There is little evidence to date of the potential impact of vegetable gardens on people living with HIV (PLHIV), who often suffer from social and economic losses due to the disease. From 2008 through 2011, Action Contre la Faim France (ACF) implemented a project in Chipinge District, eastern Zimbabwe, providing low-input vegetable gardens (LIGs) to households of PLHIV. Program partners included Médecins du Monde, which provided medical support, and Zimbabwe's Agricultural Extension Service, which supported vegetable cultivation. A survey conducted at the end of the program found LIG participants to have higher Food Consumption Scores (FCS) and Household Dietary Diversity Scores (HDDS) relative to comparator households of PLHIV receiving other support programs. This study assessed the incremental cost-effectiveness of LIGs to improve FCS and HDDS of PLHIV compared to other support programs.This analysis used an activity-based cost model, and combined ACF accounting data with estimates of partner and beneficiary costs derived using an ingredients approach to build an estimate of total program resource use. A societal perspective was adopted to encompass costs to beneficiary households, including their opportunity costs and an estimate of their income earned from vegetable sales. Qualitative methods were used to assess program benefits to beneficiary households. Effectiveness data was taken from a previously-conducted survey.Providing LIGs to PLHIV cost an additional 8,299 EUR per household with adequate FCS and 12,456 EUR per household with HDDS in the upper tertile, relative to comparator households of PLHIV receiving other support programs. Beneficiaries cited multiple tangible and intangible benefits from LIGs, and over 80% of gardens observed were still functioning more than one year after the program had finished.Cost outcomes were 20–30 times Zimbabwe's per capita GDP, and unlikely to be affordable within government services. This analysis concludes that LIGs are not cost-effective or affordable relative to other interventions for improving health and nutrition status of PLHIV. Nonetheless, given the myriad benefits acquired by participant households, such programs hold important potential to improve quality of life and reduce stigma against PLHIV. Nutrition status is an important factor in the etiology and progression of HIV. Nutrition and immunity are linked, with impaired immune function from suboptimal nutrition status hastening progression of HIV. People Food insecurity exacerbates nutritional deficits, and leads to risky coping mechanisms and poor HIV outcomes in resource-limited settings-10. AddiInterventions aiming to improve food access and diet quality of PLHIV often focus on provision of food supplements. HoweverHome and community garden projects have demonstrated a broad array of benefits to vulnerable populations in various settings. Improving access to the quality and quantity of food with home gardens helps to improve dietary diversity and micronutrient status. WorkingThe limited evidence which exists on home gardens for PLHIV has documented beneficial effects. In Ghana, home gardens were found to contribute significantly to dietary diversity among households of PLHIV, and to be valued as a productive asset by these households. In CambThis paper examines an intervention providing home gardens to PLHIV in Zimbabwe, one of the Sub-Saharan African countries most affected by HIV and AIDS, with an estimated prevalence among adults of 13%. From 20From January 2008 through January 2011, ACF implemented a EuropeAid-funded program to improve the nutrition and food security status of PLHIV through use of low input gardens (LIGs) in five wards (sub-districts) of Chipinge District. In this rural area, agriculture is the main livelihood activity, and households commonly grow staple crops  along with a limited variety of vegetables; production is sub-optimal due in part to high HIV prevalence and poor economic conditions. In order to supplement these local diets, the LIG project was intended to increase and diversify households' home production with a wide variety of nutrient-rich vegetables grown in community gardens. The gardens themselves required minimal, locally-available inputs, and relied on biological control for diseases and pests.ACF set up gardens, provided fencing, seeds and tools; constructed water points and latrines; and provided training and technical support to beneficiaries. Additional support was provided by Agricultural, Technical and Extension Services (Agritex), Zimbabwe's national agriculture extension program, which acted as a formal partner providing technical support on vegetable cultivation practices to teach households how to achieve maximum yield from the gardens. Participation in the LIG program was voluntary, and beneficiaries comprised PLHIV who were enrolled in MDM support groups, receiving counseling and accessing ART, who also chose to work in the gardens.At the end of the LIG program, a cross-sectional survey was conducted during an operational research evaluation to assess several outcomes among LIG beneficiaries, including nutritional status  and several internationally-validated composite measures of both food security  and dietary diversity . Survey Given these encouraging findings on the effectiveness of LIGs, this analysis has sought to further assess the total cost and cost-effectiveness of LIGs for improving the food consumption (FCS) and dietary diversity (HDDS) of PLHIV, compared to other agricultural and HIV support programs.This study used mixed methods to assess, from a societal perspective, the total cost and cost-effectiveness of LIGs as a strategy for improving the food consumption and dietary diversity of PLHIV in five wards of Chipinge District, relative to comparator households of PLHIV participating in other support programs but not in LIGs. Cost-effectiveness was assessed retrospectively, using accounting records, program documentation, focus group discussions and key informant interviews. All costs are presented in 2010 EUR.Costs were estimated for the full spectrum of program activities, including all known major interventions received by participant and comparator households which could contribute to food consumption and dietary diversity outcomes. These included other support programs implemented by partner organizations such as MDM, which implemented support groups that provided counseling, testing and access to ART (and upon which the LIG program was based), and Agritex which, in addition to providing specific support to the LIG program on vegetable cultivation practices, also conducted monthly training sessions on general agricultural techniques for communities in the LIG program catchment area, as part of their ongoing extension programs.Participant households were defined as those taking part in LIG program activities. Aside from the LIG program, the other aforementioned HIV and agricultural support programs were received by both participants and comparators. Comparator households were defined as those receiving only these other support programs, and not LIGs.ACF accounting data was used to assess total cost of the LIG program. For other support programs, only the costs for activities relevant to diet diversity outcomes were included. These programs were received by both participant and comparator households and therefore costs cancel each other out during incremental analysis. Costs for other support programs were estimated with an ingredients approach, using unit costs and quantities of various inputs.The period of analysis encompasses program implementation from January 2008 to January 2011; gardens were active in only 2 of these 3 years due to political unrest and contracting delays. Additionally, costs of MDM support groups were included from that program's inception in 2007, assuming that sensitization by CBCs about the importance of a healthy diet eventually helped to increase beneficiary acceptance and participation in the LIG program. Beneficiary costs for the program implementation period were estimated during focus group discussions (FGDs), to assess potential benefits and cost savings to households participating in the LIG program. These included both direct and indirect costs (i.e. opportunity costs) of program participation, an estimate of income earned from vegetable sales, and an estimated value of the land donated by beneficiaries and communities for the gardens. Beneficiary perceptions of LIG benefits provide context to quantitative findings.This analysis employed an activity-based costing (ABC) methodology, wherein program activities were used as an intermediate step to allocate the total cost of a program to its outcomes, rather than only to its inputs as is done with traditional accounting centers .Outcome data for participant and comparator households were taken from the cross-sectional survey conducted at the end of the LIG program, which included measurement of HDDS and FCS.Total cost of the LIG program was divided by number of participant households to estimate cost per beneficiary household. Costs for other support programs were subtracted from cost per beneficiary to estimate incremental cost of the LIG program. Cost-effectiveness was assessed using incremental cost-effectiveness ratios (ICERs). To explore uncertainty in costs and outcomes, we performed univariate and multivariate sensitivity analyses.Effectiveness data were taken from a cross-sectional survey conducted as part of a separate analysis. For incThe survey found that participant households were different from comparators in that they had received more food assistance, and had more land available for cultivation. Regression analysis was used to control for several variables, including socio-economic status and receipt of food assistance. Higher scores among participant households relative to comparator households for HDDS (6.6 vs. 5.7) and FCS (40.5 vs. 36.1) were found to be independent of these factors.The HDDS represents a household's dietary diversity, and is measured by summing the number of food groups consumed in the past 7 days, from 12 food groups including cereals, roots and tubers, fruits, fish and seafood, and oils and fats. The HDDS has a minimum score of 0 and a maximum of 12. The FCSField data collection for the cost-effectiveness analysis occurred in April and May 2012. FGD guides were revised for clarity with local program staff before beginning data collection.Institutional costs were estimated via a review of internal documents including program reports and accounting data, along with key informant interviews with relevant staff from ACF and partner organizations. For staff with whom an interview was not possible or practical, time allocation estimates were used from other staff implementing similar activities and from supervisory staff where available. Thirty-three key informant interviews were conducted with current and former ACF staff (n = 25), partner staff (n = 7) and local government officials (n = 1).Shona, and translated discussions into English.To conduct FGDs with households of PLHIV, a list of LIGs was purposively selected to obtain a sample of gardens with variation in source of water, climactic conditions, accessibility, access to markets and available economic opportunities in the surrounding area . FGDs were conducted at 15 garden sites with participant households , and 5 sites with comparator households identified via MDM staff . ACF staff were asked to select beneficiaries at random from the list of garden participants when organizing the discussions. During FGDs, a translator asked questions to community members in the local language of Participants were asked about time spent working on the gardens, local daily wage rates available for agricultural labor and expenses paid with garden earnings. Comparators were asked about time spent in agricultural training sessions provided in these communities, and wages for common livelihoods in their area.Total cost was estimated using a combination of accounting data (for ACF costs) and ingredient cost estimates (for costs to partner organizations and participating households). To estimate partner and beneficiary costs, a micro-costing approach was applied wherein all activities were broken down into their component ingredients, and costs were then estimated for each ingredient. IngrediSeveral assumptions were made in estimating costs. A shadow wage for community members (including LIG beneficiaries and volunteer MDM staff) was estimated using the median wage rate for rural livelihoods in Chipinge from community discussions, at 1 USD per day or 0.20 USD per hour. Within the LIG program, a smaller pilot project was implemented to assess the ability of PLHIV in Chipinge to implement Conservation Farming (CF) practices. Costs and activities relevant to this project were allocated to a separate cost center. Costs of staff time from ACF headquarters were not included in this analysis. See the Additional fileField notes from FGDs with community members were transcribed into Microsoft Word and analCost data was adjusted in several steps before arriving at the final estimates. Some costs were excluded if they were not determined to contribute to routine program operations nor to HDDS and FCS outcomes achieved. Costs of program assessments were excluded; but costs of routine monitoring were included as these contributed to program effectiveness. Capital items such as computers and cars were amortized using standard tables  and discounted at a rate of 3%. Program accounting data was converted to Euros from other currencies on a monthly basis using exchange rates from the Reserve Bank of Zimbabwe. All accounting data and ingredient cost estimates from 2008 and 2009 were adjusted for inflation using a Consumer Price Index, and allAfter adjustments, cost data was allocated to program activities via the ABC methodology. This was done by direct utilization where possible. Program support costs that were shared among multiple activities  were allocated using time allocation proportions of implementing staff, according to ABC methodology.To employ the ABC methodology, key informant interviews were conducted with program staff to determine the main program activities and their time dedicated to each activity. For each main program activity, time allocation represents a weighted average of different personnel in different sectors  spending varying amounts of time on the activities.Ingredient costs were estimated using Microsoft Excel software. Costs wBase case cost-effectiveness results used average cost per beneficiary household and observed HDDS and FCS outcomes among participant and comparator households. Incremental cost effectiveness ratios (ICER) were calculated for both HDDS and FCS outcomes, representing the additional cost of the LIG program for each additional household with HDDS in the upper tertile and with an "acceptable" FCS (>35), relative to other support programs.Sensitivity analyses were conducted to determine whether base case cost-effectiveness estimates (i.e. ICERs) would change substantially given a plausible level of variation in costs and outcomes. Uncertainty was modeled using TreeAge Pro 2012 software, employiUnivariate sensitivity analyses considered two main variables for the LIG program: cost per beneficiary household and outcome achieved . The base case estimates for probability of achieving an improved HDDS or FCS outcome were taken from the LIG survey. During A multivariate probabilistic sensitivity analysis was conducted to assess variation in multiple variables simultaneously, based on 100,000 random "Monte Carlo" simulations. The results were used to create cost-effectiveness acceptability curves for each outcome.Results are presented in several stages. First we present a qualitative analysis of beneficiary perspectives on the benefits and costs of the program. Second, an estimate of beneficiary income from vegetable sales is presented. This is followed by an analysis of program costs. Finally, results from the cost-effectiveness analysis are presented.During community discussions, beneficiaries cited multiple positive effects of the gardens on their households and communities.According to LIG members, the gardens provided body-building foods which kept them and their households healthy and strong:“We don't want to hear people call us 'sick people'; we want to be called 'farmers' because we're healthy”.“If you had seen us before, you would feel pity because we were small and sick. Now, from eating the garden food, we've grown so healthy and big, you can't even tell we're living with HIV”.Working among others in the garden gave them a social outlet and relieved isolation and anxiety:“When the garden started, most of us were very sick and we would think a lot. But now we work in the garden and talk to each other, it relieves our stress”.“The garden reduced our stress in a way. Now we grow vegetables and sell them, and then use the vegetables for transport costs to get to Chipinge town to get our ARV”.Beneficiaries also cited other intangible benefits from garden membership, including community cohesion and reduced stigma against PLHIV. Because of their access to a productive asset, they were now in a position to help others:“At the start of the gardens [in the financial crisis of 2008], people had no money, so we had to do barter trading. We would exchange vegetables for oil. This built a relationship between people in the gardens and the community. There was no more discrimination”.“People used to discriminate us before. Now that we're working in the garden, we're no longer discriminated. Now people come queuing in the garden asking us for our vegetables”.Many beneficiaries cited a sense of "unity" with other garden members:“The garden helped a lot because we developed "one-ness" that was not there before. We don't want to miss each other”.“The garden gave us unity and one-ness because we are different people from different areas who work in the garden. It also helped us to develop love for each other and we take time to care for garden members who get sick”.While beneficiaries never spent their own household money on the gardens, many gardens members organized themselves to use proceeds from vegetable sales to pay for upkeep and maintenance of the garden and the water points:“We are not using our personal funds for the garden, even now [one year after the program ended]. We buy seeds with the money from selling vegetables. When the borehole breaks down, each person needs to sell two bundles of vegetables to buy the part for repair”.“The person who repaired the borehole charged $10. Garden members contributed $0.50 each and community members also contributed since they use the borehole for water”.A primary threat to garden sustainability occurred when these upkeep and repair costs exceeded what a community was able to pay:“We didn't have enough money to finish the latrine, so we didn’t put a roof on it [used thatch instead], no ventilation, no cement. The money from the vegetables was not enough to cover that”.Beneficiaries also cited specific financial benefits of the program. Many groups started savings schemes where they would loan each other money at interest for large purchases, or during times of trouble. They could sell excess vegetables and buy other groceries, pay for household necessities like school fees for their children, and even afford transportation to Chipinge town to get their antiretroviral drugs (ARV):“When we have vegetables, each person gets five bundles from their beds and sells them. We give this money to the treasurer. We did that repeatedly until we bought a goat… Our plan is to expand the garden, and buy a fence so that other PLHIV can grow vegetables”.“When my child was sick, I sold tomatoes for money and managed to take him to different hospitals for medication, and he survived”.Table Two potential financial benefits of the program were: (1) the expenses paid by households using garden proceeds , and (2) the cost savings to households in consuming vegetables which they otherwise would have had to purchase. This analysis includes an estimate of the first benefit; an accurate estimate of the second would have involved estimating garden yields, which was challenging due to the time elapsed since implementation, and was beyond the scope of this analysis.Beneficiary cost data from Table Estimated income was converted into 2010 EUR and multiplied by the number of households participating in the project, assuming that only half of the LIGs were active in the first year, for a total of 138,272 EUR. This garden-related beneficiary income was incorporated into the analysis as a financial benefit, by deducting it from program costs.Figure Program activities and staff time allocation proportions derived from the activity-based cost analysis are presented in Figure Table Table Table The x-axis represents willingness to pay per household achieving an improved HDDS or FCS score (in thousands of EUR). The y-axis represents the base case ICER estimate for each outcome from Table For both FCS and HDDS outcomes, one-way sensitivity analyses showed that the model was most sensitive to assumptions about these outcomes (i.e. the probability of participant or comparator households achieving adequate FCS and high HDDS).Figure Providing low input gardens (LIGs) to PLHIV in a 3-year intervention, in partnership with organizations focusing on medical support for PLHIV and agricultural support for rural communities in Zimbabwe, carried an average cost of 1,525 EUR per beneficiary household from a societal perspective. For the money being spent on the LIG program, compared to these other support programs, there was a 40% increase in the number of households with an improved Food Consumption Score (FCS), and a 30% increase in the number of households with an improved Household Dietary Diversity Score (HDDS). The incremental cost for each participant household that had a higher food consumption and dietary diversity score, relative to comparators, was 8,299 EUR and 12,456 EUR respectively. These cost-effectiveness outcomes were sensitive to the assumed level of program effectiveness. The LIG strategy was most likely to be cost-effective if society was willing to pay more than 20,000 EUR to improve dietary diversity and food consumption levels of households of PLHIV. These findings cohere with other qualitative findings suggesting livelihoods programs for PLHIV are generally resource-intensive[We are aware of no other cost-effectiveness studies of similar interventions, or with similar outcomes, with which to compare these results. Cost effectiveness outcomes exist for other HIV-related programming, representing a wide array of interventions, including treatment, prevention and palliative care. Counseling and testing cost 32,000 USD per case of HIV prevented. ReductiEvidence from food assistance programs provides further context for our findings. In Ecuador, a 7-month food assistance program comparing cash, staple food rations, and food vouchers found a significant increase in HDDS (0.4-0.5 point increase) and FCS (6.1-9.4 point increase) in all 3 interventions relative to a control group. In NigeA food assistance study in neighboring Mozambique found the institutional cost of providing a staple ration to PLHIV to be 288 USD per patient over 3 months. The stuThere is no standard threshold against which to measure these cost-effectiveness outcomes; however Zimbabwe is a poor country with a 2010 per capita GDP of 449 EUR. ConsideNotwithstanding its relative success with dietary diversity outcomes, the high cost to achieve these outcomes lead us to conclude that the LIG program was not cost-effective as a means of improving dietary diversity among PLHIV in this context. While LIGs provide multiple benefits, they are considerably more expensive than other interventions to improve dietary diversity and food consumption.However, community needs can be complex. As access to ART expands in developing countries, life expectancy for PLHIV will increase. To improve the quality of these life years gained, other more holistic support services, such as income generating activities and other food security interventions will be needed-41. The The assets provided by this program - including garden tools, fencing, water points, tool kits, irrigation systems and latrines - contribute to its high costs. The cost of a single borehole can exceed 6,000 USD (ACF accounting records). This is a significant expenditure, although there is a strong humanitarian argument in favor of equitable provision of potable water to vulnerable communities.A key consideration for cost-effectiveness of LIGs is whether their benefits are sustainable. Over 80% of gardens visited for this assessment were still functioning one year after the program ended, suggesting sustainability of program benefits among the majority of participant communities. Common challenges to garden functioning were soil salinity and malfunctioning water points. The qualitative analysis found that an important threat to garden sustainability was the cost of upkeep and repairs. While garden members can organize to share these expenses, some costs may be beyond communities' ability to sustain in the long-run. This threat to sustainability will need to be considered in future garden interventions.Previous analyses have documented challenges with participation in public programs if the cost of participation, including the opportunity cost of time spent participating, is too intensive-45. ThisDiscussions with program staff uncovered inefficiencies and delays in the program timeline, due both to political unrest and delays in contracting construction of latrines and water points. These inefficiencies had implications for program cost-effectiveness by limiting beneficiary time spent in vegetable production, training sessions and other forms of sensitization. This reduced the effective implementation time from 3 to 2 years and may have limited overall effectiveness of the program in improving dietary diversity and food consumption of beneficiary households. Cost-effectiveness of future similar programs could potentially be improved through enhancing efficiency of program activities.There are important methodological limitations to the effectiveness data on which this cost-effectiveness analysis was based. While the HDDS and FCS outcomes were significant and robust to covariates such as socioeconomic status and receipt of food aid, and although participant and comparator households were matched on ward of residence, we cannot rule out the possibility that participants and comparators may have been different. This is partly due to lack of baseline measurements. Also, due to self-selection of participants, a common challenge when assessing garden programs, there mThe cost-effectiveness study was limited in that, at the time of data collection, the program had been completed for over one year. First, this meant that all respondents needed to recall events that happened more than one year in the past. Second, due to the time elapsed we were not able to access all program staff for key informant interviews and to assess their time allocation. Additionally, for the staff with whom we were able to consult, the time elapsed since the end of the program may have made it difficult to recall with accuracy their time expenditure on program activities. However, given that we were able to contact a substantial number of former staff, engaged in a variety of program activities, we do not feel that these potential limitations greatly detract from the usefulness of these findings.This analysis also has important strengths. While there is growing interest in livelihoods programs for PLHIV, to date there is limited evidence of their effectiveness, and this is the first analysis of which we are aware that assesses cost-effectiveness of such a program. Further, this analysis presents a detailed account of total program costs from a societal perspective, which provides a comprehensive picture of the financial costs and benefits to participating households. Finally, the use of mixed methods enabled us to capture beneficiary perspectives on the myriad tangible and intangible benefits of this program, which help to explain why many households were still working in the gardens more than one year after the program had finished.Previous research has identified a lack of appropriate indicators for livelihoods programs for PLHIV, which capture clinical markers as well as food security status. While cQuality of life was assessed in the operational research evaluation for this program, and was not found to differ between participant and comparator households. HoweverAdditional research should be conducted to quantify the impact of programs like LIGs on other important clinical outcomes, in order to compare the effectiveness and costs of this program strategy more broadly with other HIV-related programming. Further, this analysis has captured costs and benefits during the program cycle; future analyses could measure or model costs and benefits over a longer timeframe to estimate some of the potential longer-term impacts of this program strategy, and whether effectiveness and cost-effectiveness might increase over time.Providing low input gardens (LIGs) to PLHIV in rural Zimbabwe in a 3-year intervention, along with agricultural training and sanitation infrastructure, yielded higher food consumption and household dietary diversity outcomes among participant households, relative to comparator households receiving other agricultural and HIV support programs. Communities cited additional psychological, physical, financial and dietary benefits from working in the gardens; moreover many gardens were still functioning one year after withdrawal of program support, suggesting potential for sustainability. However, the cost to achieve these outcomes, at 20–30 times Zimbabwe's per capita GDP, is unlikely to be affordable particularly within government services. Given these findings, this analysis concludes that LIGs are not cost-effective or affordable relative to other interventions for improving health and nutrition status of PLHIV. Nonetheless, given the myriad benefits acquired by participant households, such programs hold important potential to improve quality of life and reduce stigma against PLHIV.The authors declare that they have no competing interests.CP participated in study design, collected, analyzed and interpreted data and drafted the manuscript. CS participated in study design and coordination, contributed to data interpretation and was involved in drafting the manuscript. EL and SZ contributed to data acquisition and interpretation, and helped to revise the manuscript. MA and AI participated in study design and coordination, and helped to revise the manuscript. All authors read and approved the final manuscript.Details on ingredient cost estimates and costing assumptions.Click here for fileResource use by program activity.Click here for file


The Funding section was unintentionally omitted. The complete, correct funding information is:This study was supported by the National Natural Science Foundation of China , the Major State Basic Research Development Program of China (973 program) (2015CB150502), the High Technology Research and Development Program of China (863 Program) (2012AA06A203), and the National Key Technology Rand D Program (2012BAC17B04), the Science and Technology Project of Zhejiang Province , and the Environmental Science Project of Zhejiang Province (2012B006). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.The publisher apologizes for the error.


Financial health incentives, such as paying people to lose weight, are being widely implemented by Western nations and large corporations. A growing number of studies have tested the impact of incentives on health behaviors, though few have evaluated the approach on a population-scale. In this issue of the Journal of Medical Internet Research, Liu et al add to the evidence-base by examining whether a single incentive can motivate enrollment and engagement in a preventive eHealth program in a sample of 142,726 Canadian adults. While the incentives increased enrollment significantly (by a factor of about 28), a very high level of program attrition was noted (90%). The “foot in the door” incentive technique employed was insufficient; enrollees received incentives for signing-up for, but not for engaging with, the eHealth program. To supplement this technique and drive sustained behavior change, several theoretically- and empirically-based strategies are proposed. Specifically, incentives indexed to behavioral achievements over time are highlighted as one approach to boost engagement in this population in the future. In thisn adults .Not surprisingly, and consistent with the “single-shot” incentives literature, the authors found that individuals offered the incentive were 28 times more likely to enroll in the eHealth program. The question is, was this impressive boost in enrollment meaningful considering the significant attrition (about 90%) noted by the authors? The data would suggest that this was the case. Although program attrition was substantial, the fact remains that about 5000 adults who might not have otherwise enrolled in the eHealth program (without the contingent incentive) continued onto the next step of the program , and about 1000 of those individuals remained engaged 6 weeks later .  It is not clear whether this level of engagement  was sufficient to stimulate “lifestyle” health behaviors to the extent required to produce clinically or health-economically relevant changes. This is a topic for future study . Regardless, the incentive approach employed here holds great promise for enhancing the delivery (reach) of Web-based prevention programs. In the midst of this potential, however, there is room to improve upon the design, and maximize the impact, of the incentive offering. First, the “foot in the door” design technique employed was insufficient to drive eHealth program engagement in this population. While getting people to agree to do something small , can sometimes make them more likely to do something big , according to behavioral economics , this isregular (perhaps daily or weekly) eHealth program use  may increase the immediately rewarding aspects of participation and in turn people’s propensity to log into and use the eHealth tool.The authors recommend supplemental strategies to maintain engagement that stem from previous work in the area of incentives for exercise . From thRegular incentive offerings need not be prohibitively costly either. In fact, with a stronger application of behavioral economic principles , and conThough the Liu et al  paper is


Chromosome instability usually leads to tumorigenesis. Bloom syndrome (BS) is a genetic disease associated with chromosome instability. The BS gene product, BLM, has been reported to function in the spindle assembly checkpoint (SAC) to prevent chromosome instability. BTR complex, composed of BLM, topoisomerase IIIα (Topo IIIα), RMI1  and RMI2 , is crucial for maintaining genome stability. Recent work has demonstrated that RMI2 also plays critical role in SAC. However, little is know about RMI1 regulation during the cell cycle. Here we present that RMI1 protein level does not change through G1, S and G2 phases, but significantly increases in M phase. Moreover, phosphorylation of RMI1 occurs in mitosis. Upon microtubule-disturbing agent, RMI1 is phosphorylated primarily at the sites of Serine 284 and Serine 292, which does not interfere with the formation of BTR complex. Additionally, this phosphorylation is partially reversed by roscovitine treatment, implying cycling-dependent kinase 1 (CDK1) might be one of the upstream kinases. Bloom syndrome (BS) is a severe chromosome instability disease characterized by predisposition to a wide range of cancers and around 10-fold elevation of sister chromatid exchanges (SCEs) frequency in BS cells . BS is cBLM has been reported to physically and/or functionally interact with a number of proteins, such as DNA damage checkpoint kinases ATM (Ataxia telangiectasia mutated) and ATR (ATM and Rad3-related) ; homologPrevious studies have established that BLM protein levels are regulated in a cell cycle-dependent manner. In G1 phase, the BLM protein level is relatively low. During S and G2/M phases, the amount of BLM protein increases significantly . The fluGiven that BLM protein level is cell cycle-regulated, we examined whether there are any cell cycle-specific changes in RMI1 expression level by using synchronized cells at various cell cycle stages. Treating cells with different drugs is widely used in cell synchronization. However, this method may induce DNA damage, which might result in RMI1 protein alteration. To minimize the perturbation of cell physiological status by chemical-based synchronization methods, cell cycle stage-specific cells were obtained by centrifugal elutriation of cycling HeLa cells. This mechanical method allows cells to be fractionated on the basis of their sedimentation velocity . The smaUsually the percentage of mitotic cells is very low in an asynchronous culture due to the brevity of M phase, and the sedimentation velocity of G2 and M cells is similar. Therefore, it is impossible to distinguish M-phase cells from G2-phase cells by centrifugal elutriation. To examine mitotic cells specifically, we treated HeLa cells with nocodazole, an inhibitor of microtubule assembly, to block cells at mitosis, and then manually shook mitotic cells off from nocodazole-arrested cultures. Additionally, to avoid drug effects, we also shook mitotic cells off from asynchronous HeLa cells. These highly enriched populations of mitotic cells were collected and examined by Western blot analysis. Compared to the attached non-mitotic cells, the RMI1 proteins levels are nearly three-fold higher in mitotic cells A. MoreovTo identify the mitotic phosphorylation site(s) on RMI1, initially we generated two overlapped RMI1 fragments as shown in To identify the phosphorylated residues on RMI1, we used the Scansite database to analyze RMI1 protein. With medium stringency, there are three candidate residues in the region of 238–318aa: Thr270, Ser284 and Ser292. Since the fragment RMI1 (238–625) showed the clear retarded phosphorylation band, we initially generated the mutation constructs carrying Thr270 to Val (T270V), or Ser284 to Ala (S284A), or Ser292 to Ala (S292A) on the RMI1 (238–625) fragment. The three mutant constructs and wild type RMI1 (238–625) fragment were ectopically expressed in 293T cells, which were then arrested in mitosis by overnight nocodazole treatment. Compared to WT RMI1 and the T270V mutation, the phosphorylation was significantly reduced by the S284A and S292A mutations A. SubseqGiven that both RMI1 and BLM are hyper-phosphorylated in the presence of microtubule destabilization agents, a direct question is whether these post-translational modifications could lead to the dissociation of the BTR complex. To address this question, we co-expressed FLAG-TopoIIIα with the WT or phospho-mutant (S284A/S292A) Xpress-RMI1 in 293T cells. Mitotic cells were accumulated via nocodazole treatment. Then, co-immunoprecipitation (co-IP) was performed to test whether phosphorylated RMI1 (WT) and/or unphosphorylated RMI1 (phospho-mutant) and endogenous BLM protein could be co-immunoprecipitated with Topo IIIα by anti-FLAG beads. As shown in Upon mitosis blocking agents, phosphorylation of BLM at Ser-144 and RMI2 at Ser-112 is completely dependent on the kinase MPS1, while RMI1 phosphorylation only partially depends on MPS1 , suggestRMI1/BLAP75 is an indispensible component of the BLM-Topo IIIα-RMI1-RMI2 (BTR) complex. It has been well established that RMI1 greatly stimulates the BLM-Topo IIIα-mediated double Holliday junction (dHJ) dissolution in homologous recombination, leading exclusively to non-crossover products to prevent sister chromatid exchanges (SCEs) ,26. InteFirstly, we investigated RMI1 regulation in the cell cycle. Unlike the fluctuating BLM protein levels, there is no apparent alteration for the relative amount of RMI1 protein during the cell cycle progression . HoweverIn eukaryotic cells, the accurate transmission of genetic information relies on cell cycle checkpoints that monitor DNA replication status and accurate chromosome segregation . Among tRecent work showed that mitotic RMI1 phosphorylation only partially depends on MPS1, which is responsible for both BLM and RMI2 phosphorylation at mitosis . To iden2. Transfection of DNA was carried out with Lipofectamine 2000  according to the manufacturer’s instructions.HeLa and 293T cells were cultured in Dulbecco’s modified Eagle’s medium (DMEM) supplemented with 10% fetal bovine serum (FBS) at 37 °C in a humidified incubator with 5% CONocodazole  was resuspended in DMSO to stock concentrations of 1 mg/mL and used at the dilution of 1:2000. Caffeine and roscovitine (Sigma) were resuspended in DMSO to a stock concentration of 100 and 75 mM respectively, and used at the respective dilutions 1:50 and 1:1000.2 and water to 25 µL of total volume and incubated in the presence or absence of 600 units of λ-phosphatase  for 1 h at 30 °C.Cells were washed with PBS and subjected to protein extraction. 60 µg of total protein extracts was diluted in phosphatase buffer, MnClThe expression construct, pMal-C2-RMI1, containing the full-length RMI1 was provided by Weidong Wang (NIH/NIA). The wild-type Xpress-RMI1 construct was generated by subcloning the full-length RMI1 from pMal-C2-RMI1 in-frame into the mammalian expression vector pcDNA4/HisMaxC (Invitrogen). To change the selection marker from zeocin to neomycin, the coding sequence of Xpress-BLAP75 was subcloned into another expression vector pcDNA3.1(+). For RMI1 (1–318) deletion mutant, pcDNA3.1-Xpress-RMI1 was digested by StuI and SalI to delete 921 bp of RMI1 and re-ligated the backbone to obtain partially deleted RMI1. Similarly, for RMI1 (1–237) mutant, pcDNA3.1-Xpress-RMI1 was cut by EcoNI and SalI; for RMI1 (238–625) mutant, pcDNA3.1-Xpress-RMI1 was cut by EcoRI and EcoNI. All internal deletion constructs were verified by sequencing.To construct a FLAG-tagged Topo IIIα expressed in mammalian cells, the full-length Topo IIIα was digested by NaeI and XhoI from pCMV-Sport6-Top3a , and inserted into pCMV-Tag2A vector  that was digested with EcoRV and XhoI.Conversion of Thr270, Ser284 and Ser292 in RMI1 to Val270, Ala284 and Ala292, herein designated RMI1-T270V, RMI1-S284A and RMI1-S292A, was performed using the Stratagene QuickChange site-directed mutagenesis kit. pcDNA3.1-Xpress-RMI1 was used as template and oligonucleotide primers (sense primers) as follows:RMI1-T270V: 5′-CCTCAGAACGATGTTTCGTCACAGGTAGTTCCTC-3′RMI1-S284A: 5′-CCCACAAGACAGTCAGCTTTTGAGCCAG-3′RMI1-S292A: 5′-GAGCCAGAATTTGTTATTGCTCCAAGACC-3′DNA construct containing single mutant was then used as PCR template to generate RMI1-S284A/S292A double mutant. All generated plasmids were verified by DNA sequencing.Cells were collected and lysed with 0.5% Nonidet-P40 buffer containing protease inhibitors on ice for 15 min. Total protein concentration was determined using a BCA protein assay kit . Thirty-micrograms total protein of each sample was loaded onto polyacrylamide gels and then transferred to polyvinylidene difluoride (PVDF) membranes . The primary antibodies used are as follows: rabbit anti-RMI1 antibody , rabbit anti-BLM , mouse anti-Xpress (Invitrogen), mouse anti-Flag M2 antibody (Sigma) and mouse anti-Actin antibody .3VO4; 1 mM DTT and protease inhibitor mixture) at 4 °C for 3 h in a total reaction volume of 1 mL. The beads were washed three times with 1 mL IP buffer. The precipitated proteins were eluted by boiling the beads in 2 × SDS-loading buffer for 10 min. Proteins in the supernatant were separated by 8% polyacrylamide gels and detected by western blotting with the indicated antibodies. Thirty micrograms of cell lysates was used as the input control.293T cells were co-transfected with FLAG-tagged TopoIIIα and Xpress-tagged WT or phospho-mutant (S284A/S292A) RMI1. At the same time, a GFP expression construct was solely transfected into 293T cells to monitor transfection efficiency and serve as a negative control for co-IP. Thirty-two hours after transfection, the cells were subjected to nocodazole treatment for 16 h or not. Then cells were harvested and lysed with 1% Nonidet-P40 buffer with protease inhibitors. The cell lysates containing 1 mg total protein were incubated with 25 µL anti-FLAG M2 beads (Sigma) in immunoprecipitation (IP) buffer (50 mM Tris-HCl, pH 8.0; 150 mM NaCl; 10 mM NaF; 1% Nonidet-P40; 1 mM NaIn summary, we revealed that RMI1 protein level is markedly higher in M phase than in other cell cycle phases, in which it is relatively constant. Moreover, RMI1 is phosphorylated during mitosis and the primary phosphorylation sites are Ser284 and Ser292. In the light of our findings, it is likely that RMI1 may play an important role in mitosis. Further studies are required to elucidate the mitotic function of RMI1.


A number of studies suggest that 5-HT7 receptors could be potential pharmacotherapeutic target for cognitive disorders. Several abnormalities of serotonergic system have been described in patients with autism spectrum disorder (ASD), including abnormal activity of 5-HT transporter, altered blood and brain 5-HT levels, reduced 5-HT synthesis and altered expression of 5-HT receptors in the brain. A specific role for 5-HT7 receptors in ASD has not yet been demonstrated but some evidence implicates their possible involvement. We have recently shown that 5-HT7 receptor activation rescues hippocampal synaptic plasticity in a mouse model of Fragile X Syndrome, a monogenic cause of autism. Several other studies have shown that 5-HT7 receptors modulate behavioral flexibility, exploratory behavior, mood disorders and epilepsy, which include core and co-morbid symptoms of ASD. These findings further suggest an involvement of 5-HT7 receptors in ASD. Here, we review the physiological roles of 5-HT7 receptors and their implications in Fragile X Syndrome and other ASD.Serotonin type 7 receptors (5-HT A possible malfunction of 5-HT7 receptors are highly expressed in the thalamus, hypothalamus and hippocampus of mice and rats; significant amounts were detected in cerebral cortex, amygdala, striatum, cerebellum and spinal cord . This conclusion is supported by several data: first of all, 5-HT7 receptors have been detected in the brain of adult animals  with seven transmembrane domains and were initially characterized for their ability to stimulate adenylate cyclase  for the natural agonist serotonin  and 8-hydroxy-N,N-dipropyl-aminotetralin (8-OH-DPAT), both also showing high affinity for 5-HT1A receptors , produced by Esteve pharmaceutical company  and are currently under investigation in our laboratories as possible novel 5-HT7 receptor agonists.Among all 5-HT receptor subtypes, 5-HT7 receptors and behaved as antagonists on a cyclic adenosine monophosphate (cAMP) formation assay , as shown in transfected cells expressing 5-HT7 receptors , a kinase playing an important role in microtubule assembly and cytoarchitecture rearrangements .In many of the studies above cited, 5-HT2+-dependent K+ current triggered by Ca2+ influx. The subsequent efflux of K+ ions hyperpolarizes the membrane during a few seconds reducing neuronal firing rate, a phenomenon called “spike frequency adaptation”  in thalamic neurons , another type of AHP with a time-course faster than the sAHP and with similar inhibitory effects on neuronal excitability , which is mediated by a Caon” Sah, . Activat7 receptor activation enhances neuronal firing rate and reduces spike frequency adaptation. In addition, 5-HT7 receptor-mediated modulation of sAHP is likely to involve broader functional consequences, as intrinsic excitability and synaptic inputs mutually influence each other. In fact, Ca2+ influx through N-methyl-D-aspartate (NMDA) channels can also activate the sAHP .Since 5-HT7 receptors is a hyperpolarization-activated cation current (Ih). Ih is carried by Na+ and K+ ions and is activated by hyperpolarization beyond −60 mV, thus is already active at resting membrane potential. The voltage-dependence of Ih activation is modulated by cAMP, with increases in cAMP levels facilitating Ih activation  are maximally expressed in distal dendrites, where integration of synaptic signals mostly occurs .In summary, modulation of I7 receptors differently modulate the activity of GABAergic inhibitory interneurons in distinct brain areas  recorded from rat CA1 pyramidal neurons, indicating an increased GABA release from interneurons , by Schaffer collaterals as well as by recurrent collaterals from pyramidal neurons  and dorsal raphe, where 5-HT7 receptor activation instead reduces GABAergic transmission.5-HT7 receptor activation can stimulate glutamate release from glutamatergic terminals. In rat frontal cortex, glutamate-mediated synaptic transmission was enhanced by activation of 5-HT7 receptors  from rat hippocampal slices have shown that serotonin inhibits the perforant path input to the CA1 region, an effect partially mediated by 5-HT7 receptors and exerted at a post-synaptic level .In the hippocampus, 5-HT7 receptors enhances the amplitude of the AMPA receptor-mediated component of the excitatory post synaptic current (EPSCAMPA), which is responsible for basal glutamatergic transmission  display decreased LTP in the CA3-CA1 hippocampal synapse , an endogenous neurotrophin that protects against NMDA-induced excitotoxicity .Another form of long-term depression, mGluR-LTD, is induced by activation of group I mGluRs and is mainly expressed through removal of AMPA receptors from synaptic membrane surface by endocytosis  mice that were generated and characterized by the research group of Dr. Hedlund , 5-HT7 receptors in sleep has emerged from studies using both pharmacological and genetic approaches. 5-HT7 KO mice displayed a reduced duration of REM sleep, whereas time spent during wake or non-REM sleep was not different from wild-type mice  ligand-receptor interaction  involved in sleep control  and Barnes maze  but displayed a memory deficit in the fear conditioning test, which involves hippocampus-dependent contextual learning with emotional aspects. These results indicate that the lack of 5-HT7 receptors did not affect hippocampus-independent memory and among different types of hippocampus-dependent learning, only one with a strong emotional component (fear conditioning) was selectively impaired in 5-HT7 KO mice. The specific contextual learning impairment of 5-HT7 KO mice was accompanied by a decrease of LTP in the CA1 region of the hippocampus , without any defect in egocentric memory (a striatum-dependent type of memory concerning the position of objects with respect to the observer). The same result was observed in wild-type mice following pharmacological blockade of 5-HT7 receptors , in vivo activation of 5-HT7 receptors was able to exert pro-cognitive effects and counteract a learning impairment induced by 5-HT1A receptor activation  and instrumental learning modes: in this experimental protocol, a food reward was delivered with a short delay following a light signal (conditioned learning) but was delivered immediately if the rat pressed a lever . When the 5-HT7 receptor agonist AS-19 was injected subcutaneously to animals immediately after training, the latency of responses was reduced, indicating enhanced memory performance. AS-19 administration was also able to reverse a memory impairment induced by scopolamine (an anticholinergic agent) or dizocilpine (an NMDA antagonist), suggesting that 5-HT7 receptor activation might exert a pro-cognitive effect by modulating cholinergic and glutamatergic transmission  that were not impaired in 5-HT7 KO mice.To summarize, studies on wild-type animals using 5-HT7 receptor-mediated pro-cognitive effects were observed in behavioral tests performed on adult animals, reinforcing the conclusion that 5-HT7 receptors are functional in the adult hippocampus and exert life-long effects on learning and memory.5-HT7 receptors exerted a pro-cognitive effect: in vivo administration of the 5-HT7 receptor antagonist SB-269970 to rats submitted to the radial arm maze enhanced long-term reference memory without affecting short-term working memory  and different types of memory were tested, involving different brain areas and distinct circuits. Furthermore, considering that learning and memory are strictly related to stress, 5-HT7 receptor-mediated effects on learning might also be influenced by 5-HT7 receptor-mediated effects on mood (see below).Heterogeneous results are not surprising considering that different models have been used , their activation is likely to enhance seizure sensitivity. In line with this, a pharmacological study using different mixed antagonists suggested that blockade of 5-HT7 receptors may protect against audiogenic seizures in DBA/2J mice  on these fibers  was reduced by amisulpride and by the 5-HT7 receptor antagonist SB-269970 , 5-HT7 receptor activation is likely to enhance the level of anxiety, thus might be expected to reduce hyperactivity. In line with this hypothesis, in highly active rats showing explorative behavior and low levels of anxiety, the expression level of 5-HT7 receptors in the thalamus and in the hippocampus was significantly lower than in low-activity rats (Ballaz et al., 7 receptor agonist AS-19 into the NAc decreased ambulatory activity in the rat (Clissold et al., Co-morbid symptoms of ASD, observed only in a fraction of patients, include sleep disorders, anxiety, depression, epilepsy, attention deficit and hyperactivity disorder (Spooren et al., 7 receptor agonist LP-211 enhanced locomotion in wild-type mice (Adriani et al., 7 receptors on different types of anxiety-related behaviors.Other publications instead show that systemic administration of the 5-HT7 receptors modulate neuronal excitability and synaptic function and are important physiological modulators of learning and mood. Based on these properties, 5-HT7 receptors have been proposed as a pharmacological target in cognitive impairment, depression and epilepsy.Central 5-HT7 receptors. In light of this, it would be interesting to investigate the role of 5-HT7 receptors on different features disrupted in ASD. Cognitive functions are likely to be enhanced by 5-HT7 receptor agonists; on the other side, behavioral flexibility, hyperactivity and epilepsy might benefit from blockade of 5-HT7 receptors. In many cases, predictions of a possible outcome by pharmacological manipulation of 5-HT7 receptors are complicated by heterogeneous data present in literature and a direct investigation would be necessary.Core and co-morbid symptoms of ASD involve a disruption of several functions, some of which are physiologically regulated by 5-HTThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Adansonia digitata L.) trees from the Pafuri region of South Africa yielded a 1000-year proxy rainfall record. The Pafuri record age model was based on 17 radiocarbon dates, cross correlation of the climate record, and ring structures that were presumed to be annual for two of the trees. Here we present the analysis of five additional baobabs from the Mapungubwe region, approximately 200km west of Pafuri. The Mapungubwe chronology demonstrates that ring structures are not necessarily annually formed, and accordingly the Pafuri chronology is revised. Changes in intrinsic water-use efficiency indicate an active response by the trees to elevated atmospheric CO2, but this has little effect on the environmental signal. The revised Pafuri record, and the new Mapungubwe record correlate significantly with local rainfall. Both records confirm that the Medieval Warm Period was substantially wetter than present, and the Little Ice Age was the driest period in the last 1000 years. Although Mapungubwe is generally drier than Pafuri, both regions experience elevated rainfall peaking between AD 1570 and AD 1620 after which dry conditions persist in the Mapungubwe area until about AD 1840. Differences between the two records correlate with Agulhas Current sea-surface temperature variations suggesting east/west displacement of the temperate tropical trough system as an underlying mechanism. The Pafuri and Mapungubwe records are combined to provide a regional climate proxy record for the northern summer rainfall area of southern Africa.Carbon isotope analysis of four baobab ( Adansonia digitata L.) trees in southern Africa has demonstrated the existence of a fused, multi-stem architecture that may be one of the reasons why some of these trees achieve ages in excess of 1000 years [δ13C) values of the growth lamellae are a proxy for rainfall at the time of wood formation [Radiocarbon dating of baobab . In C3 plants the discrimination between the isotopic composition of ambient CO2 in the atmosphere and that assimilated by the tree is dependent on the internal leaf concentration of CO2 (ci) and the ambient atmospheric concentration of CO2 (ca) expressed as the ratio ci/ca [ci is regulated by the photosynthetic rate, which is controlled by temperature and irradiance. In trees that are water limited it is regulated by stomatal diffusion, which is controlled by edaphic water availability, wind and relative humidity [The use of stable light isotope analyses as an environmental proxy in baobabs is based on leaf-level fractionation of carbon isotopes  [ci (dci) matches the increase in ca (dca). Trees with an active iWUE response down-regulate the impact of elevated ca by reducing stomatal conductance or by increasing photosynthetic activity. Changing iWUE in trees is the physiological mechanism underlying the use of stable carbon isotope ratios as a proxy for climate, but the distortion of the record by elevated atmospheric CO2 in recent centuries needs to be consideredIn order to produce an isotopic climate proxy record it is necessary to account for the isotopic fluctuations of atmospheric CO, and ca . The inf, and ca , but they (iWUE) . PassiveDespite these methodological considerations, stable isotope climate reconstruction in trees has advantages over traditional ring widths in terms of the number of trees that need to be measured. It has been shown that reproducible isotope records from as few as 4 trees can yield a systematic high frequency (year-to-year) record , and up 2 and only 8% endure for more than an hour [Precipitation in the summer rainfall region of Southern Africa derives mostly from convective storms , and the an hour . In addi an hour  are typi an hour , the sysThe reproducibility of the baobab isotope record is further contingent on an accurate age model for the proxy, and the Pafuri chronology used 17 radiocarbon dates, cross correlation of the climate record, and on two of the trees, ring structures that were presumed to be annual. The ability to stop growing for up to 500 years  meant thThe paucity of climate records that are sufficiently resolved in time and space has undermined the ability to discern synoptic shifts in response to long term forcing in southern Africa, as well as the cultural adaptation to these changes. Climate reconstructions from as few as 2 trees  have beeFive baobab trees were sampled in the vicinity of Mapungubwe , four ofhttp://calib.qub.ac.uk/calib/calib.html) and the Calibomb program  which uses the bomb carbon dataset of Hua et al. [The chronology for the isotopic analysis of the baobabs followed the protocol of Woodborne et al. . The cora et al.  for the Robertson et al.  and WoodThe ages used in the regressions were initially set as the most probable calibrated date for each AMS analysis, but subsequently adjusted within the one-sigma error range in order to modulate the resulting isotope time series between trees . This apShorea superba) [δ13C in the atmosphere [http://cdiac.ornl.gov/ftp/db1014/isotope.cgo).Aliquots were pre-treated to α-cellulose  and the superba) , 26, 27 mosphere , with upThe minimum length of aliquots was determined by the state of preservation of the cores, and the anticipated sample-loss during the pretreatment process. The average aliquot was 1.13mm in length for the Luna baobab core, and 1.46mm for the Schroda core. For the LKA, LKB and MPC baobabs the ring widths were not measured. The corresponding age stride of aliquots  was 2.2 years, 0.3 years, 0.8 years, 1.6 years, and 0.2 years for the Luna, Schroda, LKA, LKB and MPC baobabs respectively.A normalization step was undertaken to compensate for the physiological responses of individual trees to their edaphic conditions. On average the isotopic values from the Mapungubwe baobabs are -0.76‰ relative to the Pafuri record indicative of generally drier conditions. The Mapungubwe baobab with the closest offset is the LKB baobab, with a normalization factor of -0.71‰ relative to the Pafuri baobabs. This tree also has the broadest temporal coverage and for these reasons it was used as the reference against which the other Mapungubwe trees were normalized. The differences in isotopic values for overlapping sections of the different trees and LKB were applied as a constant correction for individual trees. The normalization resulted in correction factors of 1.42‰, 0.66‰, -0.58‰, 0‰, and -0.28‰ for the Luna, Schroda, LKA, LKB and MPC baobabs respectively.Although the age stride for aliquots was variable and in some trees represents more than a single year, each aliquot was assigned a mean age from the model. Thereafter, the isotopic time series for each of the 5 baobabs were averaged annually to yield a single time series.δ13Cplant) and the ambient atmospheric carbon isotope ratio (δ13Cair) is give by the Farquar et al. [ca and ci represent the atmospheric and plant intercellular CO2 concentrations respectively, a is the fractionation associated with stomatal diffusion (4.4‰) and b is the fractionation associated with carboxylation during photosynthesis (27‰). The value of δ13Cair and ca are known for the last 1000 years [ci for any known-age wood for which δ13C has been measured. Wang & Feng [Φ as:Φ is approximately constant for any tree. The term Φ reflects the physiological response of the tree to elevated concentrations of atmospheric CO2 and it ranges from Φ = 1 (passive response) to Φ = 0 (constant response). The value of dci and dca were calculated by subtracting the average value of ci (ca) for the period pre AD 1795 before atmospheric CO2 concentrations increased, from the period post AD 1900. By averaging these values over periods of centuries the high frequency variability is suppressed and the low frequency variation that represents the plant’s response to elevated CO2 [Φ value was calculated for these trees.The relationship between the measured carbon isotope ratio , Woodborne et al. [δ13C value incorporating the 10 years before and the 10 years after the year for which the calculation is being made. The statistic suppresses the high frequency component of the record, and emphasizes the non-stationary component [δ13C record.The high frequency e et al.  calculate et al.  for the omponent . A 21-yeδ13C values from the Pafuri and Mapungubwe baobabs. The combined record from the two areas was then compared with the climate forcing variables explored by Woodborne et al. [http://climexp.knmi.nl) that uses a Monte Carlo method to calculate the confidence ranges, and takes autocorrelations into account in calculating p-values, was used for the calculation of confidence statistics.Time series comparisons were calculated between the biweight mean e et al. . The CliPrevious age modeling of baobab rings , 24 showThat baobab growth rings are not necessarily annually formed implies that the age model should be constructed on the basis of the radiocarbon dates and climate record coherence alone. In the Pafuri record two trees were assumed to have annual rings, and these were reassessing using the revised criteria. Two of the dates on the Pafuri Gila Pan baobab are re-interpreted with amendments of 54 years and 18 years. Both of these adjustments are within the 1-sigma error ranges of the radiocarbon dates and the revised age model removes a hiatus from the previous age model. There was no evidence to suggest that the age model for the Pafuri Outpost Baobab, the second tree in the Pafuri record for which rings were presumed to be annual, be amended.Φ was 0.43 ppmvci/ppmvca (range: 0.37–0.52), which is very similar to the value of 0.46±0.02 ppmvci/ppmvca obtained across a range of species by Wang & Feng [ci in response to increasing ca by baobabs. The effect applies after AD 1795 when ca began to increase, but it becomes more pronounced in the last 50 years. Using ci pre 1795, and amounts to approximately +0.63‰ in AD 2000.The value obtained for g & Feng . This isδ13C record, and the 21-year biweight mean record from the Mapungubwe baobabs are also presented. The historic portion of these records can be compared with the instrumental rainfall record to verify the use of δ13C as a rainfall proxy.The isotopic time series for the Mapungubwe baobabs is presented in δ13C record is a proxy for rainfall , which is stronger than that reported using the previous chronology  [Two instrumental rainfall records are available for the Mapungubwe area: a continuous monthly rainfall record from the Zimbabwe Weather Service at Beitbridge border post (approximately 55km east of Mapungubwe) from 1955 to 2005. This is confirmed with a partial record from the South African Weather Service from the same location between 1962 and 1968. The correlation between these datasets is highly significant . The Zimbabwe Beitbridge rainfall record is used for the baobab comparison because it is more complete. This yields a significant correlation  confirming the previous evidence that the baobab rainfall . The revThe rainfall proxy record for Mapungubwe is presented in th Century. The relationship with the Indian Ocean Dipole Moment Index [The Pafuri rainfall proxy record was used to infer climate forcing in the region, and high frequency  variability was linked to sea-surface temperatures (SST). When the Mapungubwe record is compared with sea-surface temperatures in the Agulhas Current core region , 33 the nt Index  is weak nt Index  is weak It was suggested that the differences between the Mapungubwe and Pafuri records reflect localized effects, and this aligns with the suggestion that the Agulhas Current SST had a strong influence on the E/W position of the temperate tropical trough (TTT) cloud band that is associated with the dominant rainfall in the region . The resIf the position of the TTT system over southern Africa is determined by SST in the Agulhas Current, then the transition from wet conditions during the Medieval Warm Period to dry conditions during the Little Ice Age in Pafuri is unlikely to be the result of this mechanism. Wet conditions are associated with the TTT system in its westward modal position  and furthttps://www.ncdc.noaa.gov/paleo/study/19320.The records from Mapungubwe and Pafuri can be combined to provide a single record with higher reproducibility. The combined record and the 21-year biweight mean are presented in δ13C record derived from the Mapungubwe area is significantly correlated with the revised Pafuri record. Both proxies correlate with local precipitation and demonstrate a regional shift from wet conditions during the Medieval Warm Period transitioning to dry conditions during the Little Ice Age. A non-stationary residual between the Pafuri and Mapungubwe records is significantly correlated with SST in the Agulhas Current region indicating that localized variation in rainfall is linked to E/W displacement of the temperate tropical trough rainfall system. By combining the two records we enhance the sampling depth, providing a more comprehensive 1000-year rainfall proxy record for the northern summer rainfall region in southern Africa.The age model that was generated for the Mapungubwe baobabs demonstrates that the trees do not necessarily form annual rings, and the age model used to generate the Pafuri record was amended to produce a revised record. The


Cognitive stimulation therapy (CST) has been shown to be an useful and cost effective intervention that increases cognition and quality of life of people with mild to moderate dementia. It is increasing in popularity in the UK and worldwide, and a number of research teams have examined its effectiveness in other contexts and cultures. However, it is necessary to develop clear evidence-based guidelines for cultural modification of the intervention. This article describes a community-based developmental approach to adapt CST to different cultures, following the five phases of the formative method for adapting psychotherapy (FMAP), an approach that involves collaborating with service users as a first step to generate and support ideas for therapy adaptation. Examples based on clinical and practical experience are presented, along with suggestions for applying these changes in different cultural contexts. There are different methods available to develop “cross-cultural adaptations”, the process that looks at both language (translation) and cultural adaptation issues in the process of preparing a questionnaire or therapy for use in another setting. To date, the majority of frameworks adapting therapies to different cultures take a “top-down” theoretical approach,3The World Alzheimer Report 2011,With any new psychosocial intervention one of the barriers to wide-scale international implementation is the need for suitable adaptation to other cultures. CST has been adapted to a number of different cultural groups. This paper articulates the experiences of translating and adapting CST to other cultures. In doing so, it provides a useful evidence-based guideline to translate and adapt the therapy to other cultures. Each of the phases of the FMAP model are described in the context of CST and can be tailored to meet the individual needs of different projects. CST adaptation is illustrated through examples of the modification of CST to several culturally diverse ethnic groups: Tanzanian and Nigerian communities, a Chinese community, a South Asian community, and a Japanese community. The cultural adaptation process can therefore be used as a guide for future research and practice.The first step in adapting CST to a different culture is to decide which stakeholders to involve in the adaptation process and when to involve them. According to the FMAP, stakeholders may include (a) participants, (b) mainstream health and mental health care providers, (c) community-based organizations and agencies, (d) traditional and indigenous healers, and (e) spiritual and religious organizations.Making a Difference: An Evidence-Based Group Programme to Offer Cognitive Stimulation Therapy (CST) to People With DementiaMaking a Difference 2: An Evidence-Based Group Programme to Offer Maintenance Cognitive Stimulation Therapy (CST) to People With Dementia.A good way of consulting at this stage is through focus groups. Each focus group might consist of around four to six health workers with a range of clinical and working experiences. This will help facilitate both breadth and depth of discussions. The initial process of the focus group would include general discussions of cultural adaptation, and a review of the treatment manual and intervention as described in A culturally specific example of the phase one process follows. In the South Asian adaptation of the program,Focus groups can also be complemented with individual interviews with other key practitioners in each culture who are not part of a particular setting. This provides an opportunity to exchange ideas, build a sense of community, and strengthen referral networks.In this phase, the information generated from the community-based focus groups will be synthesized, and a new culturally adapted version of the manual can be written up. Focus group collaborations will help to reduce personal and clinician-specific biases, and collaboration with local health workers will help to ensure that cultural adaptations are grounded in cultural belief systems.A culturally specific example of the phase two process follows. In the adaptation process of CST for Tanzania and Nigeria, the structure of sessions as described in the manuals had to be modified for logistical issues, as they would have not worked otherwise. Issues that influenced the structure included distances between villages, transport arrangements, carer commitments depending on the season, harvesting or planting crops, and access to villages during the rainy season.Another consideration was the use of materials that had to be locally available and, most importantly, familiar to the group. It was also decided that the program location should be somewhat local, but where children could not observe the program process. Churches, mosques, or hospitals were also eliminated as locations, so that participants could feel comfortable regardless of their religion, and avoid feeling treated as sick.After writing the culturally adapted CST manuals, it is recommended that a further focus group be conducted with the planned CST group facilitators. At this focus group, initial impressions of the adapted intervention, and feedback for improvement, will be elicited, paying special attention to the activities included in the revised and adapted manual. Feedback will be used to finalize manual content before implementation. The manual may then be written, and translated into the desired specific language. It is best practice to follow a standardized forward and back translation method with the back translation reviewed by the UK CST team. For example for the Japanese version, three experts were involved in the translation.13Culturally specific examples of the phase three process follow. For the Tanzanian and Nigerian versions, three sessions were allocated to each member of the group for consideration and then discussed in the focus group. The main issues considered were: important local events for the centers and villages; how people become aware of current affairs ; consideration of local materials for maps, food, sweets, games, or expansion to other areas in the country.In adaptation of the program to South Asian groups, materials were tailored to South Asian cultures by including topics such as cricket due to its popularity in India and Pakistan. Other adapted sessions included preparing two different curry dishes for the “being creative” session, and sharing the dishes with the day center staff. An Urdu drama was shown and discussed as part of the “visual clips discussion” session. As most participants’ level of literacy was expected to be low (based on advice from family members), the program maximized the use of materials and equipment that incorporated visual (images) and auditory content that minimized the use of reading and writing.The developed and adapted CST manual should then be piloted in different settings in order to test the adapted program. This could involve running a full program in two carefully selected settings and using minimal outcomes to test its efficacy, such as cognitive and quality of life measures. Ideally, these would be community centers which normally provide services for people with dementia. Such locations would help ensure that the program is sustainable and that the developed intervention is feasible relative to frequency of sessions, number of participants, number of staff, duration of the sessions, transport, and financial limitations. In addition, getting other staff and managers within the selected community centers to participate in providing feedback from the pilot at this stage would help facilitate their support and adaptation of the CST program.A culturally specific example of the phase four process follows. The Japanese version included a pilot study which revealed that it was necessary to modify the content of eight sessions that appeared unsuitable for the Japanese culture.Facilitators and participants who take part in the culturally adapted pilot in phase four will be asked to take part in interviews or focus groups to elicit feedback regarding their experiences, what they found useful, what they did not like, and their recommendations for program improvement. Additional recommendations can be integrated within the adapted program manual. The adaptors of the CST program can use this information along with their own experiences to finalize the adapted CST manual.A culturally specific example of the phase five process follows. In development of the Tanzanian and Nigerian adaptation it was noted that when asking questions of the participants, facilitators had to be culturally sensitive, and consider how much information the group would be comfortable sharing. An important element was to avoid asking for any personal information in the discussion, particularly names or numbers of children, unless participants elected to voluntarily share this information individually. Elements such as access to a comfortable table and chairs, refreshments, and bathroom were considered very important. Most participants expected a small gift after the sessions, so a gift, such as a confection, was provided at the end of every session; some participants enjoyed giving these to their grandchildren.These practical recommendations provide guidance on how to culturally adapt the content and structure of CST to make it more suitable to other cultures without compromising its effectiveness. The recommendations were based on clinical and practical experience plus evidence from a review of the most common frameworks that have been used to adapt therapy to other cultures. In particular, the guidelines have been grounded in the FMAP framework and its five phases, illustrating examples of currently modified programs. The available evidence from small studies of the adapted programs indicates that they are also of benefit.13Although this manuscript describes guidelines for cultural adaptation of the CST program to other cultures, further studies will need to explore the cultural influences as a critical point. As previous literature shows, culture influences the understanding of dementia, the use of services, and the psychosocial experiences of family members.17Further research should pay attention to how the different culturally-explained definitions of old age and dementia in the different societal contexts where the intervention occurs, will shape and influence the effectiveness of this intervention in other cultures. Thus far there is little evidence-based research relative to how cultures vary in their availability and use of diagnostic procedures, and their use of different outcome measures. Further studies will need to explore and address these deficiencies in order to better understand the effectiveness of these adapted interventions. Finally, issues of empowerment and collaboration with service users are echoed within this article.


The American Board of Internal Medicine (ABIM) exam's pass rate is considered a quality measure of a residency program, yet few interventions have shown benefit in reducing the failure rate. We developed a web-based Directed Reading (DR) program with an aim to increase medical knowledge and reduce ABIM exam failure rate.Internal medicine residents at our academic medical center with In-Training Examination (ITE) scores ≤35th percentile from 2007 to 2013 were enrolled in DR. The program matches residents to reading assignments based on their own ITE-failed educational objectives and provides direct electronic feedback from their teaching physicians. ABIM exam pass rates were analyzed across various groups between 2002 and 2013 to examine the effect of the DR program on residents with ITE scores ≤35 percentile pre- (2002–2006) and post-intervention (2007–2013). A time commitment survey was also given to physicians and DR residents at the end of the study.p<0.001). This showed an improvement in ABIM exam pass rate for this subset of residents after introduction of the DR program. The time survey showed that faculty used an average of 40±18 min per week to participate in DR and residents required an average of 25 min to search/read about the objective and 20 min to write a response.Residents who never scored ≤35 percentile on ITE were the most likely to pass the ABIM exam on first attempt regardless of time period. For those who ever scored ≤35 percentile on ITE, 91.9% of residents who participated in DR passed the ABIM exam on first attempt vs 85.2% of their counterparts pre-intervention (Although residents who ever scored ≤35 percentile on ITE were more likely to fail ABIM exam on first attempt, those who participated in the DR program were less likely to fail than the historical control counterparts. The web-based teaching method required little time commitment by faculty. In-Training Examinations (ITEs) are used in residency training programs as an objective measure to assess a learner's medical knowledge base . For intUse of ITE scores to develop educational interventions has not been well studied. Moreover, interventions to improve ITE scores have shown conflicting results. Types of these interventions include educational conferences –8, indivConsidering the high stakes for residents and residency programs for passing the board examination and critical need for core knowledge development for clinical application, we, at the Henry Ford Hospital Internal Medicine residency developed a web-based teaching and feedback tool called the Directed Reading (DR) program for our internal medicine residents. We hypothesized that this tool would facilitate self-directed learning and increase medical knowledge, improve the ITE scores of internal medicine residents, and reduce the American Board of Internal Medicine (ABIM) exam failure rates in our graduates.The internal medicine residency program at our large, urban, teaching hospital includes a total of 120 residents. Residents who obtained ≤35th percentile on the ITE from 2007 to 2013 were enrolled in the DR program. Residents with ≤35th percentile on the ITE from 2002 to 2006 were used as a historical control group for analyses. We chose to use this cutoff percentile, rather than percentage, to be able to compare our results with previous studies that showed high likelihood of failure on the ABIM exam for residents scoring ≤35th percentile on ITE , 5.Our internal medicine residency policy requires all residents to take the ITE. For the study period, residents took the ITE in October and those with scores ≤35th percentile received in December then started the DR program in January. Residents could be enrolled in DR more than one year depending on subsequent ITE scores. This study was approved by the Institutional Review Board at Henry Ford Hospital.The DR program was developed in 2007 as an ongoing formative assessment for residents by one of the authors (WM) and is available to the general public as an open source software package. The main aim of the DR program was to provide a web-based platform for residents and faculty to mutually review and provide feedback regarding the educational objectives provided by the American College of Physicians based on each resident's performance on the ITE.For residents enrolled in the DR program from 2007 to 2013, ITE educational objectives answered incorrectly by each resident were obtained and loaded onto that resident's personalized DR web page. Residents were encouraged to use standard references to read on their identified objectives, including online textbooks and peer-reviewed literature. As shown in an example of an assignment in DR program residents were expected to complete five learning objectives weekly. DR residents started DR in January and continued until all their assigned ITE educational objectives were completed. Total number of educational objectives ranged from 122 to 180, which required about 24–36 weeks based on five objectives completed per week.DR preceptors were assigned four or five residents each. To provide additional oversight, a weekly report was generated from the DR website data, including number of completed submissions per resident and number of pending evaluations for preceptor review. Reports were reviewed by the program director (PD) every week during the faculty meeting. The DR preceptors included the PD, associate program directors (APDs), and the clerkship director, all of whom are board-certified internists.p-value to control the false discovery rate. In addition, a univariate repeated measures model was used to examine the effect of time period (pre-intervention 2002–2006 vs post-intervention 2007–2013) on ITE percentile.Data analysis aimed at determining the ABIM exam pass rate before and after DR implementation and whether this rate changed over time among those who were and were not eligible for DR. Rates were compared using chi-squared tests or Fisher's exact tests. To compare the ABIM exam pass rates across time and eligibility groups, pairwise comparisons were performed and the Benjamini–Hochberg adjustment  was appln=7) and residents enrolled in the DR program at that time (n=26) were asked to complete a survey about the time commitment required for the DR program. Participation was voluntary. The responses were graded on a five-point Likert scale .At the end of the study in 2013, DR preceptors (The pre-intervention group (2002–2006) included 181 residents and the post-intervention group (2007–2013) 263 residents. Using an ITE score ≤35 percentile to qualify for the DR intervention, 81 residents qualified for DR in the pre-intervention period and 111 residents qualified for and participated in DR in the post-intervention period. The DR software administrative reports showed that 97% of the 111 DR participants completed at least 90% of assigned objectives.p<0.001). This finding was also observed in the pre-intervention period , but no significance was found in the post-intervention period . For those who ever scored ≤35 percentile on ITE, 91.9% of residents who participated in DR passed the ABIM exam on first attempt compared to only 85.2% of their control counterparts .A comparison of ITE scores by time period showed that the adjusted mean ITE percentile was significantly higher in the post-intervention group  responded. The average time required by teaching physicians to search and read about the DR objective was 7 min (range 4–10 min). The average time to provide feedback in written format to the resident was 3 min (range 2–6 min). The survey response rate for DR residents was 96% (25 of 26). The average time required by residents to search and read about the DR objective was 25 min (range 10–50 min). The average time to provide response in written format by the resident was 20 min (range 5–75 min).This study demonstrated that the DR intervention was associated with an increase in ABIM exam first-attempt pass rate in the subset of residents who scored ≤35th percentile on the ITE. Those residents who participated in DR had a 6.7% absolute increase in ABIM exam pass rate compared to historical counterparts. In addition, the ≤35 percentile ITE group that participated in the DR intervention showed significantly higher ITE scores than their historical counterparts. This emphasizes the need to identify low-scoring ITE residents early and enroll them in DR sooner, as our study also showed that residents who ever scored above the 35th percentile on ITE had a significantly greater likelihood of passing the ABIM exam on first attempt.This supports findings from Waxman and others that residents scoring ≤35 percentile on ITE are more likely to fail the ABIM examination . AlthougOur study provides a novel method of utilizing web-based tools to monitor, provide feedback, and foster independent learning with a short time commitment. We believe that the success of the DR program is its direction, oversight, and guidance to read about areas of personal weakness as demonstrated on the ITE. The web-based tool not only provides a way to track residents’ progress but also offers a platform for individual faculty development.Significant improvement occurred in ITE scores in the post-intervention group. Although the DR program may be a factor in improved ITE scores, there may be other factors as well. However, this finding is consistent with a recent study validating an equation for predicting probability of passing the ABIM exam . This prOur study has several strengths. First, this is a relatively large sample size with six years of longitudinal data. Second, the study demonstrated a significant improvement in ABIM exam pass rates in select residents, even though the national trend is in the opposite direction, which further strengthens the value of this program. Third, we included the time commitment which provides important practical information about the utility of this program. With each faculty assigned only a few residents and each resident completing five DR objectives per week, the time commitment is very manageable (~1 h or less per week). In addition, the web-based feedback approach removes the often negative effects of face-to-face confrontation and cultivates an environment of mentorship and collaborative learning. The DR program capitalizes on asynchronous learning and feedback, allowing both the learner and faculty to review the objectives at times convenient for each, and not constraining either party. The DR software, which is available free of charge, is easily modifiable to any discipline and may be personalized for any learning objective.This study also has limitations. We utilized the retrospective publically available data on ABIM exam failure rates of the institution but did not collect information about learning resources used by non-DR residents. However, a prior study that reported increased use of electronic resources by residents  showed sOur study provides significant evidence to suggest that DR was associated with improved ABIM exam pass rates in residents who scored ≤35 percentile on the ITE compared to historical controls. The program was well received by residents as well as the teaching physicians with minimal time commitment by the latter. Further research is needed in larger multi-site studies to evaluate the impact of such programs, especially with the recent implementation of the ACGME Next Accreditation System.