To describe our use of intervention mapping as a systematic method to adapt an evidence-based physical activity and nutrition program to reflect the needs of rural Latinas.An intervention mapping process involving six steps guided the adaptation of an evidence based physical activity and nutrition program, using a community-based participatory research approach. We partnered with a community advisory board of rural Latinas throughout the adaptation process.Mujeres Fuertes y Corazones Saludables, within the context of the rural community. A pilot study will be conducted with overweight, sedentary, middle-aged, Spanish-speaking Latinas. Outcome measures will assess change in weight, physical fitness, physical activity, and nutrition behavior.A needs assessment and logic models were used to ascertain which program was the best fit for adaptation. Once identified, we collaborated with one of the developers of the original program  during the adaptation process. First, essential theoretical methods and program elements were identified, and additional elements were added or adapted. Next, we reviewed and made changes to reflect the community and cultural context of the practical applications, intervention strategies, program curriculum, materials, and participant information. Finally, we planned for the implementation and evaluation of the adapted program, The intervention mapping process was feasible and provided a systematic approach to balance fit and fidelity in the adaptation of an evidence-based program. Collaboration with community members ensured that the components of the curriculum that were adapted were culturally appropriate and relevant within the local community context. Obesity, physical inactivity, and diet are associated with increased risk of, and morbidity and mortality from, a range of chronic diseases and certain cancers . In 2015www.thecommunityguide.org). In order to enhance the potential to promote change, behavior change programs need to address differing social and cultural contexts across communities. Implementing an evidence-based intervention (EBI) often involves adaptation in order to fit the local context, including cultural, socioeconomic, and rural/urban factors, to resonate with the local community and enhance effectiveness [One approach to promoting physical activity and healthy eating is the use of individually adapted behavior change programs, which are recommended in The Community Guide  approach and involved community members in the adaptation process to ensure that the evidence-based program was both sensitive and relevant to the local community. For this project, we created a community advisory board (CAB), consisting of five Latinas representing various constituencies in the community . A community member who has worked with one of the researchers for many years invited Latinas living in the community to participate in the project and to be a member of the CAB. In concert with the principles of CBPR, researchers and community members shared equitably in the decision-making process and were involved in all phases of the adaptation and research process.The study took place in a town of nearly 16,000 residents within a rural, agricultural county of Washington State with a population density of 52 people per square mile and Rural-Urban Commuting Area Code (RUCA) of 4.2, meaning a large rural area. In 2010, 82% of the town residents were Latino, 30.5% were foreign born, 73% spoke a language other than English in the home, and 49% had not earned a high school diploma . The medWe describe our application and results for each of the 6 steps in the invervention mapping.Four focus groups were held with Latinas in the community over the course of a year (2011–2012) to elicit their perspectives on determinants of physical activity and healthy eating and to gather intervention ideas. Convenience sampling was used to recruit participants. Latinas who participated in two informal walking groups in the community were invited to participate in a focus group after the completion of a walking group session. All Latinas in each of the two walking groups  agreed to participate. The trained facilitator who held the groups in Spanish took notes during each of the 45-min focus groups. A qualitative researcher identified key determinants from the notes and from a discussion with facilitator. Women whose children had participated in a research study assessing an after school physical activity program were invited to participate in a focus group. Two focus groups were held in English with eight women in one group and six in the second group. The qualitative researcher who led the groups took notes during the groups and identified key determinants from these notes.The focus group resulted in some key findings, such as exercising in a group was a motivator to engage in physical activity. Participants were uncomfortable exercising or walking for exercise in public places, for example in parks. Additionally, participants identified involving family members in exercise and exercising as a family as important. Barriers identified included lack of time, lack of places to be active, and lack of opportunities to be active. Some stated that language was a barrier to using traditional exercise facilities. They wanted to exercise regularly; however, most did not exercise regularly and did not feel confident that they could start and maintain a routine of regular exercise. Participants identified several barriers to healthy eating, including limited access to affordable healthy foods, lack of time, and lack of knowledge in how to prepare healthy meals. Some expressed the belief that healthy foods are tasteless and that they would need to give up the foods they enjoyed in order to be healthy. They voiced interest in an exercise program that included information on healthy eating and, in particular, included cooking classes with healthy recipes.In 2014, we conducted environmental audits, using the Nutrition Environment Measures Survey (NEMS)  to assesThis step involved creating a series of logic models, a visual depiction of the strategies and activities that will lead to change . From a First, we created a logic model of the problem . Next, logic models of change were created  for the three identified evidence-based programs. An additional logic model was developed to delineate how to promote physical activity and healthy eating in this local community. Next, we completed a side-by-side comparison of the logic models to determine which of the three EBIs was the best fit for adaptation considering determinants addressed, behavior change strategies, culture, core elements that cannot be changed, content, delivery, level of evidence, and degree of adaptation needed.Based on this step, SWHH was identified as the most suitable program to adapt for this community of rural Latinas. Pasos Adelante was not suitable, as some of the elements that would need to be adapted were core elements of the program. The culturally tailored aerobics intervention did not address many of the determinants for physical activity and healthy eating identified by the local community. Additionally, it had different performance objectives with the main focus of the program being 60-min classes of vigorous activity delivered three times a week for six months. In comparison, the SWHH program addressed many of the same determinants for physical activity and healthy eating ; it contained similar performance objectives with a focus on both moderate physical activity and healthy eating; and, its core elements  matched key elements needed for the community to change. Thus, SWHH most closely matched the community’s matrix of change and, therefore, would involve the least amount of adaptation to meet this local community’s needs. An example of matching change and performance objectives and behavioral outcomes into a matrix is depicted in Table The developers shared the SWHH curriculum (detailed class-by-class guide) and program leader training manual. Both the CAB members and researchers reviewed the curriculum from a broad perspective looking for key determinants. Next, we identified theoretical methods and program elements or practical applications that needed to be added or adapted . For exaIn this step, the researchers held a series of meetings with the CAB members to examine the class guides (curriculum), participant information sheets, recipes, and the presentation of ideas and messages (including images) and to provide feedback on necessary adaptations to align the curriculum with the local community resources, needs, and culture . This feThe adaptations to the contextual and structural elements took the form of developing and integrating new participant information sheets (handouts), adding additional content to existing information sheets, replacing recipes, increasing exercise options, updating images, and translating all participant materials into Spanish. Each of the individual adaptations fell into at least one of the six adaptation domains: (1) Accessibility, (2) Nutrition Knowledge, 3) Health Knowledge, (4) Skills and Strategies, (5) Address Barriers, and (6) Cultural Relevance  flyers, newspaper advertisements, and radio announcements. Members of the CAB will distribute recruitment materials throughout the community  and attend local events to advertise the program and recruit participants. Inclusion criteria include Spanish-speaking Latinas, ages 40–70 years, inactive (exercise two days or less per week), BMI ≥ 24, and live in the local community. Individuals who meet these criteria will then be screened using the Physical Activity Readiness Questionnaire (PAR-Q), and those with a positive response will require health care provider permission to participate. Exclusion criteria include pregnancy and presence of a health condition precluding moderate to vigorous physical activity.The main outcomes for evaluating the adapted program are weight, cardiorespiratory fitness, physical activity, and dietary behavior. These will be measured at two time points: pre-program (T1) and post-program (T2). Table Process evaluation will occur frequently and in multiple forms throughout the study. After each class, participants and leaders will complete a feedback survey to assess fidelity and feasibility of implementing the adaptations. The leader feedback examines the percentage of participants actively taking part in the exercise, class flow, and feasibility of covering added information during each class. For participants, feedback allows them to share any barriers they face in the class and to reflect on the appropriateness of the adaptations and their receptiveness towards the class curriculum. A mid-program evaluation will be given to the participants to gain further insight into their experiences with the classes. At the start of each class, attendance will be recorded. If necessary, participants will be contacted outside of class by one of the leaders to determine the reason for any reported absences or trends in tardiness. The principal investigator and program leaders will meet each week by phone to address any unanticipated challenges that arise and identify solutions. Results of this pilot study evaluation will be reported separately once completed.We found it feasible to use the intervention mapping process to engage the local community and guide the adaptation of an evidence-based program aimed at obesity prevention through the promotion of physical activity and healthy eating. Intervention mapping employed in this unique way enabled the study team to identify core aspects of the curriculum that needed adaptation while retaining the essential core programmatic evidence-based elements. The adaptations were designed to enhance group cohesion and support for incorporating positive daily nutrition and physical activity based changes within participants’ lives, taking into account the cultural and geographic context. Collaboration with the CAB ensured that the aspects of the curriculum that were adapted were culturally appropriate and relevant to the local community. By collaborating with one of the developers of the original program, we were able to ensure that we maintained the core essential elements and did not alter the underlying logic of the intervention. The intervention mapping process allowed for a systematic and thorough examination of the community context and the program, and served as an effective approach for striking a balance between adaptation to the local context and fidelity to the original program.Cultural adaptation is essential in order to reach and engage diverse cultural communities. A meta-analysis of cultural adaptation studies found that programs were most effective in their treatment implementation when they had a greater number of cultural adaptations targeted to the background and traditions of the population . HoweverWhile cultural adaption is critical given the diversity within the US, adaptation of EBIs beyond cultural considerations have become increasingly important. Adaptation enhances the relevance of a program, increases a program’s reach into the community and alignment with local resources, and addresses barriers and facilitators unique to the community . Other dThere is an inherent tension between fidelity and adaptation, and various approaches for bridging this divide have been used. Despite ongoing debate, maintaining the fidelity of an intervention through the retention of essential core elements has been shown to produce program outcomes that are more similar to those of the original study . There iOur use of intervention mapping as a systematic approach for the adaptation of an EBI provided a guide for a deep dive into the community context and a comprehensive examination of all aspects of the EBI, including implementation and evaluation. This use of intervention mapping contributes to the growing body of research on intervention adaptation by demonstrating that intervention mapping can be re-appropriated and effectively applied to the intervention adaptation process using a community-engaged approach within a community-based setting.


Demand for interactive wearable devices is rapidly increasing with the development of smart devices. To accurately utilize wearable devices for remote robot controls, limited data should be analyzed and utilized efficiently. For example, the motions by a wearable device, called Myo device, can be estimated by measuring its orientation, and calculating a Bayesian probability based on these orientation data. Given that Myo device can measure various types of data, the accuracy of its motion estimation can be increased by utilizing these additional types of data. This paper proposes a motion estimation method based on weighted Bayesian probability and concurrently measured data, orientations and electromyograms (EMG). The most probable motion among estimated is treated as a final estimated motion. Thus, recognition accuracy can be improved when compared to the traditional methods that employ only a single type of data. In our experiments, seven subjects perform five predefined motions. When orientation is measured by the traditional methods, the sum of the motion estimation errors is 37.3%; likewise, when only EMG data are used, the error in motion estimation by the proposed method was also 37.3%. The proposed combined method has an error of 25%. Therefore, the proposed method reduces motion estimation errors by 12%.  Motion controller devices for user interfacing are utilized to recognize user’s motions or to control remote robots. Motion recognition is an approach that enables users to interact with a computer naturally by using wearable devices to capture their movements, positions, and gestures. These devices become increasingly smaller, more intelligent, and more varied in type and configuration. For example, motions are detected by measuring arm angles or muscle activities from a band worn on a arm , wearingResearchers have proposed motion estimation methods based on Bayesian probability to reduce the number of Myo device , but theThis paper proposes a method for calculating Bayesian probabilities and estimating motions using EMG and orientation data from a Myo device. The final motions are determined by comparing the Bayesian probabilities of motions applying the weights that are calculated by the proposed method based on orientations and EMGs. In this paper, the measured raw data of subjects who are not calibrated for predefined motions are used. In this paper, only the orientation and EMG are utilized without using any velocity. Orientation data and EMG signals of a Myo device measured at a rate of 30 frames is utilized. The remainder of the paper is organized as follows: There are the diverse kinds of contactable wearable devices, such as Myo device and GestTrack3D Hand Tracker of GestTrackTek in USA . Myo devWhen a Myo device is worn, the sensors measure muscle activity to determine the kind of gestures performed expressed as electrical signals. For example, an EMG extracts and amplifies the activity accompanying muscle contraction. The muscle sensor is composed of an amplifier, a high-pass filter (HPF), and a low-pass filter (LPF). EMG signals are amplified because the intensity of signals from muscle contractions is minute. The range of signals measured in the muscles is 10–2000 Hz, whereas the informative signals from the typical human’s muscles usually appears at 20–450 Hz. Therefore, signals of other frequencies can be regarded as noise. Myo device is equipped with an EMG, Bluetooth 4.0 communication, a three-axis accelerator, a three-axis gyroscope, and a three-axis magnetometer. Myo device can measure 25 finger and arm movements that are related to muscle activity, including movements more complex than simple hand gestures. It also measured the degrees of freedom (DOFs) of the hand, and can provide natural language interactions. Harrison et al. [The Myo device also has a 9-axis Inertial Measurement Unit (IMU) that includes a 3-axis gyroscope, a 3-axis accelerometer, and a 3-axis magnetometer. The direction and movement of the wearer’s arm are measured by these units and determined by analyzing the spatial data provided. Orientation represents the positions of the band in terms of roll, pitch, and yaw. The angular velocity of Myo device is provided in vector form and the accelerometer represents the acceleration corresponding of Myo device. Strelow and Singh  proposedA study of cube games using gesture recognition  recognizSince biological signals have very different body characteristics, it is necessary to use very complex algorithms, such as the classification of precise sensors and clear operation, learning, and processing using a large amount of data, and so the research scope is very limited. To improve motion estimation accuracy, the equipment used must also be improved, which can be costly. Kim et al.  proposedLee  proposedRecently, Myo’s EMG motion estimation study is Kim . They suNourhan T.  proposedMendez, I.  proposedHowever, the Myo device is better suited to determine the relative position of the arm, not the absolute position. Myo device-related approaches can be applied to diverse fields, such as robot control and remote medical support. Since Myo device’s sensor data feature always provides a constant absolute coordinate system, the Myo device orientation starts measuring and is arranged in the current position with the movement of the next position and relative position coordinates.In this sense, “relative” in this study is the Bayesian probability by taking Myo device on the upper arm and forearm of right arm in the learning stage and then taking into account their correlation. In the recognition phase, Myo device is put on the forearm of the arm, and then the Bayesian probability is determined and the motion is determined by selecting the motion having the Euclidian distance closest to the motion defined in the learning.Therefore, in order to control remote or remote objects such as robot control, it is possible to perform more accurate and elaborate missions, by calculating the displacement of the relative coordinates from the current position starting point to provide various motion recognition information. The approach of wearing Myo devices on the upper arm and forearm is generalizable to other parts of the body, such as the legs.In this paper, the methodology for motion estimation is as follows. We used the orientation and EMG raw data measured at 30 frame rates after wearing the upper arm and forearm of the right arm for the five defined stopping operations as input data. The data measured in two Myo devices are defined as independent motion and the Myo device worn at the upper arm is defined as the dependent motion. Learning is defined by defining the correlation in the learning stage. In the recognition phase, the final motion is determined by looking at the motion defined at the learning stage and the motion at the upper arm as the orientation and EMG raw data measured at one Myo device worn at the forearm of the arm for motion estimation. Detailed methodologies are described in detail in the following chapters.User’s motions can be estimated more accurately by utilizing multiple currently measured data. The following details the procedure of the proposed motion estimation method.The proposed method utilizes a wearable Myo device. To estimate a user’s motions, Myo devices are set on the upper arm and forearm of one arm, and a subordinate relation of the two are set, for example, the upper arm can be defined as a dependency on the forearm. At the end of learning, the subordinate relationship enables motion estimation of the upper arm in subordinate relation to the independent motion of the forearm at the recognition phase. The final motion is determined by selecting the motion corresponding to the signal with the highest Bayesian probability calculated by each signal.The overall structure of the motion estimation approach is shown in The proposed method consists of data processing, training, and recognition stages. Orientation and EMG data are recorded with Myo devices. The orientation data are transferred to the Bayesian probability calculation step of the training stage. The calculated Bayesian probability is used in a genetic algorithm to obtain weights, which are then transferred to the motion estimation step in the recognition stage. In the data processing phase, the Myo device measures data. Data that can be thus obtained are shown in In the proposed method, only the orientation and EMG are used, but motion estimation accuracy can be improved using additional data of other types by applying the proposed method.Training consists of two steps. The orientation data and EMG input from the data processing phase are processed, as shown in The motions not worn by Myo device are estimated by the orientation and EMG of the motions worn by Myo device. Set the independent motion The weight calculation step is shown in Each weight ranges from −1 to 1 in increments of 0.2. For orientation, three weights,The dependent motion The Bayesian probability calculation from the orientation and EMG data in the motion estimation step reflects the weights determined by the genetic algorithm as shown in Then, the Bayesian probability updated by the weights is calculated, and final motion is estimated. Of the Bayesian probabilities calculated from the x, y, and z orientations and EMG data, the motion with the highest probability as the final motion is selected as in Equation (3). Handling multiple data types can more accurately estimate motions than traditional methods.The experimental environment of this study was implemented with Unity 5.4.2 based on the Win10 operating system and four Myo device devices based on Bluetooth 2.0 were used. First, the subject calibrates his motions by the developed application connecting with Thalmic Labs’ Myo Connect manager. When the subject moves a lot, he needs to calibrate again from the beginning. In addition, the calibration is deducted by performing four pre-defined gestures, finger spread, wave-in, wave-out, and relaxed state gestures, after wearing a Myo device.The subjects’ motions were defined by five representative major motions of the arm. To learn these motions, Myo devices were worn on the upper and lower parts of the subjects’ left arm. The learned motion is recorded for each user and stored in the user table, and is used to estimate the most accurate motion in the recognition stage. In addition, motion recognition features are recorded for each user, and user-independent motion estimation could be possible using the average value obtained in the experimental data.The histogram behind the graph represents the mean value of the total error of the motion estimation. The histogram of the sum of the errors shows that the motion estimation error of the proposed algorithm is small.  show smaller differences than .As shown in The algorithm comparisons for the main frames in all estimated motions are shown in red and blue circles. As can be seen from the original motions, the proposed algorithm showed improved results.The results of the algorithm experiment on EMG data are shown in In this paper, we proposed a Bayesian probability-based motion estimation algorithm that reflects the weight of Myo device signals by utilizing a genetic algorithm. In the training phase, we showed that upper-arm motions can be estimated by learning Bayesian probability with only one lower-arm Myo device after learning using two Myo devices: one on each of the upper and lower part of one arm. In addition, the performance improved when recalculating the Bayesian probability to reflect the weights calculated by the genetic algorithm. Experimental results showed that the data used for motion estimation are complementary by using two types of data: orientation and EMG.The proposed algorithm, using a composite of orientation and EMG data, reduced motion estimation errors by 12% as compared with previous methods. Motion estimation errors from EMG data were also 37%, which agrees with traditional studies. In the future, it is necessary to study robot controls by transferring estimated users’ motions using a Myo, as proposed in this paper.


This study explores differences in characteristics of overdose (OD) and non-overdose (NOD) suicide attempts in Singapore.Four hundred eighty-five medical records of people who attempted suicide were extracted from a local general hospital patient database and classified into OD and NOD groups. Differences in socio-demographic factors, suicide characteristics and hospital admission types between both groups were examined.Indians were more likely than the Chinese and Malays to employ OD method in their attempts. More suicide attempts in the OD group than NOD group were self-reported. The most likely place for suicide attempts for both groups was at home, though more NOD suicide attempts were in public areas as compared to the OD group. Analgesics were the most used substance in the OD group. Those who attempted suicide using OD had a higher number of psychiatric ward admissions than the NOD group. Risk and protective factors varied between both groups.Differences in socio-demographics, suicide characteristics and admission characteristics between OD and NOD groups were observed. Recommendations for suicide prevention in the community are discussed. Further studies on the mediators and moderators of these trends and characteristics of suicide attempts are necessary to ensure maximal efficacy of prevention and management. Suicidal behaviour is a global public health concern that leads to not only an immense financial burden on society, but also incurs a hefty psychological toll on survivors and their loved ones. Each year, 10–20 million individuals attempt suicide and over 800,000 lives are lost , the gapth in the world in terms of number of suicide deaths [Singapore which is ranked 97e deaths , is a cue deaths . The mose deaths . Most ste deaths , 15 and e deaths  and explA total of 485 assessment records of admitted adult suicide attempters aged 21 years old and above from January 2009 to December 2012 were extracted from a general hospital  database. Data sources included the suicide risk assessment forms, psychiatric reports, in-patient records and electronic notes. The assessment was done by the psychiatrist and this was part of the protocol of standard operating procedures for patients admitted following a suicide attempt. The interview was based on a semi-structured checklist approach. A formal diagnosis was made by the psychiatrist based on the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (Text Revision) (DSM-IV-TR) criteria.The suicide risk assessment form that was used in the study contained stressors that comprised of work-related issues, family-related issues, relationship problems, financial difficulties and medical illnesses; risk factors that included history of psychiatric illnesses, family history of psychiatric illnesses, staying alone, alcohol or substance misuse, ongoing interpersonal problems, lack of confidantes, serious physical illnesses, poor coping skills, severe financial problems and unemployment; and protective factors that consisted of faith in a religion, resolution of precipitants, receiving support from dependents, expression of regret, positive plan for the future, willingness to seek help and good emotional support. All suicide attempters were also asked to rate their impression of lethality of their suicide method as part of the suicide risk assessment, which ranged from ‘not lethal’, ‘moderately lethal’ to ‘very lethal’.This assessment form was created by a team of psychiatrists in the department based on known common risk factors of suicide. The initial and main aim of the checklist form was to serve as a clinical tool for the assessing psychiatrist to avoid missing out on the common possible stressors and risk/protective factors. To standardize the assessment, all the psychiatrists were briefed and trained on asking the questions in the form so that they could reach a common consensus on the terms and what they meant prior to using the form.Attempters were classified into either the OD group if there were indications of consumption of pharmacological or chemical substances in the attempt or the NOD group for all other forms of deliberate self-harm, including lacerations, stabbing, jumping from height and hanging. Written informed consent was obtained from all the participants in the study. The study was approved by the Domain Specific Review Board (DSRB) (DSRB Reference: 2013/00800).The Statistical Packages for Social Sciences (SPSS) Version 21.0 software was used to perform statistical analysis. The Chi-square test was conducted to examine differences in characteristics and suicidal behaviours between and within the OD and NOD groups. The Mann-Whitney U test was employed to determine differences in hospital admission data between the OD and NOD attempters. The assumption of similarly shaped distributions was ascertained by visual inspection. Logistic Regression was used to test for differences between the self-perceived lethality of the suicide methods employed between OD and NOD groups.In both the OD and NOD groups Table , most ofIn comparing demographics and characteristics of attempts between the OD and NOD groups Table , ethniciSignificant risk factors for attempters in the OD group were living alone, alcohol and substance abuse, and lack of confidantes, while a significant protective factor was to have resolution of the precipitating factors. On the other hand, a significant protective factor for attempters in the NOD group was the willingness to seek help and having good emotional support Table .Table 3COf special interest was the type of drugs used by the attempters in OD group. While a wide of range of drugs was used, the five most common drugs of choice were analgesics, hypnotic agents, domestic products, antidepressants, and flu medication. Most attempters consumed only one drug Table .Table 4Dp = 0.02). Chinese OD suicide attempters had higher perceived lethality of their suicide methods  as compared to all other ethnicities. All other demographic factors did not have significant impact on their perceived lethality  and Saturdays  for both OD and NOD groups, whilst the highest occurred during mid-week on Wednesdays for the OD group  and on Thursdays for the NOD group . The lowest number of attempts was in the month of January for both OD and NOD groups , whilst the highest occurred in the month of May for the OD group  and in April for the NOD group .An exploratory analysis of geographical distribution of attempts showed that areas in Singapore with more than 20 suicide attempts had a high density of high rise residential buildings. Presence of industrial estates that is typically more isolated had little impact on the number of suicide attempts.Our results suggested that ethnicity may influence the choice of suicide method, with Indians tending to choose OD over NOD methods. This finding is also in concordance with several studies of completed suicides carried out in Malaysia –19, a neMajority of the attempts in both groups were unplanned, precipitated by relationship, family, or work problems and some attempters were observed to have acute stress reaction, depressive disorder or adjustment disorder. This is supported by a study by Chia et al.  that ideAttempters who lived alone or had a lack of confidantes had a higher risk of attempting suicide with OD methods than the NOD group. There were also fewer protective factors in the OD group, as attempters did not have good emotional support and were less willing to seek help. Social support has been found to be associated with decreased likelihood of a lifetime suicide attempt , suggestThe most common drugs consumed in the OD group  can be easily purchased over the counter or obtained through prescription by a general practitioner for sleep and mood disorders. Evidently, the ease of obtaining a substance for OD is of major importance in suicide attempts. Means restriction is an important population strategy for suicide prevention . Thus, iDifferent periods of a week or year may lead to variation in the number of suicide attempts due to differing environmental conditions and stressors . FridaysAdditionally, our data on geographical distribution indicated that attempts tended to occur at home and in high density residential areas. This provides insight on how suicide prevention or intervention strategies can be formulated to reach out to attempters or people contemplating suicide in their homes.While our study included a large sample size of patients, it is not without limitations. Firstly, the sample was obtained from only one general hospital and it only included those with attempted but not those who completed suicide. Our sample consisted of mainly younger adults and not the elderly, which reduces generalizability of the findings to other age groups. Furthermore, the NOD group had a small sample size and thus might not have been representative of the NOD suicide attempters of Singapore. Within this group, there was heterogeneity in terms of the method of suicide, which varied from laceration to jumping from height and hanging, and this carried different degrees of lethality. The measures indicated in the suicide risk assessment form were based on clinician judgement and there was no inter-rater reliability for assesment. The cross sectional nature of the data prevented the understanding and prediction of later suicide risk. There was also possibility of recall bias in this archival retrospective study. In addition, other relevant moderators and mediators of OD and NOD methods such as personality characteristics, coping methods, history of suicide ideation or attempts were not documented. Despite these limitations, our study provides valuable information on the dynamic characteristics of suicide attempts in Singapore, which could help guide the development of policies and intervention methods suited to current trends.Due to the changes in patient risk factors over time, it is important to keep abreast of the characteristics of current suicide attempts, so as to guide the government in developing up-to-date strategies for the prevention of future suicide attempts . InformaIn a recent study conducted by Chong et al. , majoritIn view of the significant number of suicide attempts being committed at home, another potential suicide prevention strategy would be to foster greater social support among the community. Since individuals who live alone are more prone to repetition of acts of deliberate self-harm , closer Future research in the direction of teasing out the factors that motivate people of different ethnicities to choose different methods of suicide, and other risk and protective factors that mediate and moderate OD and NOD suicide attempts, will allow for a more complete understanding of suicide in the Asian context.


Assessment of complex tasks integrating several competencies calls for a programmatic design approach. As single instruments do not provide the information required to reach a robust judgment of integral performance, 73 guidelines for programmatic assessment design were developed. When simultaneously applying these interrelated guidelines, it is challenging to keep a clear overview of all assessment activities. The goal of this study was to provide practical support for applying a programmatic approach to assessment design, not bound to any specific educational paradigm. The guidelines were first applied in a postgraduate medical training setting, and a process analysis was conducted. This resulted in the identification of four steps for programmatic assessment design: evaluation, contextualisation, prioritisation and justification. Firstly, the (re)design process starts with sufficiently detailing the assessment environment and formulating the principal purpose. Key stakeholders with sufficient (assessment) expertise need to be involved in the analysis of strengths and weaknesses and identification of developmental needs. Central governance is essential to balance efforts and stakes with the principal purpose and decide on prioritisation of design decisions and selection of relevant guidelines. Finally, justification of assessment design decisions, quality assurance and external accountability close the loop, to ensure sound underpinning and continuous improvement of the assessment programme. Recent discourse about what constitutes good assessment of performance has led experts to state, that assessment requires a programmatic approach consisting of a deliberate and arranged set of assessment activities Knight . These aA programmatic approach to assessment is holistic in nature and is not just about delivery of a test. In a programme of assessment, the implications need to be considered regarding faculty development, financial and organisational resources, and alignment with a specific educational context and curriculum. Limited sources are available that address assessment from a more comprehensive perspective. The Standards for Educational and Psychological Testing [(AERA), The guidelines are comprehensive and not bound to a specific educational context or approach. In comparison to studies describing quality criteria  Dijkstra . In the The Dutch Residency Training Programme in General Practice (RTPGP), was purposefully selected, because of a well-described and documented competency based educational setting and assessment programme. The 3-year residency training consists of workplace-based learning in the authentic GP setting, as well as internships at a hospital, nursing home and psychiatric clinic. In addition, the residents attend to formal education 1 day per week. The assessment programme consists of assessments at all levels of Miller’s pyramid with a traditionally strong focus on observation in GP practice Miller . AssessmThe framework for programmes of assessment and associated 73 guidelines  of the RTPGP assessment programme was drawn up by the authors. This summary was checked with the national assessment coordinator and the national assessment working group of the umbrella organisation of the Dutch RTPGP institutes for completeness and appropriateness.From the interpretive summary and input of the member check, a set of recommendations for the assessment redesign of RTPGP was formulated. These recommendations correspond to the sets of guidelines that need to be addressed in a coherent fashion when designing an assessment programme. The feasibility of these recommendations was determined based on the required effort for implementation as well as the associated stakes (or risks) and needed resources.Both from the priorities derived from the recommendations and the feasibility check an implementation plan was drawn up. This included a justification of needed design decisions based on best-practice and scientific evidence and concrete tips for change management, corresponding with the improving the programme dimension of the framework for programmatic assessment.As authors, we reflected on the phases and actions performed in the case study: from the evaluation of the RTPGP assessment programme to the formulation of the implementation plan. The questions and worries raised by the stakeholders during the interviews were taken as a starting point for deconstructing this process. During this analysis, our focus was on identifying the core elements that have characterised the evaluation of the RTPGP assessment programme. These core elements were translated in concrete actions, with the aim of achieving an approach to programmatic assessment design, a practical support which will be applicable across diverse educational contexts. In the remainder of this section the identified core elements will be outlined. The process of analysis and deconstruction is described, using the RTPGP case as a reference point.principle purpose of the assessment programme, by explicitly addressing this in the interviews. How obvious this may seem, beliefs about the purposes of the assessment programme may not always be on the surface. In the case of RTPGP, the formative function is highly valued in running assessment practices; however, the summative ‘go/no go decision’ is the main purpose in the national assessment protocol.Characteristic for this evaluation phase was the focus on data collection. An iterative exploratory approach was used to navigate between the analysis of the formal documents, stakeholder interviews and guidelines. The biggest challenge was to keep overview of all assessment practices. Therefore interviewing the assessment coordinator, who was a linking pin between national assessment policy and local practices, was crucial to collect and interpret data on the running assessment programme. A key in this process was the confirmation of the To write a summary report which is suitable for stakeholders involved with assessment, education, and management it was important to apply the framework and guidelines to the specific educational context (including jargon) of the RTPGP programme. The process of application consisted of acknowledging the context of the assessment programme: in the RTPGP case this was the specific relation between the national and local setting and workplace based learning with specific stakeholders—i.e. GP clinical supervisors, and identifying needs for development. In the RTPGP case it was prioritised to achieve balanced assessment contents to assure appropriate coverage of all competencies—i.e. the guidelines about domain mapping. In this phase, our goal was to reach a better fit of the applied (73) guidelines. Therefore, the guidelines needed to be re-grouped in order to clarify the relevance for this specific educational context. This re-grouping resulted in thematically ordered suggestions for improvement to (re-)design the assessment programme. For the RTPGP assessment programme, 12 themes of recommendations were formulated that need to be addressed in a programmatic (re-)design approach: 1. Purpose of the programme, 2. Resources/infrastructure, 3. Stakeholders, 4. Content and components, 5. Coherence and effects, 6. Decisions, standards and actions, 7. Robustness, 8. Context and implementation, 9. Procedures; rules and regulations, 10. Quality assurance, 11. Change management, and 12. Justification.national design decisions with a support base for local acceptance of the implementation plan.The focus of this next phase was to determine the starting point for the improvement of the assessment programme. Simultaneously implementing 12 recommendations appeared to be not feasible and therefore some priorities needed to be set. Essential to prioritizing the recommendations was central governance of the programme, to keep overview and avoid counterproductive measures implemented at the same time. In the case of RTPGP the national assessment working group was fit for this job, as it consists of the 8 local assessment coordinators. This body is responsible for setting out an assessment scheme that includes several assessment instruments, and its transposition into the local setting, including the alignment of decisions. designing an assessment programme in any given educational context. In total 12 actions are described in Table ‘What is the essential activity (e.g. taking a summative decision) in the assessment programme?’ This principal purpose is often directly related to the programme in action dimension of the overarching framework. A clear goal facilitates achieving the optimal compromises in the assessment programme, balancing the requirements of assessment against possibilities of the environment in the most effective way. Without a clearly formulated principal purpose, design decisions can become ambiguous and may result in inconsistencies when designing the programme.The overview of the current assessment practice needs to be clear, before being able to identify needs for improvement. There are two possible sources of information that can be used for clarification. Action 1 consists of firstly analysing formal assessment documents, describing e.g. principles of assessment and criteria, methods and tools used, and an educational blueprint. Secondly, interviewing key stakeholders with expertise and knowledge of the local assessment environment, to get inside knowledge and understand how the assessment is being carried out. This should lead to an iterative approach in which the formal documents provide structure and boundaries, while the interviews clarify the daily assessment practices in a specific educational setting. All decisions related to the design should be guided by the principal purpose of the assessment programme. As action 2 this requires that assessment information is sufficiently broad and provides a clear overview of available resources: stakeholders, stakes and finances, besides legislation and oversight of the educational curriculum. Current assessment activities are an important source of information on stakeholder roles, responsibilities, and tasks that need to be carried out. Action 3 is then to get clarity on the principal purpose at an early stage with broad stakeholder support, as it sets the roadmap for the programmatic approach. To decide on the principal purpose of an assessment programme the main question to ask is: programme in action and documenting the programme dimensions serve as a frame of reference, combined with the information collected during the evaluation of the current assessment practice. A group of stakeholders knowledgeable of the educational context and assessment practices needs to be identified and interviewed to get a clear overview of contextual issues that influence assessment design, which is action 5. The added value of organising several team meetings with these stakeholders is that they may deliver valuable input for an analysis of strengths and weaknesses of the current assessment practice and serve as a member check for the identification of developmental needs. More specifically, these issues often arise in management board meetings or the media, and should be addressed appropriately in a programmatic design approach. Early identification of key stakeholder groups  allows designers to (1) take multiple interests into account, (2) define respective roles and responsibilities in the design process and (3) support the (future) role of stakeholders in accepting the development and implementation of a programmatic approach. Assessment design is not only a psychometric measurement problem, but also an instructional design problem and even an organisational problem. Hence, it appeals to a broad spectrum of expertise that is often not present in one stakeholder alone, which makes the assessment design necessarily a team effort. In a programmatic design approach, diverse stakeholders bring in knowledge from their own fields of expertise to develop a defensible assessment programme that aligns with educational practice. The guidelines for programmatic assessment are no recipe for developing the single best assessment programme. Their relevance and applicability are contingent upon many contextual factors  of the assessment environment. The framework defined by Dijkstra et al.  context is required for developing an acceptable and feasible assessment programme, which does not function in a vacuum. Specific  educational issues, contemporary trends in education or the political environment may lead to differences in appreciated importance of certain guidelines in design decisions. In action 4 guidelines referring to the a et al.  showcasea et al. . Action supporting and improving the programme, probably contain valuable information to determine on priorities (e.g. taking robust summative decisions). These guidelines may be used to reach consensus on the needed changes and as a cross-check when developmental needs have been identified accurately. Action 9 requests an iterative approach commuting between guidelines, principal purpose and balancing of efforts and stakes, that aids in developing a working strategy for assessment design planning. In this process, central governance of assessment (design) is required to prevent contradictory decisions over time and between different activities. In the course of the development process, multiple experts (stakeholders) leave their imprints on assessment design. An oversight of the assessment programme serves a balanced use of available resources, careful planning of assessment activities and appropriate coverage of the educational and assessment purposes. This aids in preventing over- and underrepresentation of assessment activities.A potential pitfall is that most resources and efforts are spent on assessment activities that are easy to implement as they seem more appealing, at the expense of difficult assessment activities which often involve a higher stake. Action 7 is twofold: Firstly, checking available resources beforehand, which will allow compromises with regard to the scope of the assessment and/or decisions on extra investment. A clear overview of available resources before starting the design will serve the quality of the assessment programme: it sets the boundaries in advance and avoids disappointment about the feasibility of design decisions. Moreover, it allows for (more) efficient alternative assessment activities to be sought at an early stage. Resources refer not only to financial means, but also to expertise, time and infrastructure. Secondly, the identified developmental needs should to be translated into design decisions and related investments. Balancing efforts against stakes should be taken as a rule of thumb, which permeates all levels of assessment, ranging from the design of a programme or single assessment instrument to the act of writing items. Balancing the needed investment of resources with the gained output in achieving the purpose, echoes the framework’s first general guideline  has to be sufficiently clear for all stakeholders. A common pitfall is that alignment of decisions is only considered in the initial stages of assessment development. Afterwards, when the assessment programme is running, alignment of assessment activities remains an essential quality assurance procedure. Therefore it is crucial that the expertise of faculty (to be) involved in the running assessment programme is assured. By making purposeful and balanced decisions a team effort, as stated under actions 5 and 9, it becomes easier to support external accountability for the programme. Action 11 is developing an implementation plan with unambiguous and agreed evaluation criteria, crucial for a successful implementation of an assessment programme, in which principles of change management play a vital part. Therefore, finding the person who is fit and responsible for this job in each particular assessment environment is necessary. In small organisations appointment of just one person may suffice, in larger ones a team may be more appropriate. In action 12 assessment decisions and their underpinnings should be revisited at a later stage, to stimulate continuous learning and improvement—i.e. closing the loop. It is recommended that an organisation keeps records of past trajectories, to avoid counteractive decisions and re-invention of ‘the wheel’ in the future and schedule regular evaluation meetings when the (re-) designed assessment programme is up and running. Evidence for quality assurance of the assessment programme can be gathered from different sources . External parties  are increasingly requesting accountability for running assessment practices, which can be raised by defining external stakeholders and inviting external review panels (e.g. accrediting organisations) dedicated to evaluating the programme.To be able to evaluate the robustness of design decisions, the reasons for these choices should be clarified and documented, which is action 10. Decisions should preferably be based on scientific evidence, however, since not all assessment activities are sufficiently researched, best practices are a viable alternative. Sound underpinning of design decisions and explicit enunciation of their underlying rationale, can support acceptance by stakeholders. In the design process this should be actively fostered and therefore relations with the future work domain are of paramount importance. This action refers to dimensions of The goal of this study was to develop a practical support for a programmatic design approach to assessment and to determine the steps that need to be taken in the (re)design of an assessment programme. The process analysis of the RTPGP case, evaluated by applying 73 guidelines for programmatic assessment design Dijkstra , has ledfor learning), maximising the robustness of high stakes decisions (assessment of learning on promotion/selection of learners) and providing information for improving instruction and the curriculum , organising several meetings with key stakeholders to analyse its’ strengths and weaknesses (action 5) and develop a working strategy to support central governance (action 9). The alignment of complementary instruments and minimising redundancy of assessment components is addressed in the step prioritisation of the needed changes depending on effort and stakes (action 7 and 8), and development of a working strategy that avoids inefficient and counterproductive changes (action 9). In the justification of design decisions accountability of running assessment practices is promoted by concise and persistent documentation while taking into account legal regulations (action 10). Clear and acceptable procedural measures in the implementation plan may support this process in an iterative manner to reduce bias in assessment of complex tasks (action 11). From a utilitarian perspective the quality of assessment is always being defined in terms of fitness-for-purpose (action 3) in the specific educational context  paradigm. Therefore they are applicable in a wide range of educational contexts. The case study provides examples of the RTPGP case that illustrate the abstract stepwise approach for the diverse stakeholders involved in assessment practices. A potential source of bias is that we as researchers conducted both the case study and process analysis. This may have impacted on internal validity of the study results. However, our reflection in terms of an in depth analysis was needed to identify the core elements of the conducted evaluation approach. We do realise that the developed stepwise approach was based on one case study in a postgraduate medical context. We believe in the applicability to other educational settings, but we do encourage others to prove this in future studies and practice.Although few examples of assessment programmes  with the stakes is supported, while fostering a constructive alignment with the educational curriculum. This study provides a stepwise approach to apply a theory based model for programmatic assessment design. This approach and the model need implementation in other educational settings as a route to scientific validation and further development of a practice based design approach, applicable in diverse educational contexts in a feasible and pragmatic manner.


The ‘Deep End’ Links Worker Programme is being tested in general practices serving deprived populations in Glasgow, Scotland.To assess the implementation and impact of the intervention at patient and practice levels.Study design: Quasi-experimental outcome evaluation with embedded theory-driven process evaluation in 15 practices randomized to receive the intervention or not. Complex intervention: Comprising a practice development fund, a practice-based community links practitioner (CLP), and management support. It aims to link patients to local community organizations and enhance practices’ social prescribing capacity. Study population: For intervention practices, staff and adult patients involved in referral to a CLP, and a sample of community organization staff. For comparison practices, all staff and a random sample of adult patients. Sample size: 286 intervention and 484 comparator patients. Outcomes: Primary patient outcome is health-related quality of life (EQ-5D-5L). Secondary patient outcomes include capacity, depression/anxiety, self-esteem, and healthcare utilization. Practice outcome measures include team climate, job satisfaction, morale, and burnout. Outcomes measured at baseline and 9 months. Processes: Barriers and facilitators to implementation of the programme and possible mechanisms through which outcomes are achieved. Analysis plan: For outcome, intention-to-treat analysis with differences between groups tested using mixed-effects regression models. For process, case-study approach with thematic analysis.This evaluation will provide new evidence about the implementation and impact of social prescribing by general practices serving patients with complex needs living in areas of high deprivation. Health inequality is a global problem, and although it is driven by social determinants of health , 2, healA recent policy response to inequalities has been the proliferation of different social prescribing schemes across the UK National Health Service (NHS). Social prescribing aims to expand the options available beyond what is traditionally provided in healthcare consultations by directing patients to local voluntary or community services that can offer patients support in terms of financial advice, work opportunities, and leisure and social activities. However, reviews have found that the evidence-base for the effectiveness of such approaches remains limited , 11. A ‘‘What can NHS Scotland do to prevent and reduce health inequalities?’, proposed practice-attached community links workers [act as a catalyst to hope and self-determination, using the strong relationships with patients that exist in general practice as a natural community hub.” The rationale for this service development was that if individuals feel supported, they would be more likely to respond to information on ways to improve their health. It can also be seen as a response to the inverse care law, by providing practices and practitioners serving very deprived areas with an extra team member and a ‘horizontal’ referral pathway for patients, including those with complex multimorbidity spanning mental, physical, and social problems, which could potentially reduce GP and primary care workload.The Deep End paper,  workers . This pr workers . The DeeAgainst this background, the Scottish Government funded the Glasgow ‘Deep End’ Links Worker Programme, which aims to support people living in the most deprived areas of Scotland to ‘live well’ in their communities. Since September 2014, seven general practices in areas of high social deprivation in the NHS Greater Glasgow and Clyde have been provided with: (i) a practice development fund and support to attend shared learning events; (ii) a practice-attached community links practitioner (CLP), an individual with community development work experience; and (iii) management support from programme staff. With these resources, the practice staff and CLPs can work with patients on non-medical problems through referral to local community organizations and, at the same time, develop practice capacity in this role and develop links with local community organizations. The conceptual and theoretical bases for the programme, as well as the operational and practical details, have been developed by GPs at the Deep End in collaboration with the professional body for GPs and third sector organizations.The Links Worker Programme offers insight into the types of challenges likely to be encountered and the approaches that might be adopted by similar future programmes. Whilst there have been a number of ‘links-type’ initiatives in Scotland and elsewhere in the UK, the current evidence base provides little information about their impacts on patient or practice outcomes or on addressing health inequalities . ConsequThe aim of this evaluation is to provide evidence to inform future local and national programmes and policy decisions about the continuation and extension of the Links Worker Programme to practices serving deprived communities. The outcome evaluation is designed to test the hypothesis that a Links Worker Programme intervention will lead to improvements in the integration and use of community assets by practices, will enhance practice staff team morale and well-being, and will improve patients’ quality of life and well-being. The parallel process evaluation is designed to achieve an understanding of the theories of change that underpin the implementation of the intervention and of the barriers and facilitators affecting desired change.This paper describes protocol version 1.1, dated 8 January 2015. The trial is registered with the International Standard Randomised Controlled Trials (ISRCT): ISRCTN80842457. Any changes to the protocol will be approved by the Ethics Committee and notified to the Sponsor and Funder. Any changes affecting the information in the public trial register will be notified via the ISRCT.This is a quasi-experimental general-practice-level cluster randomized controlled trial with a parallel mixed-methods process evaluation. The design is based on the UK’s Medical Research Council framework for the evaluation of complex interventions . It willThe study is based in 15 Glasgow general practices serving patients living in some of the most deprived areas in Scotland, including the practice of the Programme Clinical Lead, who submitted an application and practice development plan in response to an invitation to participate in the trial of the Links Worker Programme. The Programme Clinical Lead’s practice was selected to receive the intervention. The remaining 14 practices were then randomized by the Health and Social Care Alliance Scotland, which is charged with implementing and delivering the programme. Thus, the evaluation is based on data derived from seven intervention practices  and eight comparator practices (i.e. those not randomized to receive the programme resources). All practices agreed to participate in this independent evaluation.This study was approved by the University of Glasgow College of Medical Veterinary and Life Sciences Ethics Committee (200140077). As participation in the evaluation has no associated risk to participants, no specific measures are applicable to determine patient safety.All staff in the intervention practices involved in delivery of the intervention and all staff in the comparator practices who would have been involved in the intervention had their practice been randomized to receive it. No exclusion criteria will be applied to either staff group.Adult patients (aged 18 years or over) who are registered with an intervention practice and are referred (or self-referred) to a CLP during the study recruitment period, and a random sample of adult patients registered with a comparator practice. Patients will be excluded from the study by their usual medical/healthcare provider if, in the provider’s opinion, participation is contraindicated for health or social reasons . Whilst reasons for such exclusions will be collected by the research team, identifiable information about patients will not. However, the provider will pass on the patients’ age, gender, and postcode .A convenience sample of staff from local community organizations will be recruited as a panel of key stakeholders. The organizations will be chosen with the help of the CLPs and practice staff on the basis of having had some engagement with practices and/or their patients.The intervention comprises:A practice development fund A practice-attached CLP Management support from the programme .Study participant recruitment took place between March and December 2015, with the aim of completing all follow-up data collection by March 2017.At the time of referral to a CLP, the healthcare provider gave patients the study information flyer and sought permission to pass on their contact details to the research team to discuss potential participation in the evaluation. In cases of self-referral, permission was sought by the CLP at the time of referral. When this permission had been obtained, a member of the research team telephoned patients to provide information about the evaluation and to obtain permission to mail them the study invitation pack . On receipt of a completed questionnaire, patients were mailed a letter to acknowledge this with a GBP 5 gift voucher as a token of appreciation for their help. If there was no response 10 days after the mailing of the study materials, patients were telephoned again to determine their decision about participation, and if they expressed interest in participating they were given additional options for completing the questionnaire in either a face-to-face meeting or over the telephone with the study researcher. The aim was to collect baseline questionnaire outcome data prior to the start of the CLP intervention if at all possible. Patients who were not interested in participation were thanked for their time in considering the invitation and were reassured that the research team would not contact them again. For the process evaluation, a purposive sample of patients who consented to participate in the evaluation was invited to be interviewed.Each comparator practice generated a list of a random sample of 1,000 patients on their register. The list was be reviewed by a GP principal in order to remove patients for whom contact was considered inappropriate. The practice then mailed the study invitation pack to the patients on the resultant list. On receipt of a completed questionnaire, patients were mailed a letter to acknowledge this with a GBP 5 gift voucher as a token of appreciation for their help. Patients who did not return a completed questionnaire were not followed up with any reminder telephone calls or mailings.Patients in both the intervention and comparator practices were not denied any care that was available in the NHS during the study period.Study invitations packs were left with the practice manager to distribute to all eligible staff.For the intervention practices, staff from local community organizations were sent the study invitation pack. The aim was to recruit representation from two organizations on a panel of key stakeholders; other members included the practice manager and/or a lead GP, CLP, one other member of practice staff, and up to two patients involved in the practice developments (if possible). For comparator practices, the panel members consisted of the practice manager and/or a lead GP.Patients who have completed the study baseline questionnaire but who subsequently decline or withdraw from the CLP intervention will revert to the usual care provided for other patients in their practice. Unless participants request to withdraw from the study, they will continue to be followed-up and will be analysed in the group to which the practice was allocated. If, however, any participant wishes to withdraw from the study, no further follow-up data will be requested, but data already provided will be used.The primary patient outcome is health-related quality of life, measured at baseline and at 9-months’ follow-up by the EQ-5D-5L questionnaire  Table 1Table 1. Secondary patient outcome measures at baseline and at the 9-month follow-up include the ICECAP-A measure , the HosStaff outcomes at baseline and the 9-month follow-up include the Team Climate Inventory ; job satAt baseline, data were collected on all primary and secondary outcomes as well as the number of long-term conditions and socio-demographic measures . These data will be collected again 9 months after recruitment, which is the primary outcome time point.The primary method of self-reported data collection is via postal questionnaires; however, alternative completion methods, including telephone or home visits, were offered in order to maximize response rates. No identifiable data about patients will leave the practice unless patients have provided consent. All data are stored securely and confidentially at the University of Glasgow in line with its data-management policies.It was not possible to mask participants or healthcare professionals to the group allocation of their practice. It was also not feasible to blind members of the core study team collecting the data , but the statisticians analysing the data  and all other co-authors were blinded to the allocation. The statistical analysis plan was also reviewed and approved by the lead investigators, and by the senior study statistician, prior to the release of unblinded study results.No interim analysis is planned. Patient outcomes will be summarized as a whole and by intervention and comparison group at baseline and follow-up, and as changes over time. Analysis will be on an intention-to-treat basis using all available data. Differences between groups will be tested using appropriate mixed-effects linear or generalized linear regression models, allowing for clustering by practice and including an adjustment for the baseline value of the outcome measure. Since the comparator patients are respondents from a randomly selected sample, there are likely to be differences at baseline compared with the intervention patients, who are respondents from a group of patients referred to a CLP. Alternative methods will therefore be considered to control for selection bias, including adjustment for baseline factors . Tests for interactions will be used to identify subgroups that may benefit most from referral to the CLP.The minimum target sample sizes of 286 patients for intervention and 484 patients for comparator practices is designed to have 80% power to detect a minimally important effect size of 0.274 standard deviation (SD) units in the EQ-5D-5L with a 95% degree of confidence, assuming an intra-class correlation of 0.01 and a 50% follow-up rate. This sample size will provide 90% power to detect an effect size of 0.316 SD units under the same assumptions. Analysis of staff outcomes will be descriptive as well as comparing total scores for each measure at baseline and follow-up in the intervention and comparison groups. We will also examine variation between practices within both groups. Study groups will be compared at baseline and at follow-up, and as changes over time using appropriate statistical methods.The process evaluation comprises two phases.Phase 1 developed and refined an effective theory of change (ToC) for the Links Worker Programme. The intention was to surface the ToC at the practice level; its anticipated processes and mechanisms through which change will be achieved; evidence for wider operationalization of the Self-Determination Theory (SDT) ; the proPhase 2 is guided by the RE-AIM framework  and aimsA ToC is essentially a comprehensive description and illustration of how and why a desired change is expected to happen in a particular context. It is focused, in particular, on mapping out or ‘filling in’ what has been described as the ‘missing middle’ between what a programme or change initiative does (its activities or interventions) and how these lead to desired goals being achieved. The original theories of change detailed in the programme documentation will be described and elaborated. The intervention and comparator practice plans will be reviewed in order to make explicit and compare their theories of change. These will be reviewed to comment on their likely plausibility, ‘doability’, and testability. However, to understand theories of change requires an understanding of the context in which organizations are operating. Two main types of contextual data will be considered: data on practice characteristics in relation to size and demographic profile; and data relating to the availability of potential community supports. Data relating to practice size and demographics will be accessed from the NHS Scotland Information Services Division (ISD) website using the most recent data available in February 2015:Age and gender data for the latest available quarter (1 July 2014)Deprivation data as at 30 September 2013GP data for the latest available quarter (1 July 2014).Investigation of potential differences in availability of local community support services in areas served by intervention and comparison areas we will be based on two data sources: Infobase Team at the Glasgow Council for the Voluntary Sector (GCVS) , and A LThe data will be summarized in brief descriptions of what is delivered in each practice and any perceptions of impact. This will be mapped for both intervention and control practices – what is delivered to whom, by whom, and in what ways, and compare what is delivered to whom, by whom, and in what ways, and key differences between intervention practices and between intervention and comparison practices. Over time, further analysis will focus on addressing processes for establishing and maintaining the links and connections, and whether and how community-oriented approaches, including the Links Worker Programme, are sustained.To further elaborate on sustainability of the programme and report on experiences and reactions of participants, individual interviews will be conducted with stakeholders in intervention practices towards the end of the implementation process. The interviews will gather perception of the reach and adoption of the programme at the patient level as well as experiences of its effectiveness and the processes through which these effects were achieved. The intention is to interview up to two patients, two managers of local community organizations, the CLP, a GP, and a member of reception staff or the practice manager. Interviews will focus on perceptions of sustainability of the programme, what has worked well and less well, other strengths and weaknesses of the approaches used, the perceived outcomes, and the characteristics of those most/least likely to benefit. The interview guide will again be guided, as appropriate, by the candidacy theory  and NPT Analysis of these data will be thematic, drawing on the Framework Approach . With peThe use of three theories and one overall framework (RE-AIM) will help to generalize these findings in relation to other research on enabling system changes in general practice so as to reach people in further need of support, support people to take part in health-enhancing, community-based, activities, and implement the system changes.The day-to-day management of the study is overseen by the evaluation management group, which feeds directly into the governance and management structure for the Links Worker Programme .Dissemination will include peer-reviewed publications and reports to healthcare professionals, commissioners, and policymakers. A summary report will also be sent to study participants, and linked to relevant websites such as the Scottish School of Primary Care, which is undertaking evaluations of new models of delivering primary care services.The study will be a quasi-experimental outcome evaluation of a complex intervention comprising a links-worker approach to social prescribing, with embedded theory-driven process evaluation in 15 general practices randomized to receive the intervention (seven) or not (eight). This mixed-methods evaluation will provide useful evidence about the implementation and impact of a complex intervention designed to improve social prescribing and asset-based community development by general medical practices serving patients living in areas of high socio-economic deprivation in Scotland.The findings of this study will help build on the very limited evidence-base for social prescribing , 11 in tWhilst the research team has successfully conducted research using similar methods with similar patient populations, the present study poses some challenges relating to the likely achieved patient samples. In relation to the intervention practices, little is known about the patient caseload of CLPs in terms of the number, characteristics, or problems of new referrals received over any given time. Consequently, it is not possible to use any other strategy other than random sampling for the comparator practice patient sample. To allow statistical modelling to mitigate potential differences between the achieved samples, sampling of comparator practices will be based on approximately 20% of the adult patient population, i.e. 1,000 patients from each of the eight comparator practices.The choice of quality of life as a primary outcome is a pragmatic one, as the intervention is generic and not single-disease focused and is in line with our previous approach . This isIn terms of the design of the study and intervention, it should be emphasized that the research team was commissioned to evaluate the intervention almost a year after it started, and was not involved in its design, the randomization of practices, nor the implementation of the intervention. Weaknesses include the randomization methods, and the fact that some of the intervention and control practices are located in the same health centre, raising the possibility of contamination between groups. This will be explored in both the qualitative and quantitative analysis.


This study aimed to analyse the factors associated with enrolment in and renewal and utilisation of the NHIS among migrant female head porters in the Kumasi Metropolis.As a social protection policy, Ghana’s National Health Insurance Scheme (NHIS) aims to improve access to healthcare, especially for the vulnerable. Migrant female head porters (We purposively sampled 392 migrant female head porters in the Kejetia, Asafo and Bantama markets. We used a binary logit regression model to estimate associations among baseline characteristics, convenience and benefit factors and enrolment in and renewal and utilisation of the NHIS.Age and income significantly increased the probability of NHIS enrolment, renewal and utilisation. Long waiting times at NHIS offices significantly reduced the likelihood of renewal, while provision of drugs highly significantly increased the tendency for migrant female head porters to enrol in, renew and use the NHIS. Consulting and surgery also significantly increased renewal and utilisation of the NHIS.Political commitment is imperative for effective implementation of the decentralisation policy of the NHIS through the National Health Insurance Authority in Kumasi. We argue that retail offices should be well equipped with logistic facilities to ensure convenience in NHIS initial enrolment and renewal processes by citizenry, and by vulnerable groups in particular. Human migration and the associated public health challenges are not new global phenomena. According to the 2015 World Migration Report, about 224 million people worldwide are on the move, 49% of whom are women UNDESA . Stressfkayayoo working in Kumasi  have migrated from the three northern regions while the others have migrated from neighbouring regions in Ghana and countries further afield  are unskilled and are relegated to a low status in the informal sector of the economy. They occupy the “three D’s”   ILO . There iult) ILO . Access However, it is a widely held belief that good health is associated with economic growth and development. For this reason, many governments of developing countries are combating poverty and boosting development through providing adequate access to healthcare  Freebody . These lHere: n = sample size; z = standard normal deviation 1.96; p = percentage of migrant female head porters in Kumasi Metropolis, estimated to be 56% GSS ; q = 1.0Data were verified and entered into an electronic database and analysed statistically using SPSS software, version 21.0. Descriptive statistics were carried out to describe the background characteristics of the study sample. The chi-square (2) test was used to estimate the association of respondent characteristics, convenience factors and benefit factors with enrolment in and renewal and utilisation of the NHIS. Bivariate and multivariate analyses were used to further estimate the relationship between respondent characteristics and convenience and benefit factors with regard to enrolment, renewal and utilisation. We also used a binary logit regression model to estimate the associations among baseline characteristics, convenience and benefit factors, enrolment in and renewal and utilisation of the NHIS. The interpretation of the tests results considered an error margin of less than 5% as significant.Three more models were specified on the basis of Gujarati and Porter :2\documeWhereby:ENHIS = probability that head porters would enrol in the NHIS; RNHIS = probability that head porters would renew their insurance as required by the scheme; UNHIS = probability that head porters would use the NHIS to access healthcare when sick. AGE, MS, NYSCH, INC, HS, R, HST, LWP, LNHIS, TSNHIS, C, PD and S correspond to age, marital status, number of years spent in school, income, household size, religion, health status, living with partner, location of NHIS office, time spent at NHIS office, consulting, provision of drugs and surgery respectively; α = parameters to be estimated; ε = error term.The variables in Eqs. , 3) and and3) anThe responses on enrolment in and renewal and utilisation of the NHIS are summarised in Table The responses on convenience and benefits factors are shown in Tables e = 0.018; Pr = 0.001; Pu =0.004) and income level  significantly influenced NHIS enrolment, renewal and utilisation. Marital status , number of years of education  and household size  highly significantly influenced renewal and utilisation of NHIS, but not enrolment. Religion and living with a partner also did not significantly influence enrolment in and renewal and utilisation of the NHIS.We estimated the association of respondent characteristics, convenience factors and benefit factors with NHIS enrolment, renewal and utilisation  and time spent at the office  significantly influenced renewal of the NHIS as required by the scheme but not the overall enrolment and utilisation of the NHIS. Consulting  and provision of drugs  significantly influenced enrolment in and renewal and utilisation of the scheme. Surgery  significantly influenced renewal and utilisation of the NHIS but not enrolment.Again, NHIS office location  Table . EnrolmeIn the multivariate analysis, we built three different models using binary logit regression Table . Age andTo the best of our knowledge, this is the first study investigating migrant female head porters’ enrolment in and utilisation and renewal of the NHIS in Ghana. The study found that the majority of migrant female head porters had enrolled in the NHIS. This may be attributed to a deliberate policy by the Ministry of Gender, Children and Social Protection (MGCSP) to enrol the vulnerable in the scheme for free, as a miniature of the Ghana Government’s commitment to mitigate the higher incidence of ‘cash and carry’ systems that previously existed in the healthcare delivery system. In addition, most enrollees utilised the scheme when afflicted with illness. However, there were some concerns about the NHIS since the scheme could not offer the quality healthcare needed. This corroborates the findings of Amoah Despite high initial enrolment, a substantial proportion of the head porters reported difficulties in renewing their NHIS status and were therefore denied access to healthcare. This provides evidence to suggest that head portering as an informal economic venture does not generate enough income to those involved to be able to renew their membership regularly, as required. Most people argue against the credibility of and the extent to which the NHIS provides good healthcare. This may result in fewer incentives for the head porters to engage in continual renewal of their insurance status, which is a matter of concern since sustainability of the scheme is partly dependent on the continuous renewal of the subscribers’ membership status. The disappointing renewal rate could also be explained by the long waiting times and delays that subscribers have to tolerate to reinstate their NHIS membership. This finding concurs with the observation of Gyasi , which iAge and economic status, using income level as a proxy, significantly influenced NHIS enrolment, renewal and utilisation. Older adults enrolled in and renewed and utilised the NHIS. This may be attributed to their vulnerability to various diseases. The study found that the household size of migrant female head porters has a negative significant impact on the probability to renew insurance, but a significant positive impact on the likelihood to utilise the scheme. Household size determines household consumption expenditure; hence, the larger the household is, the larger the household consumption expenditure. The study confirmed that household size has a negative impact on migrant female head porters’ probability to renew their insurance as required by the scheme. However, larger households also have more healthcare needs than smaller households, hence their propensity to use the scheme more when enrolled. These findings support previous studies such as those by Asah , DalinjoHowever, marital status, number of years of education and household size of the migrant female head porters significantly influenced renewal and utilisation of the NHIS, but not initial enrolment. Since the MGCSP registers the head porters free of charge, education levels did not have any significant influence on enrolment. Religion also did not significantly influence enrolment in or renewal and utilisation of the NHIS. Distance to NHIS offices and convenience of NHIS card issuance, however, did significantly influence NHIS renewal, but not enrolment and utilisation. The bureaucracy and stress the head porters go through in the process of enrolment demotivate them to enrol, as they cannot even afford to miss a day’s work. This could explain why the renewal rate in our sample was low and underpins empirical findings of other studies Amoah , which dThe study also found that perceptions about the quality of drugs under the scheme significantly influenced enrolment, renewal and utilisation and revealed that consulting costs are usually not prohibitively expensive for the head porters, but drugs are. As a result, when the head porters realise that the NHIS cannot fully cover the cost of drugs dispensed at the hospital, they tend not to utilise it. Waiting times at the healthcare facility did not significantly influence NHIS enrolment, renewal and utilisation, as also confirmed by the report of Amoah . EnrolmeThis study revealed that implementation of the scheme has generally contributed to the female head porters’ NHIS enrolment, utilisation and, to some extent, renewal. Although the MGCSP registers the head porters free of charge, there are still a number of them who had not enrolled to benefit from the services of the scheme. Paradoxically, there were some respondents who had not enrolled, yet they could not afford to pay their hospital bills out-of-pocket either. Our study also found that socio-economic characteristics of migrant female head porters, such as income and age, significantly influence enrolment in the scheme.This study reiterates that having insurance is not itself sufficient to access good healthcare because the insurance benefits may not adequately cover certain health services. The convenience and benefit factors contribute significantly to enrolment in and renewal of the NHIS. The study recommends an effective decentralisation of the National Health Insurance Scheme to the district level. Retail offices must be well equipped  to ensure that both enrolment and renewal processes can be done in a manner that reduces the inconvenience  head porters go through during enrolment. Moreover, NHIS authorities should be using mobile vans and officers who will visit the subscribers, especially those vulnerable ones  who live farther away from the NHIS offices to register them. This study again underscores the need to expand quality healthcare services  under the scheme so as to create a good public image and a positive perception about the scheme. NHIS authorities must examine the socio-economic characteristics of subscribers so as to create favourable environments that can promote enrolment in and renewal and utilisation of the scheme. In addition, policies enacted under the NHIS should take into consideration the vulnerable in society, such as female head porters, who are supposed to be the core beneficiaries.


The inability to achieve full compliance with drug treatment during the post-discharge period with exacerbations in the illness in patients with schizophrenia and other psychotic disorders is a major problem for the patients themselves, their families, and the healthcare staff in psychiatry.In this prospective study, it was aimed to evaluate whether the written and verbal drug education  given by the clinical pharmacist during the discharge period had an effect on drug compliance. Between 1st September 2016 and 12th June 2017, 40 patients diagnosed with schizophrenia, schizoaffective disorder, schizotypal personality disorder or acute schizophrenia-like psychotic disorder according to ICD-10 diagnostic criteria who were admitted to Hacettepe University Faculty of Medicine, Department of Psychiatry Inpatient Service, were involved in this study. A number of scales were used to evaluate the severity of illness, drug side effects and drug compliance respectively; PANSS; UKU, SAS, BARS, AIMS; MARS and ROMI. It has been emphasized during discharge to the patients by the clinical pharmacist that how important administering the prescribed medicines regularly and as directed. Six to 8 weeks after discharge, the patients were invited to be reevaluated using the scales applied during admission.There was a statistically significant increase in compliance with treatment as quantitatively assessed by the MARS after drug education (p<0.001). There was no significant correlation between compliance and gender, age, tobacco/alcohol use or marital status. At the same time, a significant correlation between severity of akathisia obtained through BARS and a decrease in MARS scores representing the level of compliance was observed . A decrease in the baseline MARS score was related to an increase in the total number of hospitalizations  and the number of psychotropic drugs used . When the factors that may affect compliance were examined by multiple regression analysis, akathisia was found to have the highest impact on compliance .These results support the literature in terms of the importance of the impact of side effects on compliance. As a result of the study, it was seen that drug counseling services given by clinical pharmacists can effectively be employed in psychiatric care, for the rational use of medicines. It appears that it is necessary to take advantage of drug counseling on drug use and to develop strategies to improve drug compliance in psychiatry.