Public-Private Partnerships in China’s Urban Water Sector

During the past decades, the traditional state monopoly in urban water management has been debated heavily, resulting in different forms and degrees of private sector involvement across the globe. Since the 1990s, China has also started experiments with new modes of urban water service management and governance in which the private sector is involved. It is premature to conclude whether the various forms of private sector involvement will successfully overcome the major problems (capital shortage, inefficient operation, and service quality) in China’s water sector. But at the same time, private sector involvement in water provisioning and waste water treatments seems to have become mainstream in transitional China.
Introduction
In the wake of the United Kingdom’s water privatization in the 1980s, the 1990s witnessed the spreading of privatization and a variety of public-private partnership (PPP) constructions in developing countries, especially following the promotion and push by international development agencies such as the World Bank, the International Monetary Fund (IMF), the Asian Development Bank (ADB) and others (Nickson 1996, 1998; Kikeri and Kolo 2006). It was believed that private sector participation in the water sector would bring in much needed investment and improve service coverage, quality, and efficiency by replacing conventional public-sector systems suffering from under-investment and inefficiencies due to excessive political interference and rent-seeking behavior by vested state and bureaucratic interests (Hall and others 2005). During the past decades, a wide literature in economics, governance, and public management has provided theoretical and empirical arguments and evidence in favor of further private sector involvement in what used to be public utilities. At the same time, however, debate continues on the different partnership constructions, the division of tasks and responsibilities between public and private sectors, and the social effects coming along with these developments. Topics, such as the relationships between ownership (public or private) and efficiency (Vining and Boardman 1992; Spiller and Savedoff 1997; Birchall 2002; Afonso and others 2005; Anwandter and Jr.Ozuna 2002; Hart 2003), the classification of various public-private constructions and their characteristics (World Bank 2004; Seppälä and others 2001; US National Research Council 2002), the consequences of privatization for governmental regulation (Nickson and Vargas 2002; Pongsiri 2002) and questions of equity and equality are still heavily debated, in particular with respect to the water sector and less so regarding other utilities.
Although private sector participation in the water sector is one of the more controversial topics in public utility management today, this wave also spread to China at the turn of the millennium, where the government started to reform public sectors (water, electricity, roads, etc.) via introducing market functions. The so-called marketization reform expected to address the increase of several water problems (water shortage, insufficient infrastructure, water pollution, etc.) to meet the requirement posed by accelerated urbanization and high economic growth. As a late comer in this field of private sector involvement in the provision of water services, China is able to learn from numerous experiences of other countries, such as the United Kingdom, France, United States, Chile, Philippines, Mexico, Argentina, and Bolivia.
Since the earlier attempts of applying the Build-Operate-Transfer (BOT) approach in the water sector in the 1990s and the full development of marketization reform in public sectors in 2002, China has applied different models of private sector involvement in over 300 water supply and wastewater projects. This marketization reform emphasizes the importance of the market, investment and financial liberalization, deregulation, decentralization, and a reduced role of the state in the water sector (also see Robison and Hewison 2005; Prasad 2006). Tariff reform with full-cost recovery, competitive bidding procedures, changing ownership structures (e.g., public and private, Sino and foreign), and restrictive fiscal policies are part of it.
This article reviews developments in private sector involvement in China’s water management and assesses whether expected results of marketization in the Chinese water sector have been met: raising investment for infrastructure, increasing service coverage and improved efficiency in China’s water supply and wastewater treatment. After interpreting further private sector involvement in China’s urban water management in terms of modernizing water governance, this article provides a country-wide overview of current privatization developments in the Chinese water sector, and subsequently makes an in-depth investigation in three distinct cases with respect to the new roles and functions of the governments and private parties. The final section assesses the current status of privatization programs in China’s water management and its implications of future research on water governance reform.
Private Sector Participation as Part of Modernizing Urban Water Governance
In the debate on private sector participation in environmental governance in general, and urban water governance in particular, we can identify three — sometimes interrelated — discourses.
First, private sector participation goes back to the literature on state failure in the early 1980s. State failure refers to the notion that the nation-state falls short in the provisioning of collective goods, in this case environmental services and quality. Some of the key publications in this regard come from Germany. Martin Jänicke’s (1986) Staatsversagen analyzed the fundamental inability of the nation-state to protect the environment in the 1980s, and called for an innovation or modernization of environmental politics, later to be labeled political modernization (e.g., Tatenhove and others 2000; Mol 2002): a reorientation towards a more preventive, pro-active and flexible strategy using new instruments and closer cooperation with and participation of non-state actors. With a similar analysis of the environmental state’s fundamental inabilities, Joseph Huber (1985) came to slightly different solutions with his strong plea for involving the private sector into environmental services and protection. Finally, around the same time Ulrich Beck (1986) formulated his Risk Society hypothesis and identified subpolitical arrangements (i.e., arrangements for environmental protection and service provision without and beyond the public state) as an alternative for the conventional environmental politics of the nation-state. Inspired by these and several other authors and ideas, from the mid 1980s onward environmental social science scholars started to develop ideas, investigate practices, and formulate theories on governing environmental problems, in which the environmental state was given a less dominant and monopolistic position.
Around the same time (the second half of the 1980s) ideas of further private participation and involvement in the provisioning of environmental services (water, waste, energy, etc.) started to develop, especially in the United States and the United Kingdom. While also here the fundamental idea is involving the private sector in tasks traditionally fulfilled by the public sector, the orientation and literature is slightly different. The majority of the literature comes from the management and organization sciences and the orientation is less focused on state failures and governance, but rather on efficiency, the bringing in of new capital and the introduction of market logics. The dominant form of organizing urban infrastructure (water, energy, waste, transport) by state agencies has been replaced in many places by various PPP constructions, with different reasons put forward to legitimate such new constructions (cf. Linder 1999). At the same time, these partnerships led to considerable debate, most significantly on issues of equity and equality: who is involved in these partnerships, for who are these constructions bringing more effective and efficient services, are local governments able to balance the power of private capital coming in (especially in situations of Transnational Companies (TNCs) in developing countries) (e.g., Oppenheim and MacGregor 2004), and what does private sector involvement mean for affordability of environmental services for the poor?
Thirdly, in the 1990s, following the United Nations Conference on Environment and Development (1992, Rio de Janeiro), and even stronger after the Rio+10 conference (2002, Johannesburg), ideas and practices of public private partnerships started to emerge forcefully on the national and global agenda (cf. Mol 2007). In this literature, the emphasis is strongly on transnational partnering of public and private entities, with a strong focus on the role of civil society organizations. The main reason behind the recent attention to private sector participation in environmental protection and service delivery is related to tendencies of globalization and governance complexities. As Davies (2002) correctly summarizes, in this interpretation the notion of partnership has a positive rhetoric referring to inclusiveness, transparency, participation and dialogue, redistribution of power, and equity. And not so much to ideas of efficiencies, capital investment, market logics, and increased service coverage.
In reviewing the arguments and legitimacy of the push for private sector involvement in China’s urban water governance, there is a strong relation to the second discourse on efficiency, capital investments and service coverage, while ideas of state-failure and political modernization incidentally emerge. By the same token, the Chinese discourse on private sector participation in urban water management hardly draws upon ideas of wide cross-sectoral partnerships and the positive logics of transparency, democracy, participation, and dialogue. Discussions on China’s urban water governance reform argue for the advantages of effectiveness and efficiency, and debate the best organizational modes, division of responsibilities, and coordination structures. Potential negative outcomes of private sector participation — so strongly emerging in and dominating western debates — are much less emphasized: loss of decision-making autonomy of states and governments; unequal power relations and information asymmetry in public-private partnerships; problems around equity, access for the poor, participation and democracy in decision-making (e.g., Hancock 1998; Poncelet 2001; Miraftab 2004).
According to the World Bank, China, Chile and Colombia are the only countries that remain active in water privatization after 2001 (Izaguirre and Hunt 2005). How to explain that, while the activities of water sector privatization intend to shrink in an increasing number of countries and international development agencies, such as the World Bank, start to slow down such privatization programs, China is actively promoting private sector involvement in urban water governance?Two interdependent arguments elucidate this. First, China’s urban water management comes from a radically different starting position, where market principles and logics were almost absent. Water management was not just completely publicly organized but also highly inefficient, with large capital shortages, poor coverage, no economic incentives and demand side management, and highly centralized. This is a fundamental, rather than marginal, difference with most of the public utility systems in OECD countries before the privatization discourses and practices of the 1980s and 1990s. Under such Chinese conditions, private sector involvement in water management means more that just handing water business over to for-profit private companies. It most of all means building economic incentives and logics, safeguarding enough financial capital for infrastructure investments, and widening the service area. Second, private sector participation in China’s urban water management is not just a matter of privatization. It is part of a much wider and complex modernization program in urban water governance, involving some of the critical issues that emerged in the privatization debates in OECD countries. The modernization of urban water governance also includes (see OECD 2003, 2004a, 2004b, 2004c, 2005a, 2005b):water tariff reforms, where costs of drinking water increasingly include full costs (also of wastewater treatment), but come along with safeguards for low income households to continue access to drinking water;transparency, accountability and control of the government;public participation in for instance water tariff setting, complaint systems on water pollution and corruption, public supervising committees on utility performance, public and media debates on water governance, disclosure of information to non-governmental actors (cf. Zhong and Mol 2007); anddecentralization of water tasks and responsibilities to the local level.In exploring the degree, nature, and forms of private sector participation in China’s urban water governance in the following sections; we have to leave these wider — related — developments aside.
Privatization Policy in China’s Water Sector
In China, the term “private sector” has been regarded as politically sensitive since 1949 when China started to establish a socialist regime characterized by the nationalization of ownership. The first breakthrough of the development of “private sector,” which was officially defined as “economic organizations that aim at making profit, in which assets are privately owned and which have eight or more employees” (Provisional Regulations of Private Enterprises in PRC, the State Council, June 25 of 1988), took place mainly in competitive sectors in accordance with the launch of China’s economic reform in the late 1970s. The government remained in control of public sectors such as water services, energy provisioning, waste management, and public transport. In the mid 1990s, Chinese Government attempted to introduce the BOT approach into the field of urban infrastructures (thermal power, hydropower, highway, water supply, etc.) via promulgating the Circular on Attracting Foreign Investment through BOT Approach (No.89 Policy Paper of 1994, the former Ministry of Foreign Trade and Economic Cooperation, January 16 of 1995) and the Circular on Major Issues of Approval Administration of the Franchise Pilot Projects with Foreign Investment (No.208 Policy Paper of Foreign Investment, the former National Development and Planning Commission, the Ministry of Electric Power Industry, and the Ministry of Communications, 1995). These two policy papers formed the first legal ground for private sector involvement and foreign capital investment in Chinese urban infrastructure. Subsequently, the National Development and Reform Commission firstly approved three BOT infrastructure projects in 1996, including Chengdu No.6 Water Supply BOT Plant (B), Guangxi Laibin Power BOT Plant, and Changsha Wangcheng Power BOT Plant (failed).
The earlier experiences of BOT projects brought in needed capital and investment to develop China’s urban water infrastructure. But it illustrated also many problems. The issue of the fixed investment return to investors was one of these problems. After intensifying control over foreign exchanges and loans in the late 1990s, the General Office of the State Council promulgated a specific circular in 2002 to correct foreign investment projects with fixed investment returns, by modifying the relevant contract terms, buying back all shares of foreign investors, transferring foreign investment into foreign loans, or dismantling contracts with often severe losses.
The full-fledged commitment of the Chinese government to private involvement in the water and other utility sectors dates from late 2002. In the December of 2002, the Opinions on Accelerating the Marketization of Public Utilities (No.272 Policy Paper of the MOC, 2002) started the marketization reform of water and other public sectors by opening public utilities to both foreign and domestic investors: multi-financing approaches, concession right and concession management, pricing mechanism, reduction of governmental monopolies and roles ended the traditional policies of public utilities. The subsequent Measures on Public Utilities Concession Management (No.126 Policy Paper of the MOC, 2004; in this policy, “concession management” refers to all forms of private sector participation.) of 2004 specifies the procedure of how to involve the private sectors in public utilities through awarding concession right, but still relies heavily on BOT modes.
These steps proved more than just giving the private sector a permission to enter public utilities. It is a complex process involving among others ownership reforms, redefinition of the role of governments and operators, restructuring the tariff mechanism, reforming governmental regulation, and designing public participation. In the early years of marketization, the emphasis was especially on market opening and financing issues. With Opinions on Strengthening Regulation of Public Utilities (No. 154 Policy Paper, the MOC, 2005) the neglect of governmental regulation and the public good character of water in the previous policy papers was corrected. This policy paper emphasizes that the water sector provide basic public and social goods and that the governmental regulation remains essential (Fu and Zhong 2005). However, there is still a lack of a systematic and comprehensive regulatory framework for the Chinese urban water sectors in practice. The MOC is attempting to introduce and develop a competitive benchmarking system that might be helpful for further regulation, but this is not yet in place. During the authors’ field surveys, the local officials of relevant water authorities are laboring under the lack of effective measurements for regulatory framework, have too much freedom of (non)regulation, and have sometimes an incorrect perception of the government role as a regulator. Fu and colleagues (2006) also refer to the fact that the government has paid some attention to assets regulation while restructuring ownership in the water sector, but neglected regulating water service quality.
Compared to the exponential growth of water projects with significant private sector involvement, the legal basis under privatization developed quite slow and is still underdeveloped in China. Different from some water privatization forerunner countries (e.g., England and Wales, Philippines), which enacted specific laws before entering into privatization, the marketization reform of and private participation in the Chinese water sector is conducted under various governmental policy papers, but without specialized legislation. The current legal codification of public-private partnering in water services is largely a reactive process, where various policy papers address specific problems in the reform process due to the lack of a well-established legal framework. Thus, much room for improvement remains in the current legal basis, for instance on further economic regulation, stronger legislative sanctions, and public participation (cf. Tong 2005; Zhang 2006; Fu and Zhong 2005; Fu and others 2005).
As implementation problems were slowly or not adequately addressed or resolved at the national level, local governments started to issue local policy papers on specific water projects. For instance, the Interim Provision on Administrating Concession Right of Chengdu (No.131 Policy Paper of Chengdu Municipality, 2001) was issued for implementing the BOT project of Chengdu No.6 Water Supply Plant (B), which was the first water BOT pilot project approved by the NDRC. And the Measures on Public Utilities Concession Management of Shenzhen (No.124 Policy Paper of Shenzhen Municipality, 2003) guided the reform of Shenzhen Water Group, the largest water project with private sector involvement in China to date.
The Current Landscape of Private Sector Involvement
In China’s water supply and wastewater services, four major types of private corporations are active (Fu and others 2006): (1) the water transnational corporations (e.g., VEOLIA and SUEZ); (2) Chinese investment developers (e.g., Beijing Capital Group and Tianjin Capital Environmental Protection Co. Ltd.); (3) liberalized water companies (e.g., Shenzhen Water Group and Beijing Sewerage Group); and (iv) environmental engineering corporations (e.g., Beijing Sound Group and Tsinghua Tongfang Water Engineering Corporation). In December of 2004, the Ministry of Construction called provincial-level authorities to summarize marketization of public sectors (e.g., water and wastewater, solid waste, gas, and public transportation). In July of 2005, a follow-up field survey was organized by the MOC, in which the authors have participated. All reported data of this section come from the reports of provincial-level authorities, supplemented by surveys of the Water Policy Research Center of Tsinghua University (in which authors participated).
According to the MOC surveys, various forms of private sector participation can be identified in both water supply and waste water treatment: (1) commercialization of public utilities: it is the transformation of a public agency/utility into an independent corporation; (2) management contract (or namely operations and maintenance contract): it refers to a contractual arrangement in which a private operator manages and maintains the service in a given period but does not have investment obligations; (3) lease contract: it is a short-term contract in which a private operator pays an agreed-upon fee to the government for the right to manage the facility; (4) Greenfield contract (such as BOT, TOT, BOOT, etc.): it means the government commits new investment projects to a private company, within the contract duration, the private operator manages the infrastructure and the government purchases the water by a contracted price (this price isn't necessarily determined by the actual water tariff); (5) concession contract: it is a long-term contract in which a private operator bears responsibilities for operations and maintenance and also assumes investment and service obligations; (6) Joint Venture: it is not a contract but, rather, an arrangement whereby a private company forms a legal entity with the public sector, in which both the private and the public parts share responsibilities and (investment) obligations; and (7) full sale (or full divesture): it is the sale of public assets to the private sector. Table 1 summarizes the various forms of private sector participation and their characteristics. Until July 2005, a total of 152 water supply projects and 200 wastewater treatment projects involved private participation. The total water production capacity of the 152 water supply projects equaled about 17% of national water production capacity of 2004. The treatment capacity of the 200 wastewater projects was over 30 million m3 per day, equaling 67% of the national total wastewater treatment capacity of 2004.
Table 1Different forms of private sector participation in China’s water sectorForm of private sector participationAsset ownershipCapital investmentOperations & maintenanceContract periodCommercialization of governmental enterprises/utilitiesPublicPublicPublicIndefiniteManagement contractPublicPublicPrivate3–5yrLease contractPublicPublicPrivate8–15yrGreenfield (BOT-type)Private/ publicPrivatePrivate20–30yrConcessionPublicPrivatePrivate25–30yrJoint ventureSharedSharedSharedIndefiniteSale or full divesturePrivatePrivatePrivateIndefinite
Figure 1 shows the prevalence of different forms of private sector participation in water supply and in wastewater projects. The joint venture approach (including the Sino-foreign joint ventures) has the largest share in the water supply sector with 51% of the 152 privatized projects. The Greenfield modes of private sector participation (including the BOT and TOT contracts) dominated in the wastewater sector, with 59% of the 200 projects. The commercialization of governmental utilities also plays an important role in both water supply (16% of 152 projects) and wastewater (13% of 200 projects). The differences in prevalence of private sector participation forms between water supply and wastewater have a close relation with the level of infrastructure development and with tariff levels. Compared to urban water supply (with service coverage of 88.8%), urban wastewater treatment lags behind, with a service coverage of 45.6% in 2004 (MOC 2005). Direct investment demand for urban wastewater infrastructure (including wastewater treatment, sewers, and sludge treatment) in China is expected to be over 30 billion US dollars between 2006 and 2010, to meet the objective of 60% municipal wastewater to be treated. Accordingly, local governments prefer direct private sector investment in and building of new wastewater infrastructure, resulting in high levels of the Greenfield modalities. In addition, the current low wastewater treatment charges result in a preference for Greenfield modes. In these modes, financing is based on negotiated prices between the government and the private sector and is less dependent to the user fee or charge; drinking water supply costs are much better represented in prices, making joint ventures more likely (Zhong and others 2006).
Fig. 1Public sector participation in water: distribution over modalities (2005)
Figure 2 categorizes public sector participation into five groups, according to project capacity. The joint venture approach leads the reform of water supply sector in all size-categories, while the Greenfield approach dominates in wastewater sector, except for projects over 500,000 m3 per day. This might also be related to the different financial risks. Larger projects require much more direct capital investment from the private sector, increasing the financial risk for private investors and moving, then, rather toward joint venture approaches. Furthermore, the full sale/divesture approach occurred more in the field of water sector and mainly in small projects in specific provinces (see Fig. 3). And commercialization is more often found among larger projects. This might be related to not only the larger capital demands of bigger projects, but also huge labor redundancies within such large projects. Existing large water projects are traditionally run by state-owned enterprises with high levels of superfluous workers. For private investors it is often difficult to improve efficiency, because government contracts often do not allow firing existing workers following a commercialization process.
Fig. 2Distribution of private sector participation in water projects by capacitiesFig. 3Distribution of private sector participation in water projects by provinces
Figure 3 visualizes the provincial distribution of water projects with private sector participation. At least 25 provinces have private sector participation experience in water supply and 23 provinces in wastewater treatment. The form of private sector participation is determined by the level of development of water/wastewater infrastructure, as well as the local economic, social and political conditions. With richer markets, more open economic policies and higher payment capacity of local residents, the southern coastal (e.g., Guangdong and Fujian) and the eastern coastal (e.g., Jiangsu) provinces witnessed high levels of reform in their water sector. Over 60% of foreign private sector investment in water supply projects and about 50% foreign private sector investment in wastewater projects were implemented in these coastal regions, according to the MOC survey. In the meanwhile, the first national BOT pilot project of Chengdu Water Supply (Sichuan Province) has triggered a wave of private sector participation in and around Sichuan Province (including Chongqing and Yunnan). Furthermore, the special environmental protection policies related to “The Three Gorges” dam might have impelled private sector participation in wastewater sector of Sichuan Province and Chongqing.
As shown in Fig. 3, in water supply the joint venture approach dominates in 19 provinces. In the wastewater sector, Greenfield projects (including BOT and TOT) dominate in 12 provinces. The commercialization of traditional state-owned water enterprises was adopted more widely in inland provinces (such as Gansu, Heilongjiang, Jilin, Sichuan, Xinjiang, Yunnan) than in coastal provinces. A joint venture approach for private sector involvement in the wastewater sector was only adopted in provinces with high wastewater treatment charges, such as Beijing, Fujian, Jiangsu, Zhejiang, and Shanghai.
Three Case Studies of Public-Private Partnerships
The reported growing involvement of the private sector has led to radical changes in China’s water management institutions. In this section, we report on fieldwork of three case studies with distinct modes of private sector involvement (a joint venture, a concession, and a Greenfield contract) to analyze in detail the new institutions and relationships between actors in these constructions. During fieldwork in Maanshan and Shanghai, we carried out face-to-face semi-structured interviews with relevant local officials (from the construction authority, price authority, planning and reform authority, state-owned assets administration authority, and environmental protection bureau) and managers of water service providers (water treatment plants/companies, wastewater treatment plants/companies). In the performance assessment project of Macau Water Company Ltd., the managers of relevant departments as well as the representative of Macau Government were interviewed. In total, around 30 interviews were held. While these three cases represent different forms of private sector involvement, they cannot be held representative. All three cases have been assessed positively by the Chinese government and independent researchers (see Fu and others 2006), making them rather best practices than representative cases. But together they illustrate the institutional transformations that come along private sector involvement.
Joint Venture: Maanshan Water Supply
Maanshan City is an industrial, prefecture-level city of 1686 square kilometers, and a population of 1.24 million (2004), of whom 46.8 per cent lives in urban areas. According to the 2004 MOC statistics, 88.7 per cent of the urban population has access to water supply. Water resources are abundant in Maanshan City due to its advantageous location on the south bank of the Yangtze River and abundant annual rainfall (1062–1092 mm). Maanshan Construction Commission (MASCC) is not only the competent authority for water supply and wastewater treatment and as such, plays a leading role in the water sector reform. It is also, as a so-called “Big Construction Commission,” the main governmental agency responsible for urban planning, construction, and management (cf Wu 2003).
In 2002, following the call of Central Government and Anhui Provincial Government, MASCC embarked upon marketization reform in water and other public utilities (e.g., gas and public transport), widely inviting business actors to become active and invest. The director of MASCC, Mr. Xu, argued that changing the current water institutions and increasing service quality were the most important reasons and objectives for embarking on marketization in the water sector in Maanshan, rather than bringing in nongovernmental capital (personal communication 2004). Marketization was expected to impel and accelerate the reform of converting the old Maanshan Water Supply Company (MASWSC, established in 1958 as state-owned and state-subsidized company with total assets of 4.37 million RMB in 2002, ca. 0.528 million US$ at the exchange rate of 1US$ = 8.277RMB) into a new institutional lay-out. After negotiating with several private companies, MASCC first started — as a kind of trial — a joint venture with Beijing Capital Group (BCG) for one water supply plant (WTP, BCG owning 60% of shares). This joint WTP sold purified water to MASWSC and performed significantly better than other WTPs managed by MASWSC alone. In 2004, MASCC expanded the joint venture cooperation with BCG to all WTPs of Maanshan City, in which BCG obtained a 60% share by bringing in 90 million RMB (ca. 10.875 million US$ at the exchange rate of 1US$ = 8.276RMB). The new joint venture company (MAS-BCWLC) was awarded a 30-year concession right. Both BCG (private sector) and MASWSC (public sector) bear responsibility of investment, operation, and maintenance of the WTPs (excluding the pipe networks) and service obligations (see Fig. 4). With respect to the pipe networks, MAS-BCWLC manages and maintains the existing (pre-2004) network by signing a lease contract with MASWSC, which remained owner of the assets and bears the financial obligations (debts). In the meanwhile, MAS-BCWLC is requested to invest in new pipe infrastructure in new development areas and in nonpiped neighborhoods.
Fig. 4Organizational structure of Maanshan water supply system
Within the new joint venture structure, the board of MAS-BCWLC (4 members from BCG and 3 from WASWSC) is the current decision-maker regarding planning (within the objectives set by the municipal master planning), investment and financing, partly replacing the tradition of government decision structures. According to the contract, the general manager of the joint venture company comes alternately from MASWSC and BCG. Taking into account the social dimensions of water provisioning, the government claimed three key conditions in the agreement with the concessionaire: first, the concessionaire (MAS-BCWLC) must ensure sufficient and safe water provision and the government can take over all facilities without any indemnity if the concessionaire fails; second, the concessionaire cannot change the public and social nature of water and should include relevant social responsibilities as governmental requirements (e.g., employing all personnel from the old water company, providing free water for firefighting, reducing/subsidizing water bills of the poor); third, the government controls the water price.
In order to ensure high-quality water and service, MASCC regulates the performance of MAS-BCWLC via assessing annually the specified objectives approved by both the MAS-BCWLC board and MASCC. For instance, MAS-BCWLC was requested to achieve 12 key objectives in 2004: (1) investment of 18 million RMB (ca. 2.175 million US$ at the exchange rate of 1US$ = 8.276RMB); (2) selling 48 million cubic meter water or more and reclaiming >90% of water bills; (3) fulfilling indicators of water service quality (for instance, >99% of the control points should reach the required water quality standards; >98% control points should reach standards for water pressure; a maximum of 30% water loss; burst pipes repairs within maximum time limits); (4) fulfilling all MASCC indicators for safe work; (5) construction of the main body of the No.4 WTP and 25 kilometer new pipes; (6) fulfilling client service indicators (for instance, 100% good client service; >90% public satisfaction); (7) fulfilling the reconstruction of Xiangshan Town water supply system; (8) elaboration and submitting a water supply plan; (9) achieving the relevant objectives of National Civilized City Assessment System (which was proposed by Central Cultural and Ideological Building Commission in 2004; it includes 119 indicators); (10) submitting water supply plans to Municipal People’s Congress and Municipal People’s Political Consultative Conference; (11) responding adequately to complaints and reporting this information to the government; and (12) take anti-corruption measures.
After establishing the joint venture in 2002, the total length of pipes and the volume of water provision have increased (see Fig. 5) and MAS-BCWLC has been in compliance with all requirements of the government, according to interviews with local officials. From 2004 to 2005, MAS-BCWLC has invested about 90 million RMB (ca. 10.875 million US$ at the exchange rate of 1US$ = 8.276RMB) for building new infrastructure, updating old facilities and aged pipes, and establishing a customer service system. In the meanwhile, the government has stopped subsidizing WTPs after the involvement of BCG and the joint venture even turned over about 18.7 million RMB (ca. 2.260 million US$ at the exchange rate of 1US$ = 8.276RMB; including 2 million RMB of the rent fee for pipe networks, 4.7 million RMB of dividends, 7.7 million RMB of corporate income tax, 3 million RMB of value added tax, and 1.3 million RMB of the expense of other taxation; the total taxation of 12 million RMB is about 25% of the total turnover of MAS-BCWLC in 2004) to the local government in 2004. The improved service quality of water provision not only satisfied the consumers, but also resulted in government (and the price public hearing; cf. Zhong and Mol 2007) support for the first tariff reform after private sector involvement in 2004. Maanshan Government increased the water tariff from 0.83 to 1.08 RMB/m3 (ca. 0.10 to 0.13 US$/m3 at the exchange rate of 1US$ = 8.276RMB; rate for household consumers) and indirectly subsidized MAS-BCWLC by moving the additional tax of water provision (e.g., 0.05 RMB/m3 for household consumers) to the income of the joint venture water company. In 2004, the per capita annual income of urban households of Maanshan was 10,189 RMB (ca. 1231.15 US$ at the exchange rate of 1US$ = 8.276RMB), of which around 1.16% was spent on water services (calculated based on daily household water use of 300 liters per capita).
Fig. 5Total length of pipes and annual water provision in Maanshan (1995–2004)
Obviously, the involvement of BCG has brought in additional capital to develop Maanshan’s water supply sector. But more importantly it has changed the institutional structure, improved the water service quality and quantity, as well as reduced the governmental input in this field (see Fig. 6). In this structure, the government benefits both from the taxations and dividends of the joint venture company, while transferring part of the financial, building, and operational risks to the private sector. Following this model of Maanshan City, BCG has successfully expanded its activities to other cities, such as Huainan (Anhui Province), Baoji (Shanxi Province), and Yuyao (Zhejiang Province).
Fig. 6Monetary flow within Maanshan water supply
However, this private sector involvement practice of Maanshan is argued to have a (potential) political risk due to the lack of a sound legal basis. In transitional China, in particular, policies are perceived to be instable and insufficiently law-based. Until now, details on measures and rules to regulate private utility companies are still missing in current national and Anhui provincial policy papers (Maanshan has no legislation right). This is a common problem in Chinese marketization practices in the water sector, as argued by many lawyers and academics. For instance, Shenyang water supply has experienced several failed marketization practices due to the constantly changing policies and decisions of the local government during 1995–2000 (field survey 2004).
Concession Contract: Macau Water Supply
Macau is one of the two Special Administrative Regions of China, together with Hong Kong. Administrated by Portugal until 1999, it was the oldest European colony in China, dating back to the 16th century. As a small territory of 28 km2 on the southern coast of China, consisting of a peninsula and the islands of Taipa and Coloane, it has a population of 508,000 (2006).
Macau has a long history in the private provision of drinking water, since the earliest Macau Water Company Ltd. (MWC) was founded in 1932 as a full private capital company invested by individuals. Three years later, MWC was taken over by a British Electricity Lighting Company for 10 years and since 1946 by the president of the Macau Economic Department and other individual shareholders. Due to lack of capital and advanced technologies, Macau had an inadequate water supply service with poor water quality and discontinuous water provision during the 1970s. In 1985, Macau Government, learning from the concession management practices in the French water sector, awarded a consortium of two private companies, NWS Holding Limits (Hong Kong) and SUEZ Environment (France), a 25-year concession contract. Macau Government remained owner of the existing, pre-1985, assets (plants and pipe networks), while the private Macau Water Supply Ltd. (MWSL, the former MWC) bears responsibilities for operations and maintenance of these assets, as well as for new investments and service obligations (see Fig. 7). This concession contract is not only the first private sector participation construction in Chinese water sector, but also the first contract that seems to end with a positive result.
Fig. 7Organizational structure in Macau water supply
Distinct from the previous private owners, who had little experience in the field of water provision, SUEZ (France) brought in advanced water knowledge and technology. According to the concession contract, MWSL must provide high-quality water supply service, as well as bear several obligations, such as planning, investment, construction, operation, and maintenance of the infrastructure under the supervision of Macao Government. In practice, Macau Government has delegated tasks, responsibilities and obligations to a very large degree to MWSL.
Coming to the end of the 25-year concession contract, MWSL has fulfilled almost all terms of the initial contract. It has, among others, considerably improved water service quality by increasing service access and provision, decreased the loss of water leakage (see Fig. 8), and kept water tariff (corrected for inflation) at a stable level (see Fig. 9).
Fig. 8Annual water demand-provision and water loss in Macau (1982–2005)Fig. 9Water tariff rates of Macau (1982–2005)
In the concession contract, the government did not specify conditions and safeguards for the poor. But in practice, MWSL not only reduced the water bill for low-income, disabled and other vulnerable groups. For instance, MWSL has launched the “Elderly-In-Needs” water subsidy program in 2001, which offers those aged over 55 free water consumption of 5 m3 per month. Since May 2005 the “Water for All” program offers free water consumption to other categories of people in needs, such as single-parent families and disabled. But also in addition, it built two potable “Wallace fountains” (a special public fountain with potable water) in Macau, providing free potable water to tourists and citizens. MWSL has also been active in various social welfare and charity activities, providing total donations of 2.08 million MOP (1MOP = 0.965RMB, 2007; ca. 0.26 million US$ at the exchange rate of 1US$ = 8.276RMB) during 2002–2005. During 1985–2005, MSWL also charged discounted water tariffs for governmental agencies, and handed in over 260 million MOP (1MOP = 0.965RMB, 2007; ca. 32.56 million US$ at the exchange rate of 1US$ = 8.276RMB) of taxes and about 56 million MOP (1MOP = 0.965RMB, 2007; ca. 7.012 million US$ at the exchange rate of 1US$ = 8.276RMB) of concession fees to the government.
In both Maanshan and Macau, the water tariff is the main financial source for water companies, while governmental subsidies have been abandoned. Accordingly, whether the water tariff can cover the costs is significant. In the case of Macau, the Macau Government owns the pre-concession infrastructure assets, which demands a smaller first investment from the Consortium. The water tariff could easily cover the cost of operation and maintenance (and not the huge capital costs of existing assets). Unlike the joint venture construction in the Maanshan case, Macau Government leaves all financial responsibilities to the private sector after the concession, and benefits from taxes, concession fees and discounts on government water bills (see Fig. 10). Due to the limited initial investments of the private consortium, sharp water tariff increases were avoided after privatization (often one of the major reasons for public resistance and failed private sector participation in other countries). The local government still owns part of the infrastructure assets, in particular the pipes system, with huge sunk-costs.
Fig. 10Monetary flow within Macau water supply
Macau is also an interesting case because of the unique regulatory system, which includes the water quality regulator (IACM), and a unique Government Delegate. IACM is in charge of the water quality regulation, and monitors and controls drinking water quality by random sampling and analysis of over 70 water samples around Macau everyday. The Government Delegate is not a government official, but an individual working in another public utility company and appointed by the government. Following Macau laws, Mr. Lin Runzhong, the Government Delegate for water supply, was appointed for a period of five years by the Macau Government, and is not only the regulator of MWSL, but also an important linkage between MWSL and the government. He participates at all MWSL board meetings and reports relevant information and documents to the government. The Government Delegate decides which information is considered relevant. He is also in charge of assessing the performance of MWSL, and comments on the five-year plans and tariff plans before MWSL sends these to the government for approval. The Macau government generally follows the comments and assessments of the Government Delegate. In this sense, the nongovernmental Government Delegate is defined a specified role and powerful position in governing the water sector. This institutional arrangement relates to the small size of Macau Government, where only a limited state capacity (in quantitative and qualitative terms) is available for numerous public tasks. In conclusion, it can be argued that after 1985 the Macau government has played a meager role in the drinking water management.
Greenfield Contract: Shanghai Wastewater
The Greenfield contract (e.g., BOT, TOT) is the dominant form of private sector participation in wastewater sector reform throughout the country. Shanghai Zhuyuan No.1 WWTP project is one of the most famous Greenfield projects in China. It is presently one of the largest WWTP in China, with a treatment capacity of 1.7 million m3 per day and an advanced primary treatment, serving an area of 107 km2 and about 23.5 million inhabitants. But it also has become famous for the lowest service price: 0.22 RMB (ca. 0.0266US$ at the exchange rate of 1US$ = 8.276RMB) per cubic meter treated wastewater.
In 2002, the Youlian Consortium (consisting of Youlian Development Company with 45% shares, Huajin Information Investment Ltd. Company with 40% shares, and Shanghai Urban Construction Group with 15% shares) won the open tender for Zhuyuan No.1 WWTP project by bidding the lowest treatment costs. A Project Company (Shanghai Zhuyuan Youlian No.1 Wastewater Treatment Ltd. CO.) was established and awarded a 20-year concession agreement by Shanghai Water Authority. A service management contract was signed with Shanghai Sewerage Company (a fully state-owned company administrated by the government) including details of rights and obligations. Two years later, Youlian Development Company withdrew from this project by transferring the shares and obligations to InterChina Holdings Group (see Fig. 11).
Fig. 11Private sector involvement in Shanghai wastewater treatment
According to the agreement between Shanghai Water Authority and the private company, Shanghai Water Authority should minimize its interventions in the construction, operation, and maintenance of WWTP and limit them to safeguarding public health and safety. All conditions and objectives with regard to water service quality are defined in the service contract between Shanghai Sewerage Company and the private company. Among others, the private company has to install an on-line monitoring system and is requested to invite an authorized third party for regular monitoring (on indicators such as BOD5, CODcr, SS, NH4-N, and phosphate). This should be paid by the private company, while reporting to the Shanghai Sewerage Company and should take place within five days. Shanghai Sewerage Company may conduct random water examination at any time. According to the local officials, Shanghai Zhuyuan WWTP has fulfilled all responsibilities and obligations required by the contract up till now, including meeting the water quality standards.
In the case of Shanghai Zhuyuan Greenfield project, the government has transferred its traditional responsibilities of investment, construction, operation, and maintenance (for the contract period) to the private Project Company, accompanied by paying a service fee (see Fig. 12). Different from the joint venture construction in Maanshan and the concession construction in Macau, in which corporate profits directly depend on the water tariff, the private operator within a Greenfield contract is paid a service price negotiated between the government and the private sector. This service price depends on the investments and agreed performance levels, rather than on the user fee level, and which provides the private sector with the financial risks. Accordingly, the low service price of Zhuyuan No.1 WWTP (which was 42% less than the projected costs by government) presented in the public bidding, was argued to have a close relation to earlier governmental input in this project. Shanghai Water Assets Management Development CO. Ltd., a fully public-owned company, was in charge of the pre-phase design and invested about 30 million US dollars in the fixed infrastructure of this project, while the government provided the land free of charge to the operator. Strictly speaking, Shanghai Zhuyuan No.1 WWTP Greenfield project is a quasi-BOT project, due to the fact that part of the investment comes from the government.
Fig. 12Monetary flow within Zhuyuan Greenfield project
The experience of Shanghai is an example of full governmental delegation of the daily management of WWTP to the private sector, while financial support via subsidies and preferential policies (e.g., land use) facilitate privatization with low service prices. It is, however, too early to fully assess the success of this project. Some BOT WWTP projects in other cities have met problems following gaps in the current national policy documents. For instance, projects in Foshan (Guangdong Province) could not run properly due to conflicts over current land use right. And projects in Beijing were delayed during the financing process because the domestic private actors met difficulties in obtaining loans from domestic banks due to the lack of a sound loan policy. The commercial banks couldn’t provide long-term loans as required for BOT-types projects as their credit policies are restricted for the private sector (Zhong and Fu 2005), while the China Development Bank can provide long-term loans for BOT-types projects only for a limited number of clients (Chang and others 2006).
Conclusions
With the emergence and blossoming of various forms of private sector involvement in the Chinese water sector, the traditional structure of full governmental provision of water supply and wastewater treatment has changed dramatically. The analysis in this article has provided evidence of the contribution of these new modes to increased capital investment, and especially of more efficient operations and improved service provision. In that sense, the original goals of the Chinese government to embark upon private sector involvement in water provisioning and treatment have been met. However, the early stage that most contracts are in, and the not yet crystallized forms and modes of privatization, prevents us from drawing any final conclusions on the impact of private sector involvement in the Chinese water sector.
From the three casestudy projects with private sector participation, we can draw some lessons for how to successfully involve the private sector into the provision of water services. Firstly, a balance between the water tariff level, profits of investor and governmental subsidies is required. As Hall and Lobina (2005) state, most practices of water privatization fail due to public resistance following sharp price increases and job losses. In China, this has not (yet) been the case, due to large increases in efficiencies and governmental support to fixed infrastructure assets, reducing financial risk of the private sector and limiting the need for large water tariff increases. At the same time, the significant economic growth levels enables local residents to cope with some tariff increases, the poor and disadvantaged have been subsidized by the government, job losses have been minimized following social policies, and public hearings have contributed to higher levels of legitimacy. This all contributed strongly to a relatively smooth transformation of China’s water sector.
Secondly, the selection of the PPP form has a close relation with the level of local water tariff. As illustrated by this article, Greenfield projects appear to be applied when tariffs are not sufficient, especially in the wastewater sector (see also Zhong and others 2006), while Joint Venture approaches are often used in cities with sufficiently high water tariff, in particularly in the water supply sector.
Thirdly, it is crucial to accelerate the establishment of systematic and comprehensive governmental regulatory framework, as the current ad hoc, fragmented and diverse regulatory system endangers efficiency in water service development and certainty and stability for foreign investors. Experiences in many countries have proven that regulation is a key aspect in successful privatization in the water sector and a competitive benchmarking system is regarded as useful in an effective regulatory approach. In late 2006, the MOC attempted to develop a Chinese water supply benchmarking system, which is still ongoing. However, the current private sector involvements in the Chinese water sector still face many legal and regulatory uncertainties. Too often local authorities experiment with systems of governmental regulation and control, or — as in Macau — seem to become marginalized. According to interviews with local officials during our fieldwork, the importance of establishing a workable regulatory and legal system is essential. Guaranteeing sufficient and safe water service to the public is jeopardized by the fact that governments can no longer fully control the planning, operation, and management of water services as before private sector participation. This might only be signs of uneasiness with the new water institutions and division of tasks and responsibilities, but can also be the heralds of an emerging debate on privatization in the Chinese water sector.
Finally, but not least, it is important to identify the differences in risk allocations in the water (service) market between the public and private sectors within different modes of PPP. As Table 1 and the three case-study projects illuminate, with the various forms of privatization, the government often transfers (smaller or larger parts of) financial risks, building risks, and operation and maintenance risks to the private sector. Meanwhile, in the end the government can always take over all facilities without paying an indemnity to the private sector if a concessionaire fails in obtaining the goals as formulated by governmental authorities, or some conflicts emerge in the further policies (e.g., the terminated contracts that are regarded as providing the private sector a fixed investment return). In that sense, the still unstable legal base in transitional China provides a major political and transfer risk for private investors.

public-private partnership
china
water governance


How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists

Guidelines for the management of low back pain (LBP) have existed for many years, but adherence to these by health care practitioners (HCPs) remains suboptimal. The aim of this study was to measure the attitudes, beliefs and reported clinical behaviour of UK physiotherapists (PTs) and general practitioners (GPs) about LBP and to explore the associations between these. A cross-sectional postal survey of GPs (n = 2000) and PTs (n = 2000) was conducted that included the Pain Attitudes and Beliefs Scale (PABT.PT), and a vignette of a patient with non-specific LBP (NSLBP) with questions asking about recommendations for work, activity and bedrest. Data from 1022 respondents (442 GPs and 580 PTs) who had recently treated patients with LBP were analysed. Although the majority of HCPs reported providing advice for the vignette patient that was broadly in line with guideline recommendations, 28% reported they would advise this patient to remain off work. Work advice was significantly related to the PABS.PT scores with higher biomedical (F1,986 = 77.5, p < 0.0001) and lower behavioural (F1,981 = 31.9, p < 0.001) scores associated with advice to remain off work. We have demonstrated that the attitudes and reported practice behaviour of UK GPs and PTs for patients with NSLBP are diverse. Many HCPs held the belief that LBP necessitates some avoidance of activities and work. The attitudes and beliefs of these HCPs were associated with their self-reported clinical behaviour regarding advice about work. Future studies need to investigate whether approaches aimed at modifying these HCP factors can lead to improved patient outcomes.
1
Introduction
Low back pain (LBP) is common, affecting 38% of adults in any one year, of whom 1 in 4 experience significant disability [37]. Only 25% of patients consulting in primary care will be symptom free 12 months later [18]. The last two decades have also seen dramatic rises in work loss and sickness benefit payments, attributed to recurrent and persistent LBP [16,36].
Guidelines for the clinical management of patients with LBP encourage health care practitioners (HCPs) to advise patients to stay active, avoid bed rest, stay at or return to work, and stress simple messages about self-management [3,31,45,47,49,50]. Previous studies have identified that HCPs do not always follow guideline recommendations for LBP [10,20,24,26] and so despite the abundance of guidelines for practice, the management of LBP poses considerable challenges and frustrations for both patients and practitioners [14] and it is increasingly clear that it is insufficient to study patient factors alone [25,48].
A potentially important but relatively unexplored influence on patients’ pain experiences is the attitudes and beliefs of the HCPs with whom they come into contact. HCPs are frequently asked to provide advice and recommendations about physical activities, work, and rest and HCPs’ attitudes and beliefs may be an integral part of the health care process, influencing the success or failure of treatment. HCPs hold a range of attitudes and beliefs about back pain [17,19,28,32,39,42–44], and these attitudes appear to be associated with the work and activity recommendations that HCPs give to patients [17,28,42,44].
In the UK, approximately 98% of the population is registered with a National Health Service general practitioner (GP) [13]. GPs serve as gatekeepers to secondary care, selecting and referring patients for specialist investigations and treatment services. Physiotherapy is one of the most common services to which patients are referred, or which patients seek out privately [36], and LBP accounts for more than half of physiotherapists’ workload in the UK [24].
Few studies have explored HCP factors in the UK, but it has been shown that many physiotherapists (PTs) continue to advise limitations of work and activity levels, despite identifying when patients with LBP are at risk of chronicity [11] and an important proportion of therapists continue treating patients with LBP even when they fail to improve [41]. The aim of this study was to measure, in national random samples, the attitudes, beliefs and reported clinical behaviour of GPs and PTs about LBP, explore their associations and evaluate the implications for both clinical practice and future research.
2
Methods
2.1
Design and setting
We conducted a cross-sectional, nationwide postal survey of UK GPs and PTs, involved in the management of patients with LBP, between April and November 2005. Ethical approval for the study was obtained from the West Midlands Multi-centre Research Ethics Committee (MREC). Written consent was not sought from each participant for use of survey data, but consent of respondents was assumed if they completed and returned the questionnaire.
2.2
Questionnaire sample and mailing process
We used simple random sampling to obtain details of GPs (n = 2000) and PTs (n = 2000) from national databases (Binleys database for GPs, n = 46,000 GPs on the list; Chartered Society of Physiotherapy membership database, n = 32,000 PTs on the list). In the UK, all GPs working in the National Health Service are included on the Binleys database [7], which is produced in conjunction with the Royal College of General Practitioners. The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body representing the UK’s chartered physiotherapists and 98% of all PTs are members of the CSP.
A sample size calculation indicated that a sample of 900 responders (450 GPs and 450 PTs) was required to allow us to find a minimum difference of 10% in the proportion of respondents with ‘helpful’ to ‘unhelpful’ beliefs by important practitioner characteristics at a significance level of 0.05 and a power of 90% [2]. A questionnaire package containing the questionnaire, a cover letter, an information sheet and a pre-paid envelope was mailed to each HCP. A single reminder was sent to all non-responders four weeks after the first mailing. In order to allow assessment of non-response bias within the survey estimates, a brief questionnaire was mailed to a random sample of non-responders. No incentives for completing the questionnaire were offered.
2.3
Questionnaire
A filter question was used to identify those HCPs who had treated at least one patient with non-specific LBP (NSLBP) in the previous six months, so that only respondents with recent experience of managing patients with LBP were included in the analysis.
2.3.1
Demographics and practice information
A number of demographic and practice questions, relevant to each profession, were included. Some items were pertinent to both professions: gender; years since qualification; postgraduate training in LBP; clinical interests/speciality and personal experience of back pain. Data gathered exclusively from GPs included whether they worked only in general practice and whether the practice was a single-handed or a group practice. Data gathered exclusively from PTs included how much of their clinical practice was based in the NHS, what proportion of their caseload was primary care patients, whether they worked alone or in a team, and grade of current job.
2.3.2
Attitudes and beliefs measure
The Pain Attitudes and Beliefs Scale (PABS.PT [28,39]) was included as a measure of HCPs’ attitudes about LBP. This was selected following a systematic review of available tools for assessing the attitudes and beliefs of HCPs about LBP [12], in which the PABS.PT fared well on pre-defined quality criteria [34]. This tool was originally developed for use in physiotherapists, but more recently has been applied to a cohort of Dutch general practitioners [30]. In addition, the members of a multi-disciplinary clinical advisory group confirmed face and content validity of the PABS.PT for both GPs and PTs after recommending that the term ‘therapy’ was changed to ‘treatment’ in two of the items of the PABS.PT. The resulting minimally amended PABS.PT was used for both GPs and PTs.
The PABS.PT assesses the strength of treatment orientation on two subscales, ‘biomedical’ and ‘behavioural’. The biomedical orientation is described as one in which the HCP believes in a biomechanical model of disease, where disability and pain are a consequence of a specific pathology within the spinal tissues and treatment is aimed at treating the pathology and alleviating the pain. The behavioural orientation is where the HCP believes in a biopsychosocial model of disease in which pain does not have to be a consequence of tissue damage, and can be influenced by social and psychological factors. We used the amended PABS.PT [28], which consists of 19 items, each rated on a six point Likert scale (‘Totally disagree’ = 1 to ‘Totally agree’ = 6), with ten items on the biomedical subscale (score range: 10–60) and nine on the behavioural subscale (score range: 9–54). Higher scores on each subscale indicate a stronger biomedical or behavioural treatment orientation, respectively.
2.3.3
Clinical behaviour measures
Clinical behaviour was elicited by asking the HCPs about diagnostic investigations and for their recommendations about work, activity levels, and bedrest, for a patient with NSLBP described in a vignette. The vignette described a patient with uncomplicated NSLBP who was not at work as a result of their symptoms (Appendix A). Vignettes have been shown to be a useful measure of clinicians’ practice behaviour and a more accurate assessment of clinical behaviour than data extracted from case notes when measured against the gold standard of standardised patients [40].
The clinical behaviour question regarding work was as follows:
“The patient described in the vignette asks what your advice would be about her work. I would recommend this patient to: (Please tick the one response that best describes what you would recommend this patient to do)a.Be off work until pain has completely disappearedb.Return to part time or light dutiesc.Be off work for a further … weeks (please state number of weeks)d.Return to normal worke.Be off work until pain has improved”
Responses for each of the work, activity and bedrest questions were subsequently classified by the authors as being ‘strictly in line with guideline recommendations’, ‘broadly in line with guideline recommendations’ and ‘not in line with guidelines’. For the work question given above, we considered option ‘d’ to be strictly in line with guideline recommendations, option ‘b’ to be broadly in line with guideline recommendations and options ‘a’, ‘c’ and ‘e’ to be not in line with guideline recommendations. This classification was based on a previously published expert consensus carried out on similar practice recommendations in a postal survey of physiotherapists, osteopaths and chiropractors in the UK [22].
2.4
Brief questionnaire
The brief questionnaire sent to a sample of non-responders contained the filter question to ensure that respondents recently involved in the management of patients with LBP could be identified. Alongside key demographic questions, we included four items from the PABS.PT (two from each subscale chosen on the basis of factor loadings described by the tool’s developers and data from a pilot study), the vignette patient and the clinical behaviour questions related to work, activity and bedrest.
2.5
Statistical analysis
Scores for the PABS.PT were calculated according to methods specified by the questionnaire developers, i.e. a simple summation of the items in each subscale [39]. No method for dealing with missing data on this measure has been published so a pragmatic decision was made that if one value was missing from a subscale, a mean score based on the remaining values was substituted. If more than one value was missing the score for the whole subscale was classed as missing. A Pearson’s correlation coefficient was calculated between the scores on the two subscales of the PABS.PT as previous work has shown that they are not totally independent [28,39]. We used descriptive statistics to summarise, by professional group, demographic, and practice data for both subscales of the PABS.PT. In addition, in response to the reviewer’s suggestions, we conducted a subgroup analysis of work, activity and bedrest recommendations for those respondents who had high biomedical scores and low behavioural scores and vice versa. Unless differences occurred by profession, analyses were performed on the combined GP and PT dataset.
The relationship between attitudes and beliefs and clinical behaviour was examined using ANOVA to test for an overall relationship with clinical behaviour and, when appropriate, for a linear trend across clinical behaviour groups (strictly in line, broadly in line and not in line with guidelines). The effect of non-response was examined by comparing responses from all responders to the full questionnaire to those completing the brief questionnaire. All analyses were carried out using the Statistical Package for Social Scientists for Windows (SPSS Inc., Chicago, IL, version 13).
3
Results
The overall response rate was 38% (n = 1534), 22% (n = 443) for GPs and 55% (n = 1091) for PTs. Of the respondents, 580 PTs and 442 GPs reported treating at least one patient with LBP in the previous six months and were included in the analysis.
3.1
Characteristics of respondents
The demographic and professional characteristics of the respondents are summarised in Table 1. The majority of GPs worked exclusively in general practice, within group practices and had at least one specialist clinical interest. The majority of PTs worked within the NHS, with other HCPs, were of senior clinical grade or above, and had a patient caseload of more than 50% primary care patients. The PTs were qualified for a shorter length of time than GPs, were more likely to be female and to have postgraduate training in LBP.
3.2
Attitudes and beliefs
Scores for both of the PABS.PT subscales could be calculated for the majority of the 1022 responders (biomedical n = 1010, behavioural n = 1004). Mean (standard deviation, range) score for the biomedical subscale was 31.0 (6.4, 12–50) overall: GPs 30.9 (5.3); PTs 31.1 (7.2), and for the behavioural subscale was 33.0 (4.6, 15–48) overall: GPs 33.7 (4.2); PTs 32.5 (4.8). For both subscales and both professional groups, the mean observed scores were in the middle of the possible ranges. The Pearson’s correlation coefficient (r = −0.38; p < 0.0001) showed a statistically significant level of dependence between the two subscales, suggesting that respondents who score higher on one subscale tend to score lower on the other subscale.
3.3
Diagnostic investigations
In response to the vignette patient, most HCPs reported that they would not want the patient described to have any diagnostic investigations. Of the GPs 33% (n = 142) reported that they would request at least one investigation, compared with 24% (n = 134) of PTs (Table 2). GPs were more likely to want laboratory tests and PTs were more likely to want an X-ray or special imaging procedure such as an MRI.
3.4
Clinical behaviour
The responses to the clinical behaviour questions were classified according to whether these were ‘strictly in line’, ‘broadly in line’ or ‘not in line’ with guideline recommendations and the responses and the classifications are summarised in Table 3. The majority of respondents reported advice that was either ‘strictly in line’ or ‘broadly in line’ with guideline recommendations’. Very small proportions of respondents reported they would provide advice that was ‘not in line’ with guideline recommendations for activity and bedrest, however, this figure was considerably higher for recommendations regarding work, with 28% of respondents reporting that they would recommend the patient in the vignette to remain off work.
The summary of responses of the two subgroups of high biomedical and low behavioural scores (n = 187) and low biomedical and high behavioural scores (n = 137), compared to the total sample, is also presented in Table 3. The proportion of practitioners recommending that the patient in the vignette remain off work, i.e. not in line with guideline recommendations, was substantially higher in those with high biomedical and low behavioural scores (44.9%) than those with high behavioural and low biomedical scores (11.9%). Similar differences were also seen for recommendations regarding activity and bedrest.
3.5
Relationship between attitudes and beliefs and clinical behaviour
Given the very small proportion of respondents whose advice was ‘not in line with guidelines’ for both activity and bedrest, associations with the PABS.PT scores were not examined. Fig. 1 shows the distributions of the PABS.PT biomedical and behavioural subscale scores for each of the reported work recommendation groups. With increasing disparity with guidelines, biomedical scores increased (mean scores: 28.3, 30.6, 33.5) and behavioural scores decreased (mean scores: 34.1, 33.3, 31.8). These associations were shown to have a significant linear trend for both the biomedical (F1,986 = 77.5, p < 0.001) and behavioural (F1,981 = 31.9, p < 0.001) subscale scores.
3.6
Effect of non-response
In order to assess the impact of non-response bias within the survey estimates, a brief questionnaire was mailed to a random sample of non-responders (GPs n = 414, PTs n = 243), and responses were received from 14% of GPs (n = 59) and 17% PTs (n = 40).
For the GPs, gender mix and years in practice were similar for those completing the full and brief questionnaire. For the PTs, those completing the brief questionnaire were slightly less experienced (mean of 12 years experience versus 15 years) and more likely to be male compared to the full questionnaire responders (25% vs. 19% male). Responses to both behavioural subscale PABS.PT items and one of the two items from the biomedical subscale were similar to those for the full questionnaire. Responders to the brief questionnaire, from both professions, were more likely to agree with the statement that ‘patients with back pain should preferably practice only pain free movements’, indicating a more biomedical orientation. The responses to the items regarding work and activity advice were similar for responders to the full and brief questionnaires. GPs responding to the brief questionnaire reported bedrest advice that was less in line with guideline recommendations than the responders to the full questionnaire (19.3% strictly in line with guidelines compared to 38.4%, respectively), whereas the PTs completing the brief questionnaire reported bedrest advice that was more in line with guideline recommendations than the initial responders (35.0% strictly in line with guidelines compared to 21.8%, respectively).
4
Discussion
4.1
Main findings
This is the first national UK survey of LBP related attitudes, beliefs and reported clinical behaviour of GPs and PTs and results show that responses are diverse. The majority of respondents reported advice that was strictly or broadly in line with guideline recommendations about activity and bedrest, however, over a quarter of HCPs recommended that the vignette patient with NSLBP should remain off work. Reasons why adherence to guideline recommendations for work is lower than for activity and bedrest are unclear, but may be due to the complex nature of the clinical consultation, and previous studies have shown that GPs see sickness certification as a potential threat to the doctor–patient relationship [15,29]. The attitudes and beliefs of HCPs were significantly associated with reported work advice for the patient described, i.e. HCPs with stronger biomedical and weaker behavioural treatment orientations were more likely to report advice, regarding work, which was ‘not in line with clinical guidelines’. The subgroup analysis supports this, although only a third of respondents could be categorized into these subgroups i.e. high biomedical and low behavioural scores on the PABS.PT or vice versa. The differences in the PABS.PT scores were small, and although statistically significant, no guidance is currently available to suggest whether these represent a clinically relevant difference.
A considerable proportion of HCPs in the UK continue to provide advice to patients about work that is not in line with guideline recommendations. The associations between attitudes, beliefs and reported clinical behaviour suggest that some HCPs continue to practice predominantly within a biomedical model, placing most importance on the severity of tissue damage when determining a patient’s level of pain and functional disability. Others have adopted a more behavioural approach to management, embracing the notion that the level of pain and functional loss may be influenced by psychological and social factors in addition to biomechanical factors.
4.2
Comparison to other studies
HCPs in this study had similar attitudes and beliefs to therapists in the Netherlands [28], with Dutch therapists having similar mean biomedical scores (29.5 vs. 31.0), but slightly higher behavioural scores (35.6 vs. 33.0) on the PABS.PT. Direct comparison of subscale scores with studies using the original PABS.PT is not possible due to a different number of items [30,39].
The attitudes and beliefs of HCPs were significantly associated with reported work advice for the vignette patient. Respondents reporting advice ‘strictly in line with guidelines’ demonstrated stronger behavioural and weaker biomedical orientations than those reporting advice ‘not in line with guideline recommendations’. Using a variety of measures, previous studies have demonstrated that advice to restrict work or activities is also associated with a biomedical treatment orientation [28], patho-anatomical focus of training courses [39], higher fear avoidance beliefs of HCPs [17,32,42] and a strong belief that pain and impairment are invariably linked [28,44]. Our study adds to this body of literature by showing a significant association between attitudes and beliefs and reported work advice in HCPs in the UK.
4.3
Implications for clinical practice and future research
The results suggest that the attitudes and beliefs of HCPs are linked to clinical practice and the recommendations provided to patients. These practitioner factors are thus part of the dynamic interaction within LBP care episodes, along with the LBP problem itself and the patient’s own perceptions about their problem. This may help explain patient outcomes, although the mechanisms behind this are likely to be complex. It is probable that HCPs’ attitudes and beliefs are expressed to patients in a variety of ways, with a range of possible consequences. By restricting activities and work, HCPs may reinforce patient’s unhelpful illness perceptions and increase spinal vigilance. Alternatively, they may over-direct the patient by providing strict advice to perform only specific activities and exclude others, encouraging an over-reliance on the HCP [35], which may make it difficult to foster the patients’ self-management skills, something recommended as part of best practice for patients with LBP.
The reported clinical behaviour of HCPs illustrates that the majority would provide advice that is strictly or broadly in line with guideline recommendations, however, nearly 30% reported they would advise the described patient to remain off work. Staying at work or an early return to work with NSLBP is recommended [50], as the longer someone is off work the likelihood of them returning steadily diminishes, with a 20% risk of long term disability for those off work for four to six weeks [51]. Although the management of LBP, in terms of advice about activity and bedrest, seems to be broadly in line with guideline recommendations, our results show that adherence about advising early return to work is suboptimal.
Attitudes and beliefs held by HCPs may help explain why implementation of current LBP guidelines has been slow and difficult [6,8,20,23,33]. Changing clinical behaviour is recognised to be a challenge [27]. Evidence from recent clinical trials suggests that although modest intervention strategies can result in moderate changes in reported adherence to guideline recommendations [8], this does not lead to a corresponding improvement in patient outcomes [9,21,30]. A better understanding of the attitudes and beliefs of HCPs, what influences these and how these relate to outcomes of patients with LBP is needed to inform development of future implementation strategies.
Future work should further test the psychometric properties of the PABS.PT to assess responsiveness and determine appropriate cut offs for ‘high’ and ‘low’ scores on the subscales and what constitutes a clinically relevant change. Methods to assess HCP attitudes, beliefs and behaviours warrant further study. For example, the validity of using methods to measure implicit attitudes about LBP, such as those employing automatic responses, could be explored in an attempt to overcome potential social desirability bias in survey responses as HCPs become more aware of clinical guidelines.
4.4
Strengths and limitations
The strengths of this study include the large sample sizes, simple random sampling of UK GPs and PTs, use of a validated beliefs measure, and investigation of potential non-response bias. The response rate of GPs was low, but comparable to other postal surveys of GPs in the UK [4,5,38]. The sample size calculation took this into account and yielded the required sample size for the planned analyses. The response rate of PTs was in keeping with other studies [11,39,41]. Responses to the brief questionnaire were broadly similar to those completing the full questionnaire in terms of attitudes, and recommendations for work and activity. However, some differences in the advice for bedrest suggest that we cannot rule out non-response bias in our survey. Responses to one PABS.PT item showed a stronger biomedical treatment orientation for responders to the brief questionnaire. Also, GPs responding to the brief questionnaire reported advice for bedrest that was less in line with guideline recommendations than responders to the full questionnaire, so for GPs, where the potential for non-response bias is greatest, our survey may underestimate the strength of a biomedical treatment orientation and the numbers providing advice not in line with guideline recommendations.
This study captured self-reported behaviour rather than real clinical practice, which is very difficult to measure. To provide a context for the clinical behaviour questions we used a vignette of a patient with NSLBP, an approach shown previously to have acceptable validity [40,46]. Although we used established tools to assess attitudes, beliefs and clinical behaviours, there may be some overlap in the constructs they measure. We attempted to address this by the wording of instructions and the order of the tools within the questionnaire. The PABS.PT attitudes measure came first with instructions to respond to the general attitudinal type statements. The vignette and the behaviour questions came later with the instruction to consider the specific management of the patient described.
5
Conclusion
This study shows the diversity of the attitudes and self-reported practice behaviour of UK GPs and PTs for patients with NSLBP. Many HCPs believed LBP necessitates some avoidance of activities and the need to be off work. For a patient with a history of being off work since onset of LBP four weeks previously, over a quarter of HCPs recommended further time off work. The attitudes and beliefs of HCPs were associated with their advice about return to work. Future studies need to investigate the associations between HCP factors and patient outcomes, and test if approaches aimed at modifying attitudes, beliefs and clinical behaviours of HCPs can be successful.

low back pain
attitudes and beliefs
health care practitioners
survey
practice behaviour


Quantitative imaging assay for NF-κB nuclear translocation in primary human macrophages

Quantitative measurement of NF-κB nuclear translocation is an important research tool in cellular immunology. Established methodologies have a number of limitations, such as poor sensitivity, high cost or dependence on cell lines. Novel imaging methods to measure nuclear translocation of transcriptionally active components of NF-κB are being used but are also partly limited by the need for specialist imaging equipment or image analysis software. Herein we present a method for quantitative detection of NF-κB rel A nuclear translocation, using immunofluorescence microscopy and the public domain image analysis software ImageJ that can be easily adopted for cellular immunology research without the need for specialist image analysis expertise and at low cost. The method presented here is validated by demonstrating the time course and dose response of NF-κB nuclear translocation in primary human macrophages stimulated with LPS, and by comparison with a commercial NF-κB activation reporter cell line.
1
Introduction
Nuclear factor kappa B (NF-κB)/rel represent a family of transcription factors, present in all eukaryotic cells, that regulate inducible expression of wide ranging genes involved in immune responses and cell-cycle regulation. Therefore activation of NF-κB provides a key molecular switch that is relevant to many aspects of cellular immunology research. In immune cells NF-κB is most abundant either as a heteromeric complex of two components, p65 (rel A) and p50, or as a p65/p65 homodimer. The p65 component contains the main transactivating domain responsible for NF-κB transcription factor function. Regulation of NF-κB activity is dependent upon cytoplasmic sequestration in association with an inhibitory molecule, IκBα. As a consequence of intracellular kinase signalling cascades IκBα is phosphorylated, and this leads to its degradation, allowing nuclear translocation of p65/rel A and hence so-called “activation” of NF-κB (Ghosh et al., 1998). Conventional methods for testing NF-κB nuclear translocation utilise a semi-quantitative electromobililty gel-shift assay. This involves incubation of nuclear extracts with 32P-labelled oligonucleotides of NF-κB binding sites and separation from unbound probe by electrophoresis in a non-denaturing polyacrylamide gel. However, this assay is principally limited by sensitivity, and requires large scale cell culture (typically > 10 × 106 cells), thus precluding its use with primary cells. Additional disadvantages are the labour-intensive protocol and the need for radioisotopes. Cell lines transfected with NF-κB promoter–reporter gene constructs are used widely to study cell signalling pathways, and are easy to quantitate with colorimetry or luminometry, but are not suitable for most primary cell culture studies. Commercial kits for enzyme linked immunosorbent assays of NF-κB quantitation within nuclear extracts have also become available, but their expense may be prohibitive.
An attractive new strategy is to image NF-κB translocation from the cytoplasm to the nucleus, using immunofluorescence staining. This can be performed on a small scale and at a single-cell level. Fluorescence microscopy, laser scanning cytometry and flow cytometry to quantify NF-κB nuclear translocation have all been reported (Deptala et al., 1998; George et al., 2006; Rogers and Fuseler, 2007; Fuseler et al., 2006). Drawbacks of these previous reports are the need for expensive imaging equipment and/or image analysis software. Here we present an alternative simple method for quantitative detection of NF-κB rel A nuclear translocation which uses standard confocal immunofluorescence microscopy and the public domain Java image processing program, ImageJ. We suggest that the general availability of all three components—fluorescence microscopy, immunostaining reagents, and the analytic protocol-provides a readily accessible method for the study of NF-κB nuclear translocation in primary cell cultures.
For this study we have chosen to use a cell system that has been difficult to analyse previously, primary monocyte-derived macrophages that have been isolated from healthy human volunteers. In vivo macrophages are resident tissue mononuclear phagocytic cells derived from circulating monocytes. They function both as sensory cells of innate immunity, and as effectors, initiating early non-specific host defences, both by local recruitment of other immune cells and by induction of an acute phase response, which leads to systemic priming of the immune system. In vitro work on these cells often includes stimulation by model innate stimuli, now known to be Toll-like receptor (TLR) ligands, such as lipopolysaccharide (LPS) (TLR-4) and Pam3CSK4 (TLR-2). Activation of the NF-κB pathway is a common downstream component of the cellular response to many different innate immune stimuli and is used frequently in these cells as a biochemical detection and quantification method to study innate immune cellular activation. Therefore analysis of the NF-κB pathway in macrophages, and in related mononuclear phagocytic cells such as dendritic cells, is an important area of research interest. However, analysis in these cells has been hampered by the lack of suitable methods. Myeloid leukaemic cell lines (e.g. U937, THP-1) are the standard for these experiments, but unless they are very carefully differentiated (which itself may involve NF-κB activation) they are not ideal models. This necessity for an accurate and reproducible primary macrophage system stimulated us to adapt the NF-κB assay as described here.
2
Methods
2.1
Macrophage culture and innate immune stimulation
Human blood samples were obtained from healthy volunteers. The study was approved by the joint University College London/University College London Hospitals NHS Trust Human Research Ethics Committee and written informed consent was obtained from all participants. Peripheral blood mononuclear cells (PBMC), consisting of monocytes and lymphocytes, were prepared by density-gradient centrifugation of heparinised blood with Lymphoprep™ (Axis-Shield) according to the manufacturer's instructions. PBMC were resuspended in RPMI 1640 with l-glutamine (Gibco, Invitrogen) (NM) containing 5% heat inactivated (56 °C for 30 min) type AB normal human serum (NHS) (Sigma Aldrich) (107 cells /ml) and seeded on to 13 mm (No 1.5) glass coverslips (VWR) using 2 × 105 cells/cover slip. After 1 h at 37 °C non-adherent cells (lymphocytes) were removed by sequential washes with Hanks buffered saline solution (HBSS) (Gibco, Invitrogen). Adherent cells (monocytes) were incubated in NM containing 10% autologous heat-inactivated HS supplemented with 20 ng/mL macrophage-colony stimulating factor (M-CSF) (R&D systems) for 3 days. Any remaining non-adherent cells were removed by further washes with HBSS, and NM/HS was replaced, but without additional M-CSF. This protocol yields adherent macrophages by day six with less than 5% contamination by lymphocytes (data not shown). Ultra-pure LPS (Invivogen) and Pam3CSK4 (Invivogen) were used as prototypic innate immune stimuli at different concentrations as outlined below. Polymyxin B (Invivogen) was used as a specific inhibitor of LPS bioactivity.
2.2
Immunofluorescence staining
For immunostaining, rabbit polyclonal affinity purified antibody to rel A (C-20) (Santa Cruz Biotechnology) was used (2 μg/ml) with a secondary antibody, Alexa-Fluor (AF)633—conjugated F(ab')2 goat anti-rabbit IgG (Invitrogen) used at 4 μg/ml. 10% normal goat serum (Sigma Aldrich) used as blocking buffer, eliminated all non-specific binding of the secondary antibody (data not shown). Cells cultured on glass coverslips were fixed with 3.7% paraformaldehyde (15 min, room temperature) and washed with Tris-buffered saline (TBS). Each coverslip was inverted on to 50 μl of solution placed on impermeable Nesco film (VWR). All reagents were diluted in TBS, and coverslips were washed by immersion into TBS between each staining step. Coverslips were incubated sequentially with 0.2% Triton-X100 (Sigma) (10 min, room temperature), blocking buffer (30 min, room temperature), primary antibody diluted in blocking buffer (overnight, 4 °C) and secondary antibody diluted in blocking buffer (1 h, room temperature). Nuclei were counterstained with 2 μg/ml of the nuclear stain DAPI (Sigma Aldrich) for 5 min. Coverslips were mounted on to glass slides (VWR) using Vectashield hard-set mounting media (Vector).
2.3
Image acquisition and analysis
Fluorescence images were captured on a Leica SP2 confocal microscope. DAPI (excitation 405 nm, emission 400–450 nm) and AF633 (excitation 633 nm, emission 650–700 nm) fluorescence were captured using sequential acquisition to give separate image files for each (Fig. 1A). A pin hole of 1 Airy (114.5 μm), scan speed of 400 Hz and 4 frame averaging was used. Photomultiplier tube gain and offset were adjusted to give sub-saturating fluorescence intensity with optimal signal to noise ratio. Image analysis was performed using ImageJ v3.91 software (http://rsb.info.nih.gov/ij). Five high power fields were selected for analysis of each stain. To avoid being biased by the NF-κB staining, each field was selected by viewing nuclear (DAPI) staining only to identify near-confluent cells and thereby maximise the cell numbers included in the analysis. Preliminary experiments demonstrated that this approach provided data on at least 500 cells, and that the variance of the data was not changed by increasing the sample size further (data not shown). For each high power field, binary image masks were created of rel A and DAPI positive staining to define regions of interest (ROI) for analysis. This was done by applying a median filter (3 × 3 pixel radius) to remove noise and to approximate the distribution of staining intensity to a median value (Fig. 1B). Automatic thresholding, using the Isodata algorithm (Ridler and Calvard, 1978) was then used to convert the image to a binary mask (Fig. 1C) that included all fluorescence data above background. The DAPI staining mask was used to define the nuclear ROI. Using the image calculator, the DAPI mask was subtracted from the rel A mask to create a staining mask defining the cytoplasmic ROI. Each of these ROI masks were then applied, by the image calculator, to the original rel A (AF633) staining images to separate nuclear and cytoplasmic staining within each high power field (Fig. 2A). Quantitative fluorescence data were exported from ImageJ generated histograms into Microsoft Excel software for further analysis and presentation (Fig. 2B). Measurement of nuclear fluorescence alone does not distinguish NF-κB nuclear translocation from increased background levels of NF-κB expression or artefactual differences in staining intensity. Therefore nuclear and cytoplasmic staining intensities were compared to give the nuclear:cytoplasmic ratio as a relative measure of rel A nuclear localisation. Nuclear and cytoplasmic histogram data were first normalised for the total number of data points included in the analysis and then comparison was made of the sum of staining intensities. In this way, NF-κB nuclear translocation is represented by an increase in nuclear:cytoplasmic ratio of rel A staining. Multiple images can be batch processed simultaneously in this way by converting individual images into DAPI and NF-κB rel A stacks.
3
Data presentation and discussion
To validate this methodology and analysis, time course and dose response studies of LPS induced NF-κB nuclear translocation were performed. Macrophages were stimulated with 0–100 ng/ml LPS in NM with 10% HS for up to 1 h. NF-κB nuclear translocation was evident by 30 min and maximal at 60 min (Fig. 3). The expected increase in nuclear:cytoplasmic ratio was also evident across the LPS dose range (Fig. 4). In addition we tested the effect of Polymyxin B (PMB), a polypeptide that binds and neutralises the bioactive lipid A component of LPS. PMB completely abrogated NF-κB nuclear translocation in response to LPS specifically, and had no effect on stimulation with the TLR2 ligand, Pam3CSK4 (Fig. 5).
To further evaluate the quantitation provided by this assay the results were compared with a commercial NF-κB reporter gene assay using the HEK-293 cell line transfected with TLR2 and a secreted alkaline phosphatase NF-κB reporter gene construct (Invivogen). Transfected cells were seeded on to glass coverslips as described above and allowed to adhere for 48 h. They were then stimulated with Pam3CSK4 (dose range 0–2 μg/ml) diluted in the manufacturer's detection media. Cells were fixed and stained as above for immunofluorescence staining of NF-κB after 1 h stimulation. Duplicate wells were allowed to incubate for 6 h to allow the reporter gene and substrate reaction to take place. Cell culture supernatants were then harvested to quantify the colorometric reaction spectrophotometrically at 630 nm. Quantitative comparison of NF-κB activation using the reporter gene expression assay and NF-κB nuclear translocation by confocal microscopy showed statistically significant correlation (Fig. 6). Importantly, reporter gene expression provides a measure of NF-κB function that is dependent on its nuclear translocation, but not exclusively regulated by it. The difference between measurement of nuclear translocation and NF-κB function is acknowledged and may in part explain the imperfect regression analysis (r2 0.83) between the two methods.
The method proposed here is most suitable for adherent cell cultures with relatively large cytoplasmic:nuclear area ratios that allow clear distinction between nuclear and cytoplasmic NF-κB staining. It requires relatively few cells and can be used to study NF-κB nuclear translocation at single-cell level or in mixed cultures. It can be readily applied to the study of NF-κB activation in macrophages, dendritic cells, epithelial and endothelial cells, and fibroblastic cells. We have also been able to apply this method to monocytic cells in suspension (THP-1 and K562 cell lines) by air drying them onto coverslips for immunostaining (data not shown), albeit their typically small nuclear:cytoplasmic area ratio may limit the accuracy of quantitation. This generic image analysis methodology may be applied to quantitative analysis of other transcription factors and signalling events in which assessment of sub-cellular localisation is necessary. Where confocal microscopy facilities are available, this method overcomes the problems related to sensitivity, use of radioisotopes and cost. It can be easily adopted in current cellular immunology research, and given the ready accessibility of the public domain image analysis software, with further validation this methodology may serve as a universal standard that allows better comparison of data from separate experiments and different research groups.

macrophages
image analysis
nuclear factor-kappa b
confocal immunofluoresence