Patient information sharing between hospitals and community pharmacies is generally insufficient. Since August 2013, the pharmacy department of Kyoto University Hospital has initiated and mediated a collaborative relationship between physicians and neighboring community pharmacies .This study describes how community pharmacists have developed as a result of this professional collaboration  and attempts to grasp its current situation through interviews with pharmacists. The authors conducted semi-structured individual interviews with community pharmacists between June and December 2014. The interview data were analyzed using the constant comparative method.Twenty-one pharmacists working for 11 neighboring community pharmacies were interviewed, at which point theoretical saturation was achieved. The mean interview time was about 50 min. Among the participants, there were 15 women and 6 men; 10 were pharmacist managers and 11 were staff pharmacists. Through the analysis of the interview data, 13 categories were generated from 32 concepts. The results indicated that, through the Kyoto University Hospital model, community pharmacists shifted from a “Mindset of being the hospital’s subcontractor” to “Being motivated to participate in team care.” Specifically, their professional attitude shifted in a positive direction to “Being motivated to participate in team care”, which was a departure from their previous feelings of inadequacy, related to their “Mindset of being the hospital’s subcontractor” and how “Barrier to medicine counseling”.Under the Kyoto University Hospital Model, hospital pharmacists encouraged active collaboration between physicians, hospital pharmacies, and community pharmacists by cultivating face-to-face relationships. This in turn helped community pharmacists become more conscious of their expert status, and thereby participate actively in patients’ treatment. Recently, in developed countries with rapidly aging populations, securing the effectiveness and safety of medication therapy for outpatients has become a major issue. To this end, the 2011 Good Pharmacy Practice guidelines  [The separation of prescribing and dispensing, also called dispensing separation, has been practiced in Japan since 1956 . As a reA tracing report system was implemented in 2012, involving the feedback of information recorded at the community pharmacy to the prescribing doctor. When sending a tracing report, community pharmacies can calculate the insurance score as a medication information provision fee. However, tracing reports were issued for only 0.04% of the total number of prescriptions in 2014 .In an effort to improve this situation, in August 2013, the Kyoto University Medical School Hospital  established a system of medical collaboration between physicians and neighboring community pharmacies, mediated by the hospital pharmacy department . The colThis was a qualitative interview study. Subjects were community pharmacists from the 11 community pharmacies around Kyoto University Hospital. Participants were eligible for inclusion if they were pharmacists who (1) had participated in one of the regular collaboration meetings held by the Kyoto University Hospital Pharmacy Department; (2) had worked in one of the 11 neighboring pharmacies for at least one year (to enable comparison with the situation one year ago); and 3) had at least three years’ work and dispensing experience. We used purposive sampling to select participants, aiming to obtain at least one pharmacist from each of the pharmacies, to ensure a balanced response. The manager of each pharmacy was asked to introduce the authors to working pharmacists, so they could be recruited directly. This recruitment procedure, which was conducted concurrently with data collection and analysis, continued until theoretical saturation was reached .The data collection was carried out via semi-structured, individual, in-depth interviews using an interview guide Table .Table 1IIn-depth interviews were selected because the authors needed frank appraisals of the Kyoto University Hospital model. The interviews were conducted at the pharmacy where each participant worked, and was audio-recorded with participants’ consent. Each interview was conducted by the first author (MH), an expert interviewer with experience working as a community pharmacist. As background, the authors administered a questionnaire asking participants about their participation status in the collaboration.A verbatim record of each interview was prepared from the recordings and used as language data for analysis. The data were analyzed using the constant comparative method, a type of thematic analysis considered particularly accurate for explaining and predicting human behavior , and theThe analysis procedure was as follows. We analyzed the data inductively by checking the analysis theme while in contact with the verbatim records. We then developed concepts from each part of the text we focused on , corresponding to the analysis theme. The concept creation and naming process was recorded in theoretical memos. Once a concept was nearly completed, the textual data was examined again to determine if there was an example of an opposite concept. When an opposite case existed, the concept was finalized; if no opposite existed, this was noted in the theoretical memo of the analysis worksheet. Concept development and opposite case-finding were repeated to generate further concepts and categories, and the relationships between the concepts and categories were examined and recorded in theoretical memos. The findings generated through this process was reviewed by a supervisor (KM) and multiple analysts, and their findings were triangulated .This research was approved by the Kyoto University ethics committee of medical doctors . The purpose of the study and privacy protection was explained to all research collaborators and cooperating organizations, and both written and verbal consent was obtained from participants.From June to December 2014, interviews were conducted with 21 pharmacists working for the 11 neighboring community pharmacies. Theoretical saturation, when no new knowledge is obtained through further investigation, was reached by the 19th participant, and we conducted two more interviews to confirm this. The mean time for interviews was 50 min. The participants were 15 women and six men; 10 were pharmacist managers and 11 were staff pharmacists. Their median practice experience was 14.5 years, and 17 of the 21 participants had participated in the regular meetings three or more times (nine meetings were held between August 2013 and December 2014). Eight participants had not submitted a tracing report  to a .Since there were many things that truly depended on imagining what patients talked about, if patients did not want to talk much. Even if I asked about the intention of the prescription change, they just said “I’m OK, I know”.Even when the community pharmacists had the opportunity to hear to the story of a (Patient who cannot be honest with their doctor), information-sharing was not possible because the doctor had a policy of  by phone. Meetings with the hospital were experienced as (One-way meetings).Because of , pharmacists felt that it was difficult to talk to the  even when there were problems. In this way they had the【Mindset of being the hospital’s subcontractor】.I think it’s probably a personal idea, but it feels like I am a subcontractor. So by any means, I think it’s very hard for me to think about that equality. (Community Pharmacist B).Against this background, a【hospital pharmacist’s visit】was facilitated.And then, for the first time, when the hospital pharmacist came, I was very surprised. And it happened that they asked us for a collaboration on inhalation guidance ... (Community Pharmacist C).The visit triggered 【The beginning of the medical collaboration】.It’s nice to hear from the hospital pharmacist, “Let’s all work together and do our best,” and we also feel a sense of intimacy. In that case, it will be easy to say anything, and I think that it is possible to go a little further and for this to become a very good relationship so that it is easy to talk at study meetings as well. (Community Pharmacist D).They experienced a 【Confrontation with blood test data】, which was the result of their lack of experience in medical management using examination results.Certainly, because we have not learned about blood test values at school, we have to study on our own. (Community Pharmacist E).Community pharmacists were 【Puzzled by the tracing report】as they did not know what to report, they expected (Difficulty with document transmission) and questioned the (Speed of doubt inquiry) by faxing the tracing report, rather than contacting the doctors telephonically.Hospital pharmacies and doctors say “Please send me a tracing report if you notice something,” but I wonder how much they really want? (Community Pharmacist F).By participating in the meetings during the collaboration, community pharmacists felt  and deepened their understanding of the collaboration by the【Recognition of roles】.At the meetings I can listen to the doctor’s lecture about what I normally see in the prescription. Since the hospital pharmacy has engaged in such collaboration, I have not quite figured out what I am doing at the hospital yet, but I think that it will become quite clear. (Community Pharmacist G).【Interaction with doctors】took place at the meetings, increasing community pharmacists’ familiarity with the doctors. It became easier to consult with doctors by increasing their (Understanding of prescription intention).I told a kidney specialist after a meeting, “If I doubt the medication dose, I am somewhat hesitant to ask questions. Because even if there is a problem with the kidneys, I would think that you probably already knew of it, and I would refrain from asking questions.” But doctor said “Oh, please ask me about that kind of doubt; sometimes we make mistakes, even in the kidney specialty.” (Community Pharmacist H).Even the Kyoto University doctor always looks at the name on the prescription, but when I actually feel that the doctor speaks, the meaning is completely different when I look at the prescription, and I feel familiarity. (Community Pharmacist B).Community pharmacists developed an 【Awareness of their responsibility】. By checking the blood test values, they could identify an (Indicator of disease condition) and provide an (Accurate medication consultation) for their patient. Their pharmacy became a (Place of OJT).I have a sense of awareness that I have to know just because the blood test values have been put on the prescription. And I also feel that some of the medicines that should be more used more mindful about kidney function and liver function are something that we must know.(Community Pharmacist I).They improved their skills to 【Change to proper administration of medication dose】 and  by acquiring knowledge.Well, when I contact the doctor about blood tests, the doctor definitely changes the dose with regard to the function of the kidneys. (Community Pharmacist J).When a community pharmacist reported a patient’s drug adherence to a doctor, the 【Support of the hospital pharmacists】encouraged and guided them. They showed (Willingness to improve skills), but also experienced (Anxiety about future policy change).When the contents were unknown, I received a call from the hospital pharmacist. I think that’s good for us. (Community Pharmacist G).The community pharmacists gradually implemented 【Active use of the tracing report】. When they noticed a therapeutic problem in a patient, they decided on the best route to (Provide adherence reports to doctor).Well, when I interviewed patients, there were sometimes things I doubted, like adverse events. I reported them and hoped that the doctor referred to them at the next patient visit. (Community Pharmacist K).Through participation in the collaboration, community pharmacists had more opportunities to be thanked by both physicians and patients, positioning them as a (Pharmacist trusted by patients). This led to them 【Being motivated to participate in team care】Fig. .Fig. 1CoOne thing that came directly from the doctor, was “Thank you for providing the information,” which was from the doctor who I gave it to. I thought that was very good. “Oh, I was happy to submit a report!” Already, I was very motivated at that time. (Community Pharmacist K).Using the constant comparative method, we analyzed community pharmacists’ change in mindset after increasing their collaboration with university hospital staff in one area of Japan. Triggered by a【Hospital pharmacist’s visit】, Community pharmacists were found to become more conscious of their role as specialists, which led to them【Being motivated to participate in team care】. This was a departure from their previous feelings of inadequacy related to their 【Mindset of being the hospital’s subcontractor】 and their perception that【Pharmaceutical management was difficult】. The direct expression of doctors’ gratitude for information they received often seemed to prompt community pharmacists’ behavioral change. This can be explained using the behavior change model advanced by social cognitive theory (SCT). According to SCT, three main factors affect the likelihood that a person will change a health behavior: (1) self-efficacy, (2) goals, and (3) outcome expectancies. If individuals have a sense of personal agency or self-efficacy, they can change their behavior even when faced with obstacles . Self-efChanges in community pharmacists’ mindset about the collaboration began with the【Hospital pharmacist’s visit】. In the interview, one community pharmacist said “I was very surprised that we were being visited by the manager and deputy manager of the Kyoto University Hospital pharmacy.” Before the collaboration began, the community pharmacists generally experienced a【Mindset of being the hospital’s subcontractor】, which is, by definition, an unequal relationship. However, when the hospital pharmacy department initiated the collaboration – particularly the regular meetings – the relationship shifted to become a face-to-face relationship. Snyder, et al. noted that when community pharmacists and physicians begin collaborating, it is important for them to establish a face-to-face relationship, as it can facilitate mutual confidence and clarification of roles . AdditioThe tracing report is a tool used by community pharmacists to inform doctors of issues with a patient’s adherence to their regimen. Medical service fees for tracing reports have been in place since 2012, but these reports are still rarely used . In the In Japan pharmacists are obliged to make pharmaceutical inquiries when doctors issue problematic prescriptions. According to Article 24 of the Pharmacist’s Law, “if there is any suspicion during prescription, consult with the doctor, dentist, or veterinarian who issued the prescription, and after confirming the suspicious point, we must dispense the medication”. Such pharmaceutical inquiries must therefore be done before dispensing, which has the disadvantage of increasing patient waiting time. Meanwhile, according to the Kyoto University Hospital pharmacy, 124 tracing reports were issued in the first eight months of the collaboration – roughly only 0.06% of the total number of prescriptions . This isUnder the Kyoto University Hospital model, several community pharmacists reported having a 【Confrontation with blood test results】. Some of their comments included: “Only some of the latest blood test data are shared with examination results;” “We have had little experience with examination results so far;” and “It is difficult to manage pharmacies because we do not know the blood test results or treatments of outpatients.” When Joosten, et al. examined the estimated glomerular filtration rate (eGFR) warning system, pharmacists were prompted to suggest a dosage for outpatient prescriptions to the doctor; 66% of these suggestions were accepted  This impThis study was conducted in the first year of the collaboration. Although pharmaceutical inquiries related to blood tests and submission of the tracing report were not sufficient in the first year, it is expected that further behavior change will take place as the collaboration continues. According to the transtheoretical model of behavior change, individuals must progress through an initial period (preparation) wherein they determine the opportunities for execution of certain behaviors, after which they become interested in particular behaviors which they ultimately apply (action) . ProgresIn this study, only 11 community pharmacies surrounding Kyoto University Hospital were covered; the behavior changes of community pharmacists in response to collaboration might differ in other areas. Furthermore, since this study was conducted in the first year of collaboration, only the short-term changes could be captured. In addition, purposive sampling was used; while at least one pharmacist from all 11 neighboring community pharmacies was recruited to prevent unbalanced opinions, it is still possible that selection bias occurred. To apply this research to the creation of collaborations between hospitals and community pharmacies in other environments, it is necessary to carefully consider the specific circumstances of those environments.Under the Kyoto University Hospital Model, hospital pharmacists encouraged active collaboration between physicians, hospital pharmacies, and community pharmacists by cultivating a face-to-face relationship. This in turn helped community pharmacists become more conscious of their expert status, and thereby participate actively in the treatment of patients.


Its Latin inscription, translated as “Here for you a smiling garden of everlasting flowers”, suggests that this herbarium was a gift for a patron of the emerging botanical science. We follow an integrative approach that includes a botanical similarity estimation of the En Tibi with contemporary herbaria  and analysis of the book’s watermark, paper, binding, handwriting, Latin inscription and the morphology and DNA of hairs mounted under specimens. Rejecting the previous origin hypothesis , we show that the En Tibi was made in Bologna around 1558. We attribute the En Tibi herbarium to Francesco Petrollini, a neglected 16th-century botanist, to whom also belongs, as clarified herein, the controversial “Erbario Cibo” kept in Rome. The En Tibi was probably a work on commission for Petrollini, who provided the plant material for the book. Other people were apparently involved in the compilation and offering of this precious gift to a yet unknown person, possibly the Habsburg Emperor Ferdinand I. The En Tibi herbarium is a Renaissance masterpiece of art and science, representing the quest for truth in herbal medicine and botany. Our multidisciplinary approach can serve as a guideline for deciphering other anonymous herbaria, kept safely “hidden” in treasure rooms of universities, libraries and museums.We reveal the enigmatic origin of one of the earliest surviving botanical collections. The 16 Botany emerged as a practice of medicine. For centuries long, apothecaries and physicians applied the remedies prescribed in the herbals of classical authors such as Dioscorides and Pliny, copied and translated in many languages, illustrated, edited and extended with additional plants and treatments . These rRenaissance Italian scholars radically changed this state of affairs, giving birth to the discipline of botany as we know it today , 4: the th-century collections, namely the Ducale Erbario Estense (hereafter “Estense herbarium”) kept in Modena ) and alphabetical  covering the book’s first pages. An embossed inscription on the cover reads En tibi perpetuis ridentem floribus hortum, “Here for you a smiling garden of everlasting flowers”, suggesting that the book was intended as a gift. Gronovius ).Regarding the other herbaria, there is some similarity between the En Tibi and the Cesalpino herbarium, but not enough to indicate a common origin, as the number of En Tibi specimens of “vague/coincidental” and “no similarity” are rather high . The mosth century. The dissimilarity of the En Tibi with the Merini and Estense herbaria cannot be merely attributed to a size difference; these two herbaria, although smaller, contain several species not present in the En Tibi , 16th ceAll in all, the remarkable similarity between the En Tibi and the Rome herbarium in both species and their original names, in the arrangement and morphological aspects of specimens, and the provenance of the species  indth century physician named Francesco Petrollini from Viterbo …” …” . Could tdosio]…” . We alsodosio]…” . It is tdosio]…” , 49. In dosio]…” , 51. A fdosio]…” . The resdosio]…” , 19–21. dosio]…” , 19, newth century. Considering that multidisciplinary puzzles need a multidisciplinary approach to be solved, we propose this integrative research as a guideline for exploring historic book herbaria of unknown origin that are archived in the collections of universities, libraries and museums around the world.The En Tibi herbarium is a masterpiece of art and science. More than a book with dried plants, the En Tibi is a luxurious output of the quest for truth in herbal medicine, the Botanical Renaissance that Italian scholars initiated in the 16After almost 500 years of anonymity, we suggest that the En Tibi herbarium was made by Francesco Petrollini in Bologna around 1558. Although Petrollini’s handwriting is not present in the book, we consider the botanical similarity to his personal collection, i.e. the Rome herbarium, strong enough to support our hypothesis. This similarity is evident in the included plant species and their attributed names, the botanical authors mentioned, and the arrangement and morphological aspects of specimens. Further archival investigation in the towns of Viterbo and Cotignola can bring to light more information about this hardly known historical figure and potentially reveal Petrollini’s birth and death dates. Despite the crucial role of Petrollini in providing the plant material for the making of the En Tibi, multiple people were apparently involved in the book’s preparation, writing the indices, the names next to the plants and gluing the specimens. The remarkable botanical similarity of the En Tibi with the Aldrovandi herbarium may be explained by the massive size of the latter, and Aldrovandi’s close relationship to Petrollini. Nevertheless, a potential participation of Aldrovandi, as well as of Mattioli or other contemporary Italian naturalists in the compilation and or commissioning of the En Tibi should be further investigated by means of historical archive work. Moreover, a search in the court book keeping archives of Rudolph II’s father and grandfather may help reveal how the En Tibi came from Bologna to Prague.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(XLSX)Click here for additional data file.S3 Appendix(DOCX)Click here for additional data file.S4 Appendix(DOCX)Click here for additional data file.S5 Appendix(DOCX)Click here for additional data file.S6 Appendix(DOCX)Click here for additional data file.S7 Appendix(DOCX)Click here for additional data file.


Emergency Medical call-takers working in Emergency Medical Communication Centers (EMCCs) are addressing complex and potentially life threatening problems. The call-takers have to make fast decisions, responding to problems described in phone calls. Recent studies focus mainly on individual aspects of call-takers’ work. The objectives of this study were to explore 1) What characterizes individual work performance of call takers in EMCCs? and 2) What characterizes work organizational factors call takers see as most relevant to the performance of their work?n = 19). Interviews were performed during the period May 2013 to September 2014. Data was analyzed using thematic analysis.The research is based upon in-depth interviews with call takers at three EMCCs in Norway  “Core technologies” and 2) “Environmental issues” . The theme “Core technologies” included the subthemes a) multiple tasks, b) critical incidents, and c) unpredictability. The theme “Environmental issues” included the subthemes a) lack of support, b) lack of resources, c) exposure to complaints, and d) an invisible service.At the individual level, multiple tasks, how to cope with critical incidents, and the unpredictability of daily work when calls are received, make the work of call takers both stressful and challenging. The individual call taker’s ability to interprete the situation by intuition and experience when calls are received, is the main factor behind the peculiarities working in the centers at the individual level. At the organizational level, the lack of resources and managerial support seems to provoke concerns about the quality of services rendered by the centers. These aspects should be taken into account in the managing of these services, making them a more integrated part of the health service system.The online version of this article (10.1186/s12913-019-4370-0) contains supplementary material, which is available to authorized users. In cases of medical urgency, emergency medical communication centers (EMCCs) are the primary contact point between callers and the health care system. The EMCCs are manned with emergency medical call takers responsible for answering emergency calls, assessing the need for health care (triage), mobilizing necessary resources and providing pre-arrival instructions to ensure lifesaving first aid until the ambulance arrive . In mostThe organization of EMCCs varies substantially throughout the world, and includes a diversity of combinations of ambulance personnel, paramedics, specialized nurses,, emergency physicians and physicians , 4. In NIn the case of call takers’ work, this expertise is both related to professional knowledge, and formalized by protocols . DevoidWhat characterizes individual work performance of call takers in EMCCs?What characterizes work organizational factors call takers see as most relevant to the performance of their work?Studies on EMCCs have mainly focused on individual aspects of call takers’ work. We wanted to further explore these aspects, but also to include organizational factors impacting on the work of call takers. As healthcare personnel with experience both as call takers, dispatchers, registered nurses and medical doctors, as well as a professor in political science/organization theory, our objectives were to exploreWe used a qualitative approach, conducting individual in-depth interviews with call takers to explore individual and organizational peculiarities of their work.In Norway, there are 16 EMCCs 2019), providing services to all 5.2 million inhabitants. Organization and function of the EMCCs are regulated by law , but EMC, providiEMCC 1 covered three regions, consisting of both rural and urban areas and a population of approximately 1,2 million people. In 2013, EMCC 1 received approximately 315,000 calls of which approximately 124,000 were emergency calls. The region had 45 regular ambulances at its’ disposal in addition to one single paramedic manned ambulance, one motorcycle unit, and one physician staffed rapid response vehicle. In addition, EMCC 1 was responsible for two physician staffed helicopters. The center employed 25 emergency medical technicians (EMTs) coordinating ambulance responses and 29 registered nurses answering emergency calls.EMCC 2 served a population of approximately 400,000 people, and deployed 31 ambulances. It was staffed by registered nurses with additional training in emergency medical dispatch answering emergency calls, and EMTs coordinating ambulance responses. In 2013, they responded to 32,776 emergency calls and handled a total of 63,025 calls.EMCC 3 covered a population of 287, 000 people. It deployed 23 ambulances, and was staffed by registered nurses with additional EMCC training answering emergency calls, and EMTs coordinating ambulance responses. EMCC 3 employed 21 dispatchers, handling almost 110,000 calls per year, responding to approximately 42,000 calls of which approximately 28,000 are emergency calls.n = 1095) of all calls concerning cardiac arrest in the three study sites during the study period [In the three EMCCs, we used a purposive sampling method, selecting information rich cases for in-depth study. The interviews are part of a larger study on EMCCs and how they handle cardiac arrest cases, hence, we had access to and reviewed audio files n = 105 of all A semi-structured interview guide was developed over several iterations, and was based on existing literature as well as discussions among the authors / paramedic (n = 2). Mean age was 45.2 years (range 29–62 years), 21% male.From EMCC 1 ten call takers participated, while five call takers participated from EMCC 2 and four call takers from EMCC 3. The call takers had been working in an EMCC for an average of seven years (range 0–19 years), and had an average of 12.6 years of working experience as a nurse  Core technologies and 2) Environmental issues. The theme “Core technologies” included the subthemes a) multiple tasks, b) critical incidents, and c) unpredictability. The theme “Environmental issues” included the subthemes a) lack of support, b) lack of resources, c) exposure to complaints, and d) an invisible service.The call takers identified several issues that were related to the core technologies in their individual work performance.The participants described their work as very complex. Responding to the 1–1-3-calls included not only to talk to the caller, but also to verify where the patient was, to try to identify the problem and to decide how to respond, as well as to give the caller instructions about what to do until the help arrived. In addition the job included to be in contact with the EMT coordinating the ambulances, as well as to respond to additional phonecalls from e.g. General Practitioners (GPs). In addition they had limited time to consider the options.Most of the participants described to do their triage based on earlier experiences, since they had no visual or physical connection with the actual patient. Participant 13 expressed: “I use my experience and intuition. This makes me able to ask further, because I have the ballast I do”.The participants were also aware of the tone of the callers voice, and signs of stress or anxiety. They also considered the patients’ age and normal vital parameters, and even location and time: “It depends on how close it is. We may not have any ambulances nearby” (Participant 18), and: “What was he doing up at that time at night?” (Participant 14).Call takers used words like “perceive”, “experience”, “interpret”, “feel”, “hear” or “understand” when describing their own decision-making. Participants emphasised that there were seldom doubt in critical cases, and that it was more difficult to judge in more vague situations.The participants identified several other tasks during the 1–1-3 calls, depicted as to “comfort the caller”, “build trust” or “support and help”. Communication challenges due to language difficulties were common, as described by many of the call takers.Many of the participants described calls that had made great impact upon them, especially related to incidents involving children. The participants described calls relating to “life or death”, and callers in crisis. Many of the participants described this a psychological challenge. Participant 10 stated: “Obviously, sometimes you feel that this case is lost. I suppose it is, but I cannot be sure”.The work at the EMCC exposed the participants to a great variation of events, being the first person in contact with the involved caller. Calls ranged from non-acute medical problems that should have been directedelsewhere, to critical accidents, severe illness and suicides. The calls made great influence on the call taker, as described by e.g. Participant 18: “It’s the psychological strain to sit there, knowing that no matter how large the incidents, I’m alone with it”. This was supported by e.g. Participant 12 who stated: “… getting the dispair straight into my ear, into my head, and it won’t disappear ”.Several of the participants told that after a critical incident with many impressions, they needed a time-out, not having to answer the next 1-1-3 call for a while.The only thing the participants could prepare for was to come to work, sit down and start taking the phonecalls. The rest was up to the caller, or what happened outside in the society. Participant 16, who had only two months experience from the EMCC, said: “Well, I’m not like adrenaline-kick-prepared. But I always have a mentality that I have to be ready for worst case scenarios”.This was also emphasized by more experienced call takers, e.g. Participant 17, who stated: “You never know if it’s an ordinary chest-pain call, or whether a plane has crashed”. Moreover, participant 1 expressed: “We are feeling stressed all the time. Even though we are not physically active. It’s not a normal physiological situation- we sit still and are stressed out”.Due to this unpredictability, several of the recruits to new jobs at the EMCCs quitted after the training period.The participants also identified several organizational factors that were relevant to their work performance.Immediately after a critical incident some of the participants described a need to “take a time-out”, leave the phone and take a walk, finding themselves “just staring into the screen in front of me” (Participant 15). Unfortunately, this was not always possible, due to multiple incoming 1-1-3- calls. Structured debriefs were performed amongst ambulance personnel, but call takers were seldom invited to these kind of events. Most of the call takers drew a picture of an absent management. This implicated that the call takers did not get any indication on the quality of their own performance, as Participant 19 stated: “I do not receive any feedback. If I choose to make a bad decision, there’s nobody there to get me on the right track”.Most of the call takers also emphasized that, if they eventually heard something from their leader, it was in cases of an error or a complaint. Call takers often experienced being called by managers at home, as described by Participant 14: “What’s not okay is that you receive a call, in your spare-time… I could have been sleeping, having a vacation, a day off. This destroys my whole day”. This aspect led to that call takers asked multiple questions to clarify most situations to “secure their own back” (Participant 6), because they did not feel sure that their leaders would support them if needed.Lack of resources where both related to internal as well as external resources. Internal resources where defined as technical equipment such as head-sets that were not able to shut out disturbing noices from the central, not functionable map-systems or computer systems that did not communicate with each other. This also included a lack of call takers to respond to the 1-1-3-calls, and EMTs to coordinate the ambulances. This was especially visible during evening and night shifts, as well as in weekends. In all of the EMCCs leaders stribed to reduce answering time, and confronted call takers with delays. Participant 13 claimed: “It is not bearable! When they (the managers) point out that four per cent of the calls waits for 20 seconds, and that is too much”.According to this call taker, this had an impact on each phonecall: “This certainly affects us and how we end the conversation in each call, right”.Lack of personnel also implicated that there was not room for any breaks if a call taker needed a “time-out”, or even to eat or to visit the toilet.In means of external resources this was related to a lack of ambulances, which again led to frustrations and arguments between call takers and EMTs. Due to this, call takers felt a somewhat pressure not to send ambulances. But, as Participant 5 prompted: “I cannot set another criterion just because we don’t have enough vehicles”.The availability to both internal and external resources negatively affected the EMCC personnel and their experience of their own job. Participant 19 stated: “You are multi-tasking thoughts and worries at work when there are few vehicles, and a major accident occurs. And then we have no guidelines in what to do, in cases of chaos”.Finally, the lack of resources had an impact on the opportunities for professional development. Several of the participants told that compensatory days off were withdrawn due to this.Call takers also expressed to be exposed to a lot of complaints at work. This occured both during a day at work, and as written complaints sent to management or health authorities. At work, primarily, this was from callers, who felt that they did not receive the help they expected. Call takers described callers who were “preachy”, “yelling” or “threathening”.Callers were described as in a crisis, they were scared, desperate, felt unsecure. Nevertheless, this reaction was experienced as a burden by the call takers. It also made it more difficult to do a triage, more difficult to divide reaction and actual problem or situation: “It’s difficult to know whether he fell down the stairs. Is he drunk? Is he awake? Is he hurt?” (Participant 10).In addition, call takers received complaints from hospital wards, GPs or primary health care providers, who had to wait for the ambulance, leading to patients not being sent home or to appropriate level of care or not being in time for e.g. specialist appointments. Most of the call takers felt pressured by these complaints. Some had negative experiences from cases brought forward to the Norwegian Board of Health Supervision, negative focus in the media, and not being allowed to answer to the complaints, due to confidenciality. According to several of the participants, these experiences, or rumours, made call takers send out more ambulances than they actually judged necessary. This again led to complaints from the ambulance personnel, as well as from the EMTs.Finally, call takers described their job as “an invisible service” or a “secret service”, because neither healthcare personnel nor the public seemed to know or understand the contents of it, or the difference they could make. The EMCCs were located in separate buildings, and personnel had to use key cards to get in there. Participant 13 stated: “This important society service. If we are put out, it will hit 1.2 million people. In this little bubble we are saving lives, right”.The “saving lives” experience was shared by most of the call takers, and seemed to be a great motivation to keep such a challenging job. Nevertheless, several of the call takers would have appreciated positive feedback, as emphasized by Participant 3: “People have no idea what kind of competence we have. We get no acknowledgements for the work we do, or the competence we have”.Due to that neither the public nor healthcare personnel had this knowledge, the EMCCs were wrongly used; e.g. people called them instead of their GP, which increased the pressure on the call takers. Participant 4 stated: “You have to accept much negativity, and then you get little positivity back. The weighing scale do not reach a balance. And then we don’t even get to see the one you are helping”.Call takers emphasized the difference in acknowledgement between clinical work and their own, as Participant 14 stated: “The ambulance personnel get his kind of acknowledgement- they are the ones saving lives”. But, she continued: “I think you have to be sort of proud of what you do. Think that we are some kind of heroes”.This approach seemed to be common amongst all of the call takers- that they were proud of their job.The call takers characterization of individual work performance related to multiple tasks, critical incidents and unpredictability. Lack of support from management, lack of resources, exposure to complaints and a feeling of invisiblity were organizational factors call takers’ reported made an impact on their work performance.The multiple tasks that characterized the call takers work can be referred to as the EMCC core techonolgy- the primary function the EMCC performs at that defines the “production process” in which it engages . In the Many of the participants described calls that had made great impact upon them, and they described this a psychological challenge. Stressors identified in a recent study included being exposed to traumatic calls, lacking control, and working in stressful environments . UnclearMost of the call takers described an abscent management, not giving any feedback or support. Research support this, showing that emergency personnel feel frustrated due to poor management, and this enhance the burden of professional responsibility and increase reported stress , 20, 21.When call takers were involved in critical incidents they had a need for a “time-out” to reflect on what had happened. These needs were not met. Research has shown that call takers who are invited to structured debriefs perceive this as management acknowledging the importance of their role in the organization. Conversely, exclusion from this has been found to contribute to a sense of decreased value by the organization . ResearcMoreover, lack of resources affected the call takers’ work performance. Problems with technical outfit could have reduced response time if improved. Lack of ambulances available sometimes caused conflicts with EMTs. who had to distribute ambulances at a regional level. Here, there is a potential conflict between the call takers’ professional judgements when receiving calls, and the overall planning of allocation of ambulance resources , 17. ThiCall takers expressed a need for a more comprehensive quality improvement strategy. E.g. Ek and Svedlund  emphasizBoth individual and work organizational factors can be seen as part of situation awareness (SA), linked to call takers’ experiences in addition to their professional knowledge. SA has been described as a state of knowledge, and an umbrella term for a range of cognitive processes, or as a skill , 29. CooThe call takers referred to a “mental picture” of what was going on at the locality, as supported by other studies . The “meResearch on the EMCCs have focused mainly on SA of individual call takers, not addressing the work organization in general. The complex relations between the characteristics of SA and other work organizational characteristics; e.g. financial resources, organizational design, or management, need to be addressed in order to understand the way the call takers work in a more comprehensive way. Consequently, our findings fill a knowledge gap, including both individual and work organizational aspects of SA in EMCCs to better understand and improve this skill.The EMCCs were organized differently, and this may potentially impact on the findings. In addition, data was gathered in 2013 and 2014, and the EMCCs have been through several structural changes since then. Hence, our findings reflect the call takers’ perspectives at that time.Since sampling were made based on both successful and challenging 1–1-3-calls, the nature of the calls could have impacted the findings. Nevertheless, this aspect was included during the process of analysis.The transparency in the methods description indicate valid findings, also indicated through issues of credibility, dependability, confirmability, and transferability.Credibility includes a confidence in the “truth” of the findings . In the Using a digital recorder, as well as rigorous and thorough orthographic transcripts including verbatim accounts of all verbal and nonverbal utterances, ensured dependability. This also support that findings are consistent, and that the study could be repeated.Confirmability was achieved through discussion of the codes, subthemes and themes among the researchers until agreement was reached. In the qualitative research design lies the lack of opportunity for generalisation of findings. Even though it could seem like the issues highlighted here are solely of a national concern, findings are in-line with findings from other countries. Transferability was sought through the inclusion of participants from different EMCCs, of both gender and a range in both age and years of experience.Reporting of findings are in-line with the Consolidated criteria for reporting qualitative studies (COREQ) .At the individual level, multiple tasks, how to cope with critical incidents, and the unpredictability of daily work when calls are received, make the work of call takers both stressful and challenging. The individual call taker’s ability to interprete the situation when calls are received by intuition and experience, is the main factor behind the peculiarities working in the EMCCs at the individual level. At the organizational level, the lack of resources and managerial support seems to provoke concerns about the quality of services rendered by the centers. These aspects should be taken into account in the managing of these services, making them a more integrated part of the health service system.Additional file 1:Interview guide. (DOCX 16 kb)


The solitary death rate in Japan is expected to continue increasing because of its growing super-aged society and the rapid growth of home care in the country. To accurately determine the actual status of solitary deaths, we used a novel analysis method of combining vital statistics and ambulatory care information in Yokohama City.Data of persons who died at home in 2013 were obtained from death certificate notifications. We also obtained the emergency transportation records that matched the cases of these death certificate notifications. Then, we gathered information regarding age, gender, marital status, and cause of death for the matched cases.n = 4847). We were able to match 1503 of these cases with emergency transportation records. These 1503 cases were divided into two groups, “solitary death” (n = 349) and “un-solitary death” (n = 1154) according to the postmortem interval until finding (PMI-f). Pearson’s χ2 tests conducted for the two groups revealed that there were significant differences regarding the proportion of persons who were elderly, unmarried, male, and had a hepatic disease and senility. A logistic regression analysis also showed that an increased likelihood of a prolonged PMI-f was associated with males and an unmarried status with hepatic diseases.There were 1890 “suspected unnatural deaths,” in which most solitary deaths could be included, among all citizens who died at home (Unmarried, male sex, and liver diseases are independent risks for solitary death in Yokohama City. Currently, Japan faces the serious concerns of rapid aging and a very low birthrate. The proportion of elderly people, aged 65 years or older, in the total population was approximately 27.6% in 2017, but it is expected to increase to approximately 33% by 2030 [Meanwhile, previous research has indicated that approximately 50% of Japanese citizens hope to die at home . For mosHowever, it has been previously noted that the status of solitary deaths in Japan is difficult to fully understand through vital statistics alone . This isIn this study, we adopted the view that the time elapsed between death and discovery of death is important for understanding solitary deaths. We estimated the length of time from the time of death to the discovery of death by comparing copies of death certificate notifications, which are the source data for vital statistics, and emergency transportation records. We then classified persons who died at home into two groups (solitary and un-solitary death) based on the postmortem interval until the body was found. Subsequently, we aimed to elucidate the risk factors of solitary death.In this study, to correctly understand the status of solitary deaths, we used a methodology that differed from the conventional analyses that mainly relied on vital statistics alone. We employed an analytical method to perform comparisons and to match emergency transportation data and death certificate notifications gathered from vital statistics. More specifically, with the cooperation of the Medical Care Bureau of Yokohama City, we applied to the Ministry of Health, Labor and Welfare, for the use of death certificate notifications from vital statistic surveys, and we obtained the data of persons who died at home in 2013 in Yokohama City. With the cooperation of the Yokohama City Fire Bureau, we also obtained emergency transportation records that matched the cases from the death certificate notifications. These data are anonymous and are not linkable to specific persons. Then, we gathered information on age, gender, marital status, and cause of death for the matched cases.The detailed version of the Vital Statistics Survey Death Forms of Yokohama citizens in 2013 was divided into “examined” and “attended” deaths, based on the presence of a postmortem certificate. In Japan, when causes of death found to be obvious disease or natural causes, the deaths were regarded as attended deaths and the death certificates were prepared by general physicians. On the other hand, when causes of death were not immediately found to be disease or natural causes, the deaths were not regarded as attended death but examined one, and the death certificates were prepared by medical examiners, along with police investigation. All postmortem examinations were performed by medical examiners in Yokohama City in 2013. Cases in which medical examiners had prepared death certificates were regarded as examined deaths, whereas cases in which general physicians had prepared the certificates were regarded as attended deaths . Then, we further sub-divided examined deaths into “pure unnatural deaths”  and “suspected unnatural deaths” .n = 349) and “un-solitary death,” (n = 1154) according to the postmortem interval until finding (PMI-f). The PMI-f of the solitary death cases was 3 days or longer, while it was 2 days or shorter for the un-solitary deaths. This is because the dead body generally begins to decompose when PMI-f is 3 days or longer. In such cases, most of the general physicians in Japan refuse to prepare death certificates and the bodies are sent to the medical examiner’s office. In other words, within 2 days after the death, death cases are generally dealt with by general physicians, as well as normal attended death cases, without any police investigations. In conclusion, in this study, we operationally defined “solitary death” as those cases for which PMI-f was 3 days or longer. Finally, information was gathered for both groups in terms of age, gender, marital status, and cause of death, from the detailed version of the Vital Statistics Survey Death Forms of Yokohama citizens in 2013.According to a previous study , most soχ2 test was conducted between two groups with regard to age, gender, marital status, and cause of death. Then, odds ratios (ORs) were calculated by a logistic regression to estimate the strength of association between the PMI-f and age, gender, marital status, and cause of death. PMI-f was used as binary data  and set as the criterion variable, whereas age, gender, marital status, and cause of death were designated as the explanatory variables. The variance inflation factor (VIF) was used to check for multicollinearity. The significance level was set at 5% for all tests. SPSS  was used for the analysis.A Pearson’s n = 4847) among all citizens who died in 2013 . There were 2305 attended deaths and 2542 examined deaths. When we further sub-divided examined deaths, we observed 652 “unnatural deaths” and 1890 “suspected unnatural deaths.”Figure p value (by Pearson χ2 test) according to the two groups (solitary death and un-solitary death). The results of the Pearson χ2 test for the proportion of elderly persons, men, and unmarried persons, and autopsies among the two groups revealed that, for a long PMI-f (3 days or longer), the proportion of persons who were elderly (p < 0.001) and senile (p = 0.001) significantly decreased, while the proportion of unmarried persons (p < 0.001), men (p < 0.001), and persons with hepatic disease (p < 0.001) increased.Table p < 0.001, respectively), indicating significant associations with PMI-f. However, there were no significant associations for age .The logistic regression analysis results are shown in Table There have been many studies that have researched solitary deaths –18; howeFurthermore, we attempted to understand the actual status of solitary deaths by classifying the cases in detail. As described above, we estimated the length of time from the occurrence of death to the discovery of death based on the length of time between the time of death and that of emergency transportation request. We subsequently classified “suspected unnatural death” cases into two groups according to this length of time.χ2 test demonstrate that the time from the occurrence of death to the discovery of death tended to be longer in unmarried, non-elderly males and hepatic diseases. In addition, the logistic regression analysis also showed that an increased likelihood of a prolonged PMI-f was associated with unmarried males with bad hepatic conditions. Various factors might help explain this finding. For example, according to comments in the emergency transportation records, many victims who were discovered relatively shortly after their deaths were found during periodic visits by their family members or relatives, etc. In other words, although it is true that being an elderly person living alone is certainly a risk factor for solitary death, this risk largely depends on the presence or absence of support from surrounding people who live outside the home.The above analyses indicate that we successfully obtained a new finding regarding the risk factors for solitary death. Previous studies have reported that elderly persons living alone are at a high risk for solitary death . In factCurrently in Japan, the proportion of unmarried persons has been increasing annually for various reasons, including lifestyle diversification and expansion of economic disparity. Unmarried persons, when compared to their married counterparts, have a lower chance of receiving support from families and neighbors, especially when they reach middle- to elderly age. In addition, this social isolation might lead to alcohol abuse, which ultimately leads to hepatic diseases, according to the findings of previous research which stated that individual and community social isolation were associated with increased odds of drinking problems , 20. ThiDespite the new findings described above, this study faced several limitations. Regarding the solitary death data used in this study, we collected data for only the cases that we were able to link for both the ambulatory care information system and the death certificate notifications. We could not match the remaining cases because the age or gender of the individuals in those cases was unidentified due to advanced decomposition or skeletonization of their bodies. However, there are a considerable number of solitary death cases in the data that we were unable to link. Future studies should aim to obtain the data of these latter cases to understand a more detailed status of solitary deaths. Also, because this study targeted only Yokohama City, it is uncertain whether the conclusions apply to other Japanese regions. In the future, researchers should conduct surveys that are similar to this study in other regions in order to test the validity of our conclusions. Finally, it is worth noting that the data from the ambulatory care information system, as well as the death certificate notifications, were anonymously compared. In other words, the common values between both datasets for the four items  were coupled based on pure speculation. In this study, because the quantity of data was relatively small, all data could confidently be matched one-to-one. However, for much larger sample sizes, it might be impossible to anonymously compare the datasets. To further advance studies on this issue, if necessary precautions are taken to protect personal information, breaking anonymity should be considered.Unmarried, male sex, and liver diseases are independent risks for solitary death in Yokohama City.


Personal genomic testing provides healthy individuals with access to information about their genetic makeup for purposes including ancestry, paternity, sporting ability and health. Such tests are available commercially and globally, with accessibility expected to continue to grow, including in Australia; yet little is known of the views/expectations of Australians. Focus groups were conducted within a multi-stage, cross-disciplinary project (Genioz) to explore this. In mid-2015, 56 members of the public participated in seven focus groups, allocated into three age groups: 18–24, 25–49, and ≥50 years. Three researchers coded transcripts independently and generated themes. Awareness of personal genomic testing was low, but most could deduce what “personal genomics” might entail. Very few had heard of the term “direct-to-consumer” testing, which has implications for organisations developing information to support individuals in their decision-making. Participants’ understanding of genetics was varied and drawn from several sources. There were diverse perceptions of the relative influence of genetics and environment on health, mental health, behavior, talent, or personality. Views about having a personal genomic test were mixed, with greater interest in health-related tests if they believed there was a reason for doing so. However, many expressed scepticisms about the types of tests available, and how the information might be used; concerns were also raised about privacy and the potential for discrimination. These exploratory findings inform subsequent stages of the Genioz study, thereby contributing to strategies of supporting Australians to understand and make meaningful and well-considered decisions about the benefits, harms, and implications of personal genomic tests. Since the mid-2000s, companies have been marketing various forms of personal genomic (DNA) testing to the public, typically online . Termed The healthcare system in Australia operates through a mix of publically funded  and private  services. Traditionally, clinical genetics has been provided through publically funded services, while funding for clinical genetic testing has varied and, depending on the test and context, the patient may pay nothing or be required to partially or fully pay for the test themselves . As healOpportunities for Australian consumers to have direct access to personal genomic testing for health and non-health related purposes have been available, predominantly through online testing companies not located within Australia. The number and type of companies selling personal genomics tests (PGT) online  seem to fluctuate rapidly , 9, 10. As the field originated in the United States, most research examining experiences with personal genomics has been specific to that context. In Australia, there has been limited empirical research examining public –14 or heWe are conducting a large multi-disciplinary and mixed methods study to understand the Australian public’s experiences and expectations of personal genomics. Genioz  commenced in 2015 and comprises five research components .Recruitment was designed to target non-expert members of the public, using a variety of approaches to notify people about the study  for data management. The analysis undertaken was qualitative description, however, since the round robin questions were directed and answered by everyone it is possible to make some semi-quantitative assessment of participants’ responses. This was done using manifest content analysis . ThematiAltogether, a total of seven focus groups with 56 participants were held in Australia between July and September 2015: three in Sydney and four in Melbourne. An extra focus group was held in Melbourne in response to the high demand for participation in the oldest age group. Since the intention of the focus groups was to gather exploratory information and provide insights to inform the next stage (the survey), recruitment until saturation of themes occurred was not the purpose, although in fact no new concepts were emerging by the end of data collection. A summary of the participant sociodemographic data can be found in Table Participants’ levels of awareness and understanding of genetic concepts varied greatly across the focus groups. When asked what immediately sprung to mind when the words “DNA” and “genes” were mentioned, there was a wide range of responses and representations .Apart from those who had recently studied genetics at university, many participants had not previously heard of the term “personal genomics” but were easily able to infer its meaning:FG5S-42: “Because you can buy it straight from the manufacturer? Rather than going through…”FGS5-44: “That was my understanding.”FG5S-42: “Like having to go to a doctor or something like that and then they give you the test.”When also asked who was familiar with the term “direct-to-consumer” genetic testing, very few people had heard of this, although in one focus group there was discussion about what it meant:In the discussion that followed the brief explanation of personal genomics and examples of testing websites, many participants were able to articulate concepts around the contribution of genetics to physical characteristics, health, behaviors and disease, and the extent to which they perceived genes have a role. Physical characteristics were often considered to be inherited, with genes playing an important part, as they did with sporting abilities and some other talents, although some were sceptical that genetic testing could predict a person’s range of abilities . In four focus groups, at least one participant in each mentioned the term “epigenetics” without prompting, although most had never heard of this specific term. Some correctly described its effects without knowing the term itself, however there was some confusion in the discussion reflecting limited understanding of how epigenetic changes actually affect gene expression When participants were asked to consider whether they would undertake personal genomic testing themselves, views were varied. More than half of participants said they would “I think if the need arose or the reason arose I’d be quite happy to have it. Unless the need arose, I don’t think I’d do it for any other reason, and certainly [would] for my family.” (FG2M-18)Many felt testing should be prompted by a reason, for example, impending ill health, or if recommended by a health professional or a health campaign from non-commercial sources.“I’d definitely make sure I got it done from a reputable person, it, yeah, cost would be a major factor though, obviously. If it was within like a significant amount of money, I’d definitely think quite hard about it.” (FGS7-51)FG4M-30: “But I see in the future that life insurance companies will be probably demanding this.”FG4M-32: “That’s a problem.”FG4M-38: “I think they do in America already.”FG4M-30: “Oh they do it already do they?”FG4M-29: “One of the things I find most worrying about it.”SM: “So are you all a bit worried about insurance?”FG4M-32: “Yeah, absolutely, misuse.”FG4M-30: “Well for all this it’s privacy isn’t it? Who owns this information?”For those less enthusiastic about purchasing a test for themselves, the main concerns raised were cost, perceived lack of validity and/or utility of the results, and worries about potential impact on privacy, insurance and discrimination.“Yeah those websites, oh this is about making money, I would be dubious and certainly from my experience on the Internet you get a bit of a sniff detector, you can pick up when something feels a bit bogus, fairly quickly.” (FG2M-13)In general, participants expressed a general sense of distrust and scepticism about the marketing rhetoric used in the websites and the commercial interests of the companies offering testing.These qualitative focus group findings are the first to be reported from a larger mixed-methods, multi-stage study on Australians’ perceptions and expectations of personal genomic testing—the Genioz study. Awareness of personal genomics was fairly limited across the focus group participants. Their level of knowledge and understanding of genetics and genomics appeared to be drawn from several sources; these included news and popular science media, formal education, experience with genetic testing and/or genetic conditions or personal interest. Overall, participants did not think in deterministic terms, acknowledging that the environment played a role in a person’s characteristics including health. While there was interest in testing for health and ancestry testing, many participants expressed scepticism about the types of PGT available and what might be done with that information.Regardless of the earlier research in Australia, the general lack of awareness of the availability of genetic tests via the internet by our focus group participants, apart from those who had studied this topic at university, does not reflect the increasing level of media attention to the rapid pace at which genetic technologies are being introduced and their potential applications . In the per se if a health professional is required to order on their behalf. Thus, there seems to be a disconnect between the language used in scholarly publications leading to policy recommendations, and that used by the testing companies and the public. This raises the question of whether the Australian public would be able to search for and find these guidance documents if this term is not part of their lexicon. More recent USA literature refers to “personal genomics” [Terms from the academic literature—“personal genomics” and “direct-to-consumer” genetic testing—were not known to the majority of the participants. Even before the discussion about personal genomics, however, participants also spoke about DNA and genes as being “unique” to an individual, underlying the link participants were able to make with “personal genomics”. A number of participants referred to TV programs around DNA forensics in crime scene investigations, which centers on the uniqueness of a person’s DNA sequence and may have contributed to their beliefs. Testing companies often refer to “DNA testing”, “genetic testing”, and more recently “personal health genomics” and “personal genome service” on their websites; the term “direct-to-consumer genetic testing” or DTC-GT is not used by the companies themselves, yet has been ascribed almost universally to this type of testing in the academic literature , 23, 24.enomics” . Based oSimilar to other studies , particiFocus group participants were relatively well-educated participants who built their understanding of genetics and genomics from a range of sources. There was discussion about the legitimacy of information sources, with some examples they construed to be authoritative. For some it was important to validate information they came across in the news media by searching original research articles, while others were more accepting of information at face value. However, one aspect of the discussion that emerged from a younger group was their perception that information they encountered multiple times seemed more credible, irrespective of its source. The tendency to follow others’ opinions has increased among Internet users, and this “bandwagon” effect has been noted amongst Internet users who are not motivated enough by a particular topic to systematically seek information, but instead peripherally judge or process the abundance of data available to them through social media with minimal effort, using a range of cues . In termIn the discussion of the various purposes for which personal genomic testing is marketed, there was a range of views on the predictive capacity of genetic tests for traits such as sporting, musical abilities, as well as personality traits, with the majority of participants expressing doubts about the usefulness of genetic testing for these characteristics. Furthermore, some participants were concerned that technology may drive and potentially undermine personal and societal values, such as providing the opportunity to create designer babies. However, there was the perception of greater usefulness of health-related genetic information, even though for some obtaining this information could be anxiety-provoking. While about half of the participants said they would consider testing, most felt their motivation to be tested would be based on anticipation that they could obtain actionable health information relevant for themselves or their family, including information regarding genetic conditions that might be passed on to future children, in other words, carrier testing. Whether this would actually translate into behavior change, however, is a matter of ongoing debate . StudiesOther motivations mentioned by the focus group participants for considering testing included an altruistic view of contributing to research, and forms of curiosity. In a systematic review of the literature on genomic testing in a range of contexts, altruism and curiosity were identified as elements of personal utility .Overall, participants in our focus groups were cautious about the companies’ commercial stake in testing and their marketing practices. Those less keen on PGT cited concerns about negative impact of testing on privacy and insurance, leading to potential discrimination. In Australia, there have been calls recently for the government to provide closer oversight of the use of genetic and genomic information by the insurance industry, with concerns about their self-regulatory practices . InsurerWe acknowledge limitations of this exploratory qualitative study. Participants were self-selected and attendance at the focus groups was also constrained by their availability regarding time and locations at which the focus groups were held. The sample is not intended to be representative of the Australian public and, in general, participants were well-educated, with about one-third of the sample being university students, but a strength of the study is the inclusion of a wide range of ages. Experience with online PGT was limited and so views were expressed from the perspective of low awareness, and provide a snapshot in time. However, these attitudes serve as a useful counterpoint to those of early adopters of testing, and likely reflect the relatively low market availability and visibility of PGT in Australia at the time. Most recently, there has certainly been a rise in the advertising of DNA testing for ancestry purposes in the Australian media .In conclusion, we present the findings from the first qualitative stage of a larger mixed-methods, multi-stage national study (Genioz) and provide exploratory data regarding views of Australians about PGT. Overall, awareness of these online tests was generally low at the time of conducting these focus groups, while their level of knowledge and understanding of genetics and genomics was varied and appeared to be drawn from several sources. Generally, participants’ views about genetics and genomics supported the contribution of environment and lifestyle to a person’s characteristics, including health. Attitudes to having PGT were mixed, with greater interest in health-related tests if there was an underlying motive; however, many participants expressed scepticism about the types of tests available and what might be done with that information. Findings will be used to inform a national survey and subsequent in-depth interviews with survey participants to gather views from a broader sample. In addition, findings will contribute to communication strategies to inform Australian policy makers and education resources for the public, with an emphasis on ensuring that language used is appropriate and relevant, and avoiding jargon such as “direct-to-consumer”.Table S1: Recruitment approachesTable S2: Focus group schedule of questionsFigure S1: Word cloud of words used in response to the question “What springs to mind when I say the words ‘DNA’ or ‘gene’?”Figure S2: Sources of information about genetics and DNA