having gone for the outreach.In addition to staff tension, the PBF may lead to other workplace difficulties such as the development of distinct work groups, reducing team spirit. Some conversations got heated, more commonly in discussions among non-VMMC teams. One FGP revealed that, “if there is anything which brings hate rage it is money. People will hate each other. If there is conflict, even team spirit will not be there.” This results in dissatisfaction among staff, leading to distinct factions, described by one FGP participant as, “‘those for circumcision, those who make money’ and those ‘who just labour in vain.’”sadza [food] when they work so they should do the HIV tests themselves. It is really a challenge.”This divisiveness may leave some feeling disenfranchised, as one FGP suggested: “The one who will be left at the hospital working without getting an incentive will feel that he or she does not belong to the system.” Also, lack of staff cohesion may also lead to some staff refusing to collaborate without an incentive. As one FGP revealed, “Personally I witnessed some non MC cadres who do HIV testing refusing to test clients. Their argument was that the VMMC team is given One FGP summed well the conflicts causing rifts between MC and non-MC teams:We are happy that our colleagues are getting these incentives, but now it’s differentiating us from them. We work with them yet we end up asking ourselves if we went to the wrong school. They now handle themselves in a rude manner if you ask them about other health issues. (Group agrees) For example, non MC patients are no longer regarded as important. Working together is becoming difficult; it seems we are in different worlds. In the end we are at conflict because we don’t benefit and teamwork no longer exists.Many VMMC staff, themselves, were displeased with the value of the incentive. Some wished for additional recognition for how hard they worked and their long hours, considering, “after this outreach, we will have to go back to our hospital duties, we won’t even rest.” Other VMMC team members felt underappreciated and poorly rewarded for their level of effort, noting that the non-MC teams:Don’t understand the nature of our work. We come back around 12 midnight from outreach programmes. I think there is need to clarify to others who are not in the programme that we are actually going an extra mile for us to get the incentive, we do other duties.Other MC team members felt that the incentive did not match their level of effort and should be increased, as noted by this MCFGP participant:The payment is little considering the work we are doing. Especially here, we sacrifice, see the time we woke up? But we are going to recruit clients in a faraway place… We will come back late in the evening having worked very hard but only get paid just $3 each. That is very little; it’s not enough and is not in line with the amount of work done…This really affects us; so it would be good if the VMMC are increased a bit.According predominantly to KIs and non-MC staff, animosity and discord at the facilities may decrease the quality of patient care. Some of these acts appear intentional, as one FGP explained: “Sometimes you come across people needing help, but just because you are not part of that VMMC group, you will not render help to those people needing the help. I will be saying it is not my duty, there are designated people for it.” Another FGP expressed the distinctions in patient care that stem from PBF: “Due to the fact that I do not benefit anything, when I prepare sadza for patients sometimes I feel like discriminating against VMMC patients and just give the food to non-MC patients. But this is not good as they are all patients.Other non-MC staff felt that the general care provided to non-VMMC clients when the MC teams were out was suboptimal since, “at times the workload becomes too much, such that one will end up with burn out and performance is compromised.” Longer wait times for non MC patients was also noticed. One KI added that “you can also find long queues at facilities since there will be shortage of staff. Patients ended up not being treated because the remaining staff will not [be] able to cover all of them.”Others believed that MC teams prioritized circumcision work over their other routine duties. For example, one FGP stated that, “when VMMC has many clients and the program takes doctors on duty because it has to reach its own targets. In the end this compromises other programmes that will be ongoing.” Another FGP was more explicit about some VMMC teams shirking other ward duties in favor of VMMC outreach.“The wards are left with no staff the whole day. If no one was receiving incentives the nurses would attend to the patients; this would result in a balance of everything because benefits will be equal. The MC team tries to reach targets because the more they circumcise the more incentive they get so they concentrate mostly on MC patients.”One KI concurred, suggesting that some MC providers may prioritize circumcision over other more urgent work which was not incentivized:“For instance, if there is a patient who needs to have a caesarean done and at the same time the doctor has to go out for MC, if he remains doing the C-section he doesn’t get any incentive for that C-section so he would rather go and do MC. So this has affected quality of care in some areas.”When asked about the future of VMMC without the incentive, some felt that the program could continue, albeit at slower rates. One KI commented, without the PBF, VMMC services would continue “since the skills are there already, I am sure they will just offer the service just like we do our work normally from 8am-4pm.” This would reflect a more passive approach to VMMC, due to decreased motivation as one MCFGP opined, “without the incentives probably we would just wait for those who come in on their own, the walk-in clients. It would be very difficult to go out and mobilize for nothing.” Outreach efforts would slow or stop as MC team members would no longer receive extra benefits that encouraged extra effort. “If people are used to getting an incentive then all of a sudden you just remove it, it means all those people who used to go for outreach might be de-motivated,” noted a KI. The lack of incentive could also affect the non-clinical team that conducted demand creation activities to complement service delivery, further reducing potential clients. One MCFGP felt that, “if mobilisers have their incentives or benefits removed they will not mobilise anyone. I don’t think they go into the community while getting nothing; it will be difficult.”Some believed that the program should never have implemented a PBF. “It might have been better had the incentives not been introduced in the first place. If it is removed productivity will go down. That is what I think,” noted one FGP. A KI added, “so many things were introduced in the system without any incentive and they were taken up very well but because this started with money, now stopping the money is like stopping the program.” Even MCFGPs agreed, with one suggesting that expansion of the program should not include the PBF as “it’s good for the people to do voluntary work, without expecting anything.”This study suggests that the PBF clearly increases motivation among the VMMC team and helps improve the facilities where VMMC services are provided. However, it also appears that the PBF contributes to antagonism at the workplace, creating a divisiveness that may reach beyond VMMC. The cost-benefit of improved, short-term productivity against potential longer-term, negative social and behavioral effects as well as diminished sustainability should be carefully considered when implementing program-specific PBF models. Several lessons learned merit discussion.First, although the program is exceeding its targets, the incentive appears to create discord in the healthcare setting, potentially creating a long-term, negative outcome within the provider community. This finding is not unique to our setting. In a 2009 Norwegian review of PBF schemes, PBF interventions were found to achieve short-term performance gains ; howeverIn addition to the inter-provider relationship strain, the PBF may also negatively affect overall patient care. The PBF may cause distortions in the healthcare system, leading to the prioritization of incentivized VMMC services over other routine duties. These distortions may result in decreased quality of care if the sole focus on the programmatic numbers and gaining financial reward . The disTo reduce workplace tension and increase sustainability, participants principally mentioned two programmatic changes: increased VMMC training and improved VMMC program integration. First, expanding the number of healthcare workers trained to perform VMMC could reduce staff animosity and increase access to VMMC. Many mentioned, similar to this MCFGP, that “if more cadres are trained in MC I think it will make life easy. If there are rotations, staff may rotate and the tension among staff members can ease.” Additional clinical teams should be trained both to rotate VMMC staff and to reach additional outreach locations, an initiative that would expand the beneficiaries of the PBF. Currently, the training model is slow and centralized, increasing the time it takes to train providers and removing trainees from their work places to gain VMMC skills. To complement this established approach for surgical VMMC, the introduction of a modified apprenticeship approach to reduce training time and allow for workplace training by experienced VMMC clinicians is worthy of consideration. Moreover, as PrePex device-based VMMC expands, additional cadres of nurses should be trained in this less invasive method. PrePex requires fewer training hours than surgical VMMC and can be implemented safely by lower cadres of nurses . FurtherIt also appears that our model of VMMC integration may not operate within healthcare system as envisaged. One KI disclosed that VMMC “is not integrated like immunizations, like ART, HIV and Tuberculosis; the approach is sort of different.” The intent of the integrated VMMC approach in conjunction with the PBF was to utilize, and incentivize, existing healthcare workers to implement VMMC as part of daily work, leveraging the current workers to meet the VMMC program goals and encourage sustainability. However, in reality, VMMC appears to operate outside of routine care provision with a separate group of healthcare workers focused on VMMC, reducing achievement of health system strengthening objectives. Several of those who worked within the clinics commented similarly to this FGP: “The program is only for those who are given incentives. We are not part of it because we are not paid for it. If the program involved everyone, then everyone would participate saying it is ‘our’ thing.” Although VMMC integration does ensure that MOHCC staff and facilities benefit from short-term training and refurbishment, long-term sustainability of VMMC under any an integrated, or any implementation, model is unlikely in the absence of targeted funding. Additionally, PBF for a narrow program focus is less common as most PBF mechanisms apply to broader service delivery. The consequence of having PBF for a singular program may contribute to staff segregation because the VMMC program often requires VMMC staff to leave their facility to perform VMMC at outreach locations.Although current funding indicates no immediate end of the PBF in Zimbabwe’s VMMC program, the eventual reduction or removal of the PBF may lead to declines in VMMC outputs: without the money, providers may no longer have the motivation to work for non-monetary rewards of recognition or satisfaction, reducing their effort on tasks that provide no incentive . TherefoThere are several limitations that influence application of the results for program and policy. First, additional insight into the selection of VMMC teams and use of the PBF at the facility and district levels would complement the current exploration. However, the study was intended to be both small-scale and rapidly implemented to explore healthcare worker opinions and not the impact of the PBF, reducing the scope of the activity. Second, the sites selected and staff interviewed were selected by convenience sample and may not be representative. Caution should be employed when extrapolating beyond the included facilities. Third, although facility teams operated exclusively in the context of the ZAZIC PBF model, PMDs could have responded based on their experiences with other VMMC models within their provinces. We are unable to determine if all PMD opinions were specific to the ZAZIC integrated VMMC model. Fourth, although additional details on the participants and the VMMC sites could aid understanding of the results, protection of participant confidentiality and prevention of site identification outweigh the potential gains in results interpretation. Furthermore, as the PBF used in the Zimbabwe VMMC program is unique in its narrow focus on VMMC, our results may not be generalizable to broader PBF models. Lastly, although interesting differences between sites may exist, sites and staff are not further described or compared to protect the confidentiality of the participants. Despite these limitations, we believe that the study provided key insights into the implementation and effects of the PBF with the VMMC programs, lessons that are worthy of consideration in Zimbabwe and the region.Overall, the PBF was one component of ZAZIC’s approach that contributed to swiftly bringing the VMMC program to scale, enabling ZAZIC to meet the program objectives. In the under-funded and short-staffed context of Zimbabwe, the PBF was a crucial factor in the rapid scale up of this program and achievement of ambitious targets. However, despite working in an integrated manner with local providers, ZAZIC’s successful attainment of high performance targets is accompanied by unintended distortion in the health care system. These side effects to this PBF approach appear to make it less advantageous and sustainable than envisioned. Although a vertical approach may still merit consideration, we believe that the strengths of the integrated approach complemented by the PBF remains favorable in terms of existing staff training, improving healthcare facilities, and strengthening aspects of the healthcare system. Careful consideration of program goals and objectives is warranted in choosing whether, and how, to implement PBF to prioritize or fast-track a public health program.S1 File(DOCX)Click here for additional data file.


Finding this factor therefore amounts to angle packing and finding an appropriate embedding dimension. Neither the embedding dimension nor the directions may be unique, and so many cp factorizations of the same given matrix may coexist. Using a bordering approach, and building upon an already known cp factorization of a principal block, we establish sufficient conditions under which we can extend this cp factorization to the full matrix. Simulations show that the approach is promising also in higher dimensions.A symmetric matrix of order  By i, j, so X is the Gram matrix of the directions F (and m) amounts to find a space X describes (length and) angles of this direction, i.e. solving an angle packing problem.One immediate geometric interpretation is as follows: write F yielding a cp factorization of X is called the cp-rank of X. In light of above interpretation, determining the cp-rank means to find the smallest embedding dimension such that the angle packing problem has a solution. This embedding dimension, i.e., the cp-rank can exceed the order n of X . But the cp-rank is bounded by The minimal number of rows in F, i.e., writingAn alternative format of cp factorization can be obtained using ns Burer , any of X of full rank and those with all entries strictly positive. The cp-rank and more general, any cp factorization of X, can give more information on X with respect to this geometrical structure and at the same time provide alternative (approximate) solutions. More detail will be provided in Sect. So both representations have their advantages and can easily be transformed into each other. In the sequel, we will adhere to the format entclass1pt{minimaY, and derive sufficient conditions under which we can specify a suitable factor H. This is the content of Sects. In this paper we aim at obtaining a cp factorization of a symmetric copositive optimization (or copositive programming) by Bomze et al. . Very few recent papers deal with approximating Once we arrive at a solution ickinson  and Dür ickinson , while aickinson .Y which we scale such thatX. Note that as Y is negative. Similarly, positive-semidefiniteness of Y implies that a zero diagonal entry forces the whole row and column to be zero, in which case we can remove it and continue with a smaller principal submatrix with strictly positive diagonal elements. In the end, we just have to enlarge the factor H by suitably adding zero columns, to obtain the original Y. Hence we may and do assume i. Next, we observe that with any positive-definite diagonal matrix Y contains only unity entries. This is the starting point of  of any matrix.Suppose that nonnegative matrix factorization (NMF) problem. For a recent survey on NMF see, e.g. Wang and Zhang  variant of the nowadays heavily researched nd Zhang . In thise et al.  where a  Gutjahr ; see als Gutjahr . In cont Gutjahr , Berman  Gutjahr , Berman  Gutjahr , Berman  Gutjahr , Dickins Gutjahr , Shaked- Gutjahr , Shaked- Gutjahr  and Spon Gutjahr  and the  Gutjahr , to cite Gutjahr  deals wir such that  in Berman and Shaked-Monderer   \documenondition  also sti and Teo  aiming aX was already (close to) minimal, then also above factorization is (close to) minimal, because the increment of embedding dimension for the angle packing problem is one. Section As mentioned, cp factorizations need not be unique, and with respect to some criteria, the one proposed above need not be optimal. However, if the cp factorization of The next section deals with condition . We willThe function atisfies . The firmentclasspt{minimaikewise, . Finallyikewise,  without alent to . As mentmentclasspt{minimatisfying , we therPu as in  with14\dmentclasspt{minimaSuppose that rization  for 1)..\documenany feasible any feasible rization ;else ility of  by putti      then ((a1) Consider the convex, linearly constrained QP    then  has no sany feasible any feasible rization ;else ility of  by putti      then ((b1) Consider the convex quadratically constrained QPmentclasspt{minimaany feasible rization ;else  is infea(c1) Consider the convex nonsmoothly constrained QPStatements (a1) and (b1) follow by multiplying the inequalities in  and 17)17), resp>0, then -feasibilProblem  can be rF is square  a aF is sqproblems  are of natisfies , 12), o, oF is satisfies . In a sment}y≥o, , (12), aent}y≥o,  are met X with cp-rank not exceeding n, but we are not sure that Y is completely positive. So the decrease of success rates with increasing dimension have to be discounted by the probability that matrices Y of this kind are completely positive with cp-rank not exceeding The figures reported in Table Y, for the following reason: then we either would have a trivial success for the simulation  izations  or 5) a a\documethe form . HoweverG are nonnegative,F is usually more dense, e.g. for the data of Berman and Shaked-Monderer .Nevertheless, this still has some justification as the solutions of copositive optimization problems arising from most applications are expected to have a low cp-rank. An admittedly heuristic argument goes as follows: imitating the proof of Shaked-Monderer et al. , Thm.3.4em Bomze , corroboem Bomze , 2010 shX we can start with any one. We will aim at enlarging the number of rows of G which will play the same role in H as in  is straightforward. Likewise, to establish (b), we calculateF is an So let us assume in the sequel that Q as in F, the only choice for Similar strategies as in Sect. position  is predeH can be less than one, which opens more possibilities to proceed similarly as above. Given above empirical evidence, this may be a promising avenue of future research.Finally we briefly sketch a possible extension if Schur complements are no longer completely positive. Then we have to abandon the upper-triangular strategy and use a general