By applying critical incident technique (CIT), five reaction themes were identified that had generated travel-behavior change: firm restrictions, unpredictability, unfair treatment, complicated trips, and earlier adverse experiences. To improve older travelers’ access to public transport, key findings were: (a) service must be designed so as to strengthen the feeling of being in control throughout the journey; (b) extended personal service would increase predictability in the travel chain and decrease travel complexity; consequently, (c) when designing new services and making effective accessibility interventions, policy makers should consider and utilize underlying psychological factors that could direct traveler behavior.Accessibility of travel may be better understood if psychological factors underlying change in travel behavior are known. This paper examines older (65+) travelers’ motives for changing their travel behavior. These changes are grounded in critical incidents earlier encountered in public-transport travel. A scientific framework is developed based on cognitive and behavioral theory. In 29 individual interviews, travelers’ critical reactions ( The proportion of journeys made by older people is expected to increase in many developed countries because of the increasing proportion of older people ,2. For e in 2011 . Functio in 2011 . In a gr in 2011 . Accessi in 2011 . Howeveri.e., barriers/facilitators) and travel behaviors, as regards the following questions: i.e., cognitions, emotions, and behavior) to critical incidents encountered in public transport contribute to the older traveler’s process of travel behavior change?How do critical reactions  are discf. . Travel cf. , althougcf. . In the cf.  found thn . Socioen , accordn , the travelers’ interpretations and critical reactions, followed by retention of the incident, perceived functional ability, motivation to travel, and actual travel behavior  are potentially perceived as critical incidents. Along the travel chain, travelers will selectively focus on various features of the situations encountered in travel environments. The travelers will therefore differ somewhat in what they perceive, because of differences in environmental properties  as well as individual features . The travelers will individually and selectively attend to stimuli in the travel environment. What is perceived as a critical incident depends partly on the individual traveler. For example, a bus driver who stops far from the pavement [pavement  may creaInterpretation. In the interpretation and cognitive processing of a situation, the travelers’ goals and values will affect the meaning ascribed to what is perceived [and of its outcome will influence the interpretation of the situation [erceived . For exaerceived . Althougerceived . Perceivituation . Perceivituation ,22. Thusituation , as wellCritical Reactions. Cognitive reactions to incidents are influenced by interpretation and may activate both positive and negative emotional and behavioral reactions [eactions ,24 or, aeactions . In serveactions  demonstreactions .Retention. Both the interpretation of an incident and the reaction to it affect what is remembered. Moreover, a minor incident may be enlarged in memory and therefore affect long-term behavior or, conversely, as the memory of the incident fades, its perceived importance will diminish. Therefore, the same incident might be described differently, depending on the time passed since it occurred [occurred .Functional Ability. Although functional limitations and other personal factors, such as age and gender, may influence functional ability, they are not the only determinants. Rosenkvist [i.e., perceived self-efficacy, may affect behavioral decisions, and different persons assess their abilities in different ways [cf. [senkvist  demonstrent ways . The expent ways . Moreoveays [cf. ). Efficaays [cf. .Motivation. A person’s motivations for a behavior are based on cognitive expectations of outcomes and are supported by conviction strength regarding efficacy and controllability, as well as by affective factors [perceived control would affect motivation and intention, but for behavior to be affected, factual control would be necessary [ factors ,30. Acco factors , motivatecessary . If a peTravel Behavior. In travel behavior research, Ajzen’s Theory of Planned Behavior (TPB) is often applied [intentions to perform a behavior are determined by three factors: her/his (a) attitudes to the behavior (because of beliefs about expected consequences); (b) normative expectations of others  [perceived behavioral control. However, even though perceived behavioral control influences intentions, for the behavior to be affected, actual behavioral control is needed. Although many travel decisions are planned and consistent, behavior may be less intentional, for example, impulsive [et al. [ applied ,33. Accoressure) ; and (c)mpulsive , and thempulsive . Alternampulsive , for exampulsive . Moreovempulsive  found thmpulsive . Anothermpulsive  and confmpulsive . Pullmanmpulsive  found th [et al.  found th [et al. . Forward [et al.  demonstr [et al. . Consist [et al. .travel behavior change is dependent on psychological factors, such as attitudes, perceived control, habits, and past behavior, as well as on intentions and emotional reactions. Interpersonal factors are also expected to affect travel behavior, such as the traveler’s normative expectations of others and relationships with the service providers in terms of trust and confidence. Moreover, even if the observed behaviors are similar, motivations and intentions may vary. To conclude, the traveler’s cognitive, emotional, and behavioral processes must be taken into account to understand why an encountered incident affects a travel behavior.In sum, apart from environmental and socioeconomic factors, quality attributes, for example, reliability and frequency of service, fare prices, and speed, have been proposed that might affect the user satisfaction of “mainstream” public transport passengers [i.e., reliability, assurance, tangibles, empathy, and responsiveness, which are appropriate for service research in general and not specific to travel environments [tangibles, which were not identified by the authors as a separate dimension, their remaining four dimensions were similar to those subsequently identified in a review by Edvardsson [Several ssengers . Other qssengers ,47,48,49ssengers  proposedronments . Except vardsson . Notablyvardsson ). There vardsson  demonstret al. [a priori definitions [why travel behavior has been affected. The travelers’ critical reactions to incidents would help explain the psychological process , makinginitions . The pre process  by whichThe critical incidents were provided by 29 older participants aged 65–91 years , 23 women and 6 men, all from the County of Stockholm, Sweden. All interviewees had some kind of functional limitation and/or degree of reduced functional ability (self-rated); most of them had more than one functional limitation . ParticiThe study was conducted in accordance with the Declaration of Helsinki. After approval from the local ethics committee (Project identification code 2011/1169-31/5), 30 post-trip semi-structured interviews were conducted. All but one, that is, 29 interviews, constitute the present dataset. One interviewee did not fulfill the inclusion criterion of having traveled by train within the last two years. One-third of the participants were recruited from an earlier questionnaire study on functional ability, barriers, and travel behavior . The othAlmost all the interviews took place either on the premises of Stockholm University or in the participant’s home; in one case, the interview took place at the participant’s workplace. The author served as the interviewer. Prior to each interview, the goal was stated and questions of anonymity and free consent were addressed. Incidents were defined as “occurrences that affected the interviewee’s experience of a journey.”Antecedents  were assessed; (4) The cognitive, emotional, and behavioral reactions to the incident were the reported explanations for the changed travel behavior.In the interview: (1) participants were asked to give information about an unlimited number of incidents, positive and negative, that they had experienced on trips (at least partly by any rail-bound mode) over the last two years in Sweden. Open-ended follow-up questions were asked to make the descriptions of situations detailed and vivid. The number of incidents described varied between 1 and 47 and the duration of the interview therefore varied between 15 min and 2½ hours; (2) The interviewees scaled each incident on a three-point scale according to how strongly it had affected their travel behavior. The response categories were “1: no influence,” “2: low influence,” and “3: high influence”; (3) With the informed consent of the participants, the interviews were recorded and the answers were immediately written down to ensure their descriptive validity . The intcritical incidents, because they were scaled by the interviewees to “highly influence” travel behavior , 67 in a negative way and 10 in a positive way  to each incident were sorted into preliminary themes . As the analysis progressed, a more theoretical process was applied in which the critical reactions were analyzed with reference to existing literature. The critical reactions were also analyzed by a colleague and former co-author who served as an independent judge in the incident categorization process [ process . In this process ) conductpositive influence implies “more frequent traveling” than in the no-incident case. A large majority, 67 of the 77 critical incidents collected (or 87%), were negative, so I will focus mainly on the critical reactions to these incidents.The critical reactions to the critical incidents encountered are regarded as mediating variables that would have a high influence on long-term travel behavior, according to the interviewees themselves. A high negative influence primarily implies that the interviewees “decreased the number of trips considerably,” “ceased to use the travel mode in question,” or “ceased to travel alone.” A high reactions to physical barriers in traveling.The main results are presented in the form of a classification system developed by the author and based on the critical reactions to the 67 negative incidents collected in the interviews. The critical reactions are viewed within a framework of cognitions, emotions, and (short-term) behaviors. Several interviewees reported that they had encountered critical incidents that they interpreted as “just impossible to overcome,” that is, firm restrictions. Except for worry during the travel situation, the interviewees described few emotional reactions to firm restrictions. Steps too high to climb or luggage shelves too high to reach generated critical reactions such as “being excluded” from certain trips. For some interviewees, an alternative travel behavior was to use the Special Transport Service, for example, when traveling with both a walker and a bag. The interviewees wished for more staff to help. Firm restrictions perceived by travelers with balance problems were underground station entrances that lacked elevators or long, fast-moving escalators. When encountering these barriers, the travelers’ critical reactions were that they had been “cut off from traveling altogether” or “forced to choose alternative ways of traveling.” In an underground station, one interviewee found herself trapped halfway down the staircase. Because of the lack of handrails, she was unable to get up or down. She requested help from a fellow passenger who happened to be present and took a taxi home instead of the underground. In the long term, she changed her travel behavior by avoiding certain trips, because of the critical reactions of dizziness and the fear of falling in the travel situation. An interviewee with balance problems at stations with long escalators would travel only in company because of vertigo. If she traveled alone, she would make a detour to another underground station with shorter escalators. Other interviewees ceased to use the underground altogether, because of the fear of using escalators. For some of the interviewees, “too expensive tickets” for long-distance trains were perceived as a firm restriction that made interviewees cease traveling by long-distance train. At the time of booking, it may be important to get information on the kind of carriage to be used, for example, to avoid cramped carriages that, in the case of joint problems, might produce aching knees. The impossibility of overcoming such barriers was typically more or less taken as fact and other options had to be chosen. In the long term, a firm restriction would evoke the emotional reaction of resignation. The long-term behaviors for dealing with such barriers were either to find other ways of traveling  or not to make the trip at all. For some interviewees, traveling in company had become the only long-term solution, resulting in dependency.For many travelers, unpredictable events were a source of worry and insecurity, and such events would leave the interviewees feeling helpless. A long-term consequence of this critical reaction might be apprehensive expectations before each trip: “It’s an adventure every time, it’s because of my balance. I become completely perplexed if the elevator is out of order and if there are no stairs. Then I suppose I would have to go home. I do try to calm down before a trip. I leave home earlier even though I get palpitations. Before Christmas I thought ‘I will never travel again,’ but then I forced myself, thinking that I cannot be stuck here” .Upon arrival at stations, several interviewees had found the elevator out of order. An immediate critical reaction was worry, while a longer-term reaction was apprehensive expectations, and one interviewee found it difficult to sleep the night before a trip. Another interviewee got lost because she could not use the usual exit; her reaction was to “feel stupid” and stressed. Her travel behavior was affected such that she initially avoided traveling. On the train, some interviewees could not relax because they were unable to keep an eye on their luggage, which they would have preferred to have near at hand.The interviewees sometimes did not know beforehand whether a bus driver would stop near the pavement or whether the kneeling function (which lowers the bus toward the curb) would be used at the bus stop. This would induce critical reactions of fear because they were afraid of falling, especially if the interviewees had to lift their walkers off the bus. One interviewee had fallen when the bus started moving before she was seated, and several other interviewees reported being afraid of falling in similar situations. This would evoke critical reactions of anxiety before and during the trip: “I thought I would fall. It happens so easily if you’re not young like my grandchildren, who can jump from the balcony without anything happening. The bus drivers are stressed and don’t have time. Most often, they are sympathetic, but when there are lots of passengers, there might not be enough time for them to think of it” .With regard to travel behavior, unpredictability may create a dilemma: whether to travel and risk encountering the barrier, or choose safety and avoid traveling. For some interviewees, a resulting travel behavior was to choose the Special Transport Service, although they could have traveled by bus if the driving had been more careful and predictable. Some interviewees stopped traveling altogether by public transport and were instead driven by car by friends and family. Some continued traveling by public transport but only in company. Others made only minor travel behavior changes such as talking to the driver instead of just pushing the stop button before getting off the bus.Lack of information induced critical reactions of irritation and worry, for example, during delays or when managing unexpected changes in travel mode if carrying luggage. A short-term behavioral consequence for one interviewee was getting on the wrong bus. A long-term travel-behavior consequence was to travel by bus instead of train, unless one could travel by train the whole distance. During a delay, another interviewee experienced critical reactions of worry and discomfort, not because of the delay itself, but because of being unable to inform her daughter, who was about to pick her up at the destination station. These stressful critical reactions, in turn, reminded her of her heart condition and that she should avoid stress: What would happen if she became ill and needed a doctor? After this event, a long-term travel behavior was to cease travelling by long-distance train.Some interviewees developed strained relationships with transport providers because they felt that the transport system had treated them disrespectfully or unfairly. Various computerized solutions were perceived as barriers by the interviewees because they felt excluded from traveling on the same terms as others. Some interviewees did not have a computer or had difficulties using one, while others felt forced to use a computer. Some interviewees had stopped traveling by long-distance train, partly for this reason. The interpretation of “being treated unequally” followed, for example, the worry of being left alone with an impossible-to-figure-out ticket machine or having to order the ticket over the Internet to get the best price.Some interviewees attributed the barriers partly to themselves: they felt “stupid,” thinking that they “should have been able to learn.” Importantly, personal assistance was regarded as a more flexible and predictable solution than the many specialized solutions involving electronic devices. In particular, interviewees asked for staff to help with ticket purchases to be made on the Internet, at least at larger stations. That way, they saw an opportunity to learn more about the electronic system and become more independent. One participant experienced first-class double-decker trains as similar to “cattle trucks,” because the carriages were cramped and unstable; the resulting travel behavior was that this participant would “never get onboard such a train again.” Notably, the interpretation of a situation as “unfair” evoked emotional reactions of irritation, anger, and humiliation. Ticket prices that fluctuated depending on departure time were conceived as deceptive, particularly if the ticket was booked close to departure time and, therefore, had increased in price. Long queues, faulty booking information, or windy, unprotected platforms were other critical incidents experienced as disrespectful treatment by the transport system. A resulting travel behavior was to choose the bus instead of the long-distance train.i.e., internal attribution) for their reactions, for example, not being able to learn how to overcome the barriers. Perceived external control  possibly impoverished the relationship with the transport provider, which was interpreted as a counterparty not interested in passenger needs. One interviewee even described this relationship as “having an enemy” and, consequently, avoided any further train travel. Some interviewees also felt insulted by the general acceptance of mobile-phone conversations onboard trains; they found themselves “listening almost compulsively,” though not wanting to, and found the situation to be “unbearable.”Although these critical incidents were attributed to the  transport system, some travelers partly blamed themselves . That way he could more easily reach the places in the city he wanted to visit. Cramped luggage space made trips more complicated, for example, by making interviewees use bags that are easy to stuff into cramped spaces but heavier and more uncomfortable to carry for travelers with balance problems.i.e., the operators) ignore the fact that not everybody has a computer … I have been talking to people who say ‘Buy the ticket on the computer’—no, I can’t do that! … It is too much trouble with the computer … I feel stupid … It takes probably one hour to book a ticket. I don’t think I have ever done that myself. I find the whole situation unpleasant” .In many cases of complicated trips, the interviewees had adapted their travel behavior, for example, by using other travel modes. Some interviewees still traveled in the same way, but less frequently than they would have if it had been easier. Encountering one barrier after another often induced irritation. The interviewees also reacted with confusion and stress when there was too much to deal with. If computerized solutions were regarded as complicated, the interviewees often perceived this as low internal control over the ticket purchase. They referred, as in the following case, to similar normative beliefs of others, but also put part of the blame on themselves. This resulted in low perceived functional ability and a long-term avoidance of travel: “They .Experiences, sometimes several years old, of power failures, hassles, being harassed, or accidents in the underground had all created critical reactions of worry, vigilance, or unease. Because of these earlier experiences, events on recent trips were perceived as negative incidents that in turn affected travel behavior in various ways: interviewees would not travel alone or would choose a carriage with other women or older couples (avoiding carriages with men only), and some avoided late-evening travel altogether. The interviewees regarded themselves as fragile, compared with when they were younger: “Nowadays, I can’t run away from anyone. I have a cardiac dysrhythmia so I wouldn’t dare run … I have to be careful” .Because of the risk of accidents, interviewees were also watchful on platforms, especially if these were crowded. This is in line with Risser, Iwarsson, and Ståhl’s  finding not entering the elevator in the underground station, unless she had someone accompanying her. This was because, in that situation, her cognitive reaction was to be “unsure of how long it would take to get help” if she became stuck. She was fully aware that she was overemphasizing a low-probability outcome and letting emotion drive her into irrational behavior.Having once been stuck in an elevator affected the travel behavior of one interviewee. Although she had tried to tell herself “Now, you are being ridiculous, just go ahead,” she always ended up Because of earlier experiences, the interviewees generally wished for more guards on platforms and in trains to counteract their reluctance to travel. They welcomed camera surveillance and the presence of staff overseeing activities.earlier positive experience or consistency making travel possible is when a traveler knows from experience that staff will be available to help at a particular station.Out of the 77 critical incidents that greatly influenced travel behavior, only 10 were positive. Just as firm restrictions, such as expensive tickets, were reasons why some older persons did not travel, other older persons had the opposite experience, for example, inexpensive tickets being regarded as opportunities and constituting reasons for traveling more often. Travel costs were more important than, for example, travel time, a result in line with Su and Bell . The intSome interviewees preferred the mostly aboveground commuter trains to the underground, because they could look out the windows at scenery and would feel less trapped inside the train if something should happen. Punctuality and low prices were also appreciated by the interviewees and therefore created positive critical reactions.i.e., unpredictability and unfair treatment) as regards negative critical incidents reported by “mainstream” travelers on public transport. However, the vulnerable travelers studied here also encounter other difficulties than those affecting mainstream travelers, that is, difficulties perceived as “firm restrictions” that cannot be overcome, as also found by Jensen et al. [The primary objective of this research was to study the process of travel-behavior change within a cognitive and behavioral framework of person–environment interaction. By examining the interviewees’ critical cognitive, emotional, and behavioral reactions to critical incidents, it was possible to identify why certain incidents resulted in changed travel behavior according to the travelers themselves. It should be noted that though the present sample of older travelers is relatively small, it is still heterogeneous. The themes identified are partly in line with categories identified by Friman   and those who used a walker were afraid of falling when getting off a bus. If an incident is interpreted as exceeding the perceived functional ability, the outcome in terms of travel behavior may be to avoid similar situations, because we tend to choose situations we believe we can handle. A more careful and consistent bus driving style  would increase the traveler’s sense of being in control and perceived functional ability in that travel situation. Similar driving style problems have been reported in earlier research and driver training has been suggested as a response [The present data suggest that the feeling of being in control is central. Encountering unpredictable events in the travel environment was found to result in critical reactions of insecurity, because of uncertainty as to whether the trip would be manageable. Not knowing what to expect creates critical reactions of stress, especially if the purpose of the trip is important and, in addition, if the risks involve the person’s own health, such as the risk of falling. For example, some of the “older” old interviewees  and possibly a more adverse self-perception; for example, some interviewees put part of the blame on themselves for not managing to travel.vis-à-vis the transport system and of being “stupid in traveling” has also been found in previous research into persons with functional limitations [not want to travel under those circumstances even though they could travel. In either case, avoidance may result in a more limited behavior repertoire. Therefore, not only the incidents per se, but also the reactions to them, including emotions and attitudes, must be considered by transport providers in order to better understand older travelers’ behaviors and needs. In line with the present research, Rosenkvist et al. [Emotional critical reactions were central to travel behavior in many interviewees. For some interviewees, the actual critical reaction  became in itself a barrier to travel, for example, if the person had a heart and/or chest condition. Notably, not only obviously severe events such as hassles or accidents but also even seemingly mildly adverse events may evoke equal fear in the individual. This could apply if the event was not even noticed by other persons present. For instance, a person who has repeatedly experienced fear of falling when getting off the bus, or “feeling stupid” because of difficulties with ticket purchase or non-functioning elevators, may develop a vigilance for as well as lowered perceived functional ability in similar situations. This humiliating interpretation of inferiority itations . If an iitations . Althougt et al.  found tht et al.  found ret et al. . As barrt et al. .cf. [et al. [The data suggest that absence of staff is central to travel behavior in a number of ways. Available staff is perceived as a general security factor, that is, “to have someone to ask in case something unexpected happens.” Moreover, personal service is viewed as far more flexible than electronic solutions , and some interviewees interpret the lack of alternatives as unfair treatment, because not all travelers have the same opportunities. According to earlier research, staff availability during trips is experienced as more important for older than for younger persons; especially for older persons, technical solutions cannot generally replace personal service (cf. ). As als [et al. , staff mcf. [There was considerable heterogeneity in the group of older persons. In this research, many of the “older old” (75+ years old) interviewees were experiencing increasing frailty, often using aids such as walkers, and had encountered certain critical incidents and reacted to them accordingly, while many of the “younger old” interviewees had encountered other kinds of incidents. Moreover, only the women (23 out of 29 in this sample) identified critical incidents based on earlier “frightening” events, sometimes experienced many years previously, that still made them react with vigilance and insecurity in similar situations. It was the women who used walkers, and therefore experienced great difficulties getting on and off buses, and were moreover the oldest interviewees. Even nationally, it is more common for women than men to use walkers . Notablycf. ). AssessA predictable travel environment in which the vulnerable traveler perceives a high level of behavioral control was found to be essential for the choice of travel behavior. One way of achieving better predictability would be to increase the access to personal service throughout the travel chain, for example, by providing alternatives to electronic solutions, more visible staff, or “help telephones” at strategic places. The present research suggests that travel behavior decisions are not based solely on “rational” decisions. Therefore, travelers’ emotional experiences of the travel environment, “irrational” reasons for decision making, as well as relational factors should all be considered when designing services. Not only the travelers’ actual ability but also their perceived ability affects their travel choices. Knowing, before a trip, that staff will be present and visible would enhance the motivation to travel for many of the interviewees, helping maintain flexible travel behavior. Extended personal service along the travel chain would increase the traveler’s sense of control, helping reduce critical reactions of worry, decrease travel complexity, and therefore also decrease the effort needed. Making public transport more attractive, for “mainstream” users as well, is important and will promote increased sustainability. Such improvement might divert travelers from excessive car use to travel via public transport, reducing environmental problems such as congestion and air pollution.


Collaboration and interprofessional practices are highly valued in health systems, because they are thought to improve outcomes of care for persons with complex health problems, such as low back pain. Physiotherapists, like all health providers, are encouraged to take part in interprofessional practices. However, little is known about these practices, especially for private sector physiotherapists. This study aimed to: 1) explore how physiotherapists working in the private sector with adults with low back pain describe their interprofessional practices, 2) identify factors that influence their interprofessional practices, and 3) identify their perceived effects.Participants were 13 physiotherapists, 10 women/3 men, having between 3 and 21 years of professional experience. For this descriptive qualitative study, we used face-to-face semi-structured interviews and conducted content analysis encompassing data coding and thematic regrouping.Physiotherapists described interprofessional practices heterogeneously, including numerous processes such as sharing information and referring. Factors that influenced physiotherapists’ interprofessional practices were related to patients, providers, organizations, and wider systems . Physiotherapists mostly viewed positive effects of interprofessional practices, including elements such as gaining new knowledge as a provider and being valued in one’s own role, as well as improvements in overall treatment and outcome.This qualitative study offers new insights into the interprofessional practices of physiotherapists working with adults with low back pain, as perceived by the physiotherapists’ themselves. Based on the results, the development of strategies aiming to increase interprofessionalism in the management of low back pain would most likely require taking into consideration factors associated with patients, providers, the organizations within which they work, and the wider systems. In the last few decades, there have been increasing demands for health providers to take part in interprofessional practices and collaboration in health systems everywhere -4. One oMany clinical practice guidelines recommend offering multidisciplinary or interdisciplinary interventions to adults with low back pain -11. The Physiotherapists are among the providers who regularly contribute to the treatment of adults with low back pain . Faced wThe complexity of low back pain, the importance of low back pain as a public health problem, and the paucity of research on the interprofessional practices of physiotherapists supported the development of this study. It was anticipated that gaining the physiotherapists’ perspectives and experiences on this subject would help inform physiotherapy practice in the private sector with adults with low back pain. Hence, the objectives of this study were to: 1) explore how physiotherapists who work in the private sector with adults with low back pain describe their interprofessional practices, 2) identify factors influencing their interprofessional practices, and 3) identify effects of interprofessional practices, as perceived by physiotherapists.This was a descriptive qualitative study , the firinterprofessional practices to translate our interest in exploring all forms of interactions between physiotherapists and other providers (e.g. not just team-based interactions), from the same and other disciplines, as well as from within the same and other work organizations.In this study, we explored interdisciplinary coordination, or the ability to link together the activities of different providers in time and space  be a member of the Order of Physiotherapy of Québec (OPPQ), mandatory to practice in Québec, 2) do clinical work in the private sector at least one day/week, 3) have a minimum 20% of clientele consulting for low back pain, 4) mainly provide interventions to adults, 5) speak, read and write in French, and 6) be located within 300 km of Québec City. Physiotherapists off work at the time of the study (e.g. on maternity leave) were excluded. Our sampling frame, made available to us by OPPQ, consisted in the list of physiotherapists who, as of June 2010, worked in the private sector in Québec, and accepted to be contacted for research purposes , which totaled 957 out of 1529 physiotherapists working in the private sector. Approximately 42% of physiotherapists work in the private sector in Québec .Multiple case sampling  was usedInstitut de réadaptation en déficience physique de Québec approved the study (project # 2010–190).The study coordinator sent a brief personalized introductory letter to potential participants and called them approximately one week later to describe the study and nature of participation, as well as to verify eligibility. An appointment was then made with interested and eligible physiotherapists. At that time, the coordinator provided more information on the study, obtained written informed consent and proceeded with the interviews with the consenting physiotherapists, of whom none were previously known by the interviewer. A 25-dollar gift certificate was offered to participants as a symbolic recognition for their time. The Ethics Committee of the Semi-structured face-to-face interviews served as the main method of data collection. An interview guide was constructed based on study objectives, literature review, frame of reference, as well as discussions with research team, experts and potential users. It was pretested with two physiotherapists, in order to refine questions and the interview procedure . The intThe content of the interviews was transcribed verbatim, noting silences, sighs, laughs and sounds  and thenThirteen physiotherapists were interviewed, while twenty-two physiotherapists were sent an introductory letter (five series of mail-outs). Indeed, upon making the follow-up phone calls, 4 physiotherapists were not working in the same organization, 2 did not fit the eligibility/sampling criteria and 3 were never reached. All physiotherapists with whom appointments were made accepted to participate in the study. Our sample of physiotherapists comprised 10 women and 3 men having between 3 and 21 years of professional experience The terms used varied between physiotherapists, but also within interviews. When prompted to define terms they used, the physiotherapists often responded showing hesitation in their choice of words or simply answered something like “that’s difficult!”.Physiotherapists identified different means of interacting with other providers: face-to-face, telephone, letter, fax, unplanned and planned face-to-face meetings, shared files, joint evaluations and referral. Many reflected indirect rather than direct interactions with other providers, such as sending a letter to another provider via the patient or sharing information from a common file. The great majority of interactions with other providers were said to be unplanned rather than planned .The other healthcare providers with whom the physiotherapists reported interacting worked in the same setting or not, and in the public and private sectors. The physiotherapists mostly mentioned interactions with medical doctors , but also talked about interactions with other physiotherapists, physiotherapy assistants, psychologists, kinesiologists, massage therapists, acupuncturists, osteopaths, chiropractors, and orthotists. When prompted to discuss other providers they had interactions with, a few physiotherapists also mentioned secretaries, because they often represented intermediaries between themselves and other providers. Claim agents of funding agencies were also mentioned as they were occasionally contacted to obtain permission to refer patients to other providers. The patients themselves were reported as intermediaries between the physiotherapists and other providers, e.g. by relaying information or a letter, by acting upon (or not) physiotherapists’ referrals to another provider or by being directly present during interactions with other providers. The physiotherapists conversely identified some providers mentioned above  and other types of providers with whom they did not have any interactions, mainly unregulated providers under the Code of Professions of Québec, e.g. bone setters, reflexologists, and orthotherapists. One participant stated:«…we can work with everybody except (…) for bone setters, for sure that doesn’t pass, we can’t do it (…), and we understand why right away, they have no notion; when we explain, they don’t understand anything (…)” (V1-5)Factors influencing the interprofessional practices of physiotherapists were found to relate to the different categories of characteristics identified in our frame of reference, as presented in Table Physiotherapists explained they had interactions with other providers based on the patient’s condition and needs. When the physiotherapists assessed a patient’s condition and felt they were missing information, had attained their limits, or that intervention was beyond their scope of practice, they were more likely to interact with other providers. For example, the physiotherapists often talked about contacting the referring MDs to suggest further investigation or medication, or to obtain information or discuss. The stage of the condition (persistent rather than acute), the course of recovery, the presence of psychosocial factors, pain location , and compensation status were all seen as factors that were associated with a greater need for interactions with other providers. One physiotherapist mentioned:“If recovery is good and it’s ‘business as usual’, well then we won’t make a note for the doctor to say ‘ehh… the patient came to see us, everything is going well’”. (V1-3)This idea was not conveyed by all physiotherapists however. The patient’s financial situation also emerged as a factor that had an impact on the physiotherapists’ interactions with other providers, mainly in regards of referral to other providers. For example, one physiotherapist explained how when she knew that paying for treatment was difficult for a patient, she would refrain from referring to another provider, even if she thought it was relevant, and also acknowledged that she sometimes cut her own interventions to allow for those of other providers. A patient’s request for physiotherapists to interact with another provider (e.g. send a letter) was also seen as an incentive.Physiotherapists’ and other providers’ attitudes emerged from the physiotherapists’ discourse as greatly influencing the frequency and quality of interactions. An open attitude and confidence in other providers were seen as important facilitators. Sharing common language and treatment orientation was also viewed as such. One physiotherapist explained that she could not interact with chiropractors because they did not share the same language or vision of treatment. Another physiotherapist talked about competition for clientele he felt from other physiotherapists working in other clinics in the same town when he tried contacting them. Hence, he had mostly abandoned interactions because of their limited interest to discuss. Having had previous positive interactions with or personally knowing another provider was viewed as an incentive for further interactions. Conversely, not knowing other providers, especially their professional roles, and feeling that other providers did not know the roles of physiotherapists or did not see them as credible professionals was expressed as a barrier to interactions. As stated by one physiotherapist:“…my boss hired the acupuncturist so… If he… if he hadn’t hired her, I wouldn’t necessarily have believed in that. (…) I’m less likely to refer my patients there (…). It’s hard to fake that I believe in it to refer…” (V1-13)Another physiotherapist mentioned:“the fact that half the doctors in the region don’t know us, or that they simply don’t want to know us, that for sure doesn’t… doesn’t motivate us to call them and to give them our opinion or to ask them their opinion because we kind of get the impression that (sighs) they don’t have time to lose with us” (V1-10)Most physiotherapists mentioned they had to be cautious when approaching some MDs, for instance by not being too affirmative in making their observations, in order to prevent unpleasant reactions. In another vein, physiotherapists’ and other providers’ workloads and work schedules were said to negatively impact interactions. Many physiotherapists reported having little time to contact other providers, although they took it, and had difficulties reaching some providers, mainly MDs. As an example:“…my schedule is loaded. So, with (…) patients every half-hour we don’t have a time-slot (…) to make phone calls for example. (…). So we make them more often when we have two free minutes or when a patient doesn’t show up.” (V1-6)Organizational factors were interrelated and linked with the organizations’ vision, resources, structures and practices, as proposed initially in our frame of reference. In some organizations, there was a clear vision to provide services from multiple providers, e.g. to be able to satisfy patients’ needs, and take part in interprofessional practices, which acted as facilitating factors for interactions. The physical proximity of other providers was viewed as facilitating. For some physiotherapists, being in the same clinic was essential, but for others, being close by (e.g. same building or across the street) was sufficient. As an example, one physiotherapist talked about the importance of working in the same physical space as other providers, which helped to construct professional credibility in the eyes of other providers:“The other professionals more precisely know what we do when they see us working. Then they know we’re professionals in our own right.” (V1-2)The organization’s structures were seen as influencing factors through the use of shared files and the mostly implicit but sometimes explicit rules of the organization regarding interactions with other providers . For instance, many physiotherapists reported that in their organization, letters were to be sent to the MDs after initial evaluation or at the time of the first follow-up visit after referral for physiotherapy. As for organizational practices, their main influence on the interprofessional practices were perceived through the arrangement of training, promotional and social activities between organizations, such as lunchtime conferences, and within-organization parties, which helped to get to know and create links with other providers that facilitated further interactions.The physiotherapists discussed factors related to the healthcare, educational and professional systems. The shortage of providers in some regions was identified as a barrier to interprofessional interactions that even had an effect on modifying physiotherapists’ professional roles. One physiotherapist mentioned going to a private gym to plan an exercise program for a patient and one of her colleagues doing worksite visits to analyze ergonomics, tasks she said they wouldn’t do if a kinesiologist and an occupational therapist, respectively, worked in the region. The rules of the provincial funding agencies were said to play a role in determining the types and timing of interactions with other providers, e.g. forms being sent to the MDs based on requests of funding agencies. The physiotherapists also talked about persisting hierarchy between professions, feeling that physiotherapists’ status was viewed as inferior in the professional system, mostly by some MDs. To this effect, every physiotherapist interviewed judged that it was much easier to interact with younger  than older MDs, hence shedding light on the influence of timing and content of training and probably changing medical culture. One physiotherapist said:“Physio evolves a lot, and new doctors now have better knowledge of what physio is. I think it’s really the older ones that are more reluctant.” (V1-7)The participants reported mostly positive effects of interprofessional practices and very few negative effects, synthesized in Table For the positive effects, the physiotherapists stated that interprofessional interactions positively influenced patients’ self-management, their sense of being “taken care of”, confidence in providers, more rapid and optimal recovery, and offered better timing of interventions  and consideration for all aspects of the person. As one physiotherapist put it:“What I say to myself is: ‘the most important, yes, we are a business here, we need clients to live (…) but that’s because we need them to recover also if we want to live ehh… from our popularity (…). For them to have a better recovery, we don’t have a choice, we need to… to all talk to each other’.”(V1-4)Similarly, one physiotherapist clearly linked good communication between providers in the organization where she worked and the organization’s good performance. Some physiotherapists also mentioned how interactions prevented from giving mixed messages to the patients. In another vein, the physiotherapists spoke about the stimulation, peer-support, reassurance, pleasure and satisfaction they felt from interacting with other providers, within and outside their own workplace. A physiotherapist said:“collaborating is… is fun (laughs)! (…) It’s fun because we communicate, and we don’t feel alone. It’s hard to take the the… the pain of our clients on our shoulders alone… So… to be able to exchange with another professional that has another vision, it sometimes helps to find other options. And hum… when we can, we even put the client with us.” (V1-4)Gaining new knowledge through interactions with other providers was highlighted too. Furthermore, the physiotherapists reported mostly receiving positive reactions following interactions with other providers, as noted by increased referral for their services or to their organization. Having interactions was also a way to inform other providers, mainly MDs, of what physiotherapists do and enhance their credibility through positive results of physiotherapy interventions. One of the physiotherapists expressed:“Well it’s certain that the doctor who sees that me, my client, well he has to recover and that I refer him all over, well he will be more likely to refer to me because the client is important.” (V1-1)Many physiotherapists spoke more generally about how their interactions helped to improve the status of physiotherapy and its role within their local health system. As for lack of interactions, it was seen as being associated with higher costs for the system.For the negative effects, some physiotherapists mentioned having unpleasant conversations with other providers, mainly MDs, mostly regarding professional limits, which made them very careful when sharing information and approaching the other providers, as evoked previously, e.g. avoid saying anything that might be interpreted as having a diagnostic message. One physiotherapist/clinic-owner even recalled having lost all physiotherapy referrals from one MD following a dispute with one of the organization’s physiotherapists. Another physiotherapist described negative effects related to over-referral within his own work organization:“…referring sometimes to people who are incompetent, that’s one thing (…) ehh or to refer all the time. (…) It’s like, if for some people coming into the clinic: “oh for sure you’re gonna go for massage therapy, for sure you’re gonna go for acupuncture, for sure you’re gonna go for osteo”. No. You know, you have to be careful. That, that could become double-edged if it’s, if it’s not well used.” (V1-11)Referring to providers in other organizations where physiotherapy was also offered was viewed as potentially leading to loss of clientele, a problem one physiotherapist/clinic-owner resolved by gradually including the types of previously referred-to providers within his own organization. Having too many providers involved in a patient’s management was seen by one physiotherapist as a rare negative consequence with people with pain problems, because of the fact that through their interventions, the providers keep the patients centered on the pain. One physiotherapist stated that for patients who don’t tell the same story to all the providers they receive interventions from, the interactions may be seen as an irritant by them, although these interactions allowed to clarify the situation between providers.In this study, we explored the perceptions and experiences of physiotherapists who work in Québec’s private sector with adults with low back pain on their interprofessional practices. More specifically, we explored the physiotherapists’ descriptions of their interprofessional practices, as well as perceived influencing factors and effects.Our exploration of physiotherapists’ descriptions showed that, for them, interprofessional practices include a wide array of processes. Indeed, physiotherapists described their practices in multiple ways, which included action-based activities such as working together and referring. As suspected, only a minority of physiotherapists practiced in contexts where there were formal team-based processes. The physiotherapists mostly mentioned interactions that took the form of unplanned information-sharing between providers, as well as referral to other providers. Hence, physiotherapists’ reported interprofessional practices in the private sector did not perfectly match often-found definitions of interprofessional collaboration that encompass intensive and formal types of interactions, usually between formal team members . Our finExploring physiotherapists’ perceptions of factors that influence their interprofessional practices allowed to highlight interrelated contributions linked with 1) patients, notably the stage and severity of their condition, 2) providers, such as attitudinal, knowledge-based and reachability factors, 3) organizations, including rules and proximity with other providers, and 4) wider systems, such as lack of providers, administrative constraints and hierarchy between professions. Our study is one of the few that specifically explored patient-related factors influencing interprofessional practices. Interprofessionnal practices and collaboration are often justified in the literature by the need to address the complexity of person or population needs and conditions. Still, how this complexity is defined and the association between complexity and interprofessional practices have rarely been the focus of empirical studies. In Sicotte et al.’s  study, aNumerous positive effects of interprofessional practices were perceived by the physiotherapists. They include gaining new knowledge as a provider, being valued in one’s own role, as well as improving treatment and outcome. Overall, the physiotherapists considered their interactions with other providers as essential, some wanting further interactions, most not wanting to work without them. In one of the few previous studies carried out in the context of physiotherapy practice , physiotThis study mainly focussed on interprofessional practices in an understudied population, physiotherapists, working in an understudied context of practice, the private sector. Faced with this lack of research, using a qualitative approach to explore the subject of interprofessional practices was warranted. Although most elements were redundant in the last few interviews leading us to conclude to data saturation, while deepening the analyses, we found that further interviewing may have helped clarify more of the latent meanings of interprofessional practices and further our understanding of the conceptualizations of the phenomenon. Categorizing the physiotherapists according to our recruitment matrix was also imperfect because on a few occasions, what the physiotherapists reported at the time of eligibility verification over the phone was different from what they stated during the interviews, for example because they had forgotten that another type of provider sometimes worked in their clinic. We nonetheless feel we were able to gather a good diversity of perspectives. However, we did not explore the views and experiences of other providers, as well as service users’, which could further help understand the phenomenon.The findings of this study provide hints for improving the organization of physiotherapy services in the private sector and improving interprofessional practices when relevant. Possible avenues in the workplace include creating occasions to interact with other providers, for example by organizing joint training sessions or social activities and taking steps to gain more knowledge on other providers’ roles . Encouraging the physical proximity of different providers in the same organization appears as a strategy worthy of further consideration and could lead to the identification of preferred models of organizations. On another level, system-wide professional culture changes and provider training related to interprofessional practices should continue to be promoted based on our results. Furthermore, because our findings highlighted multiple sources of influence shaping the interprofessional practices of physiotherapists, it is most likely that it would not be sufficient to simply ask physiotherapists to increase their interactions with other providers in order to increase such practices. Other context-specific organizational, system-level and patient-related factors would also need to be taken into account and acted upon.In these times when interprofessional practices and collaboration are greatly promoted in health systems everywhere, our results offer new insights into the interprofessional practices of private sector physiotherapists working with adults with low back pain, as perceived by the physiotherapists themselves. Based on our findings, the development of strategies aiming to increase interprofessionalism in the management of low back pain would most likely require taking into consideration factors associated with patients, providers, the organizations within which they work, and the wider systems. In the future, additional research focussing on the views of other actors, such as other providers, as well as service users, would enhance our comprehension of physiotherapists’ interprofessional practices.The authors declare that they have no competing interests.KP led study design, data collection, analysis and interpretation and drafted the manuscript. CED significantly contributed to study design, data collection, and data analysis and interpretation. MR participated in study design. DM participated in study design and data analysis. All authors contributed to manuscript preparation and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/15/160/prepub


Tovim hashnaim min ha-echad… Two are better than one; because they have a good reward for their labor. For if they fall, the one will lift up his friend: but woe to him who is alone when he falls; for he has not another to help him up.Kohelet/Ecclesiastes 4:9-10and possessing the powers of both speech and complex abstract reasoning … our friendships … connect us with one another in ways that create astonishingly far-reaching social networks capable of transmitting vitally useful information, mobilizing people to action, and in other ways, too, buffering us, our families, and our communities against the trials and tribulations of life.1Our evolved ability, our psychological and biological capacity, to make friends even with strangers is a defining characteristic of our species, an evolved human trait marking us apart from most other species on earth just as surely as … walking upright on two legs, having opposable thumbs and a prominent chin, The post-exilic biblical voice of Kohelet above is echoed, even if unintentionally, by that of contemporary anthropologist, ethnologist, and social network analyst, John Edward Terrell, a Chicago Field Museum of Natural History curator.Rambam Maimonides Medical Journal that were inspired by and composed in the wake of a visit almost a year ago (May 2014) by clinicians and scholars from the Mayo Clinic and the University of Minnesota with Israeli colleagues on the Rambam Health Care Campus in Haifa.Dear Friends and Colleagues,It was a day of formal conferences, informal conversations, a facility tour, and shared meals. It was also a day of friend-making, of creating “far-reaching social networks,” as “useful information” was exchanged and “complex abstract” ideas were debated.The Mayo articles include a survey by Lerman et al. of the promise, challenges, and imperative of international collaboration among medical clinicians and investigators.8Rambam Maimonides Medical Journal representing the field of nursing—an integral aspect of clinical practice.The Rambam articles likewise cover a broad range of relevant clinical issues. Klein and his group examine the aftereffects of combat trauma in an important cultural group serving in the Israel Defense Forces—the Bedouins.Aseh l’cha rav, ukneh l’cha haver…Get yourself a teacher, acquire for yourself a friend with whom to study, and give every person the benefit of the doubt.Pirkei Avot/Ethics of the Fathers 1:6As a whole, these considered pieces are the creative products from that day in May 2014 of valuing medical friendship with the making of “astonishingly far-reaching social networks” among Israeli and American colleagues. The fruitful ethic, medical and otherwise, most embodied by that event is finally captured in the well-known rabbinic saying:


In recent years “nature deficit disorder” among kids has evolved from a turn of phrase,,,,,Almost at the same time, researchers have dramatically expanded their understanding of the positive link between health and parks of all sorts—from the most majestic national parks to regional community parks and urban “pocket parks” with just a swing set or a few benches. They have also begun to disentangle some of the many pathways through which these benefits appear to occur.In some cases, the programs have received support from the Healthy Parks Healthy People initiative of the National Park Service (NPS), launched as a pilot in 2011 and set to expand significantly in 2016 and beyond.Other park-prescription programs are locally managed and operated, including a growing number organized around urban trails and other nontraditional “linear” parks that promote nonmotorized transport.,,,,,,Current evidence suggests that children have much to gain from time spent outdoors and much to lose from a lack of park access.,,,Several studies suggest that spending time outdoors can protect against myopia (nearsightedness).Parks and green spaces also may contribute to population health by reducing exposures to air pollution,Eventually, current trends could lead parks straight to the core of the American healthcare system, says Kristin Wheeler, associate director of the Institute at the Golden Gate, a nonprofit partner of the NPS.“This is the way that nature and parks are going to be talked about—it’s going to be commonplace for your doctor to ask you about how much time you’ve spent in nature,” Wheeler says. “It’s this perfect culmination, where everybody’s starting to see this as the wave of the future.”Zarnaaz Bashir, director of strategic health initiatives for the nonprofit National Recreation and Park Association,At least 75–100 distinct “park prescription” efforts already exist nationwide, according to Bashir. She says the programs, most of which are just one or two years old, vary in terms of how successful and how intensive they are. In any case, for the concept to truly stick and to mature beyond small-scale local initiatives, research needs to follow apace. “We’re looking for evidence that shows that the whole process of prescribing wellness at a park to a patient and going through a specific intervention is working and providing physical and mental health benefits,” she says.,Nooshin Razani, a clinical scientist and pediatrician at UCSF Benioff Children’s Hospital Oakland (UBCHO), is part of a team undertaking a study to provide just such validation. Building off a park visitation program that UBCHO Primary Care Clinic launched with a regional parks district in May 2014,“This is a pilot study based on our experiences going into nature with patients,” says Razani. “We observed that when we spent time in parks with families, children expressed joy and caregivers expressed that they were relaxed and finding new friends. There is this potential that nature can serve as a low-cost, readily available tool for buffering stress. However, since there are few resources in our clinic and many competing needs in the communities we serve, we feel compelled to find the evidence for parks as a health intervention before making assumptions.”In addition to quantifying health benefits associated with specific interventions, researchers must also identify the mechanisms through which they occur. It’s possible that mental health is a sort of “common pathway” through which most benefits of parks and green spaces travel, suggests Peter James, a research fellow at Harvard University. In other words, mental health may not be solely an end point but also a mediator for benefits related to chronic disease and other elements of overall health.More specifically, Dadvand notes two of the primary avenues through which green spaces likely promote better physical and mental health. The first is nature’s mentally restorative quality. The second is the social cohesion—the willingness of members of a group to cooperate for the common goodOriginally described in the late 1980s, attention restoration theory holds that many of the benefits of being in nature are related to its ability to rest and restore “directed attention” (focus and concentration) while gently engaging “involuntary attention” (a more relaxed state open to passing stimuli).Frances “Ming” Kuo, a researcher and associate professor at the University of Illinois at Urbana–Champaign, recently published a review that discussed 21 mechanisms for which there is evidence of a role in the nature–health connection.Physical activity in parks remains a rich area of study, with significant implications for individual fitness as well as community-scale urban planning.,Other studies have suggested that the relationship between parks and physical activity is more complex, hinging on a variety of socioeconomic factors and park characteristics.,,Deborah Cohen, a senior natural scientist with the RAND Corporation in Southern California, has sought to understand how specific park features influence physical activity. Results to date indicate that programming and activities are particularly good at drawing users to a park, and that elements appealing to different age groups and physical capabilities are also important.Cohen’s team is currently assessing park use and physical activity in 174 urban neighborhood parks in 25 states. Their goal is to better understand what gets people into parks and how to improve parks so they attract people. “Just an empty piece of land isn’t going to take someone away from an exciting movie or television show or computer game,” Cohen says. “If we want people to be active and stay healthy, we have to compete with those sort of things.”Proponents of park prescriptions recognize the challenge. “The battle is just getting over that hurdle of connecting to the outside of our home in a safe, happy, healthy way,” says UBCHO’s Razani. “I feel that we must attach more people to outdoor spaces because it’s in a crisis situation.”,Healthy Parks Healthy People Bay Area, which Razani has played a role in shaping, is the nation’s most comprehensive park-prescription program.In addition, the City of San Francisco is, to date, the only city in the world to have fully adopted park prescriptions within its Department of Public Health, with weekly health-oriented programs at parks throughout the city.On the opposite coast, Washington, DC, is home to another well-known park-prescription program. There, Unity Health Care pediatrician and park-prescription advocate Robert Zarr has built a program from the ground up in which he has mapped and rated all the green spaces in the city for accessibility, cleanliness, safety, amenities, and services, producing a database that can be linked directly to patients’ electronic medical records. Zarr’s program has considerably less institutional support than the Bay Area programCurrently 180 doctors at 26 Unity Health Care locations across the city have signed on, representing a potential reach of more than 100,000 patients. “If I’m successful in the next year and a half, I should have almost every pediatric practice [in the city] on board with prescribing nature,” Zarr says.Kids in Zarr’s own clinic, which serves low-income and uninsured families , have high rates of obesity, asthma, and mental health disorders including ADHD, depression, and anxiety. They also rarely visit parks, consistent with broader findings about socioeconomic factors and access to green spaces.Journal of Physical Activity and Health, that he says shows a statistically significant increase in time spent outdoors following a prescription.While Zarr has yet to formally evaluate the health effects of his park referrals, he recently performed a study of 212 patients, currently under review at the Gilbert Liu, a pediatrician and associate professor at the University of Louisville, recently completed a 20-month pilot park-prescription program of his own and a concurrent study to determine if park referrals changed patients’ behavior.“It’s clear that you can’t just tell somebody, ‘Hey, you really need to go to a nearby park and exercise more,’” Liu says. “You need to figure out what exercise is attractive to patients, then identify barriers and overcome those.”Prescription Trails, based in Albuquerque, New Mexico, and likely the nation’s longest-running park-prescription program, has since 2008 refined and expanded its own approach to encouraging physical activity. Detailed park descriptions and an electronic, customizable “prescription” serve as tools for physicians and other healthcare professionals to encourage patients to be active outdoors.While the New Mexico program’s grassroots approach has inspired similar efforts in other cities and states, executive director Charmaine Lindblad says she hasn’t yet found funding to assess how many local physicians have embraced park prescriptions, let alone health outcomes for the patients of those who have. “It kind of just exploded, and we’ve never been able to really keep track of who’s using it,” she says.In the coming months, park-prescription proponents will collaborate on establishing a new framework for regional park–health partnerships nationwide. “A lot of these programs have been built on the backs of individuals, but right now we are working on a larger-scale program,” Wheeler says.In April 2016 Wheeler, Bashir, and others will organize the nation’s first-ever conference on park prescriptions, designed to provide practical information for implementing and carrying out local programs. For the last two years Bashir and Wheeler have organized a smaller summit on the subject for some of its leaders nationwide,With the Bay Area program as a model, the NPS hopes to bring the Healthy Parks Healthy People concept to communities across the country. “We are at the tail end of that first phase of this program, and now what we want to do in the National Park Service is implement some of the best practices and build and sustain a national model,” says Newman.One beneficiary of emerging science and the first wave of implementation is Dorothy Ibes, a lecturer and director of the Parks Research Lab at the College of William and Mary in Williamsburg, Virginia. Ibes is currently piloting a new park-prescription program—GWA Park Rx (Greater Williamsburg Area Park Prescriptions)—with a group of physicians and psychologists on campus and in the community.Once it is widely established, GWA Park Rx will serve as a laboratory for Ibes’ research on the mental and physical health outcomes of park prescriptions as well as on ways to optimize park-prescription programs more broadly. “It’s really about getting your dose of nature right where you are and integrating it into your daily activities,” she says.Programs like hers could translate to more opportunities for the randomized controlled studies that most researchers in the field say are needed. Without rigorous longitudinal or prospective studies to establish causality and dose–response metrics, says CREAL’s Dadvand, researchers won’t be able to provide the sort of results that many healthcare providers, insurers, and government agencies require to fully buy in to the park-prescription concept.“We have a tremendous amount of evidence tying access to nature to better health outcomes for a staggering array of specific diseases and disease categories,” says Kuo. “But you don’t know for sure that there isn’t something else going on until you actually do a randomized trial. Until you’ve ruled out those other possibilities, then as scientists you can never say for sure.”While leadership from the healthcare sector on the national scale has been largely absent to date, Kaiser Permanente, one of the country’s largest providers with more than 10 million members,Wheeler acknowledges that practical roadblocks exist to full acceptance within the healthcare industry. These include finding a way for providers to bill their time in prescribing parks and, as Liu and others have found, learning how to change the behavior of patients who may be more inclined to take a pill than to visit a park.Perhaps the key is embracing a shift in perspective from treatment to prevention, and from negative to positive environmental health factors, James suggests.American Academy of Pediatrics District of Columbia Chapter and partnershttp://aapdc.org/chapter-initiatives/dc-park-rx/U.S. Department of the Interiorhttps://everykidinapark.gov/Parks Research Lab, College of William and Maryhttp://www.gwaparkrx.com/National Park Servicehttp://www.nps.gov/public_health/hp/hphp.htmInstitute at the Golden Gate and partnershttp://instituteatgoldengate.org/hphpbayareaSF Rec and Park in partnership with Healthy Parks Healthy People Bay Areahttp://sfrecpark.org/recprogram/healthy-parks-healthy-people/National Recreation and Park Associationhttp://www.nrpa.org/Grants-and-Partners/Recreation-and-Health/Park-Prescriptions/New Mexico Health Care Takes on Diabeteshttp://prescriptiontrails.org/index/index.shtmlEast Bay Regional Park District and UCSF Benioff Children’s Hospital Oaklandhttp://www.ebparks.org/activities/hphp/shine


We rehearse the processes of innovation and discovery in general terms, using as our main metaphor the biological concept of an evolutionary fitness landscape. Incremental and disruptive innovations are seen, respectively, as successful searches carried out locally or more widely. They may also be understood as reflecting evolution by mutation  versus recombination (disruptive). We also bring a platonic view, focusing on virtue and memory. We use ‘virtue’ as a measure of efforts, including the knowledge required to come up with disruptive and incremental innovations, and ‘memory’ as a measure of their lifespan, i.e. how long they are remembered. Fostering innovation, in the evolutionary metaphor, means providing the wherewithal to promote novelty, good objective functions that one is trying to optimize, and means to improve one's knowledge of, and ability to navigate, the landscape one is searching. Recombination necessarily implies multi- or inter-disciplinarity. These principles are generic to all kinds of creativity, novel ideas formation and the development of new products and technologies. Nothing is original… all creative work builds on what came before.The amount of eccentricity in a society has generally been proportional to the amount of genius, mental vigour, and moral courage which it contained. That so few now dare to be eccentric marks the chief danger of the time.1.http://on.wsj.com/1aF6gpx), and (based on a search at www.amazon.com) more than 750 books with ‘innovation’ in the title have been published in the last three months.The popularity of innovation as a buzzword can be traced back to the 1990s [Strictly speaking, innovation is not just finding a new way of doing something or discovering a new insight; it is about a translation of this insight into a specific application that would have either social or commercial impact: ‘an innovation is something original, new, and important in whatever field that breaks in to a market or society’ . The stuGiven the sheer desirability (one might even say the ‘inevitability’ in Western culture) of innovation, whether in science, technology or any other field of human endeavour, we thus take it that the better we can understand those pathways of innovation, the more easily we can foster it and attain (acquire) the virtue of innovation.et al. [et al. [et al. [et al. [Many metaphors for the process(es) of innovation are possible. However, in common with authors such as Schumpeter , Campbelet al. , Hodgsonet al. ,22, Arthet al. , Fleminget al. , Valverd [et al. , Ganco & [et al. , Caminat [et al. , Geisend [et al. , Simonto [et al. ,30, John [et al. , Vermeij [et al. , König e [et al. , Wagner  [et al. , Solé et [et al.  and Gabo [et al. , we find [et al.  develops [et al. . The ‘la [et al. –42. The  [et al. .)We note that evolution comes in various forms, including natural  evolution, directed evolution , in computational modelling , not all of whom are destined to survive (and none indefinitely), where each of whom inhabits some kind of bounded environment or ecosystem or universe .— encoding that is part of, and/or describes, the heritable properties of those individuals (entities). This will typically be in the form of a string of letters , referred to as a chromosome, though other encodings, such as ‘tree-like’ encodings (discussed below) are also possible.— A ‘genetic’ objective function, also known as a goal or a fitness that allows one to score the desirability or quality of the solution represented by the individual.— An selection scheme or step that favours (but not exclusively) the survival of those that have ‘more’ of it or are closer to it. (There may sometimes be more than one objective function.)— A The ability to perform reproduction to create a new generation of individuals from those who survive long enough to reproduce.— Means of creating diversity as part of the reproductive process, such that not every individual in a subsequent generation is identical to its parent or parents. Reproduction may be sexual (involving two or more parents) or asexual (involving only one). Typical means of creating diversity (in the genetic encoding) involve mutation  or recombination (swapping parts of chromosomes between two or more parents). Reproduction  may also be panmictic—any two individuals may mate—or more restricted  such that a specific individual may mate only with a defined  subpopulation.— For a system to exhibit the kinds of evolutionary behaviour we have in mind, which has been referred to as a ‘universal’  or ‘geneExamples of how these six components may be represented in two different domains are given in sensu lato. Here, it is useful to spend a little time on the concept of the ‘search space’ or universe that the individuals' ‘states’ may inhabit, in this case, the universe of all possible individuals. In the biological case, typically these are uncountably large, as they scale exponentially [possibilities of each ‘genetic’ element of the individual that can have different values or states. Thus, if the ‘universe’ is the list of all possible strings (i.e. sequences) of nucleic acids that are just 30 letters long (rather than say the human genome of approximately 3 000 000 000 bases or letters), and each position can have one of four letters , the ‘universe of possibilities’ is 430 which is about 1018 [ca 1017) [could exist.All of this is commonplace in the realm of natural Darwinian-style evolution. What is less recognized is that it maps generally onto the processes of engineering design and of evolution entially ,58 with out 1018 , slightlca 1017) . Under t3.XY space, used, for instance, to encode the genetic properties of an individual, and how high you are . Thus, it is assumed that the landscape reflects a metric in which things that are close to each other in XY space are close to each other in genetic sequence. In natural evolution, the landscape metaphor derives from Wright [‘Landscapes’ as three-dimensional objects are easy to visualize in terms of two distinguishable properties , namely m Wright . Althougm Wright , and it XY) position in that space, and that position has an associated fitness (height). If then the aim is to create (or breed) an individual with a greater fitness or height, and all one knows is the places that other individuals have occupied and what their fitnesses are [three interlinked concepts. The first is that locally landscapes are reasonably smooth: if one goes in a certain direction and one goes up a slope (i.e. becomes fitter), a second move in the same Cartesian XY-direction is also likely to be (further) up. In terms of the product/technology innovation, this concept translates into a gradual improvement of a specific product property, for example development of better absorptive materials. An improvement of absorbent materials could be considered in a three-dimensional space in terms of thickness of material (X), flexibility (Y) and absorbent capacity . Absorbency is a key function in diapers or nappies. There were a number of different shifts along the landscape that led to progress from the nineteenth century. The earliest from these times consisted of a cotton material, held in place with a fastening; this led to a two-part system of a disposable pad (cellulose wadding covered with cotton wool) and an outer plastic, adjustable garment with press-studs/snaps) developed by Valerie Hunter Gordon in 1947 (http://bit.ly/1zLHe19) and to today's technology based on superabsorbent polymers with multiple absorption zones [Thus, we propose to use the landscape to represent the ‘universe of possibilities’, and individuals, whether they be ideas, products, biological organisms or anything else , each ocsses are , the ‘gaon zones .Table 2second concept is that this ‘local’ improvement cannot continue indefinitely, such that in time one reaches the top of a local peak , somewhat equivalent to a ‘dominant design’ in the product world [http://intel.ly/1nMLOqM).The ct world . The devlower fitness  lighter materials; (ii) better dispensing system; (iii) multi-functional packaging materials . The landscape ruggedness describes or reflects the trade-offs involved.Clearly , there are higher peaks such as Mont Blanc (4810 m) in the Alps or Everest (8848 m) in the Himalaya, but one can only get to them by passing through regions of  sauter’ ). Thus, the distinction between incremental and disruptive innovation  and exploration . Exploration and exploitation also involve a judicious blend between hypothesis-dependent and data-driven strategies . This di4.In the previous sections, we looked at the process of innovation as an evolutionary process and also used the landscape metaphor to demonstrate differences between the processes leading to incremental and/or disruptive innovations. Taking into account these differences before beginning a project, it is very important to define what type of innovation one would like to pursue as it will help to develop a relevant research plan, select appropriate methodologies and also build the right expectations, both in terms of time and appraisal (recognition). In a way, it is similar to choosing a good problem to work on  as it caMeno’, in which Socrates and Meno discussed what human virtue is in general, rather than particular virtues, such as justice or temperance and whether it can be taught [Meno, Plato looks at virtue as a form of knowledge and then develops it into a more holistic concept where virtue encompasses knowledge and ‘something less—true belief’ [aitias logismos  [http://bit.ly/1tUDFFz) to redefine vacuum cleaner technology, following his recognition of the potential of cyclones.To describe the essence of different types of innovation, we decided to use Plato's deliberations on virtues, in particular his work ‘e taught . Our cho belief’ . True beanation) . Thus, vanation)  or to coanation) , which aanation) . Similarhttp://bit.ly/UbSp2i) or synthetic detergent technology [To distinguish between disruptive and incremental innovations as a function of time, we have turned to another philosophical text by Plato, The Symposium. The Symposium is also written in the form of a dialogue, which takes place at a symposium or drinking party in the house of the tragedian Agathon at Athens where a group of men, including Socrates examined the subject of love in a sequence of different speeches . In partchnology   has become the theoretical basis of the multi-billion dollar electronics industry , whereas‘The innovator's dilemma’ [There is also a clear distinction between incremental and disruptive innovation within the framework of the landscape metaphor. ‘Incremental’ innovation involves local improvements that do not stray far from the previous generation while improving their fitness slightly. By contrast, disruptive innovation typically involves a substantial change in both the ‘genotype  and its fitness’. In the book dilemma’ , ChristeIn science, the distinction between what he called ‘normal’  and ‘revolutionary’ (disruptive) science is of course the cornerstone of Thomas Kuhn's famous analysis of ‘the structure of scientific revolutions' . This sa5.Applying these ideas to the design of a new product , it is eIn a similar vein, and while the distinction is somewhat arbitrary, it is possible to argue that incremental innovation is more akin to mutation , whereas disruption requires the introduction of new material or ideas from afar, thus involving recombination .For example, three-dimensional printing started in the 1990s as a way of rapid prototyping development, where computer-generated three-dimensional models can be transformed into physical objects using a layer printing process . It starWe here give some examples of the kinds of innovation that clearly come from optimizing and recombining elements from different disciplines or domains of knowledge, or even different domains of the same area.5.1.5.1.1.As is well known, following the development of systematic DNA sequencing –89, ther5.1.2.Innovation can be facilitated by combining expertise from different domains (industries), for example, creating a new fibre by bringing together petroleum-based fibre expertise and biotechnology expertise. DuPont and Genencor collaborated to develop a biotechnological process in which bacteria were made to produce a required material. The gene-engineered bacteria converted glucose into propanediol which was used by DuPont to make the new fibre, Sorona, and create a more environmentally sustainable process by using starch instead of petrochemicals ,102. The5.2.5.2.1.3 = 64 triplets and 20 natural amino acids, so in some cases, more than one triplet encodes a particular amino acid, whereas three of the 64 codons, known as stop codons, encode a signal to stop reading the DNA. The aim, as ever, is to move round the search space by creating variance in the sequence while measuring the fitness in terms of properties such as the ability to catalyse, as ever, greater rates of a particular (bio)chemical reaction. A particularly clear example of innovation as evolution comes from the field known as directed evolution. In biology, genes encode proteins according to a fixed mapping (the ‘genetic code’) whereby particular triplets of bases, known as codons, encode the sequence of a protein that is then made by suitable hosts cells. There are 4M substitutions in a given protein of N amino acids is 19 M.N!/(N − M)!M! [ca 16 million and ca 30 billion. Even for a very small protein of N = 50 amino acids, the number of variants (2050) is some 1065! The same combinatorial formula applies to finding the subset of k enzymes out of n that one might wish to change for some benefit; if n is 1200 !M! . For a ptabolism –107), foto an external agency (the human experimenter) seeking a better biocatalyst (or whatever the product may be). While this is of course equally true in the human breeding of organisms whether say for agricultural purposes [What distinguishes natural evolution from directed evolution is that the selection is not done on the basis of any biological survival ability of the host organism but simply on the value purposes  or as doThus, we have examples of the role of recombination –111, fit5.2.2.Although the concept of ‘directed evolution’ is usually applied to proteins, at least in biology, similar phenomena can be observed in the ‘evolution’ of novel substances or recipes of other kinds . The inv6.The three princes of Serendip (Serendip is an ancient name for what is now Sri Lanka), whose heroes ‘were always making discoveries, by accidents and sagacity, of things they were not in quest of’. In modern terms, it might be seen as obtaining a finding that was not part of the expected outcome of a hypothesis-dependent experiment [XY-coordinates but also the fitness functions), as per ‘innovation by analogy;’ as discussed above under TRIZ.The word ‘serendipity’ was coined by Horace Walpole from the Persian fairy tale periment ,67,136. periment ,137, altperiment . Followiperiment  of the aperiment ,140, theperiment  and Listperiment , whereasperiment  had justperiment ), and howww.aber-instruments.co.uk)—came about through a search for experiments that might help one detect lateral ion transport along the surfaces of biological membranes, as part of a programme to test competing theories of membrane bioenergetics [Certainly, at least two significant scientific discoveries or innovations made by one of us (D.B.K.) came from experiments done with entirely different goals in mind. The first—a radio-frequency dielectric biomass probe ,146, leaergetics –151. Theergetics –156, camergetics –163, andergetics  or secreergetics ; howeverergetics , it is nAnother example of a serendipitous discovery by the second author was the synthesis of novel hydroxyl-benzyl amino acid derivatives when by mistake instead of an omega-amino acid that was believed to be the right molecule to study membrane interactions, its alpha-derivative was used. This new compound proved to be a potential useful diagnostic tool to study secretory kidney function ,167.In addition to serendipity in scientific discoveries, some of the world's most iconic products happened by accident—such stories include for example pharmaceuticals and the food sector. Proscar was designed to treat the benign enlargement of the prostate. After 5 years on the market in the 1990s, it became clear that one of the side effects of Proscar was hair growth on bald men and this was immediately recognized as an opportunity to launch a new product, Propecia, to treat male-pattern baldness. Pfizer developed sildenafil as a treatment for hypertension, angina and other symptoms of heart disease. However, phase I clinical trials revealed that while the drug was not great at treating what it was supposed to treat, male test subjects were experiencing a rather unexpected side effect: erections. A few years later, in 1998, it was marketed as Viagra in the USA as a treatment for ‘erectile dysfunction’ and became an overnight success. It now turns over an estimated $1.9 billion dollars a year. The recognition of the frequency of drug promiscuity  is now aBrandy started off as a by-product of transporting wine. About 900 years ago, merchants would essentially boil the water away from large quantities of wine in order both to transport it more easily and to save on customs taxes, which were levied by volume. After a while, a few of these merchants, bored perhaps after a long day on the road, dipped into their inventory and discovered that the concentrated, or distilled, wine actually tasted rather good and that is how brandy was born. Another food beverage, this time non-alcoholic, was originally invented as an alternative to morphine addiction, and to treat headaches and relieve anxiety. Coke's inventor, John Pemberton—a Confederate veteran of the Civil War who himself suffered from a morphine addiction—first invented a sweet, alcoholic drink infused with coca leaves for an extra kick. He called it Pemberton's French Wine Coca. It would be another two decades before that recipe was honed, sweetened, carbonated and eventually, marketed into what it is today Coca Cola.7.7.1.Serendipity is welcome, but is probably not the best strategy to rely upon. The question then becomes what type of innovation virtue  do we need to nurture—virtue or true virtue, incremental or disruptive innovation? There could be different schools of thoughts, with a tendency to concentrate only on disruptive innovation. However, we believe that it would be beneficial to have and foster both, and to be explicit about their pros and cons. The pros of incremental innovation are that it can generate news relatively quickly, be it via a scientific publication or the launch of a new product version. In addition to this, in dialectic terms, quantity can lead to quantity and when a critical number of incremental innovations are achieved, it can result in a major breakthrough. The cons of incremental innovation include that it can have a limited impact and may not last for very long (has limited memory) and will quickly be superseded by new developments. Disruptive innovation can though have a major impact and become a spring board for new developments, but because disruptive innovations are  rarer, disruptive innovation does require more time and ‘skill’ to develop. There are a number of ‘directive’ elements that can be applied for both incremental and disruptive innovation.7.1.1.If we accept the metaphor of all kinds of ‘innovation’ as being equivalent, at least in part, to search on an ‘adaptive’ or ‘evolutionary’ landscape for improved fitness, it becomes comparatively easy to map the elements of what we need to do to improve such searches 7.1.2.Equally important to the evolutionary process, and not entirely separable from the question of the maintenance of diversity in that it can contribute to it, is the nature of the selection regime. Peer review of grant applications and publications (leading to success in funding or publication) is an obvious example of selection in the academic world , whereas product successes in the market place are a metric of success for product innovation. It is also reasonable to consider the generation of novelty as ‘science push’ and the selection of that novelty as ‘market pull’.While the fundamental elements are the same in achieving both types of virtues , the difference comes from the ‘landscape scope’ (diversity of the landscape) and the ‘how’ (how to navigate through the landscape).7.1.3.Any breakthroughs require ‘out-of-the-box’ thinking that can be manifested in different ways. This even includes the construction or understanding of the landscape, for example an ability to construct a diverse landscape with the right fitness.The maintenance of diversity to prevent premature convergence to suboptimal solutions is a well-known means of avoiding becoming trapped in local optima, and relates to the exploration/exploitation trade-off discussed above. This diversity is in both fitness  and in ‘genotype’ (which frequently is not ).have many of them, as well as means of retaining the best ones and creating new ones [one recommendation is that to innovate one must read and experiment widely and try many combinations to achieve success [indows operating systems for personal computers [If much of the search involves changing or swapping the various components necessary for a good result, it is first and obviously necessary to new ones . So one  success . . How best to navigate the landscape is in some sense a function of its ‘ruggedness’. ‘Ruggedness’ is a term that is hard to define exactly, but if there is a good correlation between fitness and ‘distance’ a landscape is said to be (relatively) smooth, whereas if fitness and distance are weakly correlated—with lots of mountains and valleys appearing seriatim as distance varies—then the landscape is more rugged. From this perspective, exploitation makes more sense for smooth landscapes, whereas exploration makes more sense for rugged landscapes.The ability to broaden the landscape and a high degree of exploration creates opportunities to challenge the existing dogma and thus to lay the path to new discoveries. ‘History is replete with tragic and comic confrontations between experts fanatically attempting to enclose knowledge within a definitive representation of the world and discoverers stubbornly attempting to open, enlarge and disrupt it. This confrontational need to oppose dogmas and consecrated knowledge in order to achieve momentous discoveries did not always originate from improved hypotheses about the natural world. Certain major findings were not only made in spite of a misconception, sometimes they happened precisely because of it’ .8.This is a broad subject, and in a short article, we cannot possibly hope to be comprehensive. However, we find that the evolutionary metaphor is indeed extremely (and possibly surprisingly) useful for understanding diverse processes of innovation both in science and industry. It is important to recognize from the beginning which path one wants to pursue—disruptive or incremental innovation. If one would decide to engage in the development of a disruptive innovation, be it in industry or science, two key aspects should be taken into consideration: time and landscape. As discussed in the article, disruptive innovation will have a bigger impact but it could take a long time, for example the recognition of most breakthrough innovations came many years later . In term