Technical consultation on the effects of hormonal contraception on bone health : summary report, Geneva, Switzerland, 20-21 June, 2005

Publication date: 2005

on the effects of hormonal contraception on bone health Technical consultation Summary report Geneva, Switzerland 20—21 June, 2005 UNDP - UNFPA - WHO - WORLD BANK Special Programme of Research, Development and Research Training in Human Reproduction 7HFKQLFDO�FRQVXOWDWLRQ�RQ�WKH�HIIHFWV� RI�KRUPRQDO�FRQWUDFHSWLRQ� RQ�ERQH�KHDOWK *HQHYD��6ZLW]HUODQG� ��²���-XQH������ 6XPPDU\�UHSRUW 7(/�2(2������ 7HFKQLFDO�FRQVXOWDWLRQ�RQ�WKH�HIIHFWV�RI�KRUPRQDO�FRQWUDFHSWLRQ�RQ�ERQH�KHDOWK ‹�:RUOG�+HDOWK�2UJDQL]DWLRQ����� $OO�ULJKWV�UHVHUYHG��3XEOLFDWLRQV�RI�WKH�:RUOG�+HDOWK�2UJDQL]DWLRQ�FDQ�EH�REWDLQHG�IURP�:+2�3UHVV��:RUOG� +HDOWK�2UJDQL]DWLRQ�����$YHQXH�$SSLD�������*HQHYD�����6ZLW]HUODQG��WHO��������������������ID[������������� ������H�PDLO��ERRNRUGHUV#ZKR�LQW���5HTXHVWV�IRU�SHUPLVVLRQ�WR�UHSURGXFH�RU�WUDQVODWH�:+2�SXEOLFDWLRQV� ±�ZKHWKHU�IRU�VDOH�RU�IRU�QRQFRPPHUFLDO�GLVWULEXWLRQ�±�VKRXOG�EH�DGGUHVVHG�WR�:+2�3UHVV��DW�WKH�DERYH�DGGUHVV� �ID[�������������������H�PDLO��SHUPLVVLRQV#ZKR�LQW�� 7KH�GHVLJQDWLRQV�HPSOR\HG�DQG�WKH�SUHVHQWDWLRQ�RI�WKH�PDWHULDO�LQ�WKLV�SXEOLFDWLRQ�GR�QRW�LPSO\�WKH�H[SUHVVLRQ�RI� DQ\�RSLQLRQ�ZKDWVRHYHU�RQ�WKH�SDUW�RI�WKH�:RUOG�+HDOWK�2UJDQL]DWLRQ�FRQFHUQLQJ�WKH�OHJDO�VWDWXV�RI�DQ\�FRXQWU\�� WHUULWRU\��FLW\�RU�DUHD�RU�RI�LWV�DXWKRULWLHV��RU�FRQFHUQLQJ�WKH�GHOLPLWDWLRQ�RI�LWV�IURQWLHUV�RU�ERXQGDULHV��'RWWHG�OLQHV� RQ�PDSV�UHSUHVHQW�DSSUR[LPDWH�ERUGHU�OLQHV�IRU�ZKLFK�WKHUH�PD\�QRW�\HW�EH�IXOO�DJUHHPHQW� 7KH�PHQWLRQ�RI�VSHFL¿F�FRPSDQLHV�RU�RI�FHUWDLQ�PDQXIDFWXUHUV¶�SURGXFWV�GRHV�QRW�LPSO\�WKDW�WKH\�DUH�HQGRUVHG� RU�UHFRPPHQGHG�E\�WKH�:RUOG�+HDOWK�2UJDQL]DWLRQ�LQ�SUHIHUHQFH�WR�RWKHUV�RI�D�VLPLODU�QDWXUH�WKDW�DUH�QRW� PHQWLRQHG��(UURUV�DQG�RPLVVLRQV�H[FHSWHG��WKH�QDPHV�RI�SURSULHWDU\�SURGXFWV�DUH�GLVWLQJXLVKHG�E\�LQLWLDO�FDSLWDO� OHWWHUV� $OO�UHDVRQDEOH�SUHFDXWLRQV�KDYH�EHHQ�WDNHQ�E\�WKH�:RUOG�+HDOWK�2UJDQL]DWLRQ�WR�YHULI\�WKH�LQIRUPDWLRQ�FRQWDLQHG� LQ�WKLV�SXEOLFDWLRQ��+RZHYHU��WKH�SXEOLVKHG�PDWHULDO�LV�EHLQJ�GLVWULEXWHG�ZLWKRXW�ZDUUDQW\�RI�DQ\�NLQG��HLWKHU� H[SUHVVHG�RU�LPSOLHG��7KH�UHVSRQVLELOLW\�IRU�WKH�LQWHUSUHWDWLRQ�DQG�XVH�RI�WKH�PDWHULDO�OLHV�ZLWK�WKH�UHDGHU��,Q�QR� HYHQW�VKDOO�WKH�:RUOG�+HDOWK�2UJDQL]DWLRQ�EH�OLDEOH�IRU�GDPDJHV�DULVLQJ�IURP�LWV�XVH� 7KLV�SXEOLFDWLRQ�FRQWDLQV�WKH�FROOHFWLYH�YLHZV�RI�DQ�LQWHUQDWLRQDO�JURXS�RI�H[SHUWV�DQG�GRHV�QRW�QHFHVVDULO\� UHSUHVHQW�WKH�GHFLVLRQV�RU�WKH�VWDWHG�SROLF\�RI�WKH�:RUOG�+HDOWK�2UJDQL]DWLRQ� $&521<06 %0'� %RQH�PLQHUDO�GHQVLW\ %0,� %RG\�PDVV�LQGH[ &,� &RQ¿GHQFH�LQWHUYDO &2&� &RPELQHG�RUDO�FRQWUDFHSWLYH '03$� 'HSRW�PHGUR[\SURJHVWHURQH�DFHWDWH ';$� 'XDO�HQHUJ\�;�UD\�DEVRUSWLRPHWU\ ((� (WKLQ\O�HVWUDGLRO +7� +RUPRQH�WKHUDS\ ,8'� ,QWUDXWHULQH�GHYLFH 1(7�(1� 1RUHWKLVWHURQH�HQDQWKDWH��DOVR�QDPHG�1RUHWKLQGURQH�HQDQWDWH� 25� 2GGV�UDWLR 5&7� 5DQGRPL]HG�FRQWUROOHG�WULDO 55� 5HODWLYH�ULVN 6'� 6WDQGDUG�GHYLDWLRQ 81)3$� 8QLWHG�1DWLRQV�3RSXODWLRQ�)XQG 81,&()� 8QLWHG�1DWLRQV�&KLOGUHQ¶V�)XQG 86$� 8QLWHG�6WDWHV�RI�$PHULFD :+2� :RUOG�+HDOWK�2UJDQL]DWLRQ &217(176 ,QWURGXFWLRQ� � 5HYLHZ�RI�HYLGHQFH� � � (SLGHPLRORJ\�RI�KRUPRQDO�FRQWUDFHSWLRQ�DQG�SUHJQDQF\�UHODWHG�ULVNV� � � %RQH�KHDOWK�LQ�DGROHVFHQWV�DQG�DGXOWV� � � 2VWHRSRURVLV��ULVN�IDFWRUV�IRU�RVWHRSRURVLV�DQG�IUDFWXUH� � � 7KH�HIIHFWV�RI�FRPELQHG�KRUPRQDO�FRQWUDFHSWLYHV�RQ�ERQH� � � 7KH�(IIHFWV�RI�SURJHVWRJHQ�RQO\�FRQWUDFHSWLYH�XVH�RQ�ERQH�PLQHUDO�GHQVLW\� � DQG�IUDFWXUH�ULVN� � � 'HSRW�PHGUR[\SURJHVWHURQH�DFHWDWH�XVH�DQG�ERQH�PLQHUDO�GHQVLW\�LQ�\RXQJ�ZRPHQ� �� � 'HSRW�PHGUR[\SURJHVWHURQH�DFHWDWH��UHVXOWV�RI�UHFHQW�VWXGLHV�RQ�ERQH�PLQHUDO�GHQVLW\� � IURP�D�PDQXIDFWXUHU�RI�'03$� �� &RQFOXVLRQV� �� � &RPELQHG�PHWKRGV�RI�FRQWUDFHSWLRQ� �� � 3URJHVWRJHQ�RQO\�PHWKRGV�RI�FRQWUDFHSWLRQ� �� 5HFRPPHQGDWLRQV� �� .H\�HYLGHQFH�JDSV� �� 5HIHUHQFHV� �� $QQH[���/LVW�RI�SDUWLFLSDQWV� �� � ,QWURGXFWLRQ 7KH�'HSDUWPHQW�RI�5HSURGXFWLYH�+HDOWK�DQG� 5HVHDUFK�RI�WKH�:RUOG�+HDOWK�2UJDQL]DWLRQ� SURGXFHV�HYLGHQFH�EDVHG�JXLGDQFH�RQ� FRQWUDFHSWLYH�XVH��2QH�RI�LWV�JXLGHOLQHV��0HGLFDO� HOLJLELOLW\�FULWHULD�IRU�FRQWUDFHSWLYH�XVH��7KLUG� HGLWLRQ��������SURYLGHV�UHFRPPHQGDWLRQV�RQ�WKH� XVH�RI�YDULRXV�FRQWUDFHSWLYH�PHWKRGV�E\�ZRPHQ� DQG�PHQ�ZLWK�VSHFL¿F�SK\VLFDO�FKDUDFWHULVWLFV�RU� ZLWK�NQRZQ�SUH�H[LVWLQJ�PHGLFDO�FRQGLWLRQV��7KH� 'HSDUWPHQW�FDUHIXOO\�PRQLWRUV�WKH�SXEOLFDWLRQ�RI� QHZ�UHVHDUFK�HYLGHQFH�LQ�RUGHU�WR�NHHS�WKHVH� JXLGHOLQHV�FRQVWDQWO\�XS�WR�GDWH�ZLWK�WKH�VWDWH�RI� NQRZOHGJH�LQ�WKH�¿HOG� ,Q�1RYHPEHU�������WKH�8QLWHG�6WDWHV�)RRG� DQG�'UXJ�$GPLQLVWUDWLRQ�DQG�WKH�8QLWHG� .LQJGRP�&RPPLWWHH�RQ�WKH�6DIHW\�RI� 0HGLFLQHV�LVVXHG�ZDUQLQJV�RQ�WKH�XVH�RI�WKH� SURJHVWRJHQ�RQO\�LQMHFWDEOH�FRQWUDFHSWLYH�GHSRW� PHGUR[\SURJHVWHURQH�DFHWDWH��'03$���7KHVH� ZDUQLQJV�ZHUH�EDVHG�RQ�WKHLU�DVVHVVPHQW�RI� HYLGHQFH�RI�LWV�HIIHFWV�RQ�ERQH�PLQHUDO�GHQVLW\� �%0'���LQFOXGLQJ�\HW�XQSXEOLVKHG�GDWD�LVVXHG� E\�WKH�3¿]HU�FRPSDQ\��7KH�FRPSDQ\�DJUHHG�WR� VKDUH�LWV�XQSXEOLVKHG�GDWD�ZLWK�H[SHUWV�DW�:+2�� DQG�VXEVHTXHQWO\�WKH�'HSDUWPHQW�XSGDWHG�LWV� V\VWHPDWLF�UHYLHZ�RQ�$JH�DQG�XVH�RI�SURJHVWRJHQ� RQO\�FRQWUDFHSWLYHV�>'03$��QRUHWKLVWHURQH� HQDQWKDWH��1(7�(1���SURJHVWRJHQ�RQO\�SLOOV�� SURJHVWRJHQ�RQO\�LPSODQWV�DQG�OHYRQRUJHVWUHO� UHOHDVLQJ�LQWUDXWHULQH�GHYLFH��,8'�@�WR�LQFOXGH� DSSUDLVDO�RI�DOO�QHZ�HYLGHQFH� 7KH�*XLGHOLQHV�6WHHULQJ�*URXS�LV�UHVSRQVLEOH� IRU�RYHUVHHLQJ�WKH�XSGDWH�DQG�PDLQWHQDQFH� RI�:+2¶V�HYLGHQFH�EDVHG�JXLGHOLQHV�LQ�IDPLO\� SODQQLQJ��7KH�JURXS�HYDOXDWHG�WKLV�V\VWHPDWLF� UHYLHZ�DQG��WRJHWKHU�ZLWK�WKH�:+2�6HFUHWDULDW�� LVVXHG�D�VWDWHPHQW�RQ�WKH�:+2�ZHEVLWH�RQ� '03$�DQG�LWV�HIIHFWV�RQ�%0'��7KURXJK�WKLV� DSSUDLVDO�SURFHVV��WKH�*6*�DQG�:+2�6HFUHWDULDW� GHWHUPLQHG�LW�QHFHVVDU\�WR�FRQYHQH�D�WHFKQLFDO� FRQVXOWDWLRQ�WR�WKRURXJKO\�HYDOXDWH�WKH�QHZ� HYLGHQFH�LQ�OLJKW�RI�SULRU�HYLGHQFH��,Q�DGGLWLRQ� WR�D�UHYLHZ�RI�HYLGHQFH�RQ�SURJHVWRJHQ�RQO\� PHWKRGV��LW�ZDV�DOVR�GHWHUPLQHG�QHFHVVDU\�WR� HYDOXDWH�DOO�HYLGHQFH�UHJDUGLQJ�WKH�HIIHFWV�RI� FRPELQHG�KRUPRQDO�FRQWUDFHSWLYHV�RQ�%0'� �FRPELQHG�RUDO�FRQWUDFHSWLYHV��FRPELQHG�LQMHFWDEOH� FRQWUDFHSWLYHV��FRPELQHG�SDWFK�DQG�FRPELQHG� ULQJ�� $�WHFKQLFDO�FRQVXOWDWLRQ�RQ�WKH�HIIHFWV�RI�KRUPRQDO� FRQWUDFHSWLRQ�RQ�ERQH�KHDOWK�ZDV�FRQYHQHG�DW� :+2�LQ�*HQHYD��6ZLW]HUODQG����±��VW�-XQH�������� 7KH�FRQVXOWDWLRQ�EURXJKW�WRJHWKHU�WKH�*6*��RWKHU� H[SHUWV�RQ�KRUPRQDO�FRQWUDFHSWLRQ��DQG�H[SHUWV� RQ�ERQH�KHDOWK�WR�HYDOXDWH�DOO�VFLHQWL¿F�HYLGHQFH�LQ� WKLV�DUHD��$ORQJ�ZLWK�WKH�SUHVHQWDWLRQ�RI�XSGDWHG� V\VWHPDWLF�UHYLHZV�RQ�DJH�DQG�XVH�RI�KRUPRQDO� FRQWUDFHSWLYHV��ZKLFK�LQFOXGHG�HYLGHQFH�RQ�WKH� HIIHFWV�RQ�%0'�DPRQJ�GLIIHUHQW�DJH�JURXSV�� WKH�SDUWLFLSDQWV�ZHUH�SUHVHQWHG�ZLWK�GDWD�RQ�WKH� HSLGHPLRORJ\�RI�KRUPRQDO�FRQWUDFHSWLYH�XVH��ERQH� KHDOWK�DW�GLIIHUHQW�OLIH�VWDJHV��ULVN�RI�IUDFWXUHV� DQG�UHODWHG�PRUELGLW\�PRUWDOLW\��ULVN�IDFWRUV�IRU� RVWHRSRURVLV�DQG�IUDFWXUH��DQG�ZLWK�XQSXEOLVKHG� GDWD�IURP�D�SKDUPDFHXWLFDO�PDQXIDFWXUHU�RI�'03$�� 7KLV�UHSRUW�VXPPDUL]HV�WKH�PDWHULDO�SUHVHQWHG�WR� SDUWLFLSDQWV�GXULQJ�WKH�FRQVXOWDWLRQ� 2Q�WKH�ODVW�GD\�RI�WKH�FRQVXOWDWLRQ��SDUWLFLSDQWV� GHYHORSHG�FRQFUHWH�UHFRPPHQGDWLRQV�RQ�WKH� XVH�RI�KRUPRQDO�FRQWUDFHSWLYHV��WDNLQJ�LQWR� FRQVLGHUDWLRQ�DQ\�SRWHQWLDO�HIIHFWV�RQ�ERQH�KHDOWK�� 7KHVH�UHFRPPHQGDWLRQV�DSSHDU�RQ�WKH�:+2�ZHE� VLWH��KWWS���ZZZ�ZKR�LQW�UHSURGXFWLYH�KHDOWK�IDPLO\B SODQQLQJ�ERQHBKHDOWK�KWPO��DQG�DW�WKH�HQG�RI�WKLV� UHSRUW��7KH�UHFRPPHQGDWLRQV�KDYH�DOVR�EHHQ� SXEOLVKHG�LQ�WKH�:+2�:HHNO\�(SLGHPLRORJLFDO� 5HFRUG��KWWS���ZZZ�ZKR�LQW�ZHU������ZHU�����HQ� LQGH[�KWPO�� � 7HFKQLFDO�FRQVXOWDWLRQ�RQ�WKH�HIIHFWV�RI�KRUPRQDO�FRQWUDFHSWLRQ�RQ�ERQH�KHDOWK � 5HYLHZ�RI�HYLGHQFH (SLGHPLRORJ\�RI�KRUPRQDO�FRQWUDFHSWLRQ�DQG� SUHJQDQF\�UHODWHG�ULVNV 'U�/DQHWD�'RUÀLQJHU��)DPLO\�+HDOWK�,QWHUQDWLRQDO�� 5HVHDUFK�7ULDQJOH�3DUN��86$��JDYH�D�SUHVHQWDWLRQ� RQ�JOREDO�HVWLPDWHV�RI�PDWHUQDO�PRUWDOLW\�DQG� SDWWHUQV�RI�PRGHUQ�FRQWUDFHSWLYH�PHWKRG�XVH�� DQG�IRFXVHG�RQ�SURJHVWLQ�RQO\�LQMHFWDEOHV��QDPHO\� GHSRW�PHGUR[\SURJHVWHURQH�DFHWDWH��'03$��DQG� QRUHWKLVWHURQH�HQDQWKDWH��1(7�(1���:RUOGZLGH� XVH�RI�'03$�LV�IDU�JUHDWHU�WKDQ�WKDW�RI�1(7�(1��$W� WKH�WLPH�RI�WKH�FRQVXOWDWLRQ��'03$�ZDV�UHJLVWHUHG� LQ�PRUH�WKDQ�����FRXQWULHV� '03$�LV�D�KLJKO\�HIIHFWLYH��SULYDWH��DQG�FRQYHQLHQW� PHWKRG�RI�FRQWUDFHSWLRQ�WKDW�LV�QRW�GHSHQGHQW� XSRQ�GDLO\�RU�FRLWDOO\�UHODWHG�DFWLRQV��,QMHFWLRQV� RI�����PJ�GHSRW�PHGUR[\SURJHVWHURQH�DFHWDWH� DUH�JLYHQ�HYHU\�WKUHH�PRQWKV��6LGH�HIIHFWV�RI� '03$�LQFOXGH�PHQVWUXDO�GLVUXSWLRQ��DPHQRUUKRHD�� ZHLJKW�JDLQ��DQG�D�GHOD\HG�UHWXUQ�WR�IHUWLOLW\�� %OHHGLQJ�LUUHJXODULWLHV�H[SHULHQFHG�E\�XVHUV�DUH� EHOLHYHG�WR�EH�WKH�PDLQ�UHDVRQ�IRU�WKH�UHODWLYHO\� KLJK�GLVFRQWLQXDWLRQ�UDWHV�DPRQJ�'03$�XVHUV�� 1HYHUWKHOHVV��VXUYH\V�GR�UHSRUW�WKDW�DSSUR[LPDWHO\� ����RI�XVHUV�ZKR�GLVFRQWLQXH�XVLQJ�'03$�UH� LQLWLDWH�WKLV�PHWKRG�DW�D�ODWHU�WLPH����� $VVHVVLQJ�ZKHWKHU�WKH�KHDOWK�ULVNV�DVVRFLDWHG� ZLWK�LQMHFWDEOH�FRQWUDFHSWLYH�XVH�DUH�JUHDWHU�WKDQ� ULVNV�DVVRFLDWHG�ZLWK�XVLQJ�RWKHU�FRQWUDFHSWLYH� PHWKRGV��RU�ZKHWKHU�RWKHU�FRQWUDFHSWLYH�PHWKRGV� DUH�DYDLODEOH���QHFHVVLWDWHV�D�EDODQFHG�GLVFXVVLRQ� RI�WKH�SRVVLELOLW\�WKDW�D�ZRPDQ�PLJKW�H[SHULHQFH� SUHJQDQF\�UHODWHG�PRUELGLW\�RU�PRUWDOLW\��$FFRUGLQJ� WR�:+2�81)3$�81,&()�HVWLPDWHV������LQ������ WKHUH�ZHUH���������PDWHUQDO�GHDWKV�LQ�WKH�ZRUOG�� DQG�PRUH�WKDQ�����RI�WKHVH�GHDWKV�RFFXUUHG� LQ�GHYHORSLQJ�FRXQWULHV��$OWKRXJK�LQ�DEVROXWH� QXPEHUV�VOLJKWO\�PRUH�PDWHUQDO�GHDWKV�ZHUH� UHSRUWHG�IURP�$VLD��ERWK�WKH�PDWHUQDO�PRUWDOLW\� UDWLR�DQG�WKH�OLIHWLPH�ULVN�RI�PDWHUQDO�GHDWK�ZHUH�IDU� JUHDWHU�LQ�$IULFD��SDUWLFXODUO\�LQ�FRXQWULHV�ORFDWHG�LQ� 6XE�6DKDUDQ�$IULFD��ZKHUH�WKH�PDWHUQDO�PRUWDOLW\� UDWLR�LV�HVWLPDWHG�WR�EH�����PDWHUQDO�GHDWKV�SHU� ��������OLYH�ELUWKV��,Q�FRQWUDVW��PDWHUQDO�PRUWDOLW\� UDWLRV�DUH�HVWLPDWHG�WR�EH�����PDWHUQDO�GHDWKV�SHU� ��������OLYH�ELUWKV�LQ�6RXWK�&HQWUDO�$VLD�DQG����LQ� GHYHORSHG�UHJLRQV��/LIHWLPH�ULVN�RI�PDWHUQDO�GHDWK� LV�HVWLPDWHG�WR�EH���LQ����LQ�6XE�6DKDUDQ�$IULFD�� ��LQ����LQ�$VLD����LQ�����LQ�/DWLQ�$PHULFD�DQG�WKH� &DULEEHDQ��DQG���LQ������LQ�GHYHORSHG�FRXQWULHV� 0DWHUQDO�PRUWDOLW\�LV�LQÀXHQFHG�E\�PDQ\�IDFWRUV� LQFOXGLQJ�WKH�SUREDELOLW\�RI�EHFRPLQJ�SUHJQDQW� DQG�WKH�ULVN�RI�GHDWK�ZKLOH�SUHJQDQW��6LQFH� WKH�SUREDELOLW\�RI�SUHJQDQF\�LV�DVVRFLDWHG�ZLWK� WKH�DYDLODELOLW\�RI�FRQWUDFHSWLYHV�DQG�ZKHWKHU� RU�QRW�WKH\�DUH�XVHG�HIIHFWLYHO\��HVWLPDWHV�RI� FRQWUDFHSWLYH�SUHYDOHQFH�DQG�SDWWHUQV�RI�XVH�ZHUH� UHYLHZHG��(VWLPDWHV�IURP�VL[�6RXWKHDVW�$VLDQ� DQG�6XE�6DKDUDQ�$IULFDQ�FRXQWULHV�ZLWK�KLJK� UDWHV�RI�PDWHUQDO�PRUWDOLW\�VKRZ�ORZ�SUHYDOHQFH� RI�FRQWUDFHSWLRQ�DQG�KLJK�OHYHOV�RI�XQPHW� FRQWUDFHSWLYH�QHHG������ $FFRUGLQJ�WR�WKH�8QLWHG�1DWLRQV�:RUOG� &RQWUDFHSWLYH�8VH�UHSRUW������DSSUR[LPDWHO\���� RI�PDUULHG�ZRPHQ�EHWZHHQ����DQG����\HDUV�RI� DJH�XVHG�LQMHFWDEOHV�LQ�������2I�WKH������PLOOLRQ� ZRPHQ�XVLQJ�LQMHFWDEOHV�DURXQG�WKH�ZRUOG��QHDUO\� ���PLOOLRQ�OLYHG�LQ�GHYHORSLQJ�FRXQWULHV��:LWKLQ�WKH� GHYHORSLQJ�ZRUOG��$IULFD�KDG�WKH�KLJKHVW�SURSRUWLRQ� RI�ZRPHQ�UHSRUWLQJ�LQMHFWDEOH�XVH�RI�FRQWUDFHSWLYHV� ������FRPSDUHG�ZLWK�$VLD�RU�/DWLQ�$PHULFD������� DQG�������UHVSHFWLYHO\���$FFRUGLQJ�WR�VDOHV�GDWD�� RQH�'03$�PDQXIDFWXUHU�HVWLPDWHV�WKDW�����PLOOLRQ� ZRPHQ�XVH�WKH�SURGXFW�ZRUOGZLGH��DQG�XVH�LV� KLJKHVW�DPRQJ�\RXQJ�ZRPHQ�DQG�ZRPHQ�RYHU���� \HDUV� &RPSDULVRQV�RI�FRXQWU\�VSHFL¿F�GDWD�VKRZ� ,QGRQHVLD�UHSRUWLQJ�WKH�KLJKHVW�SHUFHQWDJH�RI� LQMHFWDEOH�XVH���������DV�ZHOO�DV�WKH�JUHDWHVW� QXPEHU�RI�XVHUV�������PLOOLRQ�ZRPHQ���2WKHU� FRXQWULHV�ZLWK�KLJK�SURSRUWLRQV�RI�LQMHFWDEOH�XVHUV� LQFOXGH�6RXWK�$IULFD����������1DPLELD���������� 7KDLODQG����������DQG�0DODZL����������,Q�WKH� ¿YH�FRXQWULHV�ZLWK�WKH�KLJKHVW�QXPEHU�RI�ZRPHQ� XVLQJ�LQMHFWDEOHV��%DQJODGHVK��,QGRQHVLD��.HQ\D�� 6RXWK�$IULFD��DQG�7KDLODQG���ZLWKLQ�DJH�JURXSV�� LQMHFWDEOH�XVH�LV�SURSRUWLRQDOO\�KLJKHVW�DPRQJ� \RXQJHU�ZRPHQ��0RUH�WKDQ�����RI�FXUUHQWO\� PDUULHG�ZRPHQ���±���\HDUV�RI�DJH�ZKR�XVH�D� PRGHUQ�FRQWUDFHSWLYH�PHWKRG��XVH�LQMHFWDEOHV�� 1HYHUWKHOHVV��WKHVH�FRXQWULHV�FRQWLQXH�WR� H[SHULHQFH�KLJK�UDWHV�RI�WHHQDJH�SUHJQDQF\� DQG�PRWKHUKRRG�ZLWK�PRUH�WKDQ�����RI�ZRPHQ� � ZKR�DUH����\HDUV�ROG�KDYLQJ�KDG�D�EDE\�RU�EHLQJ� SUHJQDQW�������±���)LQDOO\��VXUYH\�GDWD�IURP� ,QGRQHVLD�VKRZ�DQ�LQFUHDVHG�XVH�RI�PRGHUQ� FRQWUDFHSWLYH�PHWKRGV�EHWZHHQ������DQG������� ZKLFK�LV�ODUJHO\�DWWULEXWDEOH�WR�D�JUHDWHU�XVH�RI� LQMHFWDEOHV������ 7KXV��OLPLWLQJ�WKH�XVH�RI�'03$�ZRXOG�UHGXFH� FRQWUDFHSWLYH�RSWLRQV�LQ�D�ZD\�WKDW�PD\�EH� FULWLFDO�IRU�ZRPHQ�IURP�6RXWKHDVW�$VLD�DQG� 6XE�6DKDUDQ�$IULFD��<RXQJHU�ZRPHQ�PD\� EH�HVSHFLDOO\�YXOQHUDEOH�DV�WKHLU�RSWLRQV�IRU� FRQWUDFHSWLYHV�PD\�EH�PRUH�OLPLWHG�FRPSDUHG� ZLWK�ROGHU�PDUULHG�ZRPHQ��DQG�WKH�QHHG�IRU�KLJKO\� HIIHFWLYH�FRQWUDFHSWLRQ�FRXOG�EH�PRUH�DFXWH�GXH� WR�VRFLRFXOWXUDO�SUHVVXUHV��,Q�DGGLWLRQ��LI�ZRPHQ� PXVW�VZLWFK�WR�DQRWKHU�PHWKRG��FRQWUDFHSWLYH� RSWLRQV�YDU\�GHSHQGLQJ�XSRQ�ZKHWKHU�WKH\� LQWHQG�WR�VSDFH�WKHLU�SUHJQDQFLHV�RU�OLPLW�WKHLU� IHUWLOLW\��2SWLRQV�IRU�ZRPHQ�ZDQWLQJ�WR�VSDFH�WKHLU� SUHJQDQFLHV�LQFOXGH�SLOOV��FRQGRPV��LPSODQWV�DQG� ,8'V��ZKLOH�RSWLRQV�WR�OLPLW�WKHLU�IHUWLOLW\�LQFOXGH� ,8'V��LPSODQWV��DQG�VWHULOL]DWLRQ��IHPDOH�RU�PDOH��� *LYHQ�WKHVH�VFHQDULRV��OLPLWLQJ�WKH�XVH�RI�'03$� PD\�H[DFHUEDWH�XQPHW�FRQWUDFHSWLYH�QHHG�LQ�VRPH� DUHDV� 7KH�FKDOOHQJH�IRU�SROLF\�PDNHUV�DQG�SURJUDPPH� PDQDJHUV�OLHV�ZLWK�EDODQFLQJ�WKH�FOLQLFDO� VLJQL¿FDQFH�DQG�LPSRUWDQFH�RI�ERQH�ORVV�GXH�WR� '03$�XVH��ZLWK�ERQH�ORVV�WKDW�PD\�RFFXU�DW�RWKHU� SHULRGV�GXULQJ�D�ZRPDQ¶V�UHSURGXFWLYH�\HDUV��L�H�� GXH�WR�SUHJQDQF\�DQG�RU�ODFWDWLRQ��DQG�ZLWK�WKH�XVH� RI�SHUKDSV�OHVV�HIIHFWLYH�PHWKRGV�RI�FRQWUDFHSWLRQ� OHDGLQJ�WR�SRVVLEOH�ULVN\�XQZDQWHG�SUHJQDQF\�DQG� PDWHUQDO�PRUWDOLW\� %RQH�KHDOWK�LQ�DGROHVFHQWV�DQG�DGXOWV 'U�5HQp�5L]]ROL��8QLYHUVLW\�+RVSLWDO��*HQHYD�� 6ZLW]HUODQG��JDYH�DQ�RYHUYLHZ�RQ�ERQH�KHDOWK� GXULQJ�D�ZRPDQ¶V�OLIHVSDQ��ZLWK�D�IRFXV�RQ�WKH� UHODWLRQ�EHWZHHQ�%0'�DQG�IXWXUH�IUDFWXUH�ULVN��,Q� DGGLWLRQ��WKH�HSLGHPLRORJ\�RI�ERQH�KHDOWK��PHWKRGV� WR�PHDVXUH�ERQH�GHQVLW\��DQG�WKH�LQWHUSUHWDWLRQ�RI� ERQH�PHDVXUHPHQWV�ZHUH�GLVFXVVHG� %\�DJH�����WKH�OLIHWLPH�ULVN�RI�D�IUDJLOLW\�IUDFWXUH�IRU� D�ZRPDQ�DW�DQ\�ERQH�VLWH�LV������ZKLFK�LV�PRUH� WKDQ�WZR�WLPHV�JUHDWHU�WKDQ�D�PDQ¶V�ULVN������� DFFRUGLQJ�WR�SRSXODWLRQ�EDVHG�GDWD�IURP�6ZHGHQ�� ����%RQH�IUDFWXUHV�DUH�DVVRFLDWHG�ZLWK�PRUELGLW\�� ORVV�RI�LQGHSHQGHQFH��RU�LQFUHDVH�RI�GHSHQGHQFH��� DQG�PRUWDOLW\��0RUELGLW\�GXH�WR�YHUWHEUDO�IUDFWXUHV� LQFOXGHV�SDLQ��ORVV�RI�KHLJKW��GHIRUPLW\��UHGXFWLRQV� LQ�SXOPRQDU\�IXQFWLRQ��DQG�D�GLPLQLVKHG�TXDOLW\� RI�OLIH�������$�*HQHYD�VWXG\�UHFRUGHG������RI�KLS� IUDFWXUH�SDWLHQWV�GLHG�ZLWKLQ����GD\V�IROORZLQJ� KRVSLWDO�GLVFKDUJH�DQG�������GLHG�ZLWKLQ�RQH� \HDU�RI�WKHLU�GLVFKDUJH�������$FFRUGLQJ�WR�D�¿YH� \HDU�FRKRUW�VWXG\��WKH�DJH�VWDQGDUGL]HG�PRUWDOLW\� UDWLR�IURP�DQ�RVWHRSRURWLF�IUDFWXUH�RI�WKH�SUR[LPDO� IHPXU�LV�����IRU�ZRPHQ�DQG�����IRU�PHQ����������� )XUWKHU��LW�LV�HVWLPDWHG�WKDW�KLS�IUDFWXUHV�UHGXFH�WKH� OLIH�H[SHFWDQF\�RI�ZRPHQ�DQG�PHQ�E\�����DQG����� \HDUV��UHVSHFWLYHO\������ %RQH�IUDFWXUHV�DUH�FRPSOLFDWLRQV�RI�PHFKDQLFDO� RYHUORDG��IDOOV��WR�WKH�VNHOHWDO�V\VWHP�RU� PHFKDQLFDO�LQFRPSHWHQFH�RI�WKH�VNHOHWDO�V\VWHP� �RVWHRSRURVLV���RU�ERWK��/RZ�SHDN�ERQH�PDVV��VH[� KRUPRQH�GH¿FLHQF\��DJH��DQG�QXWULWLRQ�LQVXI¿FLHQF\� FRQWULEXWH�WR�WKH�GHYHORSPHQW�RI�RVWHRSRURVLV�� 2VWHRSRURVLV�PDQLIHVWV�DV�VNHOHWDO�IUDJLOLW\�DQG� PHDVXULQJ�RI�ERQH�PDVV��RU�%0'��LV�XVHG�WR� GLDJQRVH�WKH�GLVHDVH� %RQH�PLQHUDO�GHQVLW\�FDQ�EH�PHDVXUHG�XVLQJ� VLQJOH�RU�GXDO�HQHUJ\�;�UD\�DEVRUSWLRPHWU\��';$��� XOWUDVRXQG��FRPSXWHU�WRPRJUDSK\��RU�UDGLRJUDSK\�� &XUUHQWO\��';$�LV�WKH�PRVW�IUHTXHQWO\�UHSRUWHG� PHDQV�RI�PHDVXUHPHQW�LQ�WKH�OLWHUDWXUH�DQG�LW� KDV�UHFHLYHG�WKH�PRVW�DWWHQWLRQ�ZLWK�UHVSHFW� WR�YDOLGDWLRQ�DQG�WHFKQLFDO�GHYHORSPHQW��';$� DVVHVVHV�WKH�ERQH�PLQHUDO�FRQWHQW�RI�WKH�VNHOHWRQ� �RU�VSHFL¿F�VLWH���ZKLFK�LV�WKHQ�GLYLGHG�E\�WKH�DUHD� RI�WKH�VLWH�PHDVXUHG�WR�GHULYH�WKH�%0'�YDOXH�� %HFDXVH�%0'�YDOXHV�IRU�KHDOWK\�\RXQJ�DGXOWV� DUH�DSSUR[LPDWHO\�QRUPDO��LQGLYLGXDO�%0'�YDOXHV� DUH�H[SUHVVHG�LQ�UHODWLRQ�WR�D�\RXQJ�UHIHUHQFH� GLVWULEXWLRQ�XVLQJ�VWDQGDUG�GHYLDWLRQ��6'��XQLWV� RU�D�W�VFRUH�IRU�GLDJQRVWLF�SXUSRVHV�������6WXGLHV� RI�KRUPRQDO�FRQWUDFHSWLRQ�DQG�%0'�IUHTXHQWO\� XVH�D�]�VFRUH��ZKHUH�WKH�]�VFRUH�H[SUHVVHV�WKH� GLIIHUHQFH�LQ�%0'�DPRQJ�FRQWUDFHSWLYH�XVHUV� DQG�QRQ�XVHUV��,Q�WKLV�FRQWH[W��WKH�]�VFRUH� UHSUHVHQWV�WKH�QXPEHU�RI�VWDQGDUG�GHYLDWLRQV�WKH� PHDQ�%0'�LQ�WKH�FRQWUDFHSWLYH�XVHUV�LV�DERYH�RU� EHORZ�WKH�PHDQ�%0'�RI�WKH�QRQ�XVHUV�������%0'� PHDVXUHPHQWV�FDQ�EH�DIIHFWHG�E\�ÀXLG�UHWHQWLRQ�� ZHLJKW�JDLQ��DQG�DOWHUHG�FRPSRVLWLRQ�RI�WLVVXHV� �GXH�WR�ZDWHU�UHWHQWLRQ���7KXV��GXULQJ�SUHJQDQF\� DQG�ODFWDWLRQ��WKH�DFFXUDF\�RI�%0'�PHDVXUHPHQWV� FDQ�EH�SUREOHPDWLF��,Q�DGGLWLRQ��';$�LV�QRW������ DFFXUDWH�IRU�PHDVXULQJ�JURVV�FKDQJHV�LQ�%0'�� VLQFH�FKDQJHV�LQ�IDW�GXH�WR�GUXJV�RU�FKDQJHV�LQ� KRUPRQDO�VWDWXV�FDQ�DIIHFW�UHVXOWV��7KLV�LV�DOVR� SUREOHPDWLF�IRU�SHUVRQV�XVLQJ�DQDEROLF�VWHURLGV� $FURVV�GLIIHUHQW�DQDWRPLFDO�PHDVXUHPHQW�VLWHV�� RQH�6'�GHFUHDVH�LQ�%0'�UHSUHVHQWV�D���±���� LQFUHDVHG�UHODWLYH�ULVN�RI�IUDFWXUH�DW�DQ\�VLWH������� 7HFKQLFDO�FRQVXOWDWLRQ�RQ�WKH�HIIHFWV�RI�KRUPRQDO�FRQWUDFHSWLRQ�RQ�ERQH�KHDOWK � 7KH�:+2�VWDQGDUG�GH¿QLWLRQ�IRU�RVWHRSRURVLV�LV� ����6'�EHORZ�WKH�PHDQ�%0'�YDOXH�RI�D�KHDOWK\� SRSXODWLRQ������ $FFHOHUDWHG�LQFUHDVH�LQ�ERQH�PDVV�EHJLQV� GXULQJ�SUH�DGROHVFHQFH�DQG�DFFHOHUDWHV�GXULQJ� DGROHVFHQFH��%RWK�JLUOV�DQG�ER\V�H[SHULHQFH�ODUJH� DPRXQWV�RI�ERQH�DFFUXDO�EHWZHHQ����DQG����\HDUV� RI�DJH�������7KH�SHULRG�RI�JUHDWHVW�ERQH�PDVV� DFFUXDO�RFFXUV�RYHU�DQ�DSSUR[LPDWHO\���\HDU�SHULRG� IRU�JLUOV��ZKHUHDV�ER\V�KDYH�D�VOLJKWO\�H[WHQGHG� SHULRG�RI�ERQH�DFFUXDO����\HDUV���%RWK�VH[HV� DFKLHYH�SHDN�ERQH�PDVV�E\����\HDUV�RI�DJH��'DWD� DUH�XQDYDLODEOH�WR�DGGUHVV�ZKHWKHU�HDUO\�DJH�RI� PHQDUFKH�OHDGV�WR�D�VKRUWHU�WLPH�SHULRG�WR�DFKLHYH� SHDN�ERQH�PDVV� %RQH�PLQHUDO�GHQVLW\�LV�ODUJHO\�DIIHFWHG�E\�KHUHGLW\� IDFWRUV����±������EXW�RWKHU�IDFWRUV�LQFOXGLQJ� VH[�KRUPRQHV��QXWULWLRQ��DQG�PHFKDQLFDO�IRUFHV� GHWHUPLQH�%0'�DV�ZHOO��'XULQJ�SXEHUW\��FLUFXODWLQJ� HVWURJHQV�LQ�IHPDOHV�VHUYH�WR�LQFUHDVH�LQVXOLQ� OLNH�JURZWK�IDFWRUV�ZKLFK�SURPRWH�WKH�ORQJLWXGLQDO� JURZWK�RI�ERQHV��DQG�HVWURJHQV�ORZHU�ERQH� WXUQRYHU�RU�UHVRUSWLRQ��OHDGLQJ�WR�JUHDWHU�ERQH� FRUWLFDO�WKLFNQHVV�DQG�VWURQJHU�ERQHV��7KXV� HVWURJHQ�GH¿FLHQF\�GXULQJ�SXEHUW\�DIIHFWV�ERWK� ERQH�JURZWK�DQG�WKH�DWWDLQPHQW�RI�SHDN�ERQH� PDVV��,Q�DGGLWLRQ��WKHUH�PD\�EH�SHULRGV�ZKHQ� ERQH�LV�PRUH�VXVFHSWLEOH�WR�HQYLURQPHQWDO�IDFWRUV�� ([HUFLVH�SULRU�WR�SXEHUW\�PD\�FRQIHU�UHVLGXDO� EHQH¿WV�LQ�DGXOW�%0'�����������KRZHYHU��WKLV�KDV� QRW�EHHQ�REVHUYHG�DPRQJ�ROLJR�DPHQRUUKHLF�ORQJ� GLVWDQFH�UXQQHUV������ $FFRUGLQJ�WR�D�UHYLHZ�RI�VWXGLHV�LQYHVWLJDWLQJ�WKH� HIIHFW�RI�PDWHUQLW\�RQ�%0'��VLJQL¿FDQW�GHFUHPHQWV� LQ�%0'�DW�WKH�KLS�SHOYLV�����WR������DQG�DW�WKH� VSLQH�����WR��������RFFXU�GXULQJ�SUHJQDQF\������� 'XULQJ�VL[�PRQWKV�ODFWDWLRQ��%0'�DW�WKH�KLS�DQG� VSLQH�UHPDLQHG�VLJQL¿FDQWO\�ORZHU�FRPSDUHG�ZLWK� EDVHOLQH�%0'��)ROORZLQJ�SUHJQDQF\��UHJDUGOHVV�RI� ODFWDWLRQ�RU�OHQJWK�RI�ODFWDWLRQ��JDLQV�LQ�%0'�DW���� PRQWKV�SRVWSDUWXP�RFFXU��%0'�H[FHHGHG�EDVHOLQH� YDOXHV�IRU�WKH�VSLQH��ZKHUHDV�%0'�DW�WKH�IHPRUDO� QHFN�KDG�QRW�UHDFKHG�EDVHOLQH�DW����PRQWKV� SRVWSDUWXP� (LJKW�VWXGLHV����±����LQ�WKLV�UHYLHZ�H[DPLQHG� ZKHWKHU�%0'�YDULHV�E\�SDULW\�VWDWXV��)LYH� VWXGLHV������������±����IRXQG�SDURXV�ZRPHQ� KDG�VLJQL¿FDQWO\�KLJKHU�%0'�DW�WKH�KLS�FRPSDUHG� ZLWK�QXOOLSDURXV�ZRPHQ��DQG�VL[�VWXGLHV������ ������±����UHSRUWHG�VLJQL¿FDQWO\�KLJKHU�%0'� DW�WKH�VSLQH�DPRQJ�SDURXV�ZRPHQ�FRPSDUHG� ZLWK�QXOOLSDURXV�ZRPHQ��,Q�DGGLWLRQ��WHQ�VWXGLHV� ���±����FRPSDUHG�WKH�ULVN�RI�IUDFWXUH�DW�YDULRXV� DQDWRPLFDO�VLWHV�DPRQJ�SDURXV�DQG�QXOOLSDURXV� ZRPHQ��7KUHH�VWXGLHV��������������UHSRUWHG�SDULW\� •���FRQIHUUHG�D�VWDWLVWLFDOO\�VLJQL¿FDQW�SURWHFWLYH� HIIHFW�DJDLQVW�VXVWDLQLQJ�D�KLS�IUDFWXUH�FRPSDUHG� ZLWK�QXOOLSDURXV�ZRPHQ��ZKHUHDV�WZR�VWXGLHV� ���������IRXQG�SDULW\�•���ZDV�SURWHFWLYH��EXW�QRW� VWDWLVWLFDOO\�VLJQL¿FDQW��7ZR�VWXGLHV����������IRXQG� WKH�ULVN�RI�VXVWDLQLQJ�D�IUDFWXUH�DW�DQ\�VLWH�ZDV� VLJQL¿FDQWO\�SURWHFWLYH�DPRQJ�ZRPHQ�ZLWK�SDULW\� •���RU�SDULW\�•����FRPSDUHG�ZLWK�QXOOLSDURXV�ZRPHQ�� )LQDOO\��LQFUHDVLQJ�SDULW\�ZDV�QRW�SURWHFWLYH�DJDLQVW� VXVWDLQLQJ�D�IUDFWXUH�DW�WKH�YHUWHEUDH��KLS��RU�KLS� DQG�IRUHDUP�LQ�WKUHH�VWXGLHV�������������� ,Q�FRQFOXVLRQ��D����ORVV�RI�%0'�RFFXUV�GXULQJ� SUHJQDQF\�DQG���PRQWKV�ODFWDWLRQ��KRZHYHU��%0'� UHFRYHUV�E\����PRQWKV��:RPHQ�ZLWK�PXOWLSOH� SUHJQDQFLHV�RU�SURORQJHG�ODFWDWLRQ�KDYH�%0'� VLPLODU�WR�RU�KLJKHU�WKDQ�ZRPHQ�ZLWK�QR�RU�IHZ� SUHJQDQFLHV��:RPHQ�ZLWK�PXOWLSOH�SUHJQDQFLHV� RU�SURORQJHG�ODFWDWLRQ�KDYH�D�IUDFWXUH�ULVN�VLPLODU� WR�RU�ORZHU�WKDQ�ZRPHQ�ZLWK�QR�RU�IHZ�FKLOGUHQ� DQG�ZRPHQ�ZKR�GR�QRW�ODFWDWH�RU�GR�VR�IRU�D�VKRUW� GXUDWLRQ� 2VWHRSRURVLV��ULVN�IDFWRUV�IRU�RVWHRSRURVLV� DQG�IUDFWXUH $�SUHVHQWDWLRQ�RQ�ULVN�IDFWRUV�DVVRFLDWHG�ZLWK�ERQH� IUDFWXUH�DQG�RVWHRSRURVLV�ZDV�SURYLGHG�E\�'U�-RKQ� .DQLV��8QLYHUVLW\�RI�6KHI¿HOG��8QLWHG�.LQJGRP��� 7KH�VWUHQJWK�RI�WKH�HYLGHQFH��ZLWK�UHVSHFW�WR�WKH� FRQVLVWHQF\�DQG�TXDOLW\�RI�WKH�HSLGHPLRORJLFDO� VWXGLHV�FRPSULVLQJ�WKH�ERG\�RI�HYLGHQFH��ZDV�DOVR� GLVFXVVHG� 7KH�LQWHUQDWLRQDOO\�DFFHSWHG�GH¿QLWLRQ�RI� RVWHRSRURVLV�VWDWHV�WKDW�RVWHRSRURVLV�LV�D�V\VWHPLF� VNHOHWDO�GLVHDVH�FKDUDFWHUL]HG�E\�ORZ�ERQH�PDVV� DQG�PLFUR�DUFKLWHFWXUDO�GHWHULRUDWLRQ�RI�ERQH� WLVVXH��ZLWK�D�FRQVHTXHQW�LQFUHDVH�LQ�ERQH�IUDJLOLW\� DQG�VXVFHSWLELOLW\�WR�IUDFWXUH�������*OREDOO\��WKH� DYHUDJH�DJH�IRU�RVWHRSRURVLV�LV����\HDUV��DQG�WKH� DYHUDJH�IRU�SHUVRQV�OLYLQJ�LQ�GHYHORSHG�FRXQWULHV� LV����\HDUV��'HWHUPLQDQWV�RI�RVWHRSRURWLF�IUDFWXUH� LQFOXGH�WKH�ULVN�RI�IDOOLQJ��WKH�IRUFH�RI�LPSDFW�DQG� WKH�VWUHQJWK�RI�ERQH��%RQH�VWUHQJWK�UHOLHV�RQ� JHRPHWU\�RI�WKH�ERQH��%0'��DQG�ERQH�TXDOLW\� 1XPHURXV�ULVN�IDFWRUV�IRU�RVWHRSRURWLF�IUDFWXUH�DUH� UHSRUWHG�LQ�WKH�OLWHUDWXUH��KRZHYHU��WKH�FRQVLVWHQF\� RI�WKH�GLUHFWLRQDOLW\�RI�WKHLU�HIIHFWV�YDU\�DQG�IHZ� ULVN�IDFWRUV�KDYH�EHHQ�YDOLGDWHG�E\�VWXGLHV�WKDW�DUH� UHSURGXFLEOH��GLVSOD\�D�GRVH�UHVSRQVH�HIIHFW��DQG� � LQFOXGH�DSSURSULDWH�VWXG\�SRSXODWLRQV�������)URP� PHWKRGRORJLFDOO\�VRXQG�VWXGLHV��QXWULWLRQDO�DQG� OLIHVW\OH�IDFWRUV�WKDW�FRQVLVWHQWO\�LQFUHDVH�WKH�ULVN�RI� RVWHRSRURWLF�IUDFWXUHV�LQFOXGH��FLJDUHWWH�VPRNLQJ�� H[FHVVLYH�DOFRKRO�FRQVXPSWLRQ��DQG�ORQJ�WHUP� LPPRELOLW\��,Q�FRQWUDVW��ORZ�FDOFLXP�LQWDNH��ORZ� YLWDPLQ�'�LQWDNH��KLJK�FDIIHLQH�FRQVXPSWLRQ��DQG� ORZ�OHYHOV�RI�SK\VLFDO�H[HUFLVH�DUH�LQFRQVLVWHQWO\� DVVRFLDWHG�ZLWK�LQFUHDVLQJ�RVWHRSRURWLF�IUDFWXUH� ULVN� 'LVHDVHV�DQG�FRQGLWLRQV�NQRZQ�WR�FRQVLVWHQWO\� LQFUHDVH�IUDFWXUH�ULVN�LGHQWL¿HG�E\�ULJRURXVO\� GHVLJQHG�VWXGLHV�LQFOXGH��UKHXPDWRLG�DUWKULWLV�� SULRU�IUDFWXUH��VWURNH��YLVXDO�LPSDLUPHQW��DQG� KDYLQJ�DQ�RUJDQ�WUDQVSODQW��7KH�LQFUHDVHG�ULVN� DVVRFLDWHG�ZLWK�LQÀDPPDWRU\�ERZHO�GLVHDVH�� WK\URLG�GLVHDVH��JDVWULF�VXUJHU\��DQG�3DUNLQVRQ¶V� GLVHDVH�LV�FRQVLVWHQW��EXW�WKH�HYLGHQFH�EDVH�IRU� WKHVH�IDFWRUV�FRPHV�IURP�OHVV�ULJRURXVO\�GHVLJQHG� VWXGLHV��7KH�HYLGHQFH�IRU�ULVN�DVVRFLDWHG�ZLWK�XVLQJ� DQWLFRDJXODQWV�RU�VWDWLQV�UHPDLQV�LQFRQVLVWHQW� 6HYHUDO�IDFWRUV�UHODWHG�WR�KRUPRQDO�VWDWXV�WKDW� KDYH�EHHQ�VKRZQ�WR�FRQVLVWHQWO\�LQFUHDVH�WKH� ULVN�RI�IUDFWXUH�LQFOXGH��\RXQJ�DJH�DW�PHQRSDXVH� DQG�XVH�RI�KRUPRQH�WKHUDS\��+7���(YLGHQFH�LV� LQFRQVLVWHQW�ZLWK�UHVSHFW�WR�DJH�DW�PHQDUFKH�� LQIHUWLOLW\��SDULW\��DQG�XVH�RI�FRQWUDFHSWLYHV��2WKHU� ULVN�IDFWRUV�LQFOXGH�DJH��IHPDOH�VH[��IDPLO\�KLVWRU\�� ORZ�ERG\�PDVV�LQGH[��%0,���GH¿QHG�DV�ZHLJKW�LQ� NJ�KHLJKW�LQ�PHWUHV�VTXDUHG���ORZ�%0'��DQG�$VLDQ� RU�&DXFDVLDQ�RULJLQ�� 'DWD�DFURVV�FRXQWULHV�VKRZ�JUHDW�KHWHURJHQHLW\� LQ�WKH�OLIHWLPH�ULVN�RI�KLS�IUDFWXUH�DPRQJ�ZRPHQ� DW�DJH�����ULVN�RI�KLS�IUDFWXUH�YDULHV�IURP�OHVV� WKDQ����LQ�7XUNH\�WR�PRUH�WKDQ�����LQ�6ZHGHQ�� *OREDOO\��%0'�VWDQGDUGL]HG�IRU�DJH��KHLJKW��DQG� ZHLJKW�DW�WKH�VSLQH�DQG�IHPRUDO�QHFN�GLIIHUV� DV�ZHOO��)XUWKHU��VWXGLHV�VKRZ�PDUNHG�FRXQWU\� YDULDWLRQV�LQ�WKH�SUHYDOHQFH�RI�RVWHRSRURVLV�� SDUWLFXODUO\�ZLWK�LQFUHDVLQJ�DJH��)RU�H[DPSOH��WKH� HVWLPDWHG�SUHYDOHQFH�RI�RVWHRSRURVLV�DPRQJ���� \HDU�ROG�ZRPHQ�UDQJHV�IURP�DSSUR[LPDWHO\����� LQ�+LURVKLPD��-DSDQ�WR�����LQ�5RFKHVWHU��86$�� 7KHVH�YDULDWLRQV�DUH�GLI¿FXOW�WR�H[SODLQ�DFFRUGLQJ� WR�WKH�SUHYDOHQFH�RI�ULVN�IDFWRUV��6RPH�DUHDV� ZLWK�WKH�KLJKHVW�ULVN�RI�IUDFWXUH��VXFK�DV�QRUWKHUQ� (XURSH��DUH�DOVR�ORFDWLRQV�ZKHUH�WKH�SUHYDOHQFH�RI� SURWHFWLYH�IDFWRUV�VXFK�DV�FDOFLXP�LQWDNH��DUH�DOVR� KLJK� ,Q�FRQFOXVLRQ��WKHUH�DUH�UHODWLYHO\�IHZ�ZHOO�YDOLGDWHG� ULVN�IDFWRUV�IRU�RVWHRSRURWLF�IUDFWXUH��DQG�NQRZQ� ULVN�IDFWRUV�H[SODLQ�RQO\�D�VPDOO�SDUW�RI�WKH�JOREDO� SDWWHUQ�RI�GLVHDVH� 7KH�HIIHFWV�RI�FRPELQHG�KRUPRQDO� FRQWUDFHSWLYHV�RQ�ERQH 'U�$QQD�*ODVLHU��/RWKLDQ�)DPLO\�3ODQQLQJ�6HUYLFH�� 8QLWHG�.LQJGRP��SUHVHQWHG�UHVXOWV�IURP�D� V\VWHPDWLF�UHYLHZ�RI�HYLGHQFH�SXEOLVKHG�LQ�SHHU� UHYLHZHG�MRXUQDOV�IURP������WKURXJK�0DUFK������ RQ�WKH�HIIHFWV�RI�FRPELQHG�KRUPRQDO�FRQWUDFHSWLRQ� RQ�ERQH�KHDOWK��7KH�UHYLHZ�LQFOXGHG����FURVV� VHFWLRQDO�VWXGLHV�����SURVSHFWLYH�VWXGLHV��DQG�WZR� FDVH�VHULHV�RI�%0'�RXWFRPHV�DQG�QLQH�VWXGLHV�RI� IUDFWXUH�RXWFRPH��$WWHQWLRQ�ZDV�GUDZQ�WR�FRPPRQ� OLPLWDWLRQV�DFURVV�WKHVH�VWXGLHV��VXFK�DV�YDULDWLRQV� LQ�PHDVXUHPHQW�WHFKQRORJLHV��W\SHV�RI�FRPSDULVRQ� JURXSV��GXUDWLRQ�RI�SLOO�XVH��DQG�SLOO�IRUPXODWLRQV�� 0DQ\�VWXGLHV�FRQWDLQHG�IHZ�SDUWLFLSDQWV� &XUUHQW�FRPELQHG�RUDO�FRQWUDFHSWLYH��&2&�� XVH )RXU�FRKRUW�DQG�WZR�FURVV�VHFWLRQDO�VWXGLHV� UHSRUWHG�RQ�DGROHVFHQW�RU�\RXQJ�DGXOW�SRSXODWLRQV�� 5HVXOWV�IURP�RQH�FRKRUW�VWXG\�VKRZHG�%0'�LQ� FRPELQHG�RUDO�FRQWUDFHSWLYH��&2&�����ȝJ�HWKLQ\O� HVWUDGLRO��((�����ȝJ�GHVRJHVWUHO��XVHUV�GLG�QRW� FKDQJH�VLJQL¿FDQWO\�RYHU�¿YH�\HDUV�RI�IROORZ�XS�� ZKHUHDV�QRQ�XVHUV�JDLQHG������%0'��S�������� �����0RUHRYHU��GLIIHUHQFHV�EHWZHHQ�&2&�XVHUV� DQG�QRQ�XVHUV�ZHUH�VLJQL¿FDQW�DW�WKUHH�\HDUV� DQG�FRQWLQXHG�WR�ZLGHQ�WKURXJK�WKH�IRXUWK�DQG� ¿IWK�\HDU�RI�IROORZ�XS��,Q�FRQWUDVW��GLIIHUHQFHV�LQ� %0'�EHWZHHQ�&2&�XVHUV�DQG�QRQ�XVHUV�ZHUH� QRW�VLJQL¿FDQW�LQ�RWKHU�FRKRUW����±����RU�FURVV� VHFWLRQDO�VWXGLHV�RI�DGROHVFHQWV�RU�\RXQJ�DGXOWV�� �������� (OHYHQ�SURVSHFWLYH�VWXGLHV�����FURVV�VHFWLRQDO� VWXGLHV��DQG�WZR�FDVH�VHULHV�ZHUH�FRQGXFWHG� DPRQJ�SUHPHQRSDXVDO�DGXOW�ZRPHQ��7ZR� PHWKRGRORJLFDOO\�VRXQG�FRKRUW�VWXGLHV���������� IRXQG�%0'�DW�WKH�VSLQH��KLS��DQG�ZKROH�ERG\� GLG�QRW�GLIIHU�EHWZHHQ�&2&��”���ȝJ�((��XVHUV� DQG�QRQ�XVHUV�RYHU�RQH�RU�WKUHH�\HDUV�IROORZ� XS��$QRWKHU�FRKRUW�VWXG\�UHSRUWHG�VLJQL¿FDQW� GLIIHUHQFHV�LQ�%0'�ORVV�DW����PRQWKV�DPRQJ� ZRPHQ�XVLQJ�D�&2&�FRQWDLQLQJ�GHVRJHVWUHO�����ȝJ� ((�����ȝJ�GHVRJHVWUHO��FRPSDUHG�ZLWK�QRQ�XVHUV�� EXW�QR�GLIIHUHQFHV�ZHUH�GHWHFWHG�EHWZHHQ�XVHUV�RI� D�&2&�FRQWDLQLQJ�QRUHWKLVWHURQH�DQG�FRQWUROV������� ����$�FRKRUW�VWXG\�RI�ZRPHQ�ZLWK�VWUHVV�UHODWHG� ROLJR�DPHQRUUKRHD�REVHUYHG�VLJQL¿FDQW�JDLQV�LQ� %0'�DPRQJ�ZRPHQ�ZKR�WRRN�&2&V�FRQWDLQLQJ� ���—J�((���������RU���—J�((���������FRPSDUHG� ZLWK�FRQWUROV���������RYHU����PRQWKV�IROORZ�XS������� 7HFKQLFDO�FRQVXOWDWLRQ�RQ�WKH�HIIHFWV�RI�KRUPRQDO�FRQWUDFHSWLRQ�RQ�ERQH�KHDOWK � (YLGHQFH�RQ�FXUUHQW�&2&�XVH�DQG�%0'�DPRQJ� SHUL��RU�SRVW�PHQRSDXVDO�ZRPHQ�ZDV�HYDOXDWHG�E\� RQH�UDQGRPL]HG�FRQWUROOHG�WULDO��5&7���¿YH�FRKRUW� VWXGLHV�DQG�VL[�FURVV�VHFWLRQDO�VWXGLHV��5HVXOWV� IURP�WKH�5&7�RI�SRVWPHQRSDXVDO�ZRPHQ�ZKR�ZHUH� DVVLJQHG�WR�&2&V�����ȝJ�((�����ȝJ�GHVRJHVWUHO�� Q ����RU�+7�ZHUH�KLJKOLJKWHG�������%RWK�JURXSV� H[SHULHQFHG�VLJQL¿FDQW�JDLQV�LQ�%0'�DW�¿YH�VLWHV� �VSLQH��WURFKDQWHU��LQWHU�WURFKDQWHU��:DUG¶V�WULDQJOH�� DQG�SUR[LPDO�IHPXU���DQG�ZRPHQ�WUHDWHG�ZLWK� &2&V�DOVR�KDG�VLJQL¿FDQWO\�LQFUHDVHG�%0'�DW�WKH� IHPRUDO�QHFN��ZKLFK�ZDV�QRW�REVHUYHG�LQ�WKH�+7� JURXS��:KHQ�WKH�VDPSOH�ZDV�IXUWKHU�GLYLGHG�LQWR� ORZ�DQG�QRUPDO�%0'�JURXSV�DFFRUGLQJ�WR�EDVHOLQH� %0'�YDOXHV�������WKH�LQYHVWLJDWRUV�IRXQG�WKDW�&2&� WKHUDS\�ZDV�VLJQL¿FDQWO\�PRUH�HIIHFWLYH�WKDQ�+7� DW�LQFUHDVLQJ�WKH�VSLQDO�%0'�RI�ZRPHQ�LQ�WKH�ORZ� %0'�JURXS��S������� 3DVW�&2&�XVH 6L[WHHQ�FURVV�VHFWLRQDO�VWXGLHV�DQG�RQH�FURVV� VHFWLRQDO�DQDO\VLV�IURP�D�FRKRUW�VWXG\�DVVHVVHG� WKH�UHODWLRQVKLS�EHWZHHQ�%0'�DQG�SULRU�XVH� RI�&2&V�DPRQJ�SRVWPHQRSDXVDO�SRSXODWLRQV�� ���±����2YHUDOO��WKHUH�LV�QR�HYLGHQFH�WKDW�%0'�DW� WKH�VSLQH��KLS��IRUHDUP��RU�ZKROH�ERG\�ZDV�DIIHFWHG� E\�&2&�XVH��DOWKRXJK�]�VFRUHV�ZHUH�VLJQL¿FDQWO\� KLJKHU�DPRQJ�&2&�SDVW�XVHUV�FRPSDUHG�ZLWK� QHYHU�XVHUV�LQ�WZR�VWXGLHV�DQG�VLJQL¿FDQWO\�ORZHU�LQ� WZR�RWKHU�VWXGLHV� 2WKHU�FRPELQHG�KRUPRQDO�PHWKRGV (YLGHQFH�RQ�WKH�XVH�RI�RWKHU�FRPELQHG�KRUPRQDO� FRQWUDFHSWLYHV�DPRQJ�SUHPHQRSDXVDO�ZRPHQ� DQG�%0'�ZDV�DYDLODEOH�IURP�D�UDQGRPL]HG�WULDO� RI�D�PRQWKO\�FRPELQHG�LQMHFWDEOH�FRQWUDFHSWLYH� �0HVLJ\QDŠ�������DQG�D�SURVSHFWLYH�VWXG\�RI�D� FRPELQHG�FRQWUDFHSWLYH�YDJLQDO�ULQJ��1XYD5LQJŠ��� �����1R�FKDQJHV�LQ�VSLQDO�%0'�ZHUH�UHFRUGHG�RYHU� WZR�\HDUV�IROORZ�XS�DPRQJ�&,&�XVHUV�FRPSDUHG� ZLWK�ZRPHQ�XVLQJ�D�FRSSHU�,8'�������:KLOH� %0'�DW�WKH�VSLQH�RU�IHPRUDO�QHFN�GLG�QRW�FKDQJH� VLJQL¿FDQWO\�DPRQJ�YDJLQDO�ULQJ�XVHUV�RYHU���� PRQWKV�DQG�VLJQL¿FDQWO\�LQFUHDVHG�DPRQJ�QRQ� XVHUV��WKH�HVWLPDWHV�ZHUH�QRW�DGMXVWHG�IRU�DJH�� SDULW\��RU�SULRU�&2&�XVH��ZKLFK�ZHUH�GLIIHUHQWLDOO\� GLVWULEXWHG�EHWZHHQ�YDJLQDO�ULQJ�XVHUV�DQG�QRQ� XVHUV������ )UDFWXUH 1LQH�VWXGLHV�LQYHVWLJDWHG�WKH�DVVRFLDWLRQ�EHWZHHQ� ULVN�RI�IUDFWXUH�DQG�&2&�XVH��ZLWK�PL[HG�UHVXOWV�� (YLGHQFH�IURP�WZR�ODUJH�SURVSHFWLYH�VWXGLHV�ZDV� KLJKOLJKWHG��$FFRUGLQJ�WR�WKH�¿UVW�VWXG\��&2&� HYHU�XVHUV�ZHUH�PRUH�OLNHO\�WR�KDYH�D�IUDFWXUH�WKDQ� QHYHU�XVHUV��UHODWLYH�ULVN�>55@ ��������� &, ����±������DIWHU�DGMXVWLQJ�IRU�VPRNLQJ��VRFLDO� FODVV��DJH�DQG�SDULW\�������7KH�VHFRQG�VWXG\�� KRZHYHU��UHSRUWHG�D�UHGXFHG�ULVN�RI�KLS�IUDFWXUH� DPRQJ�HYHU�XVHUV�RI�&2&V�FRPSDUHG�ZLWK�QHYHU� XVHUV��RGGV�UDWLR�>25@ ����������&, ����±������� DGMXVWLQJ�IRU�DJH��+7�XVH��SDULW\��DQG�ERG\�PDVV� LQGH[��%0,���NJ�P���������7KHUH�ZHUH�QR�H[FOXVLYH� XVHUV�RI�ORZ�GRVH�&2&V�LQ�WKH�VWXG\�SRSXODWLRQ�� $GGLWLRQDO�SURWHFWLYH�HIIHFWV�ZHUH�QRWHG�DPRQJ� HYHU�XVHUV�RI�KLJK�GRVH�&2&V��DGMXVWHG�25 ������ ����&, ����±������DQG�ZRPHQ�ZKR�VWDUWHG�XVLQJ� &2&V�DIWHU�DJH�����DGMXVWHG�25 �����IRU�DOO� &2&V��DGMXVWHG�25 �����IRU�KLJK�GRVH�&2&V���,Q� D�VHSDUDWH�DQDO\VLV�RI�WKH�VDPH�GDWD��WKH�DXWKRUV� UHSRUWHG�VLJQL¿FDQW�HIIHFW�PRGL¿FDWLRQ�E\�&2&�XVH� RQ�WKH�DVVRFLDWLRQ�EHWZHHQ�SDULW\�DQG�KLS�IUDFWXUH�� IUDFWXUH�ULVN�ZDV�UHGXFHG�E\����SHU�FKLOG�DPRQJ� QHYHU�XVHUV�EXW�LQFUHDVHG�����SHU�FKLOG�DPRQJ� HYHU�XVHUV�RI�&2&V������ %DVHG�XSRQ�WKH�HYLGHQFH�UHYLHZHG��WKH�HIIHFW� RI�FXUUHQW�&2&�XVH�RQ�%0'�YDULHV�ZLWK�DJH�DW� WKH�WLPH�RI�XVH�DQG�D�ZRPDQ¶V�HVWURJHQLF�VWDWH�� 6WXGLHV�GR�QRW�¿QG�WKDW�SDVW�XVH�RI�&2&V�KDV� DQ�HIIHFW�RQ�%0'�ZKHQ�FRPSDUHG�ZLWK�QHYHU� XVLQJ�&2&V��)LQDOO\��GDWD�RQ�&2&�XVH�DQG�ULVN�RI� IUDFWXUH�DUH�LQFRQVLVWHQW�DQG�QR�GDWD�DUH�DYDLODEOH� IRU�FXUUHQW�&2&�IRUPXODWLRQV� 7KH�HIIHFWV�RI�SURJHVWRJHQ�RQO\� FRQWUDFHSWLYH�XVH�RQ�ERQH�PLQHUDO�GHQVLW\� DQG�IUDFWXUH�ULVN� 'U�.DWKU\Q�&XUWLV��&HQWHUV�IRU�'LVHDVH�&RQWURO� DQG�3UHYHQWLRQ��86$��SUHVHQWHG�D�V\VWHPDWLF� UHYLHZ�RI�SXEOLVKHG�HYLGHQFH�IURP������WKURXJK� 0D\������RQ�WKH�LPSDFW�RI�XVLQJ�SURJHVWRJHQ� RQO\�FRQWUDFHSWLYH�PHWKRGV�RQ�%0'�DQG�ULVN�RI� IUDFWXUH��7KH�UHYLHZ�DGGUHVVHG�WKUHH�TXHVWLRQV�� ���GR�SURJHVWRJHQ�RQO\�FRQWUDFHSWLYH�XVHUV� KDYH�DQ�LQFUHDVHG�ULVN�RI�FXUUHQW�RU�IXWXUH� IUDFWXUH�FRPSDUHG�ZLWK�QRQ�XVHUV"����GR�FXUUHQW� SURJHVWRJHQ�RQO\�XVHUV�KDYH�GLIIHUHQW�%0'�OHYHOV� WKDQ�QRQ�XVHUV"�DQG����GR�IRUPHU�SURJHVWRJHQ� RQO\�FRQWUDFHSWLYH�XVHUV�KDYH�GLIIHUHQW�%0'�OHYHOV� WKDQ�QRQ�XVHUV" )UDFWXUH (YLGHQFH�RQ�IUDFWXUH�RXWFRPH�ZDV�DYDLODEOH�IURP� RQH�FRKRUW�VWXG\�RI�8QLWHG�6WDWHV�$UP\�UHFUXLWV� DJHG���±���\HDUV��GXULQJ�HLJKW�ZHHNV�RI�EDVLF� WUDLQLQJ��ZKR�ZHUH�FXUUHQWO\�XVLQJ�'03$��Q ����� RU�D�QRQ�KRUPRQDO�PHWKRG��Q �������������$PRQJ� '03$�XVHUV��WKH�FUXGH�55�RI�VWUHVV�IUDFWXUH�ZDV� ����������&, ����±�������KRZHYHU��WKH�HVWLPDWH� � )LJXUH��D��&URVV�VHFWLRQDO�VWXGLHV�RI�DGXOW�'03$�XVHUV��VSLQH�DQG�KLS�VLWHV� )LJXUH��E��&URVV�VHFWLRQDO�VWXGLHV�RI�DGXOW�'03$�XVHUV��IRUHDUP�VLWHV� 2� �� � �� �� ��� �� �� ��� ����� �� ������� � ��� ������ � ���������� � �,,� ,��%�� �� �,,� ,��%�� �� �-'�1� ,��%�� ������-*() �'� ��(%�� � ,��%�� ��� ��'#�"+ ,�$-%� ,��%�� �� ��#.�� ,��%�� ��� ��"(% +� ,��%�� ��� �-'�1� ,��%�� ���� ��#.�� ,��%�� ��� ��"(% +� ,��%�� ��� ��'#�"+ ,�$-%� ,��%�� �� ��"(% +� ,��%�� ��� ��#.�� ,��%�� ��� ��'#�"+ ,�$-%� ,��%�� �� ��(%�� � ,��%�� ��� ����� �� �1 �*+�� �(,�)*(.#� � �(,�)*(.#� � � �� ��� ������ ����� ����2 �� �� ����� 2 �� �� 2 ��3 �� 2 ��3 ����2 ��3 ����2 �� �� ����� 2 �� ����2 �� �� ����� 2 �� �� 2 ��3 �� �'��'��(*�*�'! ��� 0� ),�/" * �& �#�'�#+�#'�#��, ���3�� ( �� (��� ��� ��#!%%���%����� �� ���� ���( �� ���� �� ����� ( �� ���( �� ���� �� ����� ( �� � �������� ��'��#$�� ���# "#�$�# ��%����� �� �� ���$�%��&���%����� �� ���# "#�$�# ��%����� �� ��#!%%���%����� �� �����! ��$��%����� ��� ���� �� ��!#�#� �� �� ��"� ���$�&���%����� ��� �� ��"� �$��$�&���%����� ��� �� � ��������� ������������� �� ���$�%��&���%����� �� ���$� $����%����� �� ��� ������ �� �����! ��$��%����� ��� &RPSDULVRQ�JURXS� ������'03$�QRQ�XVHUV ������1RQ�KRUPRQDO�XVHUV ������6WDQGDUG�QRUPDO�SRSXODWLRQ ‹ S &RPSDULVRQ�JURXS� ����'03$�QRQ�XVHUV ����1RQ�KRUPRQDO�XVHUV ‹ 7HFKQLFDO�FRQVXOWDWLRQ�RQ�WKH�HIIHFWV�RI�KRUPRQDO�FRQWUDFHSWLRQ�RQ�ERQH�KHDOWK � 1RWH��7KH�SRLQWV�RQ�WKLV�JUDSK�UHSUHVHQW�WKH�PHDQ���GLIIHUHQFH�LQ�WKH�QRQ�XVHUV ' LII HU HQ FH �LQ �P HD Q� � �F KD QJ H� �� �� �& ,� � %HUHQVRQ������ � &XQG\������ � &ODUN������‹ S � � �� ��� ��� ��� ���� �� �� �� �� ��� ��� � � )LJXUH����6SLQH�%0'��GLIIHUHQFH�LQ�PHDQ���FKDQJH�IURP�EDVHOLQH��'03$�YV�FRQWURO�LQ�DGXOWV�LQ���VWXGLHV ZDV�QR�ORQJHU�VLJQL¿FDQW�ZKHQ�DGMXVWHG�IRU� EDVHOLQH�KHHO�ERQH�GHQVLW\��,QIRUPDWLRQ�RQ�EDVHOLQH� KHHO�GHQVLW\�DQG�RWKHU�EDVHOLQH�FKDUDFWHULVWLFV� ZHUH�QRW�UHSRUWHG�LQ�WKH�DUWLFOH� &XUUHQW�'03$�XVH ,QIRUPDWLRQ�RQ�FXUUHQW�'03$�XVH�DQG�%0'�ZDV� DYDLODEOH�IURP����FURVV�VHFWLRQDO�VWXGLHV�RI�DGXOW� ZRPHQ����±����DQG�WZR�FURVV�VHFWLRQDO�VWXGLHV� RI�DGROHVFHQWV�����������&URVV�VHFWLRQDO�VWXGLHV� VKRZHG�WKDW�FXUUHQW�'03$�XVH�JHQHUDOO\�ZDV� DVVRFLDWHG�ZLWK�ORZHU�%0'��KRZHYHU��'03$� XVHUV�KDG�PHDQ�%0'�YDOXHV�JHQHUDOO\�ZLWKLQ������ VWDQGDUG�GHYLDWLRQ�RI�WKH�PHDQ�%0'�DPRQJ�QRQ� XVHUV��L�H��]�VFRUH������������±����7KH�UDQJH�LQ� ]�VFRUH�YDOXHV�IRU�WKH�KLS��VSLQH��DQG�IRUHDUP�DUH� LOOXVWUDWHG�LQ�)LJXUH��D�DQG�)LJXUH��E� 6HYHQ�ORQJLWXGLQDO�VWXGLHV�LQYHVWLJDWHG�WKH�HIIHFW� RQ�%0'�RI�FXUUHQW�'03$�XVH�DPRQJ�DGXOW�ZRPHQ�� WKUHH�RI�WKHP�DUH�VKRZQ�LQ�)LJXUH�����������±���� 7KH�QHW�GH¿FLW�LQ�%0'�LQ�'03$�XVHUV�FRPSDUHG� ZLWK�QRQ�XVHUV�UDQJHG�IURP������WR����������� ��������DW�RQH�\HDU�DQG������WR��������������� DW�WZR�\HDUV��7ZR�VWXGLHV�H[DPLQLQJ�HVWURJHQ� VXSSOHPHQWDWLRQ�DPRQJ�'03$�XVHUV�IRXQG�WKDW� DW����PRQWKV��WUHDWHG�'03$�XVHUV�ORVW�OHVV�%0'� WKDQ�XVHUV�ZKR�UHFHLYHG�VXSSOHPHQWDWLRQ�������� YHUVXV�������������DQG�DW����PRQWKV��WUHDWHG�XVHUV� H[SHULHQFHG�D������JDLQ�LQ�%0'�FRPSDUHG�ZLWK�D� ������ORVV�DPRQJ�XQWUHDWHG�XVHUV������ 6L[�ORQJLWXGLQDO�VWXGLHV�RI�DGROHVFHQWV�LQYHVWLJDWHG� '03$�XVH�DQG�%0'�����±�������������2YHU�RQH� RU�WZR�\HDUV�IROORZ�XS��VLJQL¿FDQW�GHFOLQHV�LQ� %0'�DW�WKH�VSLQH��KLS��IHPRUDO�QHFN��DQG�ZKROH� ERG\�DPRQJ�'03$�LQLWLDWRUV�RU�FRQWLQXHUV�ZHUH� UHFRUGHG�FRPSDUHG�ZLWK�QRQ�XVHU�JURXSV��0HDQ� SHU�FHQW�GLIIHUHQFHV�EHWZHHQ�XVHUV�DQG�QRQ�XVHUV� ZHUH��������WR���������IRU�WKH�VSLQH���������IRU� WKH�KLS��������IRU�WKH�IHPRUDO�QHFN��DQG�������� IRU�WKH�ZKROH�ERG\��)XUWKHU��QHZ�XVHUV�ORVW�PRUH� ERQH�WKDQ�FRQWLQXLQJ�XVHUV�DQG�PHDQ�FKDQJHV�LQ� %0'�GHFUHDVHG�ZLWK�LQFUHDVLQJ�'03$�FXPXODWLYH� XVH��,Q�D�VWXG\�RI�WHHQDJHUV�XVLQJ�'03$�ZKR� DOVR�UHFHLYHG����PRQWKV�RI�HVWUDGLRO�F\SLRQDWH� VXSSOHPHQWDWLRQ��VLJQL¿FDQW�JDLQV�LQ�%0'�DW�WKH� VSLQH�DQG�IHPRUDO�QHFN�ZHUH�REVHUYHG�LQ�WUHDWHG� XVHUV�FRPSDUHG�ZLWK�QRQ�WUHDWHG�XVHUV������� �� 6L[�ORQJLWXGLQDO�VWXGLHV�RI�DGROHVFHQWV�LQYHVWLJDWHG� '03$�XVH�DQG�%0'�����±�������������2YHU�RQH� RU�WZR�\HDUV�IROORZ�XS��VLJQL¿FDQW�GHFOLQHV�LQ� %0'�DW�WKH�VSLQH��KLS��IHPRUDO�QHFN��DQG�ZKROH� ERG\�DPRQJ�'03$�LQLWLDWRUV�RU�FRQWLQXHUV�ZHUH� UHFRUGHG�FRPSDUHG�ZLWK�QRQ�XVHU�JURXSV��0HDQ� SHUFHQW�GLIIHUHQFHV�EHWZHHQ�XVHUV�DQG�QRQ�XVHUV� ZHUH��������WR���������IRU�WKH�VSLQH���������IRU� WKH�KLS��������IRU�WKH�IHPRUDO�QHFN��DQG�������� IRU�WKH�ZKROH�ERG\��)XUWKHU��QHZ�XVHUV�ORVW�PRUH� ERQH�WKDQ�FRQWLQXLQJ�XVHUV�DQG�PHDQ�FKDQJHV�LQ� %0'�GHFUHDVHG�ZLWK�LQFUHDVLQJ�'03$�FXPXODWLYH� XVH��,Q�D�VWXG\�RI�WHHQDJHUV�XVLQJ�'03$�ZKR� DOVR�UHFHLYHG����PRQWKV�RI�HVWUDGLRO�F\SLRQDWH� VXSSOHPHQWDWLRQ��VLJQL¿FDQW�JDLQV�LQ�%0'�DW�WKH� VSLQH�DQG�IHPRUDO�QHFN�ZHUH�REVHUYHG�LQ�WUHDWHG� XVHUV�FRPSDUHG�ZLWK�QRQ�WUHDWHG�XVHUV������� 7KH�HIIHFW�RI�FXUUHQW�'03$�XVH�DPRQJ�ROGHU� ZRPHQ�RQ�%0'�ZDV�H[DPLQHG�E\�WZR�FURVV� VHFWLRQDO�VWXGLHV����������DQG�RQH�IROORZ�XS�VWXG\�� ������$FFRUGLQJ�WR�RQH�VWXG\��%0'�DPRQJ�ROGHU� '03$�XVHUV�GLG�QRW�VLJQL¿FDQWO\�GLIIHU�IURP�D� UHIHUHQFH�SRSXODWLRQ��KRZHYHU��WZR�RWKHU�VWXGLHV� UHSRUWHG�VLJQL¿FDQWO\�ORZHU�PHDQ�%0'�DW�WKH� OXPEDU�VSLQH��IHPRUDO�QHFN��WURFKDQWHU��DQG�:DUG¶V� WULDQJOH�DPRQJ�XVHUV�FRPSDUHG�ZLWK�QHYHU�XVHUV�DW� EDVHOLQH������DQG�DIWHU�WKUHH�\HDUV�IROORZ�XS������� 3DVW�'03$�XVH $PRQJ�DGXOW�ZRPHQ��WZR�FURVV�VHFWLRQDO�VWXGLHV� H[DPLQHG�WKH�LPSDFW�RI�SDVW�XVH�RI�'03$�RQ� %0'�UHFRYHU\������������%0'�RI�IRUPHU�'03$� XVHUV�GLG�QRW�VLJQL¿FDQWO\�GLIIHU�FRPSDUHG�ZLWK� QRQ�XVHUV�DFURVV�¿YH�DQDWRPLFDO�VLWHV��OXPEDU� VSLQH��IHPRUDO�QHFN��:DUG¶V�WULDQJOH��WURFKDQWHU�� WRWDO�ERG\��DQG�PHDQ�%0'�GLG�QRW�FRUUHODWH�ZLWK� GXUDWLRQ�RI�'03$�XVH��DJH�DW�LQLWLDWLRQ�RI�'03$�� DJH�DW�GLVFRQWLQXDWLRQ�RI�'03$��RU�WLPH�EHWZHHQ� GLVFRQWLQXDWLRQ�DQG�PHQRSDXVH�������7KH�VHFRQG� VWXG\�IRXQG�QR�GLIIHUHQFHV�EHWZHHQ�IRUPHU�'03$� XVHUV�DQG�QRQ�XVHUV�ZKHQ�DVVHVVLQJ�IRUHDUP� %0'������ 7KUHH�ORQJLWXGLQDO�VWXGLHV�H[DPLQHG�UHFRYHU\�RI� %0'�DIWHU�GLVFRQWLQXDWLRQ�RI�'03$�XVH�LQ�DGXOWV� ��������������DQG�RQH�ORQJLWXGLQDO�VWXG\�IROORZHG� %0'�UHFRYHU\�DPRQJ�DGROHVFHQW�JLUOV�ZKR� GLVFRQWLQXHG�'03$�XVH�������7ZR�VWXGLHV��������� VKRZHG�DGXOW�'03$�GLVFRQWLQXHUV�JDLQHG�ERQH� DW�WKH�VSLQH��KLS��DQG�IHPRUDO�QHFN�WKURXJKRXW� WZR�RU�PRUH�\HDUV�IROORZ�XS�DW�UDWHV�JUHDWHU�WKDQ� QRQ�XVHUV��UHJDUGOHVV�RI�GXUDWLRQ�RI�'03$�XVH�� 5HFRYHU\�RI�KLS�%0'�RFFXUUHG�PRUH�VORZO\�WKDQ� VSLQDO�%0'��7KH�WKLUG�DGXOW�VWXG\�������H[DPLQHG� ZRPHQ�ZKR�KDG�UHDFKHG�PHQRSDXVH��6WDWLVWLFDOO\� VLJQL¿FDQW�JDLQV�LQ�VSLQDO�DQG�KLS�%0'�DPRQJ� IRUPHU�'03$�XVHUV��ZKR�LQLWLDWHG�KRUPRQH�WKHUDS\� GXULQJ�WKUHH�\HDUV�IROORZ�XS��FRPSDUHG�ZLWK�'03$� GLVFRQWLQXHUV��QRW�XVLQJ�+7�DQG�FRQWUROV�ZKR�KDG� QHYHU�XVHG�'03$�DQG�ZHUH�QRW�XVLQJ�+7��ZHUH� UHSRUWHG��$PRQJ�DGROHVFHQWV�ZKR�GLVFRQWLQXHG� XVLQJ�'03$�������UHFRYHU\�RI�VSLQH��KLS�DQG�ZKROH� ERG\�%0'�RFFXUUHG�WKURXJKRXW�WZR�\HDUV�RI�IROORZ� XS��0RUHRYHU��DW����PRQWKV�IROORZ�XS��DGMXVWHG� PHDQ�%0'�YDOXHV�IRU�GLVFRQWLQXHUV�ZHUH�DW�OHDVW� DV�KLJK�DV�WKRVH�RI�QRQ�XVHUV�DW�DOO�VLWHV�DQG�DW�DOO� VXEVHTXHQW�IROORZ�XS�SHULRGV� 2WKHU�SURJHVWRJHQ�RQO\�FRQWUDFHSWLYH� PHWKRGV 7ZR�UHSRUWV�RI�RQH�FURVV�VHFWLRQDO�VWXG\�DQG�¿YH� ORQJLWXGLQDO�VWXGLHV�RI�FXUUHQW�XVHUV�RISURJHVWRJHQ� RQO\�LPSODQWV��SULPDULO\�1RUSODQWŠ��EXW�RQH�VWXG\�RI� ,PSODQRQŠ��VKRZHG�HLWKHU�QR�VLJQL¿FDQW�GLIIHUHQFH� LQ�%0'�RU�LQFUHDVHV�LQ�%0'�FRPSDUHG�ZLWK�QRQ� XVHUV������������������±�����1HYHUWKHOHVV��RQH� FURVV�VHFWLRQDO�VWXG\�IRXQG�WKDW�PHDQ�%0'�DW�WKH� PLG�VKDIW�RI�WKH�XOQD�ZDV�ORZHU�DPRQJ�H[FOXVLYH� XVHUV�RI�1RUSODQW�FRPSDUHG�ZLWK�QRQ�KRUPRQDO� XVHUV��7KLV�GLIIHUHQFH�ZDV�VWDWLVWLFDOO\�VLJQL¿FDQW�� KRZHYHU��LW�ZDV�ZLWKLQ�RQH�VWDQGDUG�GHYLDWLRQ�RI� WKH�PHDQ�RI�WKH�QRQ�XVHUV�������7KH�RQO\�VWXG\�RI� 1(7�(1�DOVR�IRXQG�QR�GLIIHUHQFH�LQ�FURVV�VHFWLRQDO� DQDO\VLV�EHWZHHQ�1(7�(1�XVHUV�DQG�QRQ�KRUPRQDO� XVHUV�������7KH�RQO\�VWXG\�RI�SURJHVWRJHQ�RQO\�SLOO� XVH�HYDOXDWHG�EUHDVWIHHGLQJ�ZRPHQ�DQG�IRXQG�WKDW� SLOO�XVHUV�ORVW�OHVV�ERQH�WKDQ�QRQ�XVHUV������� 9DULRXV�OLPLWDWLRQV�RI�WKH�VWXGLHV�LQFOXGHG�LQ�WKH� V\VWHPDWLF�UHYLHZ�ZHUH�GLVFXVVHG��3ULQFLSDOO\��WKHUH� LV�D�ODFN�RI�HYLGHQFH�FRQFHUQLQJ�WKH�PDLQ�RXWFRPH� RI�LQWHUHVW��IUDFWXUH��$WWHQWLRQ�ZDV�GUDZQ�WR�WKH� XUJHQW�QHHG�IRU�JOREDOO\�UHSUHVHQWDWLYH�LQIRUPDWLRQ� RQ�WKH�LPSDFW�RI�'03$�XVH�RQ�ERQH�KHDOWK��DV� ZHOO�DV�WKH�OLPLWHG�DYDLODELOLW\�RI�HYLGHQFH�RQ�RWKHU� SURJHVWRJHQ�RQO\�FRQWUDFHSWLYHV��0RVW�VWXGLHV�� SDUWLFXODUO\�VWXGLHV�RI�DGROHVFHQWV��H[SHULHQFHG� KLJK�UDWHV�RI�ORVV�WR�IROORZ�XS�DQG�PDQ\�VWXGLHV� ZHUH�FRQGXFWHG�RYHU�UHODWLYHO\�VKRUW�WLPH�SHULRGV�� )XUWKHU��WKH�SRWHQWLDO�IRU�ELDV�WR�H[SODLQ�PDQ\�VWXG\� UHVXOWV�FDQQRW�EH�UXOHG�RXW��EHFDXVH�IHZ�VWXGLHV� DGMXVWHG�IRU�SRWHQWLDO�FRQIRXQGHUV��DQG�VHYHUDO� VWXGLHV�DOORZHG�SDUWLFLSDQWV�WR�VHOI�VHOHFW�WKHLU� PHWKRG�RI�FRQWUDFHSWLRQ� 'HSRW�PHGUR[\SURJHVWHURQH�DFHWDWH�XVH�DQG� ERQH�PLQHUDO�GHQVLW\�LQ�\RXQJ�ZRPHQ 'U�'HOLD�6FKROHV��*URXS�+HDOWK�&RRSHUDWLYH�� 86$��SUHVHQWHG�UHVXOWV�IURP�WZR�FRKRUW�VWXGLHV� FRQGXFWHG�DPRQJ�\RXQJ�ZRPHQ������±������DQG� 7HFKQLFDO�FRQVXOWDWLRQ�RQ�WKH�HIIHFWV�RI�KRUPRQDO�FRQWUDFHSWLRQ�RQ�ERQH�KHDOWK �� DGROHVFHQWV������±������XVLQJ�'03$��7KHVH�DUH� SXEOLVKHG�VWXGLHV�DQG�ZHUH�WKHUHIRUH�LQFOXGHG�LQ� WKH�SUHFHGLQJ�V\VWHPDWLF�UHYLHZ�RI�SURJHVWRJHQ� RQO\�FRQWUDFHSWLYHV��$FFRUGLQJO\��WKH�SUHVHQWDWLRQ� RIIHUHG�PRUH�FRPSOHWH�LQIRUPDWLRQ�FROOHFWHG� IURP�WKH�DGROHVFHQW�FRKRUW�VWXG\��LQFOXGLQJ�VRPH� XQSXEOLVKHG�GDWD� 7KH�DGROHVFHQW�FRKRUW�VWXG\�FRPSULVHG����'03$� XVHUV�DQG����QRQ�XVHUV�DJHG����WKURXJK���� \HDUV��ZKR�ZHUH�IROORZHG�IRU�D�PLQLPXP�RI���� DQG�D�PD[LPXP�RI����PRQWKV�������$W�EDVHOLQH�� QR�VLJQL¿FDQW�GLIIHUHQFHV�LQ�ERQH�PLQHUDO�GHQVLW\�� DV�PHDVXUHG�E\�';$��ZHUH�REVHUYHG�EHWZHHQ� '03$�XVHUV�DQG�QRQ�XVHUV��+RZHYHU��VLJQL¿FDQWO\� PRUH�'03$�XVHUV�FXUUHQWO\�VPRNHG�DQG�KDG�EHHQ� SUHJQDQW�SUHYLRXVO\�FRPSDUHG�ZLWK�QRQ�XVHUV��DQG� PHDQ�GDLO\�FDOFLXP�LQWDNH�ZDV�VLJQL¿FDQWO\�ORZHU� DPRQJ�'03$�XVHUV�FRPSDUHG�ZLWK�QRQ�XVHUV�� $PRQJ�'03$�XVHUV��D�JUHDWHU�SURSRUWLRQ�RI�ROGHU� JLUOV����±���\HDUV��UHSRUWHG�KDYLQJ�KDG�WZR�RU�PRUH� LQMHFWLRQV��WKDQ�\RXQJHU�JLUOV����±���\HDUV�� 7R�FRPSDUH�FKDQJHV�LQ�%0'�DQG�DGMXVW�IRU� EDVHOLQH�DQG�WLPH�YDU\LQJ�FRYDULDWHV��PHDQ� FKDQJHV�LQ�%0'��LQ�J�FP���ZHUH�FRPSXWHG�DW� ��PRQWKO\�LQWHUYDOV�XVLQJ�UHSHDWHG�PHDVXUHV� PRGHOV�DQG�H[SUHVVHG�DV�DQQXDOL]HG��DYHUDJH� DQQXDO��SHUFHQWDJH�FKDQJH��)ROORZ�XS�GDWD�ZHUH� DYDLODEOH�IRU�����RI�DGROHVFHQWV�DW����PRQWKV�� ����DW����PRQWKV��DQG�����DW����PRQWKV��'XULQJ� ���PRQWKV�IROORZ�XS��'03$�XVHUV�ORVW�DQ�DYHUDJH� RI�������%0'�DQQXDOO\�DW�WKH�KLS�FRPSDUHG�ZLWK�D� ORVV�RI�������%0'�DPRQJ�QRQ�XVHUV��$W�WKH�VSLQH�� D�ORVV�RI�������%0'�RFFXUUHG�DPRQJ�'03$�XVHUV� FRPSDUHG�ZLWK�D�������JDLQ�DPRQJ�QRQ�XVHUV� 7R�HYDOXDWH�ZKHWKHU�UHFRYHU\�RI�%0'�IROORZLQJ� '03$�GLVFRQWLQXDWLRQ�RFFXUV�����DGROHVFHQW� SDUWLFLSDQWV�ZHUH�IROORZHG�ZKR�GLVFRQWLQXHG�'03$� XVH�GXULQJ�WKH�FRKRUW�VWXG\��7KH�PHDQ�SHULRG�RI� IROORZ�XS�IRU�GLVFRQWLQXHUV�ZDV����PRQWKV��UDQJH�� �±���PRQWKV���8VH�RI�'03$�DPRQJ�GLVFRQWLQXHUV� UDQJHG�IURP���WR����PRQWKV��$GMXVWLQJ�IRU�EDVHOLQH� DQG�WLPH�YDU\LQJ�FRYDULDWHV��'03$�GLVFRQWLQXHUV� H[SHULHQFHG�DYHUDJH�VL[�PRQWKO\�JDLQV�LQ�%0'�RI� �������J�FP��DW�WKH�KLS�DQG��������J�FP��DW�WKH� VSLQH��S ������IRU�GLIIHUHQFH�LQ�%0'�FKDQJH�LQ� QRQ�XVHUV���7KHVH�FKDQJHV�FRUUHVSRQG�WR�PHDQ� DQQXDOL]HG�%0'�JDLQV�RI�������DQG�������� UHVSHFWLYHO\��DQG�ZHUH�VWDWLVWLFDOO\�VLJQL¿FDQW� UHODWLYH�WR�WKH�FRPSDULVRQ�JURXS�RI�JLUOV�ZKR� ZHUH�QRQ�'03$�XVHUV��$PRQJ�GLVFRQWLQXHUV� DJHG���±���\HDUV��VLPLODU�¿QGLQJV�ZHUH�UHSRUWHG�� <RXQJHU�GLVFRQWLQXHUV�H[SHULHQFHG�PHDQ�DGMXVWHG� ��PRQWKO\�JDLQV�RI��������J�FP��DW�WKH�KLS��DQG� �������J�FP��DW�WKH�VSLQH��ZKHUHDV�QRQ�XVHUV� LQ�WKLV�DJH�JURXS�KDG�JDLQV�RI��������J�FP��DQG� �������J�FP���UHVSHFWLYHO\�DQG�'03$�XVHUV�KDG� ORVVHV�RI��������J�FP��DW�WKH�KLS�DQG��������J�FP�� DW�WKH�VSLQH� 'HSRW�PHGUR[\SURJHVWHURQH�DFHWDWH��UHVXOWV� RI�UHFHQW�VWXGLHV�RQ�ERQH�PLQHUDO�GHQVLW\� IURP�D�PDQXIDFWXUHU�RI�'03$ )ROORZLQJ�SUHVHQWDWLRQV�RI�SXEOLVKHG�GDWD�RQ� '03$�XVH�DQG�ERQH�KHDOWK��UHSUHVHQWDWLYHV�IURP� WKH�3¿]HU�&RPSDQ\��,QF��VKDUHG�FRQ¿GHQWLDO� GDWD�RQ�'03$�REWDLQHG�IURP�WZR�FRKRUW�VWXGLHV�� $FFRUGLQJO\��SDUWLFLSDQWV�VLJQHG�D�VWDWHPHQW�E\� ZKLFK�WKH\�DJUHHG�WR�UHVSHFW�WKH�FRQ¿GHQWLDOLW\�RI� WKH�GDWD��7KHVH�GDWD�ZHUH�FRQVLGHUHG��KRZHYHU�� GXULQJ�WKH�GHOLEHUDWLRQV�DORQJ�ZLWK�GDWD�IURP�RWKHU� SUHVHQWDWLRQV� &RQFOXVLRQV 6WHURLG�KRUPRQDO�FRQWUDFHSWLYHV��LQFOXGLQJ� RUDO�FRQWUDFHSWLYHV��LQMHFWDEOHV�DQG�LPSODQWV�� DUH�KLJKO\�HIIHFWLYH�DQG�ZLGHO\�XVHG��7KHVH� FRQWUDFHSWLYHV�KDYH�LPSRUWDQW�KHDOWK�EHQH¿WV�� LQFOXGLQJ�FRQWUDFHSWLYH�DQG�QRQ�FRQWUDFHSWLYH� EHQH¿WV��DQG�VRPH�KHDOWK�ULVNV��)RU�PRVW� ZRPHQ��WKH�KHDOWK�EHQH¿WV�RI�XVH�FOHDUO\� H[FHHG�WKH�KHDOWK�ULVNV��4XHVWLRQV�KDYH�EHHQ� UDLVHG�UHJDUGLQJ�WKH�DVVRFLDWLRQ�EHWZHHQ�XVH� RI�RQH�SDUWLFXODU�KRUPRQDO�FRQWUDFHSWLYH��GHSRW� PHGUR[\SURJHVWHURQH�DFHWDWH��'03$���DQG�WKH� ULVN�RI�ERQH�ORVV��,Q�UHVSRQVH��:+2�FRQYHQHG� D�FRQVXOWDWLRQ�LQ�*HQHYD��6ZLW]HUODQG����±��� -XQH�������WR�DVVHVV�FXUUHQW�HYLGHQFH�RQ�WKH� UHODWLRQVKLS�EHWZHHQ�WKH�XVH�RI�VWHURLG�KRUPRQDO� FRQWUDFHSWLYHV�DQG�ERQH�KHDOWK� %RQH�KHDOWK�PD\�EH�LQÀXHQFHG�E\�PDQ\�IDFWRUV� LQFOXGLQJ�SUHJQDQF\��EUHDVWIHHGLQJ�DQG�XVH�RI� KRUPRQDO�FRQWUDFHSWLYHV��7KH�SULQFLSDO�FOLQLFDO� RXWFRPH�RI�LQWHUHVW�ZLWK�UHJDUG�WR�ERQH�KHDOWK� LV�WKH�RFFXUUHQFH�RI�IUDFWXUH��%RQH�PLQHUDO� GHQVLW\��%0'��PHDVXUHPHQWV�DUH�FRPPRQO\� XVHG�WR�DVVHVV�IUDFWXUH�ULVN��EXW�WKH�DFFXUDF\�RI� PHDVXUHPHQWV�FDQ�EH�LQÀXHQFHG�E\�FKDQJHV�LQ� ERG\�FRPSRVLWLRQ��LQFOXGLQJ�FKDQJHV�LQ�OHDQ�ERG\� PDVV�DQG�IDW��)XUWKHUPRUH��IUDFWXUH�ULVN�LV�UHODWHG� WR�PDQ\�IDFWRUV��%0'�EHLQJ�RQO\�RQH�RI�WKHP�� 7KH�UHODWLRQVKLS�EHWZHHQ�GHFUHDVH�LQ�%0'�DQG� LQFUHDVH�LQ�IUDFWXUH�ULVN�KDV�EHHQ�EHVW�VWXGLHG�LQ� SRVWPHQRSDXVDO�ZRPHQ��DPRQJ�ZKRP�WKH�ULVN�RI� DQ\�IUDFWXUH�LQFUHDVHV�DSSUR[LPDWHO\�����IROG�IRU� HDFK�VWDQGDUG�GHYLDWLRQ��6'��GHFUHDVH�LQ�%0'�� �� 7KHUH�LV�OLWWOH�LQIRUPDWLRQ�RQ�WKH�LPSDFW�RI�%0'� FKDQJHV�LQ�\RXQJ�DJH�JURXSV�RQ�IUDFWXUH�ULVN�ODWHU� LQ�OLIH� &RPELQHG�PHWKRGV�RI�FRQWUDFHSWLRQ 7KH�XVH�RI�FXUUHQW�IRUPXODWLRQV�RI�FRPELQHG� RUDO�FRQWUDFHSWLYHV��&2&��PD\�KDYH�VRPH�VPDOO� HIIHFWV�RQ�%0'�WKDW�DUH�XQOLNHO\�WR�EH�RI�FOLQLFDO� VLJQL¿FDQFH��$GROHVFHQW�&2&�XVHUV�PD\�JDLQ�OHVV� %0'�FRPSDUHG�ZLWK�DGROHVFHQW�QRQ�XVHUV�ZKLOH� SHULPHQRSDXVDO�XVHUV�JHQHUDOO\�KDYH�LQFUHDVHG� %0'�FRPSDUHG�ZLWK�SHULPHQRSDXVDO�QRQ�XVHUV�� $�QXPEHU�RI�VWXGLHV�KDYH�LQYHVWLJDWHG�WKH�ULVN� RI�IUDFWXUH�DPRQJ�SRVWPHQRSDXVDO�ZRPHQ�LQ� UHODWLRQ�WR�SDVW�XVH�RI�&2&V��EXW�WKH�¿QGLQJV�DUH� LQFRQVLVWHQW��'DWD�IRU�RWKHU�FRPELQHG�KRUPRQDO� FRQWUDFHSWLYHV�DUH�VFDUFH� 3URJHVWRJHQ�RQO\�PHWKRGV�RI�FRQWUDFHSWLRQ :LWK�UHJDUG�WR�SURJHVWRJHQ�RQO\�PHWKRGV��GDWD� RQ�OHYRQRUJHVWUHO�LPSODQWV�VXJJHVW�QR�DGYHUVH� HIIHFW�RQ�%0'��2WKHU�ORZ�GRVH�SURJHVWRJHQ�RQO\� FRQWUDFHSWLYHV�VXFK�DV�SLOOV��RWKHU�LPSODQWV�DQG�WKH� OHYRQRUJHVWUHO�UHOHDVLQJ�LQWUDXWHULQH�GHYLFH�GR�QRW� DSSHDU�WR�KDYH�DQ�HIIHFW�RQ�%0'��DOWKRXJK�GDWD�IRU� WKHVH�PHWKRGV�DUH�OLPLWHG� 7KH�XVH�RI�'03$�IRU�FRQWUDFHSWLRQ�SURGXFHV�D� K\SR�HVWURJHQLF�VWDWH�LQ�ZRPHQ��VRPH�VWXGLHV� KDYH�VKRZQ�WKDW�WKLV�LV�DVVRFLDWHG�ZLWK�D�GHFUHDVH� LQ�%0'��7KH�ZHLJKW�RI�GDWD�LQGLFDWHV�WKDW�'03$� XVH�UHGXFHV�%0'�LQ�ZRPHQ�ZKR�KDYH�DWWDLQHG� SHDN�ERQH�PDVV��DQG�LPSDLUV�WKH�DFTXLVLWLRQ� RI�ERQH�PLQHUDO�DPRQJ�WKRVH�ZKR�KDYH�QRW�\HW� DWWDLQHG�SHDN�ERQH�PDVV��7KH�PDJQLWXGH�RI�HIIHFW� RQ�%0'�LV�VLPLODU�DFURVV�D�YDULHW\�RI�VWXGLHV�� &URVV�VHFWLRQDO�VWXGLHV�VKRZ�ORZHU�%0'�LQ�ORQJHU� WHUP�'03$�XVHUV�E\�DSSUR[LPDWHO\�����6'�DW�KLS� DQG�VSLQH�FRPSDUHG�ZLWK�QRQ�XVHUV��,Q�ORQJLWXGLQDO� VWXGLHV��DGXOWV��•����\HDUV��DQG�DGROHVFHQWV� �PHQDUFKH�WR������\HDUV��ERWK�ORVW�DURXQG��±��� �DSSUR[LPDWHO\�����6'��RI�%0'�DW�WKH�VDPH�VLWHV�� DIWHU�WZR�\HDUV�RI�FRQWLQXRXV�XVH�RI�'03$��7KH� UDWH�RI�ORVV�DSSHDUHG�WR�GHFUHDVH�RYHU�WLPH� :KHQ�'03$�XVH�LV�GLVFRQWLQXHG��%0'�LQFUHDVHV� DJDLQ�LQ�ZRPHQ��UHJDUGOHVV�RI�DJH��H[FHSW�IRU� WKRVH�ZKR�KDYH�UHDFKHG�PHQRSDXVH��$PRQJ� DGXOWV��%0'�YDOXHV�DSSHDU�WR�UHWXUQ�WR�WKRVH�RI� FRPSDUDEOH�QRQ�'03$�XVHUV�RYHU�D�SHULRG�RI�WZR� WR�WKUHH�\HDUV��,W�LV�QRW�FOHDU�ZKHWKHU�WKH�ORVV�LQ� %0'�DPRQJ�DGROHVFHQW�XVHUV�RI�'03$�SUHYHQWV� DWWDLQPHQW�RI�SRWHQWLDO�SHDN�ERQH�PDVV��7KHUH� UHPDLQV�D�FRQFHUQ�WKDW�ROGHU�ZRPHQ�ZKR�UHDFK�WKH� PHQRSDXVH�ZKLOH�VWLOO�XVLQJ�'03$�PD\�QR�ORQJHU� KDYH�WKH�RSSRUWXQLW\�WR�UHJDLQ�%0'�EHIRUH�HQWHULQJ� WKH�SHULRG�RI�ERQH�ORVV�QRUPDOO\�DVVRFLDWHG�ZLWK� WKH�SRVWPHQRSDXVH� $EVROXWH�IUDFWXUH�ULVN�LV�ORZ�GXULQJ�WKH�UHSURGXFWLYH� \HDUV��DQG�LQVXI¿FLHQW�GDWD�H[LVW�WR�DVVHVV�ZKHWKHU� '03$�XVH�PRGL¿HV�WKLV�ULVN��7KHUH�DUH�DOVR� LQVXI¿FLHQW�GDWD�WR�DVVHVV�ZKHWKHU�'03$�XVH� GXULQJ�WKH�UHSURGXFWLYH�\HDUV�DIIHFWV�WKH�ULVN�RI� IUDFWXUH�LQ�IXWXUH�SRVWPHQRSDXVDO�OLIH��6LQFH�WKH� HIIHFW�RQ�%0'�LV�ODUJHO\�UHYHUVLEOH��DQ\�OLIHWLPH� LQFUHDVH�LQ�IUDFWXUH�ULVN�LV�OLNHO\�WR�EH�VPDOO� 'DWD�UHJDUGLQJ�WKH�XVH�RI�WKH�RWKHU�SURJHVWRJHQ� RQO\�LQMHFWDEOH�FRQWUDFHSWLYH��QRUHWKLVWHURQH�� HQDQWKDWH��1(7�(1���DUH�LQVXI¿FLHQW�WR�GHWHUPLQH� ZKHWKHU�WKHUH�LV�DQ\�HIIHFW�RI�1(7�(1�RQ�ERQH� KHDOWK��,Q�WKH�DEVHQFH�RI�HYLGHQFH��WKH�FRQFHUQV� UHJDUGLQJ�'03$�DQG�ERQH�KHDOWK�DOVR�DSSO\�WR� 1(7�(1� '03$�LV�D�KLJKO\�HIIHFWLYH�DQG�ZLGHO\�DYDLODEOH� PHWKRG�RI�FRQWUDFHSWLRQ��ZKLFK�SOD\V�DQ�LPSRUWDQW� UROH�LQ�WKH�FRQWUDFHSWLYH�PHWKRG�PL[��7KLV�LV� SDUWLFXODUO\�VR�LQ�UHJLRQV�ZLWK�D�KLJK�XQPHW�QHHG� IRU�FRQWUDFHSWLRQ�DQG�ZKHUH�PDWHUQDO�PRUELGLW\� DQG�PRUWDOLW\�DUH�KLJK��$Q\�GHFLVLRQV�UHJDUGLQJ� FKRLFH�RI�D�FRQWUDFHSWLYH�PHWKRG�VKRXOG�DOVR� FRQVLGHU�WKLV�IDFW� :+2�ZLOO�FRQWLQXH�WR�PRQLWRU�UHVHDUFK�LQ�WKLV�DUHD� DQG�ZLOO�UHYLHZ�WKHVH�UHFRPPHQGDWLRQV�DV�DQG� ZKHQ�QHZ�HYLGHQFH�EHFRPHV�DYDLODEOH��:+2�DOVR� HQFRXUDJHV�UHOHYDQW�UHVHDUFK�LQ�WKLV�DUHD�WR�¿OO�NH\� HYLGHQFH�JDSV� 5HFRPPHQGDWLRQV :LWK�UHJDUG�WR�ERQH�PHWDEROLVP� ‡� 7KHUH�VKRXOG�EH�QR�UHVWULFWLRQ�RQ�WKH�XVH�RI� '03$��LQFOXGLQJ�QR�UHVWULFWLRQ�RQ�GXUDWLRQ�RI� XVH��DPRQJ�ZRPHQ�DJHG����WR����ZKR�DUH�RWK� HUZLVH�HOLJLEOH�WR�XVH�WKH�PHWKRG� ‡� $PRQJ�DGROHVFHQWV��PHQDUFKH�WR������DQG� ZRPHQ�RYHU�����WKH�DGYDQWDJHV�RI�XVLQJ�'03$� JHQHUDOO\�RXWZHLJK�WKH�WKHRUHWLFDO�VDIHW\�FRQ� FHUQV�UHJDUGLQJ�IUDFWXUH�ULVN��6LQFH�GDWD�DUH� LQVXI¿FLHQW�WR�GHWHUPLQH�LI�WKLV�LV�WKH�FDVH�ZLWK� ORQJ�WHUP�XVH�DPRQJ�WKHVH�DJH�JURXSV��WKH� RYHUDOO�ULVNV�DQG�EHQH¿WV�IRU�FRQWLQXLQJ�XVH�RI� WKH�PHWKRG�VKRXOG�EH�UHFRQVLGHUHG�RYHU�WLPH� ZLWK�WKH�LQGLYLGXDO�XVHU� 7HFKQLFDO�FRQVXOWDWLRQ�RQ�WKH�HIIHFWV�RI�KRUPRQDO�FRQWUDFHSWLRQ�RQ�ERQH�KHDOWK �� ‡� 5HFRPPHQGDWLRQV�UHJDUGLQJ�'03$�XVH�DOVR� SHUWDLQ�WR�XVH�RI�1(7�(1� ‡� 7KHUH�VKRXOG�EH�QR�UHVWULFWLRQ�RQ�WKH�XVH�RI� RWKHU�SURJHVWRJHQ�RQO\�FRQWUDFHSWLYH�PHWKRGV� DPRQJ�ZRPHQ�RWKHUZLVH�HOLJLEOH�WR�XVH�WKHVH� PHWKRGV��LQFOXGLQJ�QR�UHVWULFWLRQV�RQ�GXUDWLRQ�RI� XVH� ‡� 7KHUH�VKRXOG�EH�QR�UHVWULFWLRQ�RQ�WKH�XVH�RI� FRPELQHG�KRUPRQDO�FRQWUDFHSWLYH�PHWKRGV� DPRQJ�ZRPHQ�ZKR�DUH�RWKHUZLVH�HOLJLEOH�WR�XVH� WKHVH�PHWKRGV��LQFOXGLQJ�QR�UHVWULFWLRQV�RQ�GXUD� WLRQ�RI�XVH� .H\�HYLGHQFH�JDSV ��� :KDW�DUH�WKH�HIIHFWV�RI�KRUPRQDO�FRQWUDFHSWLYH� XVH�RQ�IUDFWXUH�ULVN�ODWHU�LQ�OLIH�LQ�ERWK� GHYHORSLQJ�DQG�GHYHORSHG�FRXQWU\� SRSXODWLRQV" ��� 'R�YHU\�\RXQJ�ZRPHQ�ZKR�XVH�'03$� IXOO\�UHFRYHU�%0'�WR�WKHLU�SRWHQWLDO�DIWHU� GLVFRQWLQXDWLRQ"�,V�WKLV�GHSHQGHQW�XSRQ� GXUDWLRQ�RI�XVH" ��� 'R�DGROHVFHQWV�ZKR�XVH�'03$�DWWDLQ� WKHLU�SRWHQWLDO�SHDN�ERQH�PDVV��DQG�LV�WKLV� GHSHQGHQW�XSRQ�GXUDWLRQ�RI�XVH" ��� 'R�ZRPHQ�ZKR�KDYH�XVHG�'03$�GXULQJ�WKH� SHULPHQRSDXVH�KDYH�ORZHU�%0'�LQ�SRVW� PHQRSDXVDO�\HDUV��FRPSDUHG�WR�ZRPHQ�ZKR� QHYHU�XVHG�'03$�"�:KDW�LV�WKH�LPSDFW�RI� WKHVH�FKDQJHV�RQ�IUDFWXUH�ULVN" ��� +RZ�GR�RWKHU�ULVN�IDFWRUV�IRU�RVWHRSRURVLV� LQÀXHQFH�WKH�HIIHFW�RI�'03$�RQ�%0'�DQG� IUDFWXUH�ULVN" ��� +RZ�GRHV�'03$�XVH�DIIHFW�%0'�LQ�ODFWDWLQJ� ZRPHQ" ��� :KDW�DUH�WKH�ORQJ�WHUP�HIIHFWV�RI�SUHJQDQF\� DQG�ODFWDWLRQ�RQ�%0'�DQG�IUDFWXUH�ULVN" ��� :KDW�LV�WKH�LQFLGHQFH�RI�IUDFWXUH�LQ�GHYHORSLQJ� FRXQWU\�SRSXODWLRQV" ��� :KDW�DUH�WKH�SDWWHUQV�RI�'03$�XVH�DPRQJ� ZRPHQ�LQ�GLIIHUHQW�VHWWLQJV" ����:LWK�UHJDUG�WR�WKH�DWWDLQPHQW�RI�SHDN�ERQH� PDVV��LV�WKH�XVH�RI�XOWUD�ORZ�GRVH�&2&V� �”�����—J�((��DV�DSSURSULDWH�IRU�DGROHVFHQWV�DV� SLOOV�FRQWDLQLQJ���±���—J�((" ���� $UH� WKHUH� GLIIHUHQFHV� LQ� WKH� ZD\� '03$� DQG� 1(7�(1�DIIHFW�ERQH�PHWDEROLVP" �� 5HIHUHQFHV ���� %DGDQ�3XVDW�6WDWLVWLN�6WDWLVWLFV�,QGRQHVLD��%36��20��,QGRQHVLD�'HPRJUDSKLF�DQG�+HDOWK�6XUYH\������ ������&DOYHUWRQ��0'��86$��25&�0DFUR������� ���� 8QLWHG�1DWLRQV�'HSDUWPHQW�RI�(FRQRPLFV�DQG�6RFLDO�$IIDLUV��:RUOG�3RSXODWLRQ�3URVSHFWV��7KH������ 5HYLVLRQ��6H[�DQG�$JH�'LVWULEXWLRQ�RI�WKH�:RUOG�3RSXODWLRQ��9RO��OO��1HZ�<RUN��8QLWHG�1DWLRQV������� ���� 8QLWHG�1DWLRQV�'HSDUWPHQW�RI�(FRQRPLF�DQG�6RFLDO�$IIDLUV��:RUOG�&RQWUDFHSWLYH�8VH�������>FKDUW@��1HZ� <RUN��8QLWHG�1DWLRQV������� ���� &KD\RYDQ�1��.DPQXDQVLOSD�3��.QRGHO�-��7KDLODQG�'HPRJUDSKLF�DQG�+HDOWK�6XUYH\�������%DQJNRN�� 7KDLODQG��,QVWLWXWH�RI�3RSXODWLRQ�6WXGLHV�&KXODORQJNRUQ�8QLYHUVLW\��DQG�&DOYHUWRQ��0'��86$��25&� 0DFUR������� ���� .HQ\D�&HQWUDO�%XUHDX�RI�6WDWLVWLFV�DQG�.HQ\D�0LQLVWU\�RI�+HDOWK��.HQ\D�'HPRJUDSKLF�DQG�+HDOWK�6XUYH\� ������&DOYHUWRQ��0'��86$��25&�0DFUR������� ���� 1DWLRQDO�,QVWLWXWH�RI�3RSXODWLRQ�5HVHDUFK�DQG�7UDLQLQJ��1,3257���HW�DO��%DQJODGHVK�0DWHUQDO�+HDOWK� 6HUYLFHV�DQG�0DWHUQDO�0RUWDOLW\�6XUYH\�������'KDND��%DQJODGHVK��1DWLRQDO�,QVWLWXWH�RI�3RSXODWLRQ� 5HVHDUFK�DQG�7UDLQLQJ������� ���� 6RXWK�$IULFD�'HSDUWPHQW�RI�+HDOWK��6RXWK�$IULFD�'HPRJUDSKLF�DQG�+HDOWK�6XUYH\������)XOO�5HSRUW�� 3UHWRULD��6RXWK�$IULFD��0HGLFDO�5HVHDUFK�&RXQFLO������ ���� 25&�0DFUR��,QGRQHVLD������������UHVXOWV�IURP�WKH�'HPRJUDSKLF�+HDOWK�6XUYH\��6WXGLHV�LQ�)DPLO\� 3ODQQLQJ������������������� ���� -RKQHOO�2��.DQLV�-$��$Q�HVWLPDWH�RI�WKH�ZRUOGZLGH�SUHYDOHQFH��PRUWDOLW\�DQG�GLVDELOLW\�DVVRFLDWHG�ZLWK�KLS� IUDFWXUH��2VWHRSRURVLV�,QWHUQDWLRQDO���������������������� ����� 1HYLWW�0&��7KRPSVRQ�'(��%ODFN�'0��5XELQ�65��(QVUXG�.(��<DWHV�$-�HW�DO��(IIHFW�RI�DOHQGURQDWH�RQ� OLPLWHG�DFWLYLW\�GD\V�DQG�EHG�GLVDELOLW\�GD\V�FDXVHG�E\�EDFN�SDLQ�LQ�SRVWPHQRSDXVDO�ZRPHQ�ZLWK�H[LVWLQJ� YHUWHEUDO�IUDFWXUHV��)UDFWXUH�,QWHUYHQWLRQ�7ULDO�5HVHDUFK�*URXS��$UFKLYHV�RI�,QWHUQDO�0HGLFLQH������� ������������� ����� 6FKXUFK�0$��5L]]ROL�5��0HUPLOORG�%��9DVH\�+��0LFKHO�-3��%RQMRXU�-3��$�SURVSHFWLYH�VWXG\�RQ� VRFLRHFRQRPLF�DVSHFWV�RI�IUDFWXUH�RI�WKH�SUR[LPDO�IHPXU��-RXUQDO�RI�%RQH�0LQHUDO�5HVHDUFK������� ������������� ����� &HQWHU�-5��1JX\HQ�79��6FKQHLGHU�'��6DPEURRN�31��(LVPDQ�-$��0RUWDOLW\�DIWHU�DOO�PDMRU�W\SHV�RI� RVWHRSRURWLF�IUDFWXUH�LQ�PHQ�DQG�ZRPHQ��DQ�REVHUYDWLRQDO�VWXG\��/DQFHW������������������� ����� 7URPEHWWL�$��+HUPDQQ�)��+RIIPH\HU�3��6FKXUFK�0$��%RQMRXU�-3��5L]]ROL�5��6XUYLYDO�DQG�SRWHQWLDO�\HDUV�RI� OLIH�ORVW�DIWHU�KLS�IUDFWXUH�LQ�PHQ�DQG�DJH�PDWFKHG�ZRPHQ��2VWHRSRURVLV�,QWHUQDWLRQDO�������������� �������� ����� .DQLV�-$��'LDJQRVLV�RI�RVWHRSRURVLV�DQG�DVVHVVPHQW�RI�IUDFWXUH�ULVN��/DQFHW��������������������� ����� %DQNV�(��%HUULQJWRQ�$��&DVDERQQH�'��2YHUYLHZ�RI�WKH�UHODWLRQVKLS�EHWZHHQ�XVH�RI�SURJHVWRJHQ�RQO\� FRQWUDFHSWLYHV�DQG�ERQH�PLQHUDO�GHQVLW\��%-2*�%ULWLVK�-RXUQDO�RI�2EVWHWULFV�DQG�*\QDHFRORJ\������� �������������� ����� 0DUVKDOO�'��-RKQHOO�2��:HGHO�+��0HWD�DQDO\VLV�RI�KRZ�ZHOO�PHDVXUHV�RI�ERQH�PLQHUDO�GHQVLW\�SUHGLFW� RFFXUUHQFH�RI�RVWHRSRURWLF�IUDFWXUHV��%ULWLVK�0HGLFDO�-RXUQDO��������������������������� ����� :+2��$VVHVVPHQW�RI�IUDFWXUH�ULVN�DQG�LWV�DSSOLFDWLRQ�WR�VFUHHQLQJ�IRU�SRVWPHQRSDXVDO�RVWHRSRURVLV�� WHFKQLFDO�UHSRUWV�VHULHV�������������*HQHYD��:+2� 7HFKQLFDO�FRQVXOWDWLRQ�RQ�WKH�HIIHFWV�RI�KRUPRQDO�FRQWUDFHSWLRQ�RQ�ERQH�KHDOWK �� ����� %RQMRXU�-3��HW�DO��&ULWLFDO�\HDUV�DQG�VWDJHV�RI�SXEHUW\�IRU�VSLQDO�DQG�IHPRUDO�ERQH�PDVV�DFFXPXODWLRQ� GXULQJ�DGROHVFHQFH��-RXUQDO�RI�&OLQLFDO�(QGRFULQRORJ\� �0HWDEROLVP��������������������� ������ %DVVH\�(-��HW�DO��3UH��DQG�SRVWPHQRSDXVDO�ZRPHQ�KDYH�GLIIHUHQW�ERQH�PLQHUDO�GHQVLW\�UHVSRQVHV�WR�WKH� VDPH�KLJK�LPSDFW�H[HUFLVH��-RXUQDO�RI�%RQH�0LQHUDO�5HVHDUFK������������������������ ����� .DUOVVRQ�0��+DV�H[HUFLVH�DQ�DQWLIUDFWXUH�HI¿FDF\�LQ�ZRPHQ"�6FDQGLQDYLDQ�-RXUQDO�RI�0HGLFLQH� � 6FLHQFH�LQ�6SRUWV������������������ ����� *UHPLRQ�*��5L]]ROL�5��6ORVPDQ�'��7KHLQW]�*��%RQMRXU�3��2OLJR�DPHQRUUKHLF�ORQJ�GLVWDQFH�UXQQHUV�PD\� ORVH�PRUH�ERQH�LQ�VSLQH�WKDQ�LQ�IHPXU��0HGLFLQH�DQG�6FLHQFH�LQ�6SRUWV� �([HUFLVH������������������� ����� .DUOVVRQ�0.��$KOERUJ�+*��.DUOVVRQ�&��0DWHUQLW\�DQG�ERQH�PLQHUDO�GHQVLW\��$FWD�2UWKRSDHGLFD������� ����������� ����� %ODFN�$-��7RSSLQJ�-��'XUKDP�%��)DUTXKDUVRQ�5*��)UDVHU�:'��$�GHWDLOHG�DVVHVVPHQW�RI�DOWHUDWLRQV�LQ� ERQH�WXUQ�RYHU��FDOFLXP�KRPHRVWDVLV��DQG�ERQH�GHQVLW\�LQ�QRUPDO�SUHJQDQF\��-RXUQDO�RI�%RQH�0LQHUDO� 5HVHDUFK������������������ ����� 'ULQNZDWHU�%/��&KHVWQXW�&+��%RQH�GHQVLW\�FKDQJHV�GXULQJ�SUHJQDQF\�DQG�ODFWDWLRQ�LQ�DFWLYH�ZRPHQ��D� ORQJLWXGLQDO�VWXG\��%RQH�0LQHUDO������������������ ����� +ROPEHUJ�0DUWWLOD�'��6LHYDQHQ�+��7XLPDOD�5��&KDQJHV�LQ�ERQH�PLQHUDO�GHQVLW\�GXULQJ�SUHJQDQF\�DQG� SRVWSDUWXP��SURVSHFWLYH�GDWD�RQ�¿YH�ZRPHQ��2VWHRSRURVLV�,QWHUQDWLRQDO���������������� ����� .DUOVVRQ�&��2EUDQW�.-�.0��3UHJQDQF\�DQG�ODFWDWLRQ�FRQIHU�UHYHUVLEOH�ERQH�ORVV�LQ�KXPDQV�� 2VWHRSRURVLV�,QWHUQDWLRQDO������������������ ����� 0RUH�&��%HWWHPEXN�3��%KDWWRD�+3��%DORJK�$��7KH�HIIHFWV�RI�SUHJQDQF\�DQG�ODFWDWLRQ�RQ�ERQH�PLQHUDO� GHQVLW\��2VWHRSRURVLV�,QWHUQDWLRQDO������������������ ����� 1D\ORU�.(��,TEDO�3��)OHGHOLXV�&��)UDVHU�5%��(DVWHOO�5��7KH�HIIHFW�RI�SUHJQDQF\�RQ�ERQH�GHQVLW\�DQG�ERQH� WXUQRYHU��-RXUQDO�RI�%RQH�0LQHUDO�5HVHDUFK������������������ ����� 5LWFKLH�/'��)XQJ�(%��+DOORUDQ�%3��7XUQOXQG�-5��9DQ�/RDQ�0'��&DQQ�&(��$�ORQJLWXGLQDO�VWXG\�RI�FDOFLXP� KRPHRVWDVLV�GXULQJ�KXPDQ�SUHJQDQF\�DQG�ODFWDWLRQ�DQG�DIWHU�UHVXPSWLRQ�RI�PHQVHV��$PHULFDQ�-RXUQDO� RI�&OLQLFDO�1XWULWLRQ������������������ ����� 6RZHUV�0��5DQGROSK�-��6KDSLUR�%��-DQQDXVFK�0��$�SURVSHFWLYH�HYDOXDWLRQ�RI�ERQH�PLQHUDO�FKDQJH�LQ� SUHJQDQF\��2EVWHWULFV� �*\QHFRORJ\������������������ ����� $OGHUPDQ�%:��:HLVV�16��'DOLQJ�-5��8UH�&/��%DOODUG�-+��5HSURGXFWLYH�KLVWRU\�DQG�SRVWPHQRSDXVDO�ULVN� RI�KLS�DQG�IRUHDUP�IUDFWXUH��$PHULFDQ�-RXUQDO�RI�(SLGHPLRORJ\������������������� ����� &XPPLQJ�5*��.OLQHEHUJ�5-��%UHDVWIHHGLQJ�DQG�RWKHU�UHSURGXFWLYH�IDFWRUV�DQG�WKH�ULVN�RI�KLS�IUDFWXUHV�LQ� HOGHUO\�ZRPHQ��,QWHUQDWLRQDO�-RXUQDO�RI�(SLGHPLRORJ\��������������������� ����� &XPPLQJV�65��1HYLWW�0&��%URZQHU�:6��6WRQH�.��)R[�.0��(QVUXG�.(�HW�DO��5LVN�IDFWRUV�IRU�KLS�IUDFWXUH� LQ�ZKLWH�ZRPHQ��6WXG\�RI�2VWHRSRURWLF�)UDFWXUHV�5HVHDUFK�*URXS��1HZ�(QJODQG�-RXUQDO�RI�0HGLFLQH� ������������������ ����� &XUH�&XUH�&��&XUH�5DPLUH]�3��7HUDQ�(��/RSH]�-DUDPLOOR�3��%RQH�PDVV�SHDN�LQ�PXOWLSDULW\�DQG�UHGXFHG� ULVN�RI�ERQH�IUDFWXUHV�LQ�PHQRSDXVH��,QWHUQDWLRQDO�-RXUQDO�RI�*\QHFRORJ\� �2EVWHWULFV������������������ ����� +RIIPDQ�6��*ULVVR�-$��.HOVH\�-/��*DPPRQ�0'��2¶%ULHQ�/$��3DULW\��ODFWDWLRQ�DQG�KLS�IUDFWXUH�� 2VWHRSRURVLV�,QWHUQDWLRQDO����������������� �� ����� 0LFKDHOVVRQ�.��%DURQ�-$��)DUDKPDQG�%<��/MXQJKDOO�6��,QÀXHQFH�RI�SDULW\�DQG�ODFWDWLRQ�RQ�KLS�IUDFWXUH� ULVN��$PHULFDQ�-RXUQDO�RI�(SLGHPLRORJ\��������������������� ����� 1JX\HQ�79��-RQHV�*��6DPEURRN�31��:KLWH�&3��.HOO\�3-��(LVPDQ�-$��(IIHFWV�RI�HVWURJHQ�H[SRVXUH� DQG�UHSURGXFWLYH�IDFWRUV�RQ�ERQH�PLQHUDO�GHQVLW\�DQG�RVWHRSRURWLF�IUDFWXUHV��-RXUQDO�RI�&OLQLFDO� (QGRFULQRORJ\� �0HWDEROLVP�������������������� ����� 2¶1HLOO�7:��6LOPDQ�$-��1DYHV�'LD]�0��&RRSHU�&��.DQLV�-��)HOVHQEHUJ�'��,QÀXHQFH�RI�KRUPRQDO� DQG�UHSURGXFWLYH�IDFWRUV�RQ�WKH�ULVN�RI�YHUWHEUDO�GHIRUPLW\�LQ�(XURSHDQ�ZRPHQ��(XURSHDQ�9HUWHEUDO� 2VWHRSRURVLV�6WXG\�*URXS��2VWHRSRURVLV�,QWHUQDWLRQDO��������������� ����� 3DJDQLQL�+LOO�$��&KDR�$��5RVV�5.��+HQGHUVRQ�%(��([HUFLVH�DQG�RWKHU�IDFWRUV�LQ�WKH�SUHYHQWLRQ�RI�KLS� IUDFWXUH��WKH�/HLVXUH�:RUOG�VWXG\��(SLGHPLRORJ\��������������� ����� 3HWHUVRQ�+&��HW�DO��5HSURGXFWLRQ�OLIH�KLVWRU\�DQG�KLS�IUDFWXUHV��$QQDOV�RI�(SLGHPLRORJ\������� ����������� ����� 3RODWWL�)��3HURWWL�0��)LOLSSD�1��*DOOLQD�'��1DSSL�5(��%RQH�PDVV�DQG�ORQJ�WHUP�PRQRSKDVLF�RUDO� FRQWUDFHSWLYH�WUHDWPHQW�LQ�\RXQJ�ZRPHQ��&RQWUDFHSWLRQ������������������ ����� &URPHU�%$��%ODLU�-0��0DKDQ�-'��=LEQHUV�/��1DXPRYVNL�=��$�SURVSHFWLYH�FRPSDULVRQ�RI�ERQH�GHQVLW\� LQ�DGROHVFHQW�JLUOV�UHFHLYLQJ�GHSRW�PHGUR[\SURJHVWHURQH�DFHWDWH��'HSRW�3URYHUD���OHYRQRUJHVWUHO� �1RUSODQW���RU�RUDO�FRQWUDFHSWLYHV��-RXUQDO�RI�3HGLDWULFV������������������� ����� &URPHU�%$��6WDJHU�0��%RQQ\�$��/D]HEQLN�5��5RPH�(��=LHJOHU�-�HW�DO��'HSRW�PHGUR[\SURJHVWHURQH� DFHWDWH��RUDO�FRQWUDFHSWLYHV�DQG�ERQH�PLQHUDO�GHQVLW\�LQ�D�FRKRUW�RI�DGROHVFHQW�JLUOV��-RXUQDO�RI� $GROHVFHQW�+HDOWK������������������ ����� /DUD�7RUUH�(��(GZDUGV�&3��3HUOPDQ�6��+HUWZHFN�63��%RQH�PLQHUDO�GHQVLW\�LQ�DGROHVFHQW�IHPDOHV�XVLQJ� GHSRW�PHGUR[\SURJHVWHURQH�DFHWDWH��-RXUQDO�RI�3HGLDWULF�DQG�$GROHVFHQW�*\QHFRORJ\���������������� ����� /OR\G�7��7D\ORU�'6��/LQ�+0��0DWWKHZV�$(��(JJOL�')��/HJUR�56��2UDO�FRQWUDFHSWLYH�XVH�E\�WHHQDJH� ZRPHQ�GRHV�QRW�DIIHFW�SHDN�ERQH�PDVV��D�ORQJLWXGLQDO�VWXG\��)HUWLOLW\� �6WHULOLW\������������������ ����� /OR\G�7��3HWLW�0$��/LQ�+0��0DWWKHZV�$(��(JJOL�')��/HJUR�56��/LIHVW\OH�IDFWRUV�DQG�WKH�GHYHORSPHQW�RI� ERQH�PDVV�DQG�ERQH�VWUHQJWK�LQ�\RXQJ�ZRPHQ��-RXUQDO�RI�3HGLDWULFV������������������� ����� 1DSSL�&��'L�6SLH]R�6DUGR�$��$FXQ]R�*��%LIXOFR�*��7RPPDVHOOL�*$��*XLGD�0�HW�DO��(IIHFWV�RI�D�ORZ�GRVH� DQG�XOWUD�ORZ�GRVH�FRPELQHG�RUDO�FRQWUDFHSWLYH�XVH�RQ�ERQH�WXUQRYHU�DQG�ERQH�PLQHUDO�GHQVLW\�LQ�\RXQJ� IHUWLOH�ZRPHQ��D�SURVSHFWLYH�FRQWUROOHG�UDQGRPL]HG�VWXG\��&RQWUDFHSWLRQ������������������� ����� 5HHG�6'��6FKROHV�'��/D&URL[�$=��,FKLNDZD�/(��%DUORZ�:(��2WW�60��/RQJLWXGLQDO�FKDQJHV�LQ�ERQH� GHQVLW\�LQ�UHODWLRQ�WR�RUDO�FRQWUDFHSWLYH�XVH��&RQWUDFHSWLRQ������������������ ����� %HUHQVRQ�$%��5DGHFNL�&0��*UDG\�--��5LFNHUW�9,��7KRPDV�$��$�SURVSHFWLYH��FRQWUROOHG�VWXG\�RI�WKH�HIIHFWV� RI�KRUPRQDO�FRQWUDFHSWLRQ�RQ�ERQH�PLQHUDO�GHQVLW\��2EVWHWULFV� �*\QHFRORJ\������������������ ����� %HUHQVRQ�$%��%UHLWNRSI�&5��*UDG\�--��5LFNHUW�9,��7KRPDV�$��(IIHFWV�RI�KRUPRQDO�FRQWUDFHSWLRQ�RQ�ERQH� PLQHUDO�GHQVLW\�DIWHU����PRQWKV�RI�XVH��2EVWHWULFV� �*\QHFRORJ\������������������� ����� &DVWHOR�%UDQFR�&��9LFHQWH�--��3RQV�)��0DUWLQH]�GH�2VDED�0-��&DVDOV�(��9DQUHOO�-$��%RQH�PLQHUDO� GHQVLW\�LQ�\RXQJ��K\SRWKDODPLF�ROLJRDPHQRUUKHLF�ZRPHQ�WUHDWHG�ZLWK�RUDO�FRQWUDFHSWLYHV��-RXUQDO�RI� 5HSURGXFWLYH�0HGLFLQH������������������ ����� 7DHFKDNUDLFKDQD�1��$�UDQGRPL]HG�WULDO�RI�RUDO�FRQWUDFHSWLYH�DQG�KRUPRQH�UHSODFHPHQW�WKHUDS\�RQ� ERQH�PLQHUDO�GHQVLW\�DQG�FRURQDU\�KHDUW�GLVHDVH�ULVN�IDFWRUV�LQ�SRVWPHQRSDXVDO�ZRPHQ��2EVWHWULFV� � *\QHFRORJ\���������������� 7HFKQLFDO�FRQVXOWDWLRQ�RQ�WKH�HIIHFWV�RI�KRUPRQDO�FRQWUDFHSWLRQ�RQ�ERQH�KHDOWK �� ����� 7DHFKDNUDLFKDQD�1��'LIIHUHQFH�LQ�ERQH�DFTXLVLWLRQ�DPRQJ�KRUPRQDOO\�WUHDWHG�SRVWPHQRSDXVDO�ZRPHQ� ZLWK�QRUPDO�DQG�ORZ�ERQH�PDVV��-RXUQDO�RI�WKH�0HGLFDO�$VVRFLDWLRQ�RI�7KDLODQG������������6XSSO��� V����V���� ����� %HUQLQJ�%��YDQ�.XLMN�&��6FKXWH�+(��.XLSHU�-:��'URJHQGLMN�$&��)DXVHU�%&��'HWHUPLQDQWV�RI�OXPEDU�ERQH� PLQHUDO�GHQVLW\�LQ�QRUPDO�ZHLJKW��QRQ�VPRNLQJ�ZRPHQ�VRRQ�DIWHU�PHQRSDXVH��$�VWXG\�XVLQJ�FOLQLFDO�GDWD� DQG�TXDQWLWDWLYH�FRPSXWHG�WRPRJUDSK\��%RQH�0LQHUDO������������������ ����� )RUVPR�6��6FKHL�%��/DQJKDPPHU�$��)RUVHQ�/���+RZ�GR�UHSURGXFWLYH�DQG�OLIHVW\OH�IDFWRUV�LQÀXHQFH�ERQH� GHQVLW\�LQ�GLVWDO�DQG�XOWUDGLVWDO�UDGLXV�RI�HDUO\�SRVWPHQRSDXVDO�ZRPHQ"�2VWHRSRURVLV�,QWHUQDWLRQDO� ��������� ����� )RUWQH\�-$��)HOGEOXP�3-��7DOPDJH�59��=KDQJ�-��*RGZLQ�6(��%RQH�PLQHUDO�GHQVLW\�DQG�KLVWRU\�RI�RUDO� FRQWUDFHSWLYH�XVH��-RXUQDO�RI�5HSURGXFWLYH�0HGLFLQH������������������ ����� *UDLQJH�0-��&RXSODQG�&$&��&OLIIH�6-��&KLOYHUV�&('��+RVNLQJ�'-��5HSURGXFWLYH��PHQVWUXDO�DQG� PHQRSDXVDO�IDFWRUV��:KLFK�DUH�DVVRFLDWHG�ZLWK�ERQH�PLQHUDO�GHQVLW\�LQ�HDUO\�SRVWPHQRSDXVDO�ZRPHQ"� 2VWHRSRURVLV�,QWHUQDWLRQDO������������������ ����� +DQVHQ�0��2YHUJDDUG�.��5LLV�%��&KULVWLDQVHQ�&��3RWHQWLDO�ULVN�IDFWRUV�IRU�GHYHORSPHQW�RI� SRVWPHQRSDXVDO�RVWHRSRURVLV�H[DPLQHG�RYHU�D����\HDU�SHULRG��2VWHRSRURVLV�,QWHUQDWLRQDO������� ��������� ����� .ULW]�6LOYHUVWHLQ�'��%DUUHWW�&RQQHU�(��%RQH�PLQHUDO�GHQVLW\�LQ�SRVWPHQRSDXVDO�ZRPHQ�DV�GHWHUPLQHG�E\� SULRU�RUDO�FRQWUDFHSWLYH�XVH��$PHULFDQ�-RXUQDO�RI�3XEOLF�+HDOWK������������������ ����� /DX�(0&��/\QQ�+��:RR�-��0HOWRQ�,,,�/-��$UHDO�DQG�YROXPHWULF�ERQH�GHQVLW\�LQ�+RQJ�.RQJ�&KLQHVH��$� FRPSDULVRQ�ZLWK�&DXFDVLDQV�OLYLQJ�LQ�WKH�8QLWHG�6WDWHV��2VWHRSRURVLV�,QWHUQDWLRQDO���������� ����� /LQGVD\�5��7RKPH�-��.DQGHUV�%��7KH�HIIHFW�RI�RUDO�FRQWUDFHSWLYH�XVH�RQ�YHUWHEUDO�ERQH�PDVV�LQ�SUH��DQG� SRVW�PHQRSDXVDO�ZRPHQ��&RQWUDFHSWLRQ������������������ ����� 0DVDU\N�3��/XQW�0��%HQHYROHQVND\D�/��(IIHFWV�RI�PHQVWUXDO�KLVWRU\�DQG�XVH�RI�PHGLFDWLRQV�RQ�ERQH� PLQHUDO�GHQVLW\��WKH�(926�6WXG\��&DOFL¿HG�7LVVXH�,QWHUQDWLRQDO������������������ ����� 0HOWRQ�,,,�/-��%U\DQW�6&��:DKQHU�+:��,QÀXHQFH�RI�EUHDVWIHHGLQJ�DQG�RWKHU�UHSURGXFWLYH�IDFWRUV�RQ�ERQH� PDVV�ODWHU�LQ�OLIH��2VWHRSRURVLV�,QWHUQDWLRQDO��������� ����� 0XUSK\�6��.KDZ�.7��&RPSVWRQ�-(��/DFN�RI�UHODWLRQVKLS�EHWZHHQ�KLS�DQG�VSLQH�ERQH�PLQHUDO�GHQVLW\�DQG� RUDO�FRQWUDFHSWLYH�XVH��(XURSHDQ�-RXUQDO�RI�&OLQLFDO�,QYHVWLJDWLRQ������������������ ����� 3DVFR�-$��.RWRZLF]�0$��+HQU\�0-��3DQDKL�6��6HHPDQ�(��1LFKROVRQ�*&��2UDO�FRQWUDFHSWLYHV�DQG�ERQH� PLQHUDO�GHQVLW\��D�SRSXODWLRQ�EDVHG�VWXG\��$PHULFDQ�-RXUQDO�RI�2EVWHWULFV� �*\QHFRORJ\������� ������������ ����� 3URJHWWR�0HQRSDXVD�,WDOLD�6WXG\�*URXS��5LVN�RI�ORZ�ERQH�GHQVLW\�LQ�ZRPHQ�DWWHQGLQJ�PHQRSDXVH�FOLQLFV� LQ�,WDO\��0DWXULWDV������������������ ����� 6WHYHQVRQ�-&��/HHV�%��'HYHQSRUW�0��&XVW�03��*DQJHU�.)��'HWHUPLQDQWV�RI�ERQH�GHQVLW\�LQ�QRUPDO� ZRPHQ��5LVN�IDFWRUV�IRU�IXWXUH�RVWHRSRURVLV"�%ULWLVK�0HGLFDO�-RXUQDO�&OLQLFDO�5HVHDUFK�DQG�(GXFDWLRQ� ���������� ����� 6XOWDQD�6��&KRXGKXU\�6��&KRXGKXU\�6$��(IIHFW�RI�FRPELQHG�RUDO�FRQWUDFHSWLYHV�RQ�ERQH�PLQHUDO�GHQVLW\� LQ�SUH��DQG�SRVWPHQRSDXVDO�ZRPHQ��0\PHQVLQJK�0HGLFDO�-RXUQDO���������������� ����� 7DYDQL�$��/D�9&��)UDQFHVFKL�6��2UDO�FRQWUDFHSWLYHV�DQG�ERQH�PLQHUDO�GHQVLW\��$PHULFDQ�-RXUQDO�RI� 2EVWHWULFV� �*\QHFRORJ\������������������� �� ����� 8OULFK�&0��*HRUJLRX�&&��6QRZ�+DUWHU�&0��*LOOLV�'(��%RQH�PLQHUDO�GHQVLW\�LQ�PRWKHU�GDXJKWHU�SDLUV�� UHODWLRQV�WR�OLIHWLPH�H[HUFLVH��OLIHWLPH�PLON�FRQVXPSWLRQ��DQG�FDOFLXP�VXSSOHPHQWV��$PHULFDQ�-RXUQDO�RI� &OLQLFDO�1XWULWLRQ���������������� ����� YRQ�.HVVHUX�(��(WFKHSDUHERUGD�--��:LNLQVNL�5��%HLHU�6��3UHPHQRSDXVH�FRQWUDFHSWLRQ�ZLWK�PRQWKO\� LQMHFWDEOH�0HVLJ\QD�ZLWK�VSHFLDO�HPSKDVLV�RQ�VHUXP�OLSLG�DQG�ERQH�GHQVLW\�SDWWHUQV��&RQWUDFHSWLRQ� ����������������� ����� 0DVVDL�5��0DNDUDLQHQ�/��.XXNDQNRUSL�$��.OLSSLQJ�&��'XLMNHUV�,��'LHEHQ�7��7KH�FRPELQHG�FRQWUDFHSWLYH� YDJLQDO�ULQJ��1XYD5LQJ��DQG�ERQH�PLQHUDO�GHQVLW\�LQ�KHDOWK\�SUHPHQRSDXVDO�ZRPHQ��+XPDQ� 5HSURGXFWLRQ������������������������ ����� &RRSHU�&��+DQQDIRUG�3��&URIW�3��.D\�&5��2UDO�FRQWUDFHSWLYH�SLOO�XVH�DQG�IUDFWXUHV�LQ�ZRPHQ��D� SURVSHFWLYH�VWXG\��%RQH���������������� ����� 0LFKDHOVVRQ�.��%DURQ�-$��)DUDKPDQG�%<��3HUVVRQ�,��/MXQJKDOO�6��2UDO�FRQWUDFHSWLYH�XVH�DQG�ULVN�RI�KLS� IUDFWXUH��D�FDVH�FRQWURO�VWXG\��/DQFHW��������������������� ����� /DSSH�-0��6WHJPDQ�05��5HFNHU�55��7KH�LPSDFW�RI�OLIHVW\OH�IDFWRUV�RQ�VWUHVV�IUDFWXUHV�LQ�IHPDOH�$UP\� UHFUXLWV��2VWHRSRURVLV�,QWHUQDWLRQDO���������������� ����� %DKDPRQGHV�/��3HUURWWL�0��&DVWUR�6��)DXQGHV�$��3HWWD�&��%HGRQH�$��)RUHDUP�ERQH�GHQVLW\�LQ�XVHUV�RI� 'HSR�3URYHUD�DV�D�FRQWUDFHSWLYH�PHWKRG��)HUWLOLW\� �6WHULOLW\������������������ ����� %HNVLQVND�0(��6PLW�-$��.OHLQVFKPLGW�,��)DUOH\�700��0EDWKD�)��%RQH�PLQHUDO�GHQVLW\�LQ�ZRPHQ�DJHG� ������\HDUV�XVLQJ�GHSRW�PHGUR[\SURJHVWHURQH�DFHWDWH��QRUHWKLVWHURQH�HQDQWKDWH�RU�FRPELQHG�RUDO� FRQWUDFHSWLYHV�IRU�FRQWUDFHSWLRQ��&RQWUDFHSWLRQ������������������ ����� &XQG\�7��&RUQLVK�-��5REHUWV�+��(OGHU�+��5HLG�,5��6SLQDO�ERQH�GHQVLW\�LQ�ZRPHQ�XVLQJ�GHSRW� PHGUR[\SURJHVWHURQH�FRQWUDFHSWLRQ��2EVWHWULFV� �*\QHFRORJ\������������������ ����� *ERODGH�%��(OOLV�6��0XUE\�%��5DQGDOO�6��.LUNPDQ�5��%RQH�GHQVLW\�LQ�ORQJ�WHUP�XVHUV�RI�GHSRW� PHGUR[\SURJHVWHURQH�DFHWDWH��%ULWLVK�-RXUQDO�RI�2EVWHWULFV� �*\QHFRORJ\������������������� ����� 2WW�60��6FKROHV�'��/D&URL[�$=��,FKLNDZD�/(��<RVKLGD�&.��%DUORZ�:(��(IIHFWV�RI�FRQWUDFHSWLYH�XVH� RQ�ERQH�ELRFKHPLFDO�PDUNHUV�LQ�\RXQJ�ZRPHQ��-RXUQDO�RI�&OLQLFDO�(QGRFULQRORJ\� �0HWDEROLVP������� ����������� ����� 3DLYD�/&��3LQWR�1HWR�$0��)DXQGHV�$��%RQH�GHQVLW\�DPRQJ�ORQJ�WHUP�XVHUV�RI�PHGUR[\SURJHVWHURQH� DFHWDWH�DV�D�FRQWUDFHSWLYH��&RQWUDFHSWLRQ������������������ ����� 3HURWWL�0��HW�DO��)RUHDUP�ERQH�GHQVLW\�LQ�ORQJ�WHUP�XVHUV�RI�RUDO�FRPELQHG�FRQWUDFHSWLYHV�DQG�GHSRW� PHGUR[\SURJHVWHURQH�DFHWDWH��)HUWLOLW\� �6WHULOLW\������������������� ����� 3HWLWWL�'��HW�DO��6WHURLG�KRUPRQH�FRQWUDFHSWLRQ�DQG�ERQH�PLQHUDO�GHQVLW\��D�FURVV�VHFWLRQDO�VWXG\�LQ�DQ� LQWHUQDWLRQDO�SRSXODWLRQ��7KH�:+2�VWXG\�RI�+RUPRQDO�&RQWUDFHSWLRQ�DQG�%RQH�+HDOWK��2EVWHWULFV� � *\QHFRORJ\������������������ ����� 6FKROHV�'��/D&URL[�$=��2WW�60��,FKLNDZD�/(��%DUORZ�:(��%RQH�PLQHUDO�GHQVLW\�LQ�ZRPHQ�XVLQJ�GHSRW� PHGUR[\SURJHVWHURQH�DFHWDWH�IRU�FRQWUDFHSWLRQ��2EVWHWULFV� �*\QHFRORJ\������������������ ����� 7DQHHSDQLFKVNXO�6��%RQH�PLQHUDO�GHQVLW\�GXULQJ�ORQJ�WHUP�WUHDWPHQW�ZLWK�1RUSODQW�LPSODQWV�DQG�GHSRW� PHGUR[\SURJHVWHURQH�DFHWDWH��$�FURVV�VHFWLRQDO�VWXG\�RI�7KDL�ZRPHQ��&RQWUDFHSWLRQ������������������ ����� 7DQHHSDQLFKVNXO�6��,QWDUDSUDVHUW�6��7KHSSLVDL�8��&KDWXUDFKLQGD�.��%RQH�PLQHUDO�GHQVLW\�LQ�ORQJ�WHUP� GHSRW�PHGUR[\SURJHVWHURQH�DFHWDWH�DFFHSWRUV��&RQWUDFHSWLRQ�������������� ����� 7DQJ�26��7DQJ�*��<LS�36��/L�%��)DQ�6��/RQJ�WHUP�GHSRW�PHGUR[\SURJHVWHURQH�DFHWDWH�DQG�ERQH�PLQHUDO� GHQVLW\��&RQWUDFHSWLRQ���������������� 7HFKQLFDO�FRQVXOWDWLRQ�RQ�WKH�HIIHFWV�RI�KRUPRQDO�FRQWUDFHSWLRQ�RQ�ERQH�KHDOWK �� ����� 7KDUQSULVDUQ�:��7DQHHSDQLFKVNXO�6��%RQH�PLQHUDO�GHQVLW\�LQ�DGROHVFHQW�DQG�\RXQJ�7KDL�JLUOV�UHFHLYLQJ� RUDO�FRQWUDFHSWLYHV�FRPSDUHG�ZLWK�GHSRW�PHGUR[\SURJHVWHURQH�DFHWDWH��D�FURVV�VHFWLRQDO�VWXG\�LQ�\RXQJ� 7KDL�ZRPHQ��&RQWUDFHSWLRQ������������������ ����� 9LUXWDPDVHQ�3��:DQJVXSKDFKDUW�6��5HLQSUD\RRQ�'��.ULHQJVLQ\RW�5��/HHSLSDWSDLERRQ�6��*XD�&�� 7UDEHFXODU�ERQH�LQ�ORQJ�WHUP�GHSRW�PHGUR[\SURJHVWHURQH�DFHWDWH�XVHUV��$VLD�2FHDQLD�-RXUQDO�RI� 2EVWHWULFV� �*\QDHFRORJ\������������������ ����� :DQLFKVHWDNXO�3��.DPXGKDPDV�$��:DWDQDUXDQJNRYLW�3��6LULSDNDP�<��9LVXWDNXO�3���%RQH�PLQHUDO� GHQVLW\�DW�YDULRXV�DQDWRPLF�ERQH�VLWHV�LQ�ZRPHQ�UHFHLYLQJ�FRPELQHG�RUDO�FRQWUDFHSWLYHV�DQG�GHSRW� PHGUR[\SURJHVWHURQH�DFHWDWH�IRU�FRQWUDFHSWLRQ��&RQWUDFHSWLRQ������������������ ����� 6FKROHV�'��/D&URL[�$=��,FKLNDZD�/(��%DUORZ�:(��2WW�60��7KH�DVVRFLDWLRQ�EHWZHHQ�GHSRW� PHGUR[\SURJHVWHURQH�DFHWDWH�FRQWUDFHSWLRQ�DQG�ERQH�PLQHUDO�GHQVLW\�LQ�DGROHVFHQW�ZRPHQ�� &RQWUDFHSWLRQ����������������� ����� &ODUN�0.��6RZHUV�05��1LFKROV�6��/HY\�%��%RQH�PLQHUDO�GHQVLW\�FKDQJHV�RYHU�WZR�\HDUV�LQ�¿UVW�WLPH� XVHUV�RI�GHSRW�PHGUR[\SURJHVWHURQH�DFHWDWH��)HUWLOLW\� �6WHULOLW\�������������������� ����� &XQG\�7��5HLG�,��'HSRW�PHGUR[\SURJHVWHURQH�DQG�ERQH�GHQVLW\��%ULWLVK�0HGLFDO�-RXUQDO������������ ���������� ����� &XQG\�7��$PHV�5:��+RUQH�$��&OHDUZDWHU�-0��5REHUWV�+��*DPEOH�*�HW�DO��$�UDQGRPL]HG�FRQWUROOHG�WULDO� RI�HVWURJHQ�UHSODFHPHQW�WKHUDS\�LQ�ORQJ�WHUP�XVHUV�RI�GHSRW�PHGUR[\SURJHVWHURQH�DFHWDWH��-RXUQDO�RI� &OLQLFDO�(QGRFULQRORJ\� �0HWDEROLVP���������������� ����� 0HUNL�)HOG�*6��1HII�0��.HOOHU�3-��$���\HDU�SURVSHFWLYH�VWXG\�RQ�WKH�HIIHFWV�RI�GHSRW� PHGUR[\SURJHVWHURQH�DFHWDWH�RQ�ERQH�PDVV�UHVSRQVH�WR�HVWURJHQ�DQG�FDOFLXP�WKHUDS\�LQ�LQGLYLGXDO� XVHUV��&RQWUDFHSWLRQ���������������� ����� 1DHVVHQ�7��2OVVRQ�6(��*XGPXQGVRQ�-��'LIIHUHQWLDO�HIIHFWV�RQ�ERQH�GHQVLW\�RI�SURJHVWRJHQ�RQO\�PHWKRGV� IRU�FRQWUDFHSWLRQ�LQ�SUHPHQRSDXVDO�ZRPHQ��&RQWUDFHSWLRQ���������������� ����� 6FKROHV�'��/D&URL[�$=��,FKLNDZD�/(��%DUORZ�:(��2WW�60��,QMHFWDEOH�KRUPRQH�FRQWUDFHSWLRQ�DQG�ERQH� GHQVLW\��UHVXOWV�IURP�D�SURVSHFWLYH�VWXG\��(SLGHPLRORJ\������������������ ����� %XVHQ�1+��%ULWW�5%��5LDQRQ�1��%RQH�PLQHUDO�GHQVLW\�LQ�D�FRKRUW�RI�DGROHVFHQW�ZRPHQ�XVLQJ�GHSRW�� PHGUR[\SURJHVWHURQH�DFHWDWH�IRU�RQH�WR�WZR�\HDUV��-RXUQDO�RI�$GROHVFHQW�+HDOWK������������������ ����� 6FKROHV�'��/D&URL[�$=��,FKLNDZD�/(��%DUORZ�:(��2WW�60��&KDQJH�LQ�ERQH�PLQHUDO�GHQVLW\�DPRQJ� DGROHVFHQW�ZRPHQ�XVLQJ�DQG�GLVFRQWLQXLQJ�GHSRW�PHGUR[\SURJHVWHURQH�DFHWDWH�FRQWUDFHSWLRQ��$UFKLYHV� RI�3HGLDWULF�$GROHVFHQW�0HGLFLQH������������������� ������ &URPHU�%$��/D]HEQLN�5��5RPH�(��6WDJHU�0��%RQQ\�$��=LHJOHU�-�HW�DO��'RXEOH�EOLQGHG�UDQGRPL]HG� FRQWUROOHG�WULDO�RI�HVWURJHQ�VXSSOHPHQWDWLRQ�LQ�DGROHVFHQW�JLUOV�ZKR�UHFHLYH�GHSRW�PHGUR[\SURJHVWHURQH� DFHWDWH�IRU�FRQWUDFHSWLRQ��$PHULFDQ�-RXUQDO�RI�2EVWHWULFV� �*\QHFRORJ\����������������� ������ 7DQJ�26��7DQJ�*��<LS�36��/L�%��)XUWKHU�HYDOXDWLRQ�RQ�ORQJ�WHUP�GHSRW�PHGUR[\SURJHVWHURQH�DFHWDWH�XVH� DQG�ERQH�PLQHUDO�GHQVLW\��D�ORQJLWXGLQDO�FRKRUW�VWXG\��&RQWUDFHSWLRQ������������������ ������ 2UU�:DONHU�%-��HW�DO��7KH�HIIHFW�RI�SDVW�XVH�RI�WKH�LQMHFWDEOH�FRQWUDFHSWLYH�GHSRW�PHGUR[\SURJHVWHURQH� DFHWDWH�RQ�ERQH�PLQHUDO�GHQVLW\�LQ�QRUPDO�SRVW�PHQRSDXVDO�ZRPHQ��&OLQLFDO�(QGRFULQRORJ\������� ����������� ������ &XQG\�7��&RUQLVK�-��5REHUWV�+��5HLG�,5��0HQRSDXVDO�ERQH�ORVV�LQ�ORQJ�WHUP�XVHUV�RI�GHSRW� PHGUR[\SURJHVWHURQH�DFHWDWH�FRQWUDFHSWLRQ��$PHULFDQ�-RXUQDO�RI�2EVWHWULFV� �*\QHFRORJ\������� ������������ �� ������ %HHUWKXL]HQ�5��YDQ�%HHN�$��0DVVDL�5��0DNDUDLQHQ�/��+RXW�-��%HQQLQN�+&��%RQH�PLQHUDO�GHQVLW\�GXULQJ� ORQJ�WHUP�XVH�RI�WKH�SURJHVWRJHQ�FRQWUDFHSWLYH�LPSODQW�,PSODQRQ�FRPSDUHG�WR�D�QRQ�KRUPRQDO�PHWKRG� RI�FRQWUDFHSWLRQ��+XPDQ�5HSURGXFWLRQ������������������ ������ 'L�;��/L�<��=KDQJ�&��-LDQJ�-��*X�6��(IIHFWV�RI�OHYRQRUJHVWUHO�UHOHDVLQJ�VXEGHUPDO�FRQWUDFHSWLYH�LPSODQWV� RQ�ERQH�GHQVLW\�DQG�ERQH�PHWDEROLVP��&RQWUDFHSWLRQ������������������ ������ 'LD]�6��5H\HV�09��=HSHGD�$��*RQ]DOH]�*%��/RSH]�-0��&DPSLQR�&��1RUSODQW�LPSODQWV�DQG�SURJHVWHURQH� YDJLQDO�ULQJV�GR�QRW�DIIHFW�PDWHUQDO�ERQH�WXUQRYHU�DQG�GHQVLW\�GXULQJ�ODFWDWLRQ�DQG�DIWHU�ZHDQLQJ�� +XPDQ�5HSURGXFWLRQ�������������������� ������ ,QWDUDSUDVHUW�6��7DQHHSDQLFKVNXO�6��7KHSSLVDL�8��&KDWXUDFKLQGD�.��%RQH�GHQVLW\�LQ�ZRPHQ�UHFHLYLQJ� 1RUSODQW�LPSODQWV�IRU�FRQWUDFHSWLRQ��-RXUQDO�RI�WKH�0HGLFDO�$VVRFLDWLRQ�RI�7KDLODQG������������������ ������ &DLUG�/(��5HLG�7KRPDV�9��+DQQDQ�:-��*RZ�6��*ODVLHU�$)��2UDO�SURJHVWRJHQ�RQO\�FRQWUDFHSWLRQ�PD\� SURWHFW�DJDLQVW�ORVV�RI�ERQH�PDVV�LQ�EUHDVW�IHHGLQJ�ZRPHQ��&OLQLFDO�(QGRFULQRORJ\������������������ �� 7HFKQLFDO�FRQVXOWDWLRQ�RQ�WKH�HIIHFWV�RI�KRUPRQDO� FRQWUDFHSWLRQ�RQ�ERQH�KHDOWK 6DOOH�$��:RUOG�+HDOWK�2UJDQL]DWLRQ� *HQHYD����±���-XQH����� /LVW�RI�SDUWLFLSDQWV $QQH[ 'U�/XLV�%DKDPRQGHV 'HSDUWPHQW�RI�2EVWHWULFV�DQG�*\QHFRORJ\ 6FKRRO�RI�0HGLFLQH 8QLYHUVLGDWH�(VWDGXDO�GH�&DPSLQDV &DL[D�3RVWDO����� ����������&DPSLQDV�63 %UD]LO 'U�0LULDP�&KLSLPR $GROHVFHQW�DQG�5HSURGXFWLYH�+HDOWK��6SHFLDOLVW 3��2��%R[������ 1HGNH�+RXVH /XVDND =DPELD 'U�0DUtD�GHO�&DUPHQ�&UDYLRWR 'HSDUWPHQW�RI�5HSURGXFWLYH�%LRORJ\ 1DWLRQDO�,QVWLWXWH�RI�0HGLFDO�6FLHQFHV�DQG�1XWULWLRQ�� 6DOYDGRU�=XELUiQ� 9DVFR�GH�4XLURJD��� 'HOHJDFLyQ�7ODOSDQ &��3��������0p[LFR��'�)� 0H[LFR 'U�.DWH�&XUWLV 'LYLVLRQ�RI�5HSURGXFWLYH�+HDOWK &HQWHUV�IRU�'LVHDVH�&RQWURO�DQG�3UHYHQWLRQ .RJHU�5KRGHV�%XLOGLQJ &'&�0DLOVWRS�.��� �����%XIRUG�+LJKZD\��1( $WODQWD��*$����������� 8QLWHG�6WDWHV�RI�$PHULFD 'U�/DQHWD�'RUÀLQJHU )DPLO\�+HDOWK�,QWHUQDWLRQDO 3��2��%R[������ 5HVHDUFK�7ULDQJOH�3DUN��1&������ 8QLWHG�6WDWHV�RI�$PHULFD 'U�$QQD�*ODVLHU 1+6�/RWKLDQ�)DPLO\�3ODQQLQJ�6HUYLFH ���'HDQ�7HUUDFH (GLQEXUJK�(+���1/ 8QLWHG�.LQJGRP 'U�(]]HOGLQ�2WKPDQ�+DVVDQ 7KH�1DWLRQDO�(J\SWLDQ�)HUWLOLW\�&DUH�)RXQGDWLRQ ��$�0DKURXN\�6WUHHW�0RKDQGHVVHQ 32%�����2UPDQ *L]D (J\SW 'U�-RKQ�.DQLV $YHQXH�GHV�.ODXZDHUWV��� �����%UXVVHOV�� %HOJLXP 'U�(QULFR�/LJJHUL 'LUHFWRU��:RUOG�:LGH�7HDP�/HDGHU� 7DUJHWHG�%UDQGV��3¿]HU� (DVW���QG�6W�����������6 1HZ�<RUN��1<������ 8QLWHG�6WDWHV�RI�$PHULFD 'U�(QULTXLWR�5��/X -+3,(*2�)DPLO\�3ODQQLQJ�5HSURGXFWLYH�+HDOWK� &HQWHU�RI�([FHOOHQFH� �����7KDPHV�6W�6XLWH���� %DOWLPRUH��0'������ 8QLWHG�6WDWHV�RI�$PHULFD 'U�3LVDNH�/XPELJDQRQ 'HSDUWPHQW�RI�2EVWHWULFV�DQG�*\QHFRORJ\ )DFXOW\�RI�0HGLFLQH .KRQ�.DHQ�8QLYHUVLW\ .KRQ�.DHQ������ 7KDLODQG 'U�3DPHOD�/\QDP� 5HJLRQDO�7HFKQLFDO�'LUHFWRU��(DVW�DQG�6RXWKHUQ�$IULFD -+3,(*2���-RKQV�+RSNLQV�8QLYHUVLW\� 3�2�%R[�������� 1DLUREL .HQ\D� 'U��7UHQW�0DF.D\ 6SHFLDO�$VVLVWDQW�IRU�2EVWHWULFV�DQG�*\QHFRORJ\ &RQWUDFHSWLRQ�DQG�5HSURGXFWLYH�+HDOWK�%UDQFK &HQWHU�IRU�3RSXODWLRQ�5HVHDUFK 1DWLRQDO�,QVWLWXWH�IRU�&KLOG�+HDOWK�DQG�+XPDQ� 'HYHORSPHQW 1DWLRQDO�,QVWLWXWHV�RI�+HDOWK �����([HFXWLYH�%OYG��6XLWH��%�� %HWKHVGD��0'������� 8QLWHG�6WDWHV�RI�$PHULFD 0V�6XPPHU�0DUWLQV 'LYLVLRQ�RI�5HSURGXFWLYH�+HDOWK &HQWHUV�IRU�'LVHDVH�&RQWURO�DQG�3UHYHQWLRQ .RJHU�5KRGHV�%XLOGLQJ &'&�0DLOVWRS�.��� �����%XIRUG�+LJKZD\��1( $WODQWD��*$����������� 8QLWHG�6WDWHV�RI�$PHULFD �� 'U�2ODY�0HLULN ,QVWLWXWR�&KLOHQR�GH�0HGLFLQD�5HSURGXFWLYD -RVH�5DPRQ�*XWLHUUHV������'HSWR�� 6DQWLDJR &KLOH 'U�+HUEHUW�%��3HWHUVRQ 'HSDUWPHQW�RI�0DWHUQDO�DQG�&KLOG�+HDOWK 3URIHVVRU��'HSDUWPHQW�RI�2EVWHWULFV�DQG�*\QHFRORJ\ 7KH�8QLYHUVLW\�RI�1RUWK�&DUROLQD�DW�&KDSHO�+LOO &%��������5RVHQDX�+DOO &KDSHO�+LOO��1&����������� 8QLWHG�6WDWHV�RI�$PHULFD 'U�$PULW�5D\ :RUOGZLGH�0HGLFDO�7HDP�/HDGHU 7DUJHWHG�%UDQGV�DQG�'LYHUVL¿HG�3URGXFWV� 3¿]HU� (DVW���QG�6W�����������6 1HZ�<RUN��1<������ 8QLWHG�6WDWHV�RI�$PHULFD 'U�+HOHQ�5HHV 5HSURGXFWLYH�+HDOWK�5HVHDUFK�8QLW 8QLYHUVLW\�RI�:LWZDWHUVUDQG &KULV�+DQL�%DUDJZDQDWK�+RVSLWDO 32�%HUWVKDP����� -RKDQQHVEXUJ 6RXWK�$IULFD 'U�5HQH�5L]]ROL 'HSDUWPHQW�RI�5HKDELOLWDWLRQ�DQG�*HULDWULFV 'LYLVLRQ�RI�%RQH�'LVHDVHV *HQHYD�8QLYHUVLW\�+RVSLWDO 5XH�0LFKHO�GX�&UHVW��� �����*HQHYD��� 6ZLW]HUODQG 'U�'HOLD�6FKROHV 6HQLRU�,QYHVWLJDWRU�� &HQWHU�IRU�+HDOWK�6WXGLHV� *URXS�+HDOWK�&RRSHUDWLYH�� �����0LQRU�$YH����WK�ÀRRU�� 6HDWWOH��:$������� 8QLWHG�6WDWHV�RI�$PHULFD 'U�-DPHV�6KHOWRQ 2I¿FH�RI�3RSXODWLRQ %XUHDX�RI�6FLHQFH�DQG�7HFKQRORJ\ 86$,' �����3HQQV\OYDQLD�$YHQXH��*�3+1 :DVKLQJWRQ��'&������ 8QLWHG�6WDWHV�RI�$PHULFD 'U�%XOEXO�6RRG 3URJUDP�0DQDJHPHQW�6SHFLDOLVW &HQWUH�IRU�'HYHORSPHQW�RQ�3RSXODWLRQ�$FWLYLWLHV� 1HZ�'HOKL ,QGLD 'U�0DUFHO�9HNHPDQV ,QWHUQDWLRQDO�3ODQQHG�3DUHQWKRRG�)HGHUDWLRQ 5HJHQW¶V�&ROOHJH��,QQHU�&LUFOH 5HJHQW¶V�3DUN /RQGRQ�1:���16 8QLWHG�.LQJGRP 'U�.HYLQ�:ROWHU 7DUJHWHG�%UDQGV�DQG�'LYHUVL¿HG�3URGXFWV� 3¿]HU (DVW���QG�6W�����������6 1HZ�<RUN��1<������ 8QLWHG�6WDWHV�RI�$PHULFD 'U�:X�6KDQJFKXQ 1DWLRQDO�5HVHDUFK�,QVWLWXWH�IRU�)DPLO\�3ODQQLQJ ���'D�+XL�6L��+DL�'LDQ�4X� %HLMLQJ������� 3HRSOH¶V�5HSXEOLF�RI�&KLQD 6(&5(7$5,$7 'U�3DXO�9DQ�/RRN��'LUHFWRU��5+5 0V�.DWKU\Q�&KXUFK��5+5 'U�&DWKHULQH�G¶$UFDQJXHV��5+5 'U�0DU\�/\Q�*DI¿HOG��5+5 0V�6DUDK�-RKQVRQ��5+5 0UV�*ORULD�/DPSWH\��5+5 0UV�1DWDOLH�0DXUHU��5+5 'U�1XUL\H�2UWD\OL��5+5 0V�0LUULDK�9LWDOH For more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20, CH-1211 Geneva 27 Switzerland Fax: +41 22 791 4171 E-mail: reproductivehealth@who.int www.who.int/reproductive-health

View the publication

You are currently offline. Some pages or content may fail to load.