Pakistan, Nigeria, and Afghanistan remain the only countries in the world where polio is still a serious threat. This review article addresses the political, sociological, and epidemiological factors behind the failure in eradication. A relatively popular Nigerian conspiracy theory about polio vaccines spread in Pakistan and, as a result, there is some considerable resistance to polio vaccination. Conspiracy theories about vaccines have a long history, and the fact that polio vaccinators were used as spies in order to plan for Bin Laden’s death has made polio vaccination a bigger challenge. Furthermore, vaccination is strongly correlated with literacy and Pakistan is still struggling against illiteracy. However, these obstacles are by no means insurmountable, and a joint effort by the government, policymakers, education department, community mobilizers, and public health professionals can indeed make major improvements. Poliomyelitis is an infectious disease caused by the human enterovirus, poliovirus, which transmits via the fecal-oral route. Its most common symptom is muscle weakness, which results in an inability to move. Although most patients with muscle weakness fully recover, about 2% to 5% of children and 15% to 30% percent of adults die because of respiratory failure [Poor sanitary conditions in these countries have made it difficult to fully eradicate the poliovirus . Yet, paThis theory claims that vaccination programs seeking to eradicate polio within Pakistan are a scheme created by the United States and Israel to sterilize the Muslim population. The origin of this conspiracy theory has been traced to the 1988 World Health Organization campaign, “Kick Polio Out of Africa.” This was a major effort put forth with the goal of eradicating polio from Africa by the year 2000 . High-prHowever, in 2003, officials of the regions of Kano, Kaduna, and Zamfara in Nigeria refused to allow vaccine administration in their territories. The rationale was that the polio vaccine may have had an anti-fertility estradiol hormone, human immunodeficiency virus (HIV), and other cancerous agents. In Nigerian public opinion, this view was granted legitimacy because it was defended by a notorious Nigerian physician, Ibrahim Datti Ahmed .This particular physician headed the Supreme Council of Shariah in Nigeria and after the events of September 11, 2001, took an aggressive stand against the West and the United States in particular by publicly proclaiming that polio vaccines were “corrupted and tainted by evildoers from America and their Western allies.” Inasmuch as acquired immunodeficiency syndrome (AIDS) has been a big concern for African countries, Ahmed further added, “We believe that modern-day Hitlers have deliberately adulterated the oral polio vaccines with anti-fertility drugs and viruses, which are known to cause HIV and AIDS” . This kiAlthough this conspiracy theory was upheld and propagated by Islamist groups in Nigeria, it found the greatest resonance in Pakistan. Public health officials working on vaccination campaigns have been frequently attacked by militant groups, especially in tribal areas controlled by the Taliban . Today, In order to do so, public health officials and policymakers need to be aware that the popularity of this conspiracy theory in Pakistan does not come out of a vacuum. In fact, despite Pakistani animosity toward the eroding influence of Western culture, the polio vaccine conspiracy theory has Western origins. Mistrust of vaccines has, in fact, a long history. This has also been coupled with a mistrust of physicians and healthcare professionals, as a result of some infamous cases of gross violations of ethical guidelines . SuspiciYet, despite the Western origins of many elements of this conspiracy theory, Pakistan’s complex place in the geopolitical stage after the attacks of September 11, 2001, and its uneasy relationship with the United States ever since, have made it a fertile sociological ground for conspiracy mongering. In this article, we will review some of the historical and sociological background to the polio vaccine conspiracy theory in Pakistan.vaccinae, meaning “of the cow.” The word was originally created by Edward Jenner, an 18th Century English country gentleman. At the time, smallpox was rampant throughout Europe. In fact, smallpox was only officially eradicated in 1980 but, by far, it has been the disease that has killed the greatest number of human beings [The history of conspiracy theories regarding vaccinations goes back to the very first vaccine. The word vaccine comes from the Latin Jenner had many scientific interests; however, given the frequent devastation of smallpox, Jenner sought to explore ways of preventing the disease. His social interactions with English farmers and cattle herders led him to discover that those people who were in frequent contact with cows had a lower propensity to suffer from smallpox. He was aware of the folk wisdom that claims that cowpox (a disease that causes blisters on cows’ udders) can prevent against smallpox in humans. Jenner thus proceeded to expose farmers who had suffered cowpox to the smallpox virus. None were infected. He then deliberately infected a boy with cowpox and then exposed him to smallpox. The boy did not get sick; thus, the first vaccine was born .Needless to say, Jenner’s contribution to the history of medicine was monumental, though it is very doubtful that it complied with ethical standards . Jenner Perhaps this troublesome moral aspect of Jenner’s achievement was an important factor in the public’s reaction to his proposed method of curing smallpox. The fact that an apparently risky procedure was done on a healthy boy aroused many moral suspicions, even if, indeed, time proved that Jenner was right.Vaccines are, for the most part, administered during childhood. At that age, individuals cannot truly give consent, which makes vaccines morally suspicious among some people. To a certain extent, this may be the case with the mistrust of polio vaccination in Pakistan. Furthermore, Jenner’s procedure seemed very counterintuitive at the time. How could exposure to a similar virus actually prevent a disease as deadly as smallpox? We now know how vaccines work. They stimulate the immune system . During Indeed, Jenner’s innovation was not immediately well-received. Certain religious groups argued that men should not alter God’s plan. The fact that the cure for smallpox came from ill cows disgusted many. There were further concerns about what unforeseen consequences such a medical procedure could also bring forth.In the scientific community, Jenner’s innovation was quickly accepted, and public health officials soon realized that the only effective way of controlling smallpox was by imposing mandatory vaccination, as in the Compulsory Vaccination Acts of the 1850s passed by the British Parliament . Being iThe original anti-vaccination campaign was derived from a basic political argument that claims that individuals are entitled to control of their own body and, thus, it is oppressive to impose mandatory vaccination. However, as too often has been the case, anti-vaccination campaigns have been far more driven by irrational and emotional appeals. Even during Jenner’s time, his critics claimed that recipients of the smallpox vaccine could grow horns, implying a falsified notion that vaccinated individuals would become cow-like as a result of the cowpox virus in their system . UltimatThe most recent anti-vaccination campaign relates to the measles, mumps, and rubella (MMR) vaccine and its alleged link to autism . In 1998Wakefield then proceeded to perform intestinal biopsies on the subjects, and the results came out positive for inflammation. According to Wakefield et al., vaccines were causing this intestinal inflammation. The study had some considerable methodological flaws. Some of the patients’ parents reported that their children had symptoms of autism before symptoms of bowel disease. This fact does not cohere well with Wakefield’s theory. If autism is a result of intestinal inflammation, it would be normal to expect that symptoms of the latter would actually appear first; yet, that was not the case. In fact, video footage of autistic children’s first birthday parties has been compared to footage of non-autistic children’s first birthday parties, and researchers are able to predict, with a high degree of accuracy, which children turned out to be autistic and which did not. This is strong evidence that symptoms of autism chronologically antecede the administration of vaccines, which, in turn, suggests that vaccines do not cause autism .It later became public that there were very serious ethical issues with Wakefield’s original study. In 2004, 10 of the authors of Wakefield’s original article retracted. According to some journalistic investigations by Brian Deer, Wakefield received financial incentives from lawyers of parents of autistic children, who had the intention of taking legal action against the companies that manufactured the MMR vaccine. Wakefield never undisclosed this conflict of interest. Furthermore, Wakefield had the intention of registering a patent for a vaccine that, if launched in the market, would have competed with the conventional MMR vaccine .Despite strenuous debunking of both the ethics and methodology of Wakefield’s study, his claims managed to resonate with a growing sector in the United States and the United Kingdom. As a result of Wakefield’s infamous study, the vaccination rates of MMR have dropped significantly, and expectedly, some occasional outbreaks of measles, mumps, and rubella have been reported .Wakefield’s original article had little conspiracy mongering, but as soon as his claims became popular in the media, conspiracy theorists added to his original allegations by claiming that “Big Pharma” was behind the MMR vaccine and that the rise in autism prevalence was actually a direct consequence of the pharmaceutical companies’ profit .Tellingly, only five years after Wakefield’s article, the polio vaccine conspiracy theory was first formulated in Nigeria. There is no formal data to support the hypothesis that Wakefield’s article was ultimately a causal factor, but we may conjecture that, indeed, Wakefield’s article contributed to the environment of mistrust in Nigeria and Pakistan regarding vaccines in general.Population control conspiracy theoriesPrior to industrialization, fertility was highly valued universally and there was little concern with population control. With insufficient levels of technological advancement, manpower was highly valued for the production of wealth. However, as the Industrial Revolution took shape in Western Europe during the late 18th Century, it was accompanied by the so-called “demographic transition.” Cities became more crowded, and as technologies began to replace manpower, overpopulation became a concern .This was explicitly addressed by Robert Malthus in his classical 1798 book, An Essay on the Principle of Population. Malthus argues that food resources grow at an arithmetic rate, whereas the population grows at an exponential rate. This would eventually cause a mismatch, and populations would be pressured to reduce their sizes through war, disease, and famine. Malthus disapproved of contraceptive methods but insisted on the need for abstinence for purposes of population control. He also opposed laws and social programs that would provide some assistance to the poor, as he thought such initiatives encouraged population growth .Malthus’ opposition to welfare programs was enthusiastically taken by adherents of social Darwinism in the later 19th Century . Given tThe Club of Rome, a high-profile intellectual organization created in the 1970s, took a neo-Malthusian approach to address many global issues and published a widely read report, The Limits to Growth. The book warned about potential problems if growth was not controlled . Yet, co As a result of all these theories, a common trope of conspiracy mongering has been the so-called “New World Order,” an imagined project headed by the Illuminati, whose goal is to establish global rule through puppet governments, by constantly keeping in check population size, especially in Third World countries. Conspiracy theorists have traditionally believed this project is already underway, through things such as water fluoridation, genetically modified food, and airplane contrails (erroneously believed by conspiracy theorists to be poisonous “chemtrails”).Vaccines play an important role in this conspiracy theory. According to influential conspiracy theorist Leonard Horowitz (1997), the medical industry is actively seeking to control population size through the continuous manufacture of new viruses . AIDS anHorowitz claims that vaccines control population size by deliberately killing people. Yet, that is not exactly the same claim made in Pakistan. The claim made by conspiracy theorists in Pakistan, following the original Nigerian version, is that vaccines only contribute to infertility. A common documented trend in the formation of conspiracy theories is how bits and pieces are amalgamated into a unified whole, even though originally, they may be have been unrelated to each other -29.Pakistan’s fertile ground for conspiracy theoriesThe distrust of vaccines and conspiracy theories regarding population control have been mostly a phenomenon of Western origin. Yet, sociology has documented that conspiracy-mongering thrives more in regions with specific sociological and cultural circumstances . UnfortuThe most important social predictor of belief in conspiracy theories is perceived powerlessness and a sense of lack of control . This isPakistan itself was born out of the concern that, in a unified India, Muslims would be persecuted by Hindus. Pakistan’s founder, Muhammad Ali Jinnah may or may not have been right in his warnings about a unified India, but the fact remains that, from the very moment of its birth, Pakistan, as a nation, was immersed in paranoia over its hostile and more powerful neighbor. This sense of suspicion was reinforced when India annexed Muslim-majority Kashmir upon partition, and in four consecutive wars, defeated Pakistan. These experiences added to a very unstable political situation that led to military coups in 1953, 1958, 1977, and 1999 .Pakistan’s place in the geopolitical scenery and uneasy relationship to the West  has further contributed to the collective feeling of suspicion and lack of control of its own affairs. During the Cold War, as India’s ties to the Soviet bloc seemed to grow closer, Pakistan received considerable military and economic support from the United States. This was further intensified when, under Zia Ul Haq’s regime, Pakistan offered substantial support to Afghanistan’s mujahideen in their armed resistance to the Soviet invasion . The UniThe attacks on New York City on September 11, 2001, changed the situation dramatically. The Soviet Union no longer existed and, now, Pakistan was scrutinized by the United States as a possible collaborator with terrorist militant groups. Under Pervez Musharraf’s regime, Pakistan pledged alliance to the United States in the so-called “war on terror,” and received massive financial and military aid. Unlike the prior collaboration during the Afghan-Soviet war, this time, there was wide suspicion in the American government that Pakistani authorities were actually harboring militants ,33-34.The United States then began an aggressive program of drone attacks violating Pakistani sovereignty and disregarding civilian deaths. This, in turn, massively contributed to suspicion of American integrity amongst the Pakistani population. The American government continuously claimed that Osama Bin Laden was hiding in Pakistan, and in 2011, again violating Pakistani sovereignty, conducted a military raid that ended his life in the Pakistani city of Abbottabad ,34.Upon Bin Laden’s death, various conspiracy theories began to circulate in Pakistan. Some groups claimed that Bin Laden died shortly after the attacks of 2001, as he had been suffering from Marfan syndrome; the United States pretended that he was still alive, as an excuse to launch the “War on Terror.” Other groups claimed that Bin Laden was killed somewhere else, as he was never in Pakistan in the first place, but the United States made up the story as an excuse to exert military control over Pakistan. Other groups even claim that Bin Laden is still alive. The fact that Abbottabad hosts an important military academy increased the suspicion that something was not right in the official version of Bin Laden’s death, as it could hardly have taken place without Pakistani military personnel noticing .These conspiracy theories have no empirical support whatsoever. Yet, regarding Bin Laden’s death, there is one conspiracy theory that has turned to be true. It was reported that, as part of planning for the military operation that killed Bin Laden, spies posing as polio vaccinators got close to Bin Laden’s home and collected information about his whereabouts. This claim has been sufficiently confirmed by multiple independent sources , includiThis military tactic has been widely criticized by medical ethicists, both for its deceptive nature and for the potential harm that it may cause in the future . Indeed,Description of the epidemiological situation of polio in PakistanDespite the fact that there are only three countries, including Pakistan, which are still affected by the poliovirus, Pakistan is making some progress toward the eradication of polio. In Baluchistan, a province in Pakistan, a circulating vaccine-derived poliovirus type 2 (cVDPV2) has been collected and verified from the environmental samples . PakistaIt is becoming difficult to eradicate polio from Pakistan, as the roots of poliovirus are found and confirmed in almost all cities, even metropolitan cities like Karachi, Peshawar, and Quetta. These metropolitan cities are capable enough to transmit the polio virus to other cities and to the remote areas in Pakistan.To understand the prevalence and reasons behind the poliovirus, it is also necessary to analyze the literacy rate and epidemiological conditions in the area. In Pakistan, there are places like Sindh and Balochistan where the literacy rate is even below 20% ,37. ThisIn Pakistan, three high polio transmission zones (HPTZ) have been identified so that the corrective and preventive actions can be planned in these regions. These identified places are Khyber Pakhtunkhwa (KPK) region, Federally Administered Tribal Areas (FATA), and the third identified zone is the metropolitan city Karachi. In all these three polio transmission zones, there are total 33 districts, which are identified as “highly endangered districts.”Alternatives, hopes, and proposal for public policyWith declining rate and number of cases detected with poliovirus, government, and other stakeholders like WHO and United Nations (UN) organizations are more inclined towards the eradication of polio, not only from Pakistan but globally. Comparing the last few figures of reported cases, poliovirus-affected individuals were 282 in the year 2014 and declined tremendously to 49 cases in 2015 . After tFor the community engagement and acceptance for any public health program, one of the contributing factors is engaging someone from the local community who is easily welcomed and accepted by the community. For polio eradication program, one of the key recommendations is engaging and hiring local women who represent their society and they are well-welcomed in the society. They can motivate and aware of the local community more easily as compared with someone from outside the community ,40. ThesOne of the studies was conducted on the behavior and attitude of healthcare workers towards poliovirus and its effect on children, and the result was quite surprising. In this study, it was found that the healthcare workers themselves rate poliovirus not a challenge for children in Pakistan . In thisConsidering the challenges in Pakistan in regards to the expanding spread of poliovirus, a collaborative effort should be created by the government, policymakers, education department, community mobilizers, and public health professionals to understand the severity of polio and how to begin the journey towards its eradication from Pakistan. The country faces opposition towards the vaccination as a result of a combination of the historical, sociological, and political perspectives cultivated in the region. However, tackling the misunderstandings that the Pakistani population has towards vaccines will allow for more successful attempts to eradicate the poliovirus from the country.


The study aimed to explore and identify factorsmotivating junior doctors to engage as long-term clinical tutors inundergraduate medical education.In this qualitative study, twenty-seven participants wererecruited among junior doctors attending preparatory tutor courses at theSahlgrenska Academy, University of Gothenburg, and the Primary Healthcaresystem, West Sweden. They were asked to respond to open-ended questions andwrite a short account of their needs as clinical tutors for medical students. Aqualitative content analysis was performed.A main theme emerged: “Let me develop my skills in asupportive workplace, provide feedback and merits, and I will continuetutoring”. Participants described suitable personality as fundamental, and theneed to develop professional skills, both as clinical tutors and physicians.Tutor education was animportant source of knowledge and stimulation. A workplace environment,supporting learning and the tutor’s role, was considered important, includinghaving an adequate time frame. A clear and well-prepared assignment wasregarded essential. Junior doctors requested feedback and merits in their workas long-term tutors. Clinical tutorship was considered an optional task.In this exploratory study, motivatingfactors of junior doctors’ engagement as future long-term tutors wereidentified. It is important to form a process where junior doctors can build upprofessional competence as clinical tutors and physicians. To ensure asustainable tutorship in the future, we suggest that universities andhealthcare authorities acknowledge and further study these motivating factors. Improvements in clinical education were called for, due to research and development in medical education during the last decades.--,-Consequently, universities throughout the world have modernized curriculums where medical students begin early developing clinical skills, professional attitudes, and clinical experience.,-,-Over the last years, the importance of a socio-cultural perspective on student learning at the workplace has been discussed.,-,,Clinical tutors often face difficulties when combining tutoring with clinical practice.-,However, recent studies have shown benefits in using junior doctors when introducing students to the clinical environment.,To reach a deeper understanding of the participants’ views, a qualitative approach was chosen. Qualitative inquiry methods are regarded suitable to attain a deeper understanding from the participant’s perspective.Clinical tutors associated with the Program in Medicine at the Sahlgrenska Academy of Gothenburg University, and the Primary health care system of West Sweden, participate in preparatory tutor courses arranged by the University to qualify for tutorship. Applicants to these courses are junior doctors and have no or little, experience of working as clinical tutors. They may have met students briefly at their clinics, but normally, do not fulfil the requirements for tutorship before attending a preparatory course. The foundation and specialist (residency) programs in medicine include minor tutor courses arranged by the Sahlgrenska Academy and the Primary health care organization. Informants were recruited from participants of these courses.From January 2014 to August 2015, 478 participants in the tutor mentioned above courses were asked to participate in the study. Seventy-three persons signed an acceptance form. In a letter sent by e-mail, and by regular post, they were then asked to write a short account of their needs as clinical tutors. As an introduction, open-ended questions, similar to an interview situation, were presented: “In your opinion, what factors would motivate or impede you to take on the task of a clinical tutor for medical students? What conditions should be met for you to continue working as a tutor for an extended length of time? Please, share your thoughts and views in writing concerning these issues in your own words consisting of 1-2 pages.”In the letter, participants were informed that their participation was confidential and that their decision would not affect their forthcoming task as a clinical tutor. Another e-mail with a reminder to respond to the study question was later sent to all those accepting participation. By using a participant recruiting process among a number of tutor courses, a sample with a diversity of age, gender, and experience within our definition of the target group was obtained. Participants were to write their accounts personally, and send them by e-mail as an attached file, or by regular post, to a researcher associated with the Research and Development unit. This researcher removed participants’ names on each text and forwarded the texts to one of the authors (BB), using encrypted e-mails. Information regarding gender, age, and professional level as a physician was attached to each text.Twenty-seven physicians delivered texts, twenty-six by e-mail and one by regular post. Among participants were eighteen women and nine men. Median age was 30 (26-43) years. Eleven were foundation doctors, twelve were in their medical specialist training period, and four were specialists.Ethical approval was obtained from the Regional Ethical Review Board of the University of Gothenburg. By using an intermediator and encryption during the e-mail process, confidentiality was assured. No participants reported negative experiences after participation in the study.Qualitative content analysis analysed participant accounts. This method is often used in qualitative educational research and was found suitable for our research question. The analysis included the following steps:1.        The texts were read for an overview of the content.2.        Units of meaning were extracted and coded.3.        Coded units of meaning were condensed into subcategories and categories.4.        A theme was created based on the latent content of the categories.5.        Categories and the theme were compared with the original text to ensure their rooting in the material.All authors read the entire material for an overview. Four of these performed an individual analysis. The analysis was made step-wise as new texts were received from the informants. The last two texts generated no new data, and data saturation was considered reached.  Several meetings were held to discuss the results, and all authors were involved in the formation of subcategories, categories, and theme. Furthermore, feedback on results was gained in several tutor seminars.,Theoretical perspectives used in interpretation were an experience-based, learner-centred perspective,In the analysis, a theme emerged: “Let me develop my skills in a supportive workplace, provide feedback and merits, and I will continue tutoring”. This theme was based on three categories:  1. Develop my personality towards professional skills as a tutor and physician, 2. Workplace culture supports education, 3. Clear-cut assignment, feedback, and merits .Participants expressed that personality was the basis, upon which competence as a tutor could be built. Some were more suited for tutorship than others, as this resident physician said:“A conducive factor in becoming a tutor, in my opinion, is, above all, the physician’s personality”.If a clinical tutor did not commit tutoring, results would be poor, as this foundation doctor said:“A lack of interest in tutoring will lead to poor results. Students can feel a tutor’s lack of interest within three minutes, creating a situation nonconducive to learning”.Participants found preparatory tutorial education very important, with an ambition to be well prepared and competent for the task:Most of all I think that training…before tutoring is important; to receive clear instructions concerning my job as a tutor”.We also found a fear among some participants, that as young doctors early in their careers, they felt they might have had too little clinical experience for tutoring. Thus, they found it important to gain greater professional competence as doctors to adequately fulfil their roles as tutors, as this doctor expressed:It’s important to feel I have some knowledge of the area they are to be tutored in. I can, of course, provide support even if I’m not as knowledgeable as a consultant, but it feels easier to take on the job of a tutor if I know so much that I can…guide the discussion or plan…if what the student suggests is incorrect.Participants also reported that continuous education as a tutor was important, both as a source of gaining greater competence, but for stimulation as well, through meeting colleagues:I need… to get updated on possible changes to the training setup, but also to gain inspiration and make contact with other tutors to exchange experiences and get tips.Many participants reported that the attitude at the workplace towards tutoring and meeting students was very important. They sought a positive educational culture:Another positive factor to becoming a tutor is to work at a place inspired by education that encourages others to tutor.And:An atmosphere at the workplace where other colleagues supervise students and express that tutoring is fun, challenging, and important, is of great importance.A positive educational atmosphere should include support and acceptance from clinical management, as this foundation doctor said:It is important that tutoring is seen as something positive from the manager's viewpoint.This resident, a forthcoming GP, expressed:Even the management should share the same attitude, considering it a contribution to the training of new physicians, and, furthermore, that it is meritorious for the health center physicians to participate in the learning process, and that it advances one’s own professional development.Participants also reported that support from colleagues and staff was important and facilitated tutorship:What close colleagues feel about me supervising students is also important. In most cases, one is dependent on benevolent colleagues when tutoring.Many participants reported the importance of being given adequate time for tutoring students, to avoid too heavy a workload, as this foundation doctor said:An important factor is, of course, time, and that the workload is not too heavy at your workplace. Best for the students and me is to have time reserved for tutoring.Adequate time for tutoring would also help informants to fulfil their duties as clinicians, as this resident physician reported:If I am too busy and feel that tutoring takes time from my clinical responsibilities in such a way that good and safe patient care cannot be guaranteed, it would keep me from accepting tutorship.Some participants reported that adequate space for students and tutors at the ward or health center when tutoring was also important:It is important to have adequate space where tutoring is to take place. Too many students in one place can be a burden for patients and staff, bringing difficulties to the role of a good tutor.Participants reported the importance of getting a clear and defined task from the university, including information about course plans and study aims. They found it important to have easy ways of contacting the responsible course leaders at the university and sought information regarding the task well in advance. This allowed planning the attachments well, as this resident physician said:I must have adequate advanced planning from the University so that both myself, as a supervisor, and my manager and scheduler, can plan accordingly. It's about having well-known and established routines so that each tutoring session comes as a natural part of operations.Some participants wanted to have an influence on course content and form:A prerequisite for acting as a tutor over a longer period of time is to be able to influence course structure and content.Participants regarded clear information about the task, its terms and conditions, as important in a process where the doctor could choose to accept or reject the offer to become a tutor. A foundation doctor expressed:A prerequisite conducive to accepting the task (as a tutor) is first and foremost information on what acceptance implies so that I can decide whether this is something I want to do for myself and my students.Further, participants emphasized the importance of feedback from students, colleagues, and clinical management on tutoring, as these doctors related:It's probably very important that students show enthusiasm and interest for me to enjoy being involved in their supervision.andI need feedback on my tutoring, not only from students but from colleagues as well, to be stimulated to improve and develop my tutorship.For some participants, a positive response also included personal financial gain, academic merits, or both:It is desirable that /tutoring/ is merit considered equally important as research, I believe, not just in the pay envelope but career-wise as well.andWhen tutorial work is well performed it should be rewarded with higher pay.Participants felt it important for their clinic to be rewarded financially for tutoring students, in order to prioritize education among clinical duties:Money to the clinic is also needed to motivate receiving students, which puts a strain on the clinic's resources.Our findings reveal that among this group of young and less experienced physicians, participants identify several motivating factors for continuing their tasks as clinical tutors. These factors concern education, professional competence, and stimulation, as well as the learning culture and organization of the workplace, the importance of adequate time, support, feedback, and merits.,,Participants address personality as an important foundation on which competence as a tutor can be built. This is consistent with earlier research, showing that tutors’ non-cognitive characteristics, such as interpersonal skills, and relationship-building, are important when creating a sound learning environment for students.,,Participants express how tutors’ preparatory education is important; they wish to be well prepared and competent. Some participants indicated that they are unsure of their abilities and competence as tutors.Preparatory education can improve a range of competencies necessary to a tutor, including a sense of self, and relationship to others, facilitating growth and development as a tutor.Several participants describe lack of professional confidence as physicians as a negative factor when tutoring. This is not surprising, as this group of clinical tutors are young, with less clinical experience; some are even foundation doctors. Some participants are worried that there could be some students who know more about specific patient care and treatment methods than themselves, e.g. educated nurses. These concerns can be dealt with during preparatory tutorial education. In an earlier study focusing on experienced tutors, we did not find this fear,,,-In this exploratory study, participants strongly express the need for a supportive culture of education at the workplace. According to the previously mentioned socio-cultural perspective, and the concept of community of practice, this culture should include the entire staff.,Participants voice a wish to get clear information about the task and the course, including course goals from the university, which is more clearly expressed in this study than in our earlier findings.-Participants express the importance of feedback, both from students, their superiors, and colleagues, on tutoring. The literature on feedback principles in medical education is growing rapidly.Another response on tutoring, which participants find important, is financial compensation and merit gain. This view is clearer than in our earlier findings,,,We followed guidelines for qualitative research methodology by maintaining open minds and bracketing, i.e., avoiding distortion from our preconceptions during the analysis. A limitation of this study concerns selection. Participants were recruited among physicians attending preparatory tutor courses arranged in Gothenburg, Sweden, and minor tutor courses during foundation years, and specialty training periods in the region of western Sweden. This would support our aim to recruit physicians with little or no experience of earlier tutorship since they are beginners when they attend a preparatory course. We observed diversity in age, gender, and professional experience in the study. Among those seventy-three who accepted participation, twenty-seven delivered written accounts. Due to confidentiality in the study design, the group that did not deliver texts could not be analysed. However, the reason for this drop-out might have been lack of time, since all were active clinicians, or having more difficulty in formulating their accounts. Lack of interest in the subject was less likely since they had chosen to attend a preparatory tutor course. However, all participants could be regarded as interested in medical education and tutoring. Thus, transferability to other groups of physicians and more experienced clinical tutors may be questionable. Still, we consider the results interesting and relevant to today’s tutors who work in the Swedish health care system, but also in a Nordic or European context, where young colleagues are recruited as clinical tutors.In this exploratory study, main motivating factors of junior doctors’ engagement as a future long-term tutor were identified. The study indicates that young doctors have several requests concerning tutorship for medical students. Tutorship is regarded as a voluntary task that can be rejected. Junior doctors want to build up professional skills as physicians and clinical tutors. They also expect active support and merits from their workplaces in order to take on a long-term assignment as a clinical tutor. Clinical tutors play a crucial role in today’s undergraduate medical education, and junior doctors will be needed in this role. To ensure a sustainable tutorship in the future, we suggest that universities and health care authorities acknowledge and further study factors that motivate junior doctors to engage as clinical tutors.The authors would like to thank the participating physicians who made this study possible. The authors also would like to thank Lena Nordeman, PhD, at the Research and Development unit, Primary Health Care, Southern Älvsborg county, Borås, Sweden, for participation in the process of encrypting the written accounts. Financial support was obtained from the Research and Development unit, Primary Health Care, Southern Älvsborg county, Borås, Sweden.The authors declare that they have no conflict of interest.


We performed a qualitative study to investigate the experiences of participants in a multicentre randomized controlled trial on a home-based palliative approach (HPA) for adults with severe multiple sclerosis (MS) and their caregivers. Our aim was to explore the strengths and challenges of the intervention, and circumstances that may have influenced its efficacy.Participants to the qualitative study were the patients, their caregivers, patient referring physicians, and the teams who delivered the HPA intervention. We performed semi-structured one-on-one interviews with 12 patients and 15 informal caregivers chosen using a maximum variation strategy, two focus group meetings with patient referring physicians (4 participants each), and one with the HPA teams (9 participants).From data analysis (framework method) 38 sub-categories emerged, which were grouped into 10 categories and 3 themes: 'expectations,' 'met and unmet needs', and 'barriers’. Intervention benefits were improved control of symptoms and reduced sense of isolation of the patient-caregiver dyads. Limitations were: factors related to experimental design ; team issues ; limitations of the intervention itself ; and external factors . The referring physician focus groups provided little experiential data.The HPA reduced patient symptoms and sense of isolation in patients and caregivers. The indirect role of the HPA teams, and insufficient length of the intervention were key limitations. The experimental design imposed additional burdens on the dyads. Key barriers were the paucity of available services, the demanding administrative procedures, and lack of networking facilities. These findings suggest that two major requirements are necessary for home palliative care to be effective in this patient population: HPA teams well-connected with MS rehabilitation services, and care delivered over the long-term, with variable intensity.ISRCTN73082124 (Registered 19/06/2014).Current Controlled Trials  Multiple sclerosis (MS) is a chronic neurological disease with unpredictable course. Around 15% of MS patients have a primary progressive course, and a further 35% develop secondary progressive disease after a variable period with a relapsing-remitting disease –4. AspirA qualitative study that explored the needs of people with severe MS found that disability and poor quality of life (QOL) were the main worries, while death was not a concern . ImproviThe PeNSAMI  trial, the most recently published study, was a two-arm parallel, examiner-blind RCT that assessed a home palliative approach (HPA) in 50 patient-caregiver dyads versus usual care in 26 dyads. Participant characteristics and the intervention are summarized in The present qualitative study, nested within the PeNSAMI trial, assessed the experiences and perspectives of: patients with severe MS and informal caregivers who received the intervention; the teams that delivered the intervention; and the patient referring physicians. The qualitative design was used to ‘augment’ the RCT findings: qualitative data collection and analysis took place after the intervention, to help explain the (quantitative) results, explore how the intervention worked in practice, identify its strengths and limitations, and contextual factors that may have influenced its implementation.Our referral framework was the mixed methods approach which, by integrating the quantitative findings with the qualitative findings, aims to provide a more comprehensive picture of the intervention than either method can do . More spThe framework method of analysis was chosen because it is particularly suitable to explore and describe the subjective experience of the different players  involved in the implementation of the home care intervention . Our aimFor the patients and the caregivers the home-based personal semi-structured interviews were considered most appropriate to limit interview burden and hopefully make it easier for participants to express their feelings, and recount their experiences of the intervention. For the teams and the patient referring physicians we chose the focus group meetings as they promote interaction and exchange of ideas.The PeNSAMI protocol  specifiePatients and caregivers were interviewed separately at patient homes. The interviews took place within six months of trial completion, and lasted no more than an hour (patients) or an hour-and-a-half (caregivers).A minimum of 12 patient and 12 caregiver interviews was planned. Data from each set of interviews were analyzed immediately and used to decide the characteristics of the next interviewee dyad, revise the interview guide (if necessary), and indicate when interviewing should cease because of data saturation .The interviews were conducted in Milan by a psychologist experienced in qualitative research (EB), and in Rome and Catania by specially trained psychologists . Neither patients nor caregivers had met the interviewers previously. A purposive sampling technique was used to select the participants (at least four dyads from each center) who obtained the greatest and least benefit from the intervention (in terms of primary outcomes). At least two caregivers of patients with severe cognitive compromise (patients not interviewed) were also selected.Before starting, interviewees were informed of study aims and requirements, and provided written consent, as required by the Helsinki Declaration and EU Good Clinical Practice guidelines. The interviewer then explained that the aim of the interview was to obtain participant feedback on experience of the PeNSAMI trial and stressed that positive and negative experiences of, and feelings about, the intervention were welcome. Participants were assured that the interviews were confidential, and that the audio recordings and subsequent transcripts would be fully anonymized. The interviewer then posed each question in turn, neutrally (so as to not suggest any particular reply) and in an open-ended fashion . As each question was discussed, follow-up questions clarified and explored participant responses. Participants were also encouraged to elaborate on any pertinent themes or views that emerged. The interviewer also noted any potentially informative non-verbal gestures. At the end of the interview, the interviewer verbally summarized the key points and asked the participant if the summary was full and correct.All participants provided written informed consent prior to participating. The meetings were audio-recorded and transcribed verbatim. All were conducted by a single facilitator , whose job was to engage all participants, promote exchange, moderate conflicts, ensure that all pre-specified topics were adequately covered, and allow exploration of any pertinent issues that arose. She first explained the purpose of the meeting and asked participants to introduce themselves. She then introduced each topic in turn, in an open-ended fashion. At any point the facilitator could probe for further information and ask follow-up questions to stimulate further discussion. After all pre-specified topics had been fully discussed, the facilitator summarized the main points, and asked for further feedback and whether all concerns had been fully aired. The co-moderator (AS) took notes and oversaw the audio recording. Subsequently, the facilitator produced a report from the audio recordings/transcript and her field notes, which was submitted to participants for review .The protocol and consent procedures were approved by the Ethics Committee of: Foundation IRCCS Neurological Institute C. Besta, Milan ; Foundation IRCCS S. Lucia, Rome ; University Hospital Policlinico Vittorio Emanuele, Catania .The methods of framework analysis were applied to the data. Framework analysis uses an inductive approach to identify the themes and categories that emerged from the interviews and meetings –19. Two A joint report of interview and focus group meeting findings was produced. In this report − and the present paper − the categories identified were compared with those identified in the qualitative study used to inform the development of the PeNSAMI intervention . Where aBetween October 2015 and April 2016, 27 interviews of mean duration 28 minutes (range 11–60) were conducted, 12 with patients and 15 with caregivers . Two of The referring physician focus group meetings took place in June  and July  2016. Of the 34 eligible physicians, 21 (61.7%) refused to participate. Reasons for refusal were work commitments (n = 19) and holidays (n = 2). Five agreed to participate but did not show up for unscheduled work commitment (n = 3), family commitment (n = 1), and oversight (n = 1). The characteristics of the eight participants (4 per meeting) are shown in The HPA team meeting was held at the Foundation IRCCS Neurological Institute C. Besta, Milan, in October 2016 and lasted 120 minutes. Of the 12 eligible, 6 participated in person, 2 via videoconference  and 1 via audioconference . Three could not attend, 2 for work commitments  and the other for personal reasons (Catania team psychologist).The two referring physician focus group meetings produced little experiential data and their findings are presented separately. From the patient and carer interviews, and HPA team focus group meeting, 38 sub-categories emerged which were grouped into 10 categories and three themes: ‘expectations,’ ‘met and unmet needs’, and ‘barriers.’ The findings are presented by theme, with quotations to illustrate their derivation. The provenance of quotations is indicated as patient (P), carer (C), or team member (T), with other information included as appropriate ."With PEG it was fundamental to educate our patients about how to manage and clean the device.” .“They helped us find a more suitable wheelchair…” . Participants also reported presence of a reference point as an improvement. “If I had a neurological emergency, I’d[now] call Dr *** and ask for advice” . “I’m still in touch with many of them. We exchange emails, phone each other…” .For disease management, improvements were reported in terms of symptoms management, aids and medical devices, and presence of a reference point. All three parties reported that the intervention was effective in reducing pain and other symptoms. “I think they did a good job psychologically […] they dug inside me” . “I just opened up and said what I was thinking. It was comforting when they came […] we spoke differently than usual” . “We dedicated time talking together during each visit. Some of them needed psychological support more than nursing assistance”. Caregivers and team members also reported a reassurance effect. “The opportunity to ask them [the team] for suggestions, made me feel safer.” . “Being there is something really positive for them and it is strictly connected with one of their major needs: safety and reassurance” . Similarly, caregivers and patients reported that interaction with the team was an opportunity to communicate and exchange opinions, a first step to resolving difficulties. “We solved things because of this dialogue […] I improved simply because of this dialogue with them.” . “Having the opportunity to interact with health professionals with specific competences was worthwhile.” .Findings on psychological and social issues were grouped into emotional support, reassurance, communication, information, and administrative issues. All parties recognized that the dyad derived emotional support from interaction with the team. Patients and caregivers in particular perceived the interaction as an opportunity to stay in contact with their feelings and to express them. “It was beautiful for a patient to receive explanations and many other things” . “We made some modifications based on nurse’s and social worker’s suggestions” ; “We suggested how they could get what they were entitled to, even though they hardly ever got it in practice.” . All parties reported that the intervention had a positive impact on administrative issues. “They hastened procedures at the local health offices” . “Several times the social worker went to city offices with my husband […] to discuss things. In short, she always went along with him.” . “We reduced caregiver’s burden by providing them with clear indication about administrative procedures” .The team also provided the dyads with practical information. "It‘s important [for doctors] see us at home […] it gives the possibility of a more meaningful interaction." . "We always have to go to the doctor. […] In our situation a home visit would be more than welcome!" . "With some treatments, compliance is low because no one is monitoring it from week to week. Going to the patient’s home can be crucial." . It was also noted that qualified health professionals, and a case manager to coordinate health professionals and match dyad needs to available resources, were not available. "We need experienced MS specialists who visit the patients at home […] the family doctor does not feel competent enough […] we need skilled professionals around the patient." . "Yes. Coordination is required." . "Give me a [single] reference point without having to go through thousands of levels." . “These patients need a case manager, someone able to integrate all the competencies, someone able to notice family needs and to matching them with the resources available.” . All three parties said that more physiotherapy was needed. “Now what I really need is physio” . “We need all kinds of services… she should have more physio.” . “Sometimes their unmet needs were really concrete: more physiotherapy!” Despite these improvements, some needs (same two categories as above) remained unmet. For disease management, all parties complained that home care was lacking. “If only I had people at hand to talk to, to go out with.” . “Letting them get out a bit, maybe with the family, for a day, all together, relatives included [would be good].” . “I wish patients could get out of the house, but we haven’t had much success with this; they stay at home with all their problems[…] in short, they need some activity” .As regards psychological and social needs, all parties found deficits in available resources which limited intervention efficacy. Unmet psychological and social needs were grouped into social integration, helping others, psychological support, management of family problems, and reduction of caregiver burden. Social integration and connection emerged as crucial for all parties. Dyads and teams complained strongly about the lack of means to promote dyad social participation. “I am sick but I also want to help others, as long as I have the strength to speak […] I’d also like to tell others how I feel.” .Some patients expressed a desire to help others, both as a way of being part of the community and as a means of expressing themselves as individuals. “They [the team] came, and asked me: What about meeting a psychologist? I answered: It sounds great to me!” . "I need to talk to a psychologist, I need to communicate." . "Very few of them go to a psychotherapist or get any kind of psychological support. Everything is buried, swept under the rug." . Consistent with this, teams reported that some families experienced relational conflicts, for which psychological support was needed. However it was impossible for teams access such support in the public health domain. “It all came out—conflicts between family members that had degenerated and had a negative impact on patient management. […] We couldn’t find any services [to deal with this]." .The need for psychological support was reported by dyads, and recognized as important by teams. "Well, I need someone to help [my husband]. He had a heart attack" . "One person is not enough to take care of a patient like this" . "I don’t say I don’t need any help, although I can manage. At times though I really wish I had help. There are days when I go well, I manage […] here full-time: I move her, dress her, undress her, put her to bed." . “Caregiver depression and stress is always really high!” .Reducing caregiver burden was another important issue. Participants reported it was burdensome to be the only carer, and hard to find someone to relieve them. The main barriers  reported"One can be a facilitator when services are in place, but when there are no services what can I facilitate? In Rome, for example, many [patients] do not get rehabilitation, because of limited mobility, and ambulances cost too much" . “There remains the problem of lack of services provided by the local health authority […]services are few and badly delivered.".Organizational barriers were insufficient services, lack of networking facilities, complex administrative procedures, and structural factors (e.g. unsuitable housing). Inadequacy of services prevented resolution of difficulties even after the team identified them. “A better collaboration between services would be greatly appreciated.” . The family doctor viewed the intervention as an occasion for respite rather than for collaboration and networking. "You have difficulty in contacting the family doctor, and when you finally do, he says well, there you are, one more reason not to involve me; […] they’re good professionals, but obviously in this system they have a hard time." . "I informed them [family doctors]. I sent emails summarizing the study, and then we sent them our reports: social, psychological, nurses’ and medical. But no answer." .Lack of networking limited the efficacy of the intervention. “Better access to services is needed […] you always have to start procedures well in advance” . “We [the team] often experienced the powerlessness of being unable change things because of bureaucratic inertia.” .The complexity of administrative procedures emerged as a major burden. “I don’t have the space to install a lifter.” . “We have concrete difficulties […] we need a special chair like one used in ambulances to transfer patients. Every time I go with her to see the doctor [lack of such a chair] makes it always so complicated.” .Unsuitable housing sometimes prevented the introduction of devices or adaptations. "I was hoping it would last longer." . “The intervention should have been more intense and it should have last longer!” . “As soon as you start working with the dyad, the 6 months intervention ended! We had the feeling to have not enough time!” .With regard to experimental design, four limitations emerged: intervention too short, burdensome examiner visits and telephone interviews, difficulty defining examiner and team roles, indirect (hands-off) role of the team. All three parties reported the need for an intervention lasting more than six months. “They asked me things I was not interested in.” . As the intervention addressed the patient-caregiver dyad, the caregiver had to be present during team visits. Furthermore since patient and caregiver outcomes were endpoints (and for patients with severe cognitive compromise caregiver-reported patient outcomes were used) the caregiver also had to be present during the (blinded) examiner visits. “They wanted me to be present […] getting organized wasn’t easy. Then there was never agreement about the date […] they said we lived far away […] I work in the afternoon and have a son, a little boy […] these are things to keep in mind." . "They all came separately [team and examiner] but asked the same questions.” . Participants were confused about the role of the different health professionals . “I don’t remember whether he was the social worker […]I remember he was a man, that’s all I remember.” .“Once two people came […] but I don’t know who they were. For us it was all the same, I no longer knew who came and who did what.” . “It was difficult to figure out who was supposed to do what … the when, the what, and the how.” . Some dyads reported that the home visits were invasive. “Familiarity… with strangers coming into your house […] it’s not easy!” .Both patients and caregivers perceived the assessment as burdensome. “Some more help… something more concrete […] would have been appreciated.” . “I can’t say it was a great experience. They came, they listened, but they did nothing really concrete.” . “It’s an extra for them [the dyads] and also a reason for frustration, because they still want support, they want help, but in fact, apart from mediating relations with local health providers, offices and so on, we couldn’t do anything else for them." . “Clearly our role was not one of direct care, it was facilitating[…] the picture was clear. The problem was how to do that in practice, how to accomplish [things]." . “l had difficulties understanding what I had to do, what I could do, and was right to do according to study objectives.” .Caregivers and team members complained about hands-off role of the HPA teams. “I’d recommend having a physiotherapist and a speech therapist on the teams, to assess specific problems and provide advice.” .With regards to the teams, team members reported the following barriers: lack of other health care professionals; need for more teambuilding; insufficient supervision of teams. Caregivers also complained of a lack of other health care professionals on the team, particularly a physiotherapist and speech therapist. “Team members had specific competences, but some like me lacked skills in caring for MS patients. I had to learn about this new disease […] to this was added the need to become familiar with other team members.” Palliative care nurses of the Milan and Rome teams noted the challenge of gaining experience in caring for people with MS. We didn’t know each other, we didn’t have the prerequisites to work as a team in the sense that none of us, except for [the team nurse] had team-work experience.” . “Working as a team, as a group, was difficult. I’m not sure whether we as a group needed more training or whether this need was more general, and regarded how to manage the dynamics that usually manifested within a group.” .“Supervision [which was insufficient] is crucial in this kind of job!” .All teams reported difficulties with team working and asked for more supervision. “"They asked us many explicit questions but many questions remained unvoiced: they came out by asking us for help on issues that were apparently organizational, but in fact were about chronic conflicts between family members that impacted on patient care and organization. These occurrences were taxing for us, since after recognizing these unexpressed questions, it was then up to us to figure out whether there were intervention areas or not." . “What impressed me most was the difficulty that dyads had exploring their needs, as if they were not used to doing this. I guess the first time they really approached this was when they had the baseline visit. For relatives it was too difficult for them to express their personal needs, as all their needs were linked in some way to the needs of the patient. This required time and work." . "[…] for years [problems] are kept there [repressed]. You have no access, they have no access, so even if you realize from certain dynamics there are problems, they [the dyads] won’t acknowledge this." .Difficulties of dyad functioning were also recognized as a barrier. Patients and carers had difficulties articulating their needs. There are two main problems: huge bureaucracy, and difficult relations within the families’ . They also noted that MS centres were unsuitable for managing this patient population: ‘The point is that when the disease progresses the MS centre can offer so little to these patients …’ . Family doctors pointed out that they followed many patients with chronic diseases, but only a few with severe MS: ‘I am a so called maximalist, as I have 1600 patients on charge, many with chronic diseases and comorbidities. But only five have severe MS’ . Referring physicians from Milan were concerned about the unrealistic patient-caregiver expectations that the intervention elicited, and after it closed they would be left with these ‘expectant’ patients. Most physicians said they received no intervention feedback from their patients. Referring physicians from Rome noted that they had not been involved by the teams, but were careful to add that they could have done little due to existing workload: ‘Well, even if they [the PeNSAMI team] contacted me, I receive so many emails, and calls […] In case they required a prescription, as an example of a liquid gel thickener, I did it.’ . When asked how the intervention could be improved, the main suggestions were inclusion of a physiotherapist on the team, and replacing the team with a case manager: ‘More than a team, they need someone who can collect their needs, a case manager, not necessarily an health professional, who is in close contact with the family’ .The facilitator had great difficulty in placing the comments of the referring physicians in context: they tended to be theoretical and general rather than experiential; they emphasized the challenges of caring for these patients, most of whom had complex symptoms and comorbidities, and distressed and often dysfunctional families: ‘This study explored the expectations, the met and unmet needs, and the barriers to intervention success as experienced by PeNSAMI trial recipients and providers. Despite being skeptical, the patient-caregiver dyads had a positive attitude towards the trial, expecting it to increase understanding of people with severe MS and improve disease management. Most of the met needs regarded things that could be directly managed by the teams, with minimal involvement of health/social services, and consisted of improvements in symptom management, psychological wellbeing  and some organizational aspects. Nevertheless, some needs remained unmet in each of these categories. Furthermore, barriers, particularly lack of professional support services (chiefly rehabilitation) and networking facilities, and insufficient intervention duration, reduced the effectiveness of the intervention on patients’ and caregivers’ outcomes.In the PeNSAMI RCT, the HPA teams identified the pre-specified care needs  and those which were/were not fulfilled at the end of the intervention [Discrepancy between quantitative and qualitative results were detected for emotional wellbeing. This is probably due to two reasons. First, the qualitative study allowed at best to scrutinize this category, identifying different aspects . Second, the aim of qualitative research is depicting stakeholders’ experience independently from its frequency, while that of the quantitative research is finding general trends. This could also explain differences between some improvements reported in the qualitative study and the absence of statistically significant changes in some of the PeNSAMI RCT outcomes, specifically patient quality of life and caregiver burden. In fact, if the control of pain and other symptoms was achieved relatively quickly, a longer term but variable intensity intervention with emphasis on rehabilitation seems necessary in order to improve patient autonomy and social integration. Furthermore, the teams should have been able to call upon MS rehabilitation services in order to effect improvements. Although team members did successfully intercede in some cases, the paucity of available services, the demanding administrative procedures, and lack of networking facilities served as effective barriers. An additional difficulty arose from the fact that teams’ role in the intervention was to assess dyad needs, and activate pertinent services. This indirect role contrasted with the usual hands on working mode of most team members. Paradoxically, some of the good experiences reported by the dyads  were instances of deviations in trial protocol by team members.Team members also reported difficulties in building working relationships with patient referring physicians (neurologists or family doctors). This is consistent with outcomes of the referring physician focus groups, whose participants discussed at a theoretical or general level instead of recounting their experiences of the trial–suggesting that they were at best only superficially involved in it. Notwithstanding this, the HPA teams should probably have dedicated more efforts in building up this connection.Elaboration on the trial experience as a whole was not a pre-specified objective (our focus was the intervention), however the study design consistently emerged as an additional challenge. Having a blinded examiner was a plus in terms of methodological rigor and trial quality, but was a barrier to interaction with team members. Dyads were also confused about the roles of team members and the examiner, which added considerably to caregiver burden.In a previous study that investigated patient and caregiver needs, caregivers complained about not having time to themselves and difficulties articulating their needs . It is lAll team members experienced difficulties in team working and it was generally acknowledged that more supervision of teams was required. Notably, the Milan and Rome nurses with longstanding experience in palliative care, reported that dealing with MS sufferers was a new and demanding experience for them.Although we attempted to capture the gamut of experiences and perspectives of dyads who received the PeNSAMI intervention, it is possible that some diversity may have been missed. Additionally, the Catania referring physician focus group was not held, and we cannot rule out that more experiential (and productive) discussion would have emerged from this meeting. Moreover, while every effort was made to arrange a convenient time for the HPA team focus group, not all team members could attend. It is thus possible that we did not capture some important aspects of team experience. Finally, another important point is the qualitative design of this study that does not allow us to generalize findings beyond this sample. Trial recipients and providers’ narratives should be interpreted as reconstructions of their experiences, rather than the absolute truth.This qualitative study embedded in the PeNSAMI trial scrutinized the experiences of recipients and providers of a complex intervention. The findings illuminate the quantitative findings of the trial, and regard three main aspects. The first  is that the main strengths and limitations of the intervention were identified. Some of the limitations may be overcome by increasing intervention duration, and by investing more time and resources in building a functioning team, well-connected with key services, chiefly MS rehabilitation services. The second aspect is that the facilitating aim of the intervention was to a considerable extent frustrated by the lack of available services. The third aspect pertains to conducting high-quality randomized controlled trials on complex interventions : our effS1 ChecklistCompleted checklist (except items 30–32) of Consolidated Criteria for Reporting Qualitative Studies (COREQ) to provide supplementary information and locate key points in paper. N.R. is not reported.(DOCX)Click here for additional data file.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.S3 Appendix(DOCX)Click here for additional data file.


In recent years, neural networks have become very popular in all kinds of prediction problems. In this paper, multiple feed-forward artificial neural networks (ANNs) with various configurations are used in the prediction of Parkinson’s disease (PD) of tested individuals, based on extracted features from 26 different voice samples per individual. Results are validated via the leave-one-subject-out (LOSO) scheme. Few feature selection procedures based on Pearson’s correlation coefficient, Kendall’s correlation coefficient, principal component analysis, and self-organizing maps, have been used for boosting the performance of algorithms and for data reduction. The best test accuracy result has been achieved with Kendall’s correlation coefficient-based feature selection, and the most relevant voice samples are recognized. Multiple ANNs have proven to be the best classification technique for diagnosis of PD without usage of the feature selection procedure (on raw data). Finally, a neural network is fine-tuned, and a test accuracy of 86.47% was achieved. Parkinson’s disease (PD) is a chronic neurodegenerative disorder of the nervous system which predominantly affects motor function. It is classified as a movement disorder, with features of inability of voluntary movement (akinesis), diminished and slow movement (bradykinesis), increased muscle tonus (rigidity), and shaking movement in the resting position (Parkinson’s tremor) . Some otThe diagnosis is made most commonly with neurological clinical evaluation. No laboratory parameter has been identified to detect PD, however, there is a method of nuclear imaging study that can confirm and distinguish between Parkinson’s and some other similar diseases. Nuclear imaging detects gamma radiation of various radioactive substances and can quantify signals in various parts of the brain which can confirm brain patterns in patients with PD . The imaIn recent years, more research has been made in specific voice and speech patterns in people who suffer of PD ,15. It iThe work that has been done on the subject of PD detection using classification algorithms is very diverse. Classification algorithms and other intelligent methods are offering experts support tools for predictions ,26,27, aThe aim of this study is to evaluate the performance of neural network-based classification using different feature selections. Feature selection and dimensionality reduction is performed with self-organizing maps, principal component analysis, and on the basis of Pearson’s and Kendall’s correlation coefficient. The novelty of this study is that it offers deeper insight into how different feature selection procedures and neural network architectures influence the performance of classification to diagnose the presence of PD. The Parkinson’s dataset used in this study is taken from the University of California at Irvine (UCI) Machine Learning Repository ,38. The Classification of people with PD and healthy controls is a pattern classification problem. In order to detect those patterns successfully, the data are separated into subdatasets containing tests of individuals speaking only one type of word, so-called voice samples. Then, feature selection of each voice sample is performed, with evaluating the level of influence that features have on the presence of PD. Selected features of each voice sample . Then, we choose to eliminate all features (per sample) that have lower than specified association. For this paper, feature selection is performed so only features with absolute values Kendall’s correlation coefficient represents the degree of concordance between two columns of ranked data. It is a non-parametric test, as it does not rely on any assumptions on the distributions of variables. We adopt a similar procedure as in the case of Pearson’s correlation coefficient by elimination of less relevant features. Features that are considered as relevant in this study are features with PCA is a well-established statistical procedure for feature extraction and dimensionality reduction that uses an orthogonal transformation to convert a set of observations with correlated variables into a smaller set of values of linearly uncorrelated variables. It is based on the assumption that most of the information about certain classes is contained in the features with most variance. Its idea is that the e matrix . In thisA self-organizing map  is an uFor this study, 2 × 2, 3 × 3, 4 × 4, 5 × 5, and 6 × 6 two-dimensional SOM hexagonal grid topologies have been trained for 250 iterations using a batch unsupervised weight/bias training algorithm. The training procedure is divided into coarse and fine training. During the coarse training, the Gaussian neighborhood function radius is shrunk from 4 to 0.5 for 200 iterations. During fine training (lasting 50 iterations), the Gaussian neighborhood function radius is kept constant at 0.5. The features selected of a certain voice sample are then mapped linearly on the interval  as a preprocessing step for classification.ANNs are biologically inspired; they mimic the human brain processes and have emerged as one of the tools that can handle the classification problem. ANNs have been used to solve many problems in the Economic, Social and Engineering Sciences, as well as Health Sciences ,44,45. TAn ANN consists of an input layer of nodes, one or more hidden layers, and an output layer. The input layer, in our case, consists of neurons that represent different sound parameters. The hidden layer is a collection of neurons which provide an intermediate connection between the input layer and the output layer. The hidden layer of the neural network simply maps the inputs into image space Г. The number of neurons in the output layer is determined by the number of classes. The architecture of the network is one of the most important considerations when solving problems using multilayer feed-forward neural networks. An oversimplified network architecture is less flexible  and mightansig”) [purelin” and “logsig”. Training the algorithm provides ANN with a strategy for efficient adjusting of weights belonging to a certain neuron. In our case, mostly scaled conjugate gradient backpropagation (“trainscg”) is used, because it is very suitable for large data processing. During the fine-tuning of our algorithm, other training algorithms were also used, like “trainlm” and “trainbf”. The strategy for preventing overfitting is the early stopping, because this method is suitable with a scaled conjugate gradient backpropagation training algorithm. Transfer functions determine the way the signals are processed by the neurons. They are used as an integral part of the network. The transfer functions used in the majority are the sigmoidal (“tansig”) , that haSince an algorithm has multiple classifiers each providing certain response if, for instance, feature selection is not used, classification with all 26 classifiers is adopted, each for a certain vocal test. Each classifier will predict the class label of its own subset; a label of “1” means the subject has PD, and “0” otherwise. The majority vote decides a class that a person belongs to. If the majority of classifiers have voted for “1”, then the subject has PD, if not, otherwise. The problem emerges when there is even number of classifiers and the result is tied. In that case, the majority voting procedure is tilted toward “1”, since it is better to examine the healthy individual further than to take no action on an individual with PD. For the validation of our neural network model, since we do not have independent validation samples, we must build predictors using subsets of the data samples available for training and test them with the rest of the data. Using the conventional leave-one-out or bootstrapping technique ,56,57 woClassification is one of the most frequently encountered problems in decision-making tasks. In Machine Learning and Statistics, classification is described as the problem of identifying to which of a set of categories (subpopulations) a new observation belongs, on the basis of a training set of data containing observations (or instances) whose category membership is known. Several measures have been used in order to evaluate the effectiveness of our classification. These measures are accuracy, sensitivity, specificity, MCC, and confusion matrix. A confusion matrix  containsAccuracy is the ratio of correctly classified instances to the whole instances:MCC is used as a measure of the quality of binary classifications. It takes into account true and false positives and negatives, and is generally regarded as a balanced measure, even if the classes are of very different size. The formulation of MCC metric is given as follows:The MCC values range between −1 and +1. The MCC coefficient is equal to +1 when a classifier makes perfect predictions, −1 when the predictions and actual values totally disagree, and 0 when the classification is no better than random prediction.r (ppq5) . In ordeFive different ANN configurations are tested, two with one hidden layer with 5 and 10 neurons (named ANN 5 and ANN 10), two with two hidden layers (ANN 5-5 and ANN 10-10), and one with three hidden layers of neurons (ANN 5-10-5). Neural networks are trained for 500 epochs, and entire LOSO cross-validation is preformed 30 times for each ANN configuration using selected features based on Pearson’s correlation coefficient, Kendall’s correlation coefficient, principal component analysis, and self-organizing maps. Test accuracies of different ANN topologies combined with feature selection techniques are stated in Different ANN topologies performances with regard to different feature selection methods are shown in For comparison with study , filter-The best results achieved in this study are stated in In this work, multiple ANNs with feature selection based on Pearson’s correlation coefficient, Kendall’s correlation coefficient, PCA, and SOM have been developed for addressing the PD diagnosis problem. The multiple ANN algorithms are used to classify the individuals into classes. Each subject is classified into the class “healthy” or “PD” based on the majority voting procedure. In Machine Learning, one of the problems is identifying a representative set of features from which to construct a classification model for a particular task. With using feature selection, the procedure size of the problem is reduced by reducing the dimensionality of the data, and improvement of ANN performance can then be achieved by removing the noisy or irrelevant features and preventing the overfitting to noisy data. Using more hidden layers and adding more neurons to existing layers has been proven to alter the result, meaning that appropriate ANN response is dependent on ANN architecture. The same thing can be concluded for usage of certain types of feature selection procedure. With regard to statistical significance of results, no claims can be made because extensive statistical tests were omitted.It was observed that multiple ANNs achieved the highest accuracy among classifiers of PCA-ANN and SOM-ANN achieved similar recognition rates, and were surpassed by correlation coefficient-based feature selection procedures. It was shown that one-layer ANN topologies, with PCA and SOM feature selections, could not adequately model the PD problem, consequently achieving low test and training accuracies. Feature selection with Kendall’s and Pearson’s correlation coefficient enhanced multiple ANNs accuracies. Based on fact that multiple ANNs with Kendall’s correlation coefficient surpassed accuracies of multiple ANNs with Pearson’s correlation coefficient, we can conclude that the data have no normally distributed nature. Some of the voice samples used by other authors for determining presence of PD, such as vowel “a”, have been shown to carry little information. We can state, based on Pearson’s and Kendall’s correlation coefficients, that voice samples of “number 4” and “short sentence 4” have been recognized to carry the most information about PD. This may indicate that more information about the presence of PD is imbedded in voice samples consisting of more diverse sounds compared to simple sounds like sustained vowels pronunciations. The excellent performance obtained on the PD dataset has proven that the proposed system can distinguish well enough between patients with PD and healthy individuals. It can be concluded safely that developed ANNs can, to some extent, assist physicians to make accurate diagnostic decisions.As an extension of this study, we suggest a research direction for future work: it is possible to improve the ANNs’ performance by using other feature selection procedures and by additional work on fine-tuning. Future work should also be oriented into collecting several vocal tests in other languages and performing the classification on those datasets. A described approach for detection of PD is, in this stage, clearly experimental and cannot, by its own, be used for clinical diagnosis.


In this Letter to the Editor, the writer, shares his experience on providing a sustainable 24/7/365 interventional radiology service. Sufficient manpower resources, adequate bandwidth for quality personal and family time, consistent work processes and a cohesive team with a “whole of the patient” approach were some of the reasons emphasised. To the Editor,I read with interest the article “Trends and implications of 24/7 interventional radiology in a newly opened acute hospital”. Chung et al., The authors indicate that a sufficient number of trained interventionalists with sufficient free time compensation is recommended to support a sustainable 24/7 IR clinical service in an acute hospital. I could not agree more with the authors. Burnout has high costs not only for the physician’s mental and physical health, but can impact patient health, causing adverse care events and errors as well. Kaplan, . I was tWe decided very early in the beginning that we need to give adequate time for our radiologists to rest and recover, to re-fresh and to re-charge and so that they are ready, well rested, re-energise and re-vitalize, for their next duty on the roster and on-call rota. Drawing brighter lines between work and time off — family, friends, outside activities, and old-fashioned daydreaming — has clear benefits for productivity, creativity, and wellness. Downtime can be essential for mental, physical, and social health. There’s an upside to downtime. (Coleman and Coleman, This was a critical reason why the department was able to provide and grow the services, despite having only one single IR radiologist, during the period from before 2010 to 2014. We did increasingly more number of cases during this period of time (Table 1 and 2, Chung et al., Another important ingredient for the success of the service was the “whole of patient” approach in our practice. A successful multidisciplinary health team strives to make the most comprehensive assessment of a patient’s situation and deliver coordinated patient care to treating the whole patient Hughes, . Our teaConsistency in practices and processes is key to quality in care delivery, patient safety, and clinical outcome. Standardized processes or instruments help ensure consistent quality of care Brett, . Works pThere was also a wonderful teamwork that drove and strived the IR service. A positive workplace increases positive emotions and well-being, and achieve significantly higher levels of organizational effectiveness (Seppälä and Cameron,