Female medical students often prefer primary care specialties, while male students appear to be attracted to hospital specialties. Notwithstanding the steady feminisation of medicine, in many countries there are still difficulties in recruiting trainees for general practice. This seeming paradox raises the question on what specific role gender plays in a specialty choice. The authors looked at the (a) the role of gender in general practice specialty choice of Dutch medical students, (b) the decisive factors in career choice and relation of gender to these, and (c) differences in how male and female students are influenced by the GP clerkship.A cohort of 206 final year medical students at the Maastricht University, the Netherlands were asked to complete a questionnaire focusing on career preferences before and after a 12-week general practice clerkship and at graduation, a couple of months later.Gender was significantly related to willingness to become a GP in bivariate analysis. Adding variables in multivariate analysis made this effect disappear. While females expressed overall higher preference for general practice than males, after the GP clerkship likelihood of choosing general practice increased with 38% among male and 22% among female students. After graduation, interest in general practice had dropped, mainly among females. Attitudes predicting a GP career choice were: extrinsic career motivation before the clerkship, and the content of GP work  and motivation to work with chronic and palliative patients after the clerkship.Gender 'as such' appeared not to be a distinctive predictor of specialty choice. It is students' attitudes towards GP work and preferred patient category that determine the career choice in general practice. However, more male students were positively influenced by the GP clerkship than female students. The motivating effect of the clerkship is not long lasting. Especially female graduates change their interest in favour of other specialties, which may explain why eventually few students choose general practice. It might be worthwhile to reinforce an initial preference for general practice by motivational guidance throughout the whole period of clerkships. All over the world a steady feminisation of medicine is taking place -7. FormeGender differences in medical specialty preferences have been explained from structural as well as from individual theories ,19. SeenIndividual-oriented explanations of specialty choice have as their starting point that interests in and attitudes towards specialties are in themselves strongly gender-based. For example, women value patient contacts more, while men usually score higher in biomedical orientation, academic interest, prestige en (high) income expectations.There is also evidence that men are more likely to choose technical challenge, earning potential, prestige, while women consider work conditions, part-time work and parental leave ability more important . In thisSteady feminisation of medicine in combination with higher preference for part-time work will influence the workforce outcome, in particular in general practice, i.e. one would expect increasing numbers of medical students entering general practice. However, a peculiar paradox is that there are still difficulties in recruiting trainees for general practice . While sPast research identified several factors which influence the specialty choice in general practice. For example, early interest and experience in primary care significantly influences students' intentions of pursuing general practice as a future profession ,25-28. MWe sought to answer the following specific research questions:(a) What is the role of gender in GP specialty preference?(b) What are decisive factors in specialty preference and are these different for male and female students?(c) Is there a gender difference in how medical students are influenced by the GP clerkship?In 2002–2003, we surveyed students in the final year of the 6-year undergraduate medical curriculum of the University of Maastricht, the Netherlands. The clerkship in general practice (similar to family medicine in the U.S.) is compulsory and takes 12-weeks. Though the sequence of the clerkships is different for every student, the general practice clerkship always takes places in the final year.Of the 206 registered students (55% women) participating in general practice clerkship, 184 students (56% women) completed questionnaire before and after the general practice clerkship. We asked the students to complete the questionnaire during group meetings at the start and at the end of the clerkship. In total 119 students (60% women) returned the postal questionnaire sent after graduation. Because some questionnaires were not fully completed, student's numbers in the analysis vary slightly.New clerkship groups start every four weeks, the whole year through, between September and June. We asked the students to complete a questionnaire during group meetings at the start and at the end of the clerkship. Researchers distributed the questionnaires before the meeting and collected them afterwards. Students' consent was asked by the physicians responsible for the organization of the clerkships. At the end of the academic year, the students were sent a short postal questionnaire. The questionnaire, which was primarily based on previous studies mentioned above, contained questions about personal characteristics , general attitude towards a future physician career, general practice in particular, and likelihood to become a general practitioner. Factor analysis (varimax rotation) and scaling techniques were used to construct attitude variables from the questions about students' attitudes towards three main categories: (a) preferred patient category and type of work, (b) preferred work conditions in the future and (c) assessment of general practice as a profession. The items , attitude variables (composed of sum scores), and reliabilities  are presented in table The questionnaires at the start and at the end of the clerkship were identical. The postal questionnaire, sent after the students had qualified, contained a question on their ultimate specialty choice.We performed ANOVA (using SPSS) for gender, background characteristics, students' attitudes towards, and the likelihood of becoming a general practitioner (GP) before and after the general practice clerkship. Subsequently, we used multiple regression analyses to examine which factors predicted the perceived likelihood of becoming a GP before and after the clerkship. The likelihood of becoming a GP was the dependent continuous variable; background characteristics, preferred patient categories and type of work, preferences for future work conditions, and evaluation of becoming a GP were the independent variables. To compare the longitudinal changes in likelihood of becoming a GP between the three time points, we used one-way repeated-measures ANOVA. Because of variance or low frequencies, age (23–27 years old), marital status (2% married), and having children (1%) were left out of the analysis.Attitude variables related to career choice are differently related to gender table . Female Before and after the clerkship female gender was positively associated with a preference for general practice as a career Table . This efBefore the clerkship, having considered an allied profession and having studied for another healthcare occupation were both positively related to a preference for general practice, as were positive attitudes towards the extrinsic job characteristics of general practice, such as status, income, and career opportunities. The preference of becoming a GP was lower among the students who had interest in acute patients and who were drawn to the technological aspects of medicine.Comparing the predictors of general practice preference before and after the clerkships shows that a positive assessment of the extrinsic aspects of general practice was not related to a higher likelihood to become a GP afterwards. After the clerkship, motivation to work with chronically ill and palliative patients and positive assessment of the intrinsic aspects of general practice  became significant predictors of a higher likelihood of becoming a GP.The likelihood of pursuing a career in general practice before and after the clerkship and at graduation is represented on figure We investigated the effects of gender and a number of other factors on the perceived likelihood of planning a GP career before and after the clerkship in general practice. Previous studies have shown that gender is an important determinant of a specialty choice in general practice. In our multivariate analyses, however, we found that the relationship between gender and students' preferences did not hold after we included attitudinal variables. This raises the intriguing question of what the gender effect stands for. On the basis of the findings, we suggest that gender differences in selecting general practice as a specialty is not a clear-cut male-female distinction but instead reflects a combination of a number of factors, such as having a broader view of medicine, preferred type of work and patients and content of work. Regarding gender differences in medical specialty choices, two explanations were offered in the literature: individual and structural theory . The quecontent of work in general practice, measured by work-intrinsic factors such as kind of treatments, long term patient contacts, and variety of work, is the crucial factor when considering a career in this field. The finding that stimulation of students' interest in the type of problems faced in a certain specialty is the strongest motivational factor of the specialty choice, concurs with previous research [The individual-oriented approach describes gender differences in terms of individual, gender-related interests and specialty preferences. In this study, interest in the research . It is iOur results further suggested that men were more interested in the technological and aspects of medicine and acute patients, whereas women were more interested in palliative care and chronically ill patients.Although men and women had diverse primary interests in type of work and patients, this difference did not play an important role in the GP specialty preference. Similar conclusions were drawn from another study, where male and female residents were attracted to a particular specialty for similar reasons . For botThe structural approach attempts to explain the gender difference in the light of work conditions and societal context. The disappearance of the impact of extrinsic factors  after the clerkship in favour of work-intrinsic factors underscores the importance of inner interest in the GP specialty. Assessment of work conditions (work load and hours) in general practice did not predict the likelihood to become a GP either. Additionally, despite our expectations based on previous studies, controllable lifestyle options did not relate to a GP specialty preference.The fact that individualistic theory only partially explains the difference between male and female students in our study, and that structural approach did not substantiate the results, asks for additional explanations ,32. FirsAnother finding is that medical students ground their initial choices on the content of a subject matter. At the undergraduate stage work conditions seem less important to them. Probably, the question of a balance between work and private life is a question of later concern. There is evidence from earlier research that women were initially as likely as men to start a career in surgery and internal medicine . HoweverWith regard to other factors affecting the choice for general practice, we found that having studied another, medicine related discipline had a positive predictive value. We surmise that these students have been able to develop a broader view on medicine and, therefore, are more likely to opt for a GP career. Students with "broad-based" undergraduate preparation frequently chose specialties with many doctor-patient interactions . Thus, aIn this study, the factors we have explored seem to offer only a partial explanation for the perceived likelihood of becoming a general practitioner. Possible other determinants such as personality characteristics and social background may be included in future research.We started this article with describing the paradox of the increasing influx of women and new generations of physicians in medicine on one hand, and the difficulties to recruit sufficient trainees for general practice on the other. Our study showed that men and women do not differ substantially in their interest in general practice. Flexible work conditions, which are mainly the preference of women, are not important at the undergraduate stage when initial specialty preferences are shaped. Hence, an increasing share of female students would not directly lead to the increase in the popularity of general practice.The question, however, is what happens to all the potential trainees for general practice at graduation? Our results show that the positive effect of the clerkship was not long lasting, and relatively few students persisted in their initial plan to become a general practitioner after they had graduated. At graduation the interest in general practice had dramatically fallen amongst female students and became even lower than among male students. This drop may partly explain the inconsistency between the expectations of increasing interest in general practice care and low popularity of this specialty. Zinn and colleagues, in their study of students' primary care orientation, noted a decline in primary care interest among medical students between the fourth year and the residency . ResidenBased on our findings, we suggest some implications for the practice. In order to stimulate students to choose general practice as a specialty, emphasis should be placed on the attractiveness of the content of work and type of patients in general practice. Other factors like working conditions and lifestyle considerations are less salient in shaping specialty preferences of undergraduate students.Furthermore, seeing that the increased interest of students in general practice after the clerkship rotation was found to have diminished at graduation particularly among women, it seems advisable to take measures to sustain students' interest in general practice also after the clerkship, for instance by offering them experiences in general practice throughout the clinical phase of the curriculum until graduation. To support our findings, a similar survey could be replicated across more than one cohort of students.Predominantly individual interest in the content of GP work and preferred type of patients to work with determine the specialty choice in general practice, regardless of gender. Gender 'as such' appeared not to be a predictor of career choice. Male and female interests in medical specialty choice tend to converge. Work conditions do not play a role in the specialty preference at the undergraduate stage. Even though more females prefer to become a GP, males are influenced more by the clerkship than female students. However, the motivating effect of the clerkship is not long lasting. Mainly female graduates change their interest in favour of other specialties. This might explain why in spite of the rising number of female medical students general practice is still not a popular career choice among students. It might be worthwhile to reinforce an initial preference for general practice by motivational guidance throughout the whole period of clerkships. There is more longitudinal research needed to explore why students abandon the option to become a GP and what are the factors which play role in the definitive specialty choice of medical graduates.The authors declare that they have no competing interests.All authors designed the study and contributed to the development of the questionnaire. TM collected and analyzed the data, and drafted the manuscript. BB was responsible for data acquisition and contributed to the manuscript. AS, JvdZ, FS revised the different drafts critically for important intellectual content.The pre-publication history for this paper can be accessed here:


This is a case study describing how climate change may affect the health of British Columbians and to suggest a way forward to promote health and policy research, and adaptation to these changes. After reviewing the limited evidence of the impacts of climate change on human health we have developed five principles to guide the development of research and policy to better predict future impacts of climate change on health and to enhance adaptation to these change in BC. We suggest that, with some modification, these principles will be useful to policy makers in other jurisdictions. It is also essential to create a research infrastructure to provide more accurate baseline and continuing data on the future impacts of climate change on human health. Given the complex way in which climate change will act in concert with other socio-economic and environmental factors it is best to approach the study of climate change and health using a social determinants of health framework.The purpose of this paper is to outline how climate change is likely to affect the health of British Columbians and to suggest a way forward to promote health, policy research, and adaptation to these changes. Although this study was conducted in the Western Canadian province of British Columbia (BC) we feel that the insights from this case will be useful for other jurisdictions grappling with questions of research and policy in relation to climate change and health.In the first section of the paper, the basic conceptual frameworks used to investigate climate changes and health are introduced. In the second section, we describe the health status of British Columbians with a particular focus on the health status of rural residents of the province as it is quite likely that rural and remote communities will be among the first to experience the impacts of climate change as it unfolds in the province. In the third section we outline the evidence linking climate change to adverse health outcomes. Because there is limited evidence available for BC , we extrapolate from this limited evidence to suggest possible impacts of climate change on the health of British Columbians. In the fourth section, we outline a “made in BC” set of principles and priorities for a research and policy agenda to improve adaptation to the health impacts of climate change. In the final section of the paper we suggest ways in which this BC case may apply to other jurisdictions.2.Several conceptual models have been developed in order to frame research on the impacts of climate change on health –12. In mIndirect effects on health arise from the sustained impact of altered climate which cause changes to ecosystems and which, in turn, impact human health through various pathways . For exaet al. (2008) also take a place-based approach to better understanding the potential for climate change to affect health noting that public health threats related to climate change are location specific [et al. (2008) show how place attachment is important in climate change adaptation, as it fosters both increased awareness of the ecological shifts seen with climate change as well as motivation to adapt in order to maintain effective place attachment relationships. This may be important in BC, particularly among the province’s aboriginal peoples, who tend to have strong place attachment that may be helpful in climate change adaptation targeting these vulnerable groups.Other researchers have taken a more ecological and place-based approach to conceptualizing the potential impacts of climate change on health ,12,17–23specific . They pret al. (1998), the magnitude of the effects of climate change on health will be a function both of the nature and magnitude of climatic changes and the vulnerability of the affected populations [Thus, it is essential that research on human health effects of climate change must, not only grapple with the intensity and pace of climate change but also with the location and extent of vulnerability of human populations most likely exposed to climate change [Finally, according to Woodward ulations . Thus, ie change ,4.3.British Columbia is Canada’s westernmost province. It is a ruggedly mountainous place, with extensive forest cover and limited arable land. The population of approximately 4.5 million people is concentrated around the city of Vancouver located in the extreme south-west of the province and, to a lesser extent, in the south-central Okanagan Valley and on Southern Vancouver Island.i.e., high populations of seniors and/or children and youths relative to the working age population). Rural regions attract fewer immigrants and also have a higher proportion of Aboriginal residents than most urban regions. The study also showed that while death rates for most cancers were lower for rural Canadians they experienced much lower life expectancy, higher all-cause mortality, higher prevalence of arthritis, greater mortality from injury and accidents, suicides, diabetes, cardio-vascular disease and they had a higher prevalence of smoking and obesity relative to urban Canadians. The greatest differences between urban and rural Canadians was in the much higher prevalence of arthritis/rheumatism in rural regions and the much greater mortality from injury and accidents (particularly from motor vehicle accidents), and from suicide [An investigation into the health status of rural compared to urban Canadians using mortality data from 1996 to 2001 and the 2001 Canadian Community Health Survey (CCHS) demonstrated that rural Canadians were systematically worse off than urban Canadians. Residents of rural regions across Canada were also much poorer than people living in urban places. As well, people in rural Canada had lower levels of education, higher rates of unemployment, and higher dependency ratios  or northern areas . These rBesides this heightened socio-economic and environmental vulnerability, residents of northern regions of the province are less healthy on average than residents of urban communities. For example, according to the 2005 Canadian Community Health Survey, approximately 20 percent of residents of BC’s northern regions were obese and approximately 25 percent smoked, compared to, respectively, 8 and 12 percent in the city of Vancouver, the major urban center located in the south-west corner of the province . This heThese urban/rural and urban/northern differences in self-reported health behaviours are also evident for objectively measured health outcomes. As an example of the seriousness and extent of this northern/urban health gap in BC, the average age standardized mortality rate between 1997 and 2000 was 6.4 deaths per 1,000 in the Fraser Health Authority (largely urban and located in the south west corner of the province) compared to 8.4 per 1,000 in the Northern Health Authority  ,32. The This health divide is also found when considering life expectancy. Residents in Vancouver currently have life expectancies that are among the highest in the world (approximately 82 years) but residents of the Northern Health Authority, on average, have life expectancies which are 4 or 5 years less than this. Thinking about the gap in self-reported health status, morbidity, mortality, and life expectancy temporally, it is as if current residents of some rural and northern communities have health status that was typical of urban British Columbians 40 years ago .While health vulnerability is high for people living in rural and remote regions of the province there are also vulnerable sub-populations in the province’s towns and cities. While it is not completely clear how these vulnerable urban populations will be affected in BC by future climate changes we know from studies, mainly in the United States and Northern Europe, that the urban poor are particularly vulnerable to adverse impacts arising from acute heat exposure during prolonged heat waves .For example, heat exposure has been studied in the United States and Northern Europe mainly in relation to urban heat waves. Cities are disproportionately affected by heat because of the urban heat island effect. In major urban areas increases in temperature of up to 11°C warmer than in surrounding areas have been observed . The impSome individuals living in poor urban areas and some living in remote and rural regions of the province are vulnerable both socio-economically and in terms of their health status. As well, in the case of rural and remote communities, there is some evidence that their social fabric may be less able to adapt to economic and environmental disruption relative to urban communities . This he4.British Columbia is a province with a classic wet temperate climate along the coast and Vancouver Island. Most of central BC has a typical continental climate with a cold winter and a warm summer with precipitation distributed relatively evenly through the year. The exception is the Okanagan Valley in the south centre of the province. This region is very dry all year round. The north of the province is characterized by a sub-arctic climate. The province is traversed by large mountain ranges and major river systems, including the Columbia, Fraser, Liard, and Stikine rivers. The geography, hydrology, and climate of the province is complex and diverse making the development of predictive models linking future climate change and human health particularly challenging.4.1.A factor of importance in considering the potential impacts of climate change on human health in BC is the major infestation of the province’s extensive pine forests by the Mountain Pine Beetle (MPB) . The MouImpacts of climate change on health due to fire and flood could be considerable given the complicating factor of widespread forest kill due to MPB infestation. MPB killed trees retain their dead needles for as much as 3 or 4 years after initial infestation. During this period, these trees are at higher risk for fire than healthy trees. As well, dead standing trees, in combination with increased precipitation due to climate change, especially during spring melt, may intensify spring water run-off patterns increasing the potential for flooding and drinking water contamination –46. It iPeople living in communities located in the interior and northern interior of the province are therefore vulnerable, not only in terms of their reduced economic and health resilience, but also because of the direct and indirect impacts of this major biological disaster, likely itself, directly due to the effects of a changing climate.4.2.Exposure to fire, flood, heat and increased air pollution are all likely pathways to increased health risk for residents in both urban and rural regions of BC as climate change accelerates. Cities are disproportionately affected by heat because of the urban heat island affect  which isWhile parts of the province will get wetter, some regions are at risk of shortages of both surface and ground water ,46,52. RForest fires are projected to become more frequent and severe in Western Canada ,61 and iAir pollution has a well known adverse impact on respiratory health ,66. Air via its impacts on food security may be moderate or even positive at least in the short and medium term.It is possible that climate change in temperate places, like BC, will produce relatively benign conditions for agricultural production in the short and medium term as temperatures warm in formerly northern cold regions ,71. Ther4.3.Water-borne diseases may increase as a result of increased precipitation and flooding . Many reRise in temperature may alter living conditions for animal and plant vectors of diseases ,77–79. TNew fungal pathogens from warmer and wetter climates may find the local soil ecology and climate more welcoming with climate change. For example, Cryptococcus gatti, a tropical fungus, first appeared in 1999 on the South East coast of Vancouver Island an emergence that may be due to changing climatic conditions . This fu4.4.Most of the discrepancy in chronic and physical and mental illness seen across cultural, economic, ethnic, and geographic dimensions arises as a result of social rather than biological determinants of health . BC’s vuThe importance of a focus of climate change research and policy on vulnerable rural and remote communities in BC cannot be overstated for several reasons. First, approximately 25 percent of the province’s population lives in rural and remote places . Second,5.et al. (2008) have proposed a public health approach to climate change based on the essential public health services emphasizing the necessity of developing and coordinating classical public health, non-governmental and government services to deal with the complex health and infrastructural problems that will arise as climate change begins to impact human health [Frumkin n health . As welln health . Based i5.1.It is necessary to obtain better local meteorological data as climate monitoring networks are not adequate to measure BC’s highly variable climate. Next it is necessary to develop models that apply accurate regional climate change to regional topography, hydrology and ecological systems, to better predict flood and fire risk, surface and ground water quality change, and the introduction and spread of new and existing vector-borne and other infectious illnesses. Presently, accurate climate change projections are not possible because the models are not well developed and also because future emissions trajectories are also not yet clear. As well, it is imperative to conduct field testing to confirm the predictive power, particularly of hydrological models, developed in order to determine their utility. In the meantime, there are reasonable regional estimates of past current and climate change projections available that account for topography for the province ,94.Given the high prevalence of chronic illness, particularly cancer, depression, respiratory, and heart disease in BC, relatively small disease exacerbations associate with climate change could result in substantial increases in absolute disease burdens. Research is required to elucidate these indirect pathways with these outcomes. It is essential to have good quality longitudinal health data sets available for research as climate change and health studies require at least 30 years worth of data . BC is uThe data base has been extensively utilized over the past 15 years for complex longitudinal investigations of various health outcomes, in several different populations, and in relation to a variety of environmental and occupational exposures –100. The5.2.Action is required to enhance the adaptive capacity of the most vulnerable regions and the most vulnerable people within regions. An emerging research agenda must focus on understanding regional and community resilience, particularly among vulnerable sub-populations in order to build on these. Research on social capital of communities, flexibility and innovation of government, private sector and non-profit agencies, and programs is needed. In short the role of collective coordination and action in facilitating adaptation is important .In the BC context, the potential for adverse impacts due to climate change will be particularly high in rural and remote Aboriginal communities where the combination of highly socio-economically vulnerable and health vulnerable populations and long distances from health and emergency services will potentiate any adverse impacts arising due to climate change. Other vulnerable communities in BC include some non-Aboriginal rural and remote communities as well as many poor urban ones.5.3.Promotion of local adaptation policies requires public and professional buy-in and greater awareness by the public. In terms of the latter, it will be essential to investigate the perceived risk of climate change in the population –104. TheMobilization of the public and government and non-government stakeholders may not be easy even in relation to climate change. For example, Leiserowitz (2006)  has showEngagement is key to moving individuals and community leaders forward in developing adaptive strategies to deal with climate change as it unfolds because it is only when individuals in communities feel vulnerable to the impacts of climate change and understand that their community livelihood and their health may be threatened that they will be moved to make individual changes and press their communities for adaptive strategies. A key area of research to develop is in risk perception of climate change impacts of health in order to understand regional variation in these perceptions as these will be a marker of the potential for successful adaptation polices to be enacted at the local level.5.4.et al., is key here [The approach outlined by Frumkin key here . Public i.e., efforts to anticipate and prepare for effects of climate change thereby reducing the associated health burden). The idea that steps to protect public health from threats of climate change cannot await full scientific certainty is also consistent with prevailing public health practice and management for other illnesses [Also, several public health principles point to well established public health approaches to climate change. First, what public health professionals understand as primary prevention would be mitigation. Secondary and tertiary prevention would be adaptation  is essential. Second, climate change will aggravate existing health disparities so that research and adaptive policy must be directed towards those people and communities currently with the greatest deficits in health. Third, this means that vulnerability assessment (g others ) must be


The Developmental eVOC ontologies presented are simplified orthogonal ontologies describing the temporal and spatial distribution of developmental human and mouse anatomy. Model organisms represent an important resource for understanding the fundamental aspects of mammalian biology. Mapping of biological phenomena between model organisms is complex and if it is to be meaningful, a simplified representation can be a powerful means for comparison. The Developmental eVOC ontologies presented here are simplified orthogonal ontologies describing the temporal and spatial distribution of developmental human and mouse anatomy. We demonstrate the ontologies by identifying genes showing a bias for developmental brain expression in human and mouse. Biological investigation into mammalian biology employs standardized methods of data annotation by consortia such as MGED (Microarray Gene Expression Data Society) and CGAP (Cancer Genome Anatomy Project) or collaborative groups such as the Genome Network Project group at the genome Sciences Centre at RIKEN, Japan . Data geAn ontology is a commonly used method of standardization in biology. It is often defined as a formal description of entities and the relationships between them, providing a standard vocabulary for the description and representation of terms in a particular domain ,3. GivenMany anatomical and developmental ontologies have been created, each focusing on their intended organisms. As many as 62 ontologies describing biological and medical aspects of a range of organisms can be obtained from the Open Biomedical Ontologies (OBO) website , a systeEfforts are being implemented in order to simplify ontologies for gene expression annotation. The Gene Ontology (GO) Consortium's GO slim  containsThe laboratory mouse is being used as a model organism to study the biology of mammals . The expThe study of developmental biology incorporates the identification of both the temporal and spatial expression patterns of genes expressed in the embryo and fetus . It is iUsing mice as model organisms in research requires the need for comparison of resulting data and provides a means to compare mouse data to human data . The croFunction of most human genes has been inferred from model organism studies, based on the transitive assumption that genes sharing sequence similarity also share function when conserved across species . The samThe terminology currently used to annotate human and mouse gene expression can be ambiguous  among spWe have attempted to address the issue by developing simplified ontologies that allow the comparison of gene expression between human and mouse on a temporal and spatial level. The distribution of human and mouse anatomy terms across development match the structure of the human adult ontologies that form the core of the eVOC system.Due to the ambiguous annotation of current gene expression data between human and mouse, and the lack of data mappings accompanying the available ontologies, the ontologies presented here have been developed in concert with semi-automatic mapping and curation of 8,852 human and 1,210 mouse cDNA libraries. We have therefore created a resource of standardized gene expression enabling cross-species comparison of gene expression between mammalian species that is publicly available.The ontologies were originally created to accommodate requests by the FANTOM3 consortium  for a siShared structure between the ontologies ensures effective interoperability on the developmental and species levels. The importance of shared structure between two ontologies becomes apparent when attempting to align them for comparison. If two terms in an ontology are mapped to each other, ontology rules infer that the children terms in each of the ontologies share the same characteristics. For example, if gene X is mapped to 'heart' in a human ontology and gene Y is mapped to 'cardiovascular system' in mouse, we can infer that because 'cardiovascular system' is the parent of 'heart' in both ontologies, gene X and gene Y have an association with respect to their expression in the cardiovascular system although their annotations are not identical. This is especially important when the granularity of annotation in one species is different to that of another.Terms from the EMAP, MA and HUMAT ontologies have been used to create 28 mouse and 23 human ontologies, representing the 28 Theiler stages and 23 Carnegie stages of mouse and human development, respectively. The 28 Theiler stages represent mouse embryonic, fetal and adult anatomical development, whereas the 23 Carnegie stages represent only human embryonic development. Human adult is represented by the Anatomical System ontology of the eVOC system, upon which the other ontologies are based. The terms from the source ontologies  have been mapped to the equivalent term in the developmental eVOC ontologies to ensure interoperability between external ontologies and eVOC. Terms from the mouse have also been mapped to those from human to enable cross-species comparison of the data mapped.The integration of the ontologies is described in Figure The presence of species-specific anatomical structures posed a challenge when aligning the mouse and human terms. An obvious example is the presence of a tail in mouse but not in human. We decided that there would simply be no mapping between the two terms. Further challenges involved structures such as paw and hand. The two terms cannot be made identical because it is incorrect to refer to the anterior appendage of a mouse as a hand. However, due to the fact that the mouse paw and human hand share functional similarities, the two terms are not identical, but are mapped to each other based on functional equivalence.In order to provide simplified ontologies, the 28 mouse and 23 human ontologies were merged to create two ontologies - one for each species. In addition, a Theiler Stage ontology was created that represents the Theiler stages of mouse development. The human stage ontology is represented by the current eVOC Development Stage. A cross-product of two terms (one from the merged and one from the stage ontology) for a species can, therefore, represent any anatomical structure at any stage of development.The relationship between the developmental mouse and individual ontologies is illustrated in Figure The ontologies presented here are simplified versions of existing human and mouse developmental and adult ontologies, containing 1,670 and 2,840 terms, respectively. Table The resources providing ontologies to annotate gene expression do not always provide the data themselves. In order to obtain mouse and human data, one would have to search separate databases for each species. An example of this would be searching MGI for mouse gene expression data, and ArrayExpress for human. Apart form having to access different databases to obtain data, the terminology used to describe the data is ambiguous and differs in the level of granularity, impacting on the accuracy of inter-species data comparison. The ontology terms have, therefore, been used to annotate 8,852 human and 1,210 mouse cDNA libraries from CGAP .The mapping process revealed inconsistencies in the annotation of the human and mouse CGAP cDNA libraries, requiring manual intervention and emphasizing the need for a standardized annotation. All genes associated with the libraries have been extracted by association through UniGene. A gene was considered to be associated with a cDNA library if at least one EST was evident for the gene in a particular library. The result is a set of 21,152 human and 24,047 mouse genes from UniGene that are represented by CGAP cDNA libraries and annotated with eVOC terms, and represent the set of human and mouse genes for which there is expression evidence. CGAP represents an ascertainment bias where there is a strong over-representation for cancer genes, and, therefore, future efforts for this research will include obtaining a well-represented, evenly distributed dataset of human and mouse gene expression. The list of human and mouse orthologs were extracted from HomoloGene to represent the 16,324 human-mouse orthologs. Two genes were considered to be orthologs if they shared the same HomoloGene group identifier.Genes may be categorized according to their eVOC annotation on a spatial or temporal level, or a combination of both. An example of this would be genes expressed in the heart at Theiler stage 26 for mouse. For the purposes of this study, we searched for human-mouse orthologs that are expressed in the normal postnatal and developmental brain of both species, where a gene is classified as normal if its originating library was annotated as 'normal'. Research involving gene expression of the brain aims at identifying causes of psychological and neurological diseases, many of which originate during development. With the use of mice as model organisms in this kind of research, it is important to identify genes that are co-expressed in human and mouse on the temporal and spatial levels. The results of our analysis show that of the available 16,324 human-mouse orthologs, 14,434 can be found in CGAP libraries for both human and mouse. When looking at brain gene expression, we could segregate genes according to their spatial and temporal expression patterns. We found that of all the orthologs expressed in the brain, 10,980 genes were expressed in the post-natal brain of both species whereas 1,692 genes were expressed in the developing brain of both species. Of these two sets of genes, 90 genes were found to have biased expression for developmental brain , and three mouse genes were expressed only in the mouse brain  as opposed to all other tissues . The highest correlation score between an ortholog-pair is 0.646 (HomoloGene identifier: 27813), having identical expression profiles during development (expressed in liver and stem cell), but differing during post-natal expression . The correlations observed suggest that the expression profiles of orthologs across these major tissues are only partially conserved between human and mouse. This finding strengthens our understanding of orthologous gene expression in that although two genes are orthologs, they do not share temporal and spatial expression patterns and, therefore, probably do not share a majority of their regulatory modules [To assess the similarity in expression across major human and mouse tissues other than brain, the expression profiles of the 90 genes with bias for developmental expression were determined for developmental and adult expression in the following tissues: female reproductive system, heart, kidney, liver, lung, male reproductive system and stem cell. These tissues were chosen based on the availability of data for each tissue in the developmental and adult categories. For each ortholog-pair, we determined the correlation between their expression profiles . We found that, according to the cDNA libraries, one mouse gene was found to be expressed in all the tissues in both post-natal and development  section of the EMAP ontology were inserted to create the Theiler Stage 26 developmental eVOC mouse ontology. Proceeding from Theiler stage 26 to Theiler stage 1, each stage was used as a template for the next stage and any term not occurring at that specific stage, using EMAP as reference, was removed. Similarly, if a term occurred in EMAP that was not present in the previous stage, it was added to the ontology. The result is a set of 26 ontologies, one for each Theiler stage of mouse development, with many terms appearing and disappearing throughout the ontologies according to changes of anatomy during mouse development.The Theiler Stage 28 (adult mouse) ontology was constructed in the same way as the developmental ontologies, using the MA ontology as a reference. A previously unavailable Theiler Stage 27 ontology was developed by comparing Theiler stage 26 and Theiler stage 28. Any terms that differed between the two stages were manually curated and included or removed in Theiler stage 27 as needed. The Theiler Stage 27 ontology therefore represents all immature, post-natal anatomical structures. Theiler Stage 28 ontology terms have been mapped to the adult human eVOC terms by using the human eVOC accession identifiers as database cross-references in the mouse ontology. Similarly, the EMAP accession number for each term was mapped to the developmental mouse ontologies. The result is a set of 28 ontologies that are an untangled form of the EMAP and MA ontologies, with mappings between them.A set of human developmental ontologies were created by using the same method as was used for mouse. The reference ontologies for human development were the HUMAT ontologies, which describe the first 23 Carnegie stages of development, classified according to morphological characteristics.The 28 mouse and 23 human ontologies were merged into two ontologies - one for mouse and one for human. Each merged ontology (named Mouse Development and Human Development) contains all terms present in the individual ontologies. A Theiler Stage ontology was created for mouse, which contains all 28 Theiler stages categorized into embryo, fetus or adult. The existing eVOC Development Stage ontology serves as the human equivalent of the mouse Theiler Stage ontology. The Mouse Development, Human Development, Theiler Stage and the existing Development Stage ontologies form the core of the Developmental eVOC ontologies.Mouse and human cDNA libraries were obtained from the publicly available CGAP resource and mapped (semi-automated) to the entire set of eVOC ontologies. The eVOC ontologies consist of Anatomical system, Cell type, Developmental stage, Pathology, Associated with, Treatment, Tissue preparation, Experimental technique, Pooling and Microarray platform. The 'age' annotation of the mouse CGAP libraries was manually checked against the Gene Expression Database (version 3.41)  to deterThe genes were filtered according to the presence or absence of expression evidence and homology. A gene passed the selection criteria if it has an ortholog and if both genes in the ortholog pair have eVOC-annotated expression. According to eVOC annotation, genes were categorized into those that showed expression in normal adult brain and those expressed in normal developmental brain, many genes appearing in more than one category. Genes expressed in normal adult brain were subtracted from those with expression in normal developmental brain to establish genes whose expression in the brain occurs only during development. The expression profiles of the developmentally biased genes annotated to female reproductive system, heart, kidney, liver, lung, male reproductive system and stem cell for post-natal and developmental expression were determined according to the eVOC annotation of the cDNA libraries, and the correlation coefficient of the ortholog-pairs were calculated.The mouse eVOC ontologies, their mappings and the datasets referred to in this manuscript are available under a FreeBSD-style license at the eVOC website .CAGE, capped analysis of gene expression; CGAP, Cancer Genome Anatomy Project; DAG, directed acyclic graph; EMAP, Edinburgh Mouse Atlas Project; EST, expressed sequence tag; FMA, Foundational Model Of Anatomy; GO, Gene Ontology; HUMAT, Edinburgh Human Developmental Anatomy; MA, Adult Mouse Anatomy; MGI, Mouse Genome Informatics; OBO, Open Biomedical Ontologies; SAEL, SOFG Anatomy Entry List.AK was responsible for ontology development and integration, data mapping, data mining and drafting the manuscript. OH helped with ontology development and integration between the human and mouse ontologies. PC and YH drove development requirements for the study. WH was responsible for study design and revised the manuscript. All authors read and approved the final manuscript.The following additional data are available with the online version of this paper. Additional data file Genes for human and mouse grouped together if they are expressed in post-natal or developmental brain, respectively. The intersection between the human and mouse developmental brain genes represent those genes showing common expression in the two species. Subtracting genes commonly expressed in human and mouse post-natal brain determines those genes that show developmental restriction in either human, mouse or both species.Click here for fileThe table lists the Entrez Gene identifier and gene symbol of the 9,378 human-mouse orthologs found not to have an expression bias towards the embryonic and fetal stages of brain development. Genes were considered for analysis only if they have an ortholog, and if the ortholog also has expression evidence based on eVOC annotation.Click here for fileThe table lists the HomoloGene group identifier, Human Entrez Gene identifier, Human Entrez gene symbol, Mouse Entrez Gene identifier, Mouse Entrez gene symbol and the correlation coefficient between the expression profiles of the genes in each species.Click here for fileThe tissues represented are female reproductive system, heart, kidney, liver, lung, male reproductive system and stem cell for both post-natal and developmental expression. The table lists the HomoloGene group identifier, Entrez Gene identifier and Entrez gene symbol for human and mouse, as well as the species each row represents. Values in the table are 1 if the genes (in rows) are expressed in the given tissues (in columns) and 0 if the genes are not found to be expressed in the tissues.Click here for file


Alzheimer's disease is the leading cause of dementia in older adults. Although memory problems are the most characteristic symptom of this disorder, many individuals also experience progressive problems with communication. This systematic review investigates the effectiveness of methods to improve the verbal communication of individuals with Alzheimer's disease with their caregivers. The following databases were reviewed: PsychINFO, CINAHL, EMBASE, MEDLINE, REHABDATA, and COMDIS. The inclusion criteria were: (i) experimentally based studies, (ii) quantitative results, (iii) intervention aimed at improving verbal communication of the affected individual with a caregiver, and (iv) at least 50% of the sample having a confirmed diagnosis of Alzheimer's disease. A total of 13 studies met all of the inclusion criteria. One technique emerged as potentially effective: the use of memory aids combined with specific caregiver training programs. The strength of this evidence was restricted by methodological limitations of the studies. Both adoption of and further research on these interventions are recommended. Alzheimer's disease (AD) is the leading cause of dementia in older adults. Currently 4.5 million Americans have AD and this number is expected to rise to 13.2 million by the year 2050 . The objThe decline of communication abilities in AD is gradual and is characterized primarily by problems with object naming –9, coherThe deterioration of the individual's ability to communicate contributes considerably to the stress and burden of caregivers –18 and idesire to communicate, another aspect of communication that often remains intact in individuals with dementia [Memory aids generally consist of biographical information , photos of family members, and descriptions of important events in the life of the individual. By using images and phrases that are brief and simple, memory aids seek to capitalize on patients' automatic communication abilities, with the goal of improving the structure and quality of communication with others . At the dementia .Caregiver communication enhancement education and training techniques constitute another group of methods used to improve communication between caregivers and care recipients. An example of these methods is the program, “FOCUSED” . FOCUSEDOther similar programs incorporate a variety of additional strategies including: offering positive feedback when individuals with dementia follow through on requests, giving the individuals sufficient time to answer a request or a question, and speaking with the individuals about their life and pastimes. Feedback to caregivers related to their use of specific versus general instructions, one-step instructions, and positive comments to the person with dementia is also recommended .In addition, there are programs to teach caregivers tailor-made strategies to improve communication on the part of a particular person with AD. These rely on “conversation analysis” . This inAs well, there are a number of activity-based approaches to increasing communication. These interventions may be carried out individually or in groups and use very specific  or diverse activities to stimulate communication. Generally, the focus of these groups is on improving or maintaining a number of functional skills, with communication being one . To date, there have been two systematic reviews of interventions to improve the communication of persons with AD with caregivers. In the first, no quantitative analysis of the results was included . In the It was anticipated that the literature would contain only a limited number of randomized controlled trials (RCTs) investigating the efficacy of methods used to improve communication between individuals with AD and their caregivers. Therefore, it was decided that all relevant studies, regardless of the experimental method used, would be included in this review. The following inclusion criteria were adopted: (i) the study must be experimentally-based; (ii) the results must be quantitative in nature; (iii) the intervention examined by the study must be specifically designed to improve verbal communication between the individuals with dementia and their caregivers; (iv) at least 50% of the individuals sampled must have a confirmed diagnosis of AD. Where the specific dementia diagnosis of the participants was not provided, the studies were included if the majority of the participants were women, since AD is the most common dementia diagnosis among women . The twoA literature search was conducted up to July 2006 and then updated in June 2009 using the following computerized databases: PsychINFO (starting from 1872), CINAHL (starting from 1982), EMBASE (starting from 1980), MEDLINE (starting from 1966), REHABDATA, and COMDIS. Search terms were identified by a research librarian (search terms available on request). Identified articles were back-searched for additional relevant studies. As well, we consulted a database of articles relevant to communicating with individuals diagnosed with dementia that had been compiled by Kerry Byrne under the supervision of her doctoral advisor, J.B. Orange.The review progressed as follows. First, all of the titles of articles produced by the literature search were read by two reviewers (two of the authors) who judged whether the study was likely to meet the inclusion criteria. Next, for all those judged as potential candidates by either reviewer, abstracts were obtained and read. Subsequently, the actual articles were obtained if both reviewers felt that the abstract indicated that the study was likely to meet the inclusion criteria. In cases where there was disagreement, a third individual (another author) was consulted to cast the deciding vote.P-values where possible. Postintervention values of the dependent variables were used in these calculations.Following retrieval of the articles, the two reviewers performed a detailed analysis of each study. They determined which of the retrieved articles actually met the inclusion criteria. They then extracted the information used to summarize and evaluate each study. Advice was provided by the other authors during this process as needed. A third author calculated effect sizes (Cohen's d) and Finally, based on these results, a summary recommendation was made concerning communication interventions with individuals with AD using the Strength of Recommendation Taxonomy (SORT) criteria . Using tTitles and abstracts of 2000 articles were identified in the electronic searches . Sixty-seven papers were identified as potentially appropriate to the review and were obtained and assessed. Fifty-three were excluded from the review . Among s Thirteen studies reported in 14 papers met all of the inclusion criteria. Results from the Bourgeois et al. study  were alsOf the 13 studies included in the review, eight examined the effects of memory books, three evaluated training programs, and two reported on the outcomes of activity programs. The setting, participants, interventions, and designs of these studies are summarized in Eight studies assessed the impact of memory books with varying levels of caregiver training. Of these eight studies, two were RCTs Bourgeois 2001  and BurgThe results of one of the RCTs examining the impact of memory aids and caregiver training on participants' communication with formal caregivers indicated that, following this intervention, participants produced significantly more utterances and more informative communications during 5-minute conversations with their formal caregivers . Due to The pretest-posttest study of memory aids and staff training indicated that the percentage of time in coherent speech, percentage of time talking with others, and the number of positive statements to formal caregivers per hour all increased following intervention, but that these effects returned to pretest levels at one-month followup .Two of the multiple baseline single-subject studies demonstrated improvement in on-topic statements to informal caregivers following the use of memory books and caregiver training for most of the participants , 90. An Using the SORT criteria, given the above results, the use of memory aids with caregiver training would be recommended for use by clinicians with a rating strength of B. This rating is supported by results from two RCTs from which there were mixed results.There were three studies that examined different education and training programs for the communication partner. One, a lower-quality RCT, assessed a family visit training program McCallion 1999 . One preNo clinically or statistically significant changes in communication were noted in the lower-quality RCT of family visiting intervention program McCallion 1999 . The preWithin these studies there was no firm support for intensive caregiver training, with the exception of individualized communication prescriptions. Overall, the strength of recommendation for this intervention was C, a result supported by one RCT.The remaining two studies examined the effects of activity-based programming. One, a high-quality RCT, examined the effects of a walking and talking intervention Cott 2002 . The othIn the only high-quality RCT included in this review, Cott and her colleagues  examinedUsing the SORT criteria, straight conversational or walking and talking programs would not be recommended, but a breakfast-based activity group would receive a recommendation with a rating strength of B. This rating is not supported by results from an RCT.Prior to discussing some generalities regarding ways of improving communicative interactions between individuals with AD and their caregivers gleaned from this, it is important first to note some important observations from our search results. First, almost one-third of the excluded papers reported the results of interventions to enhance communication between individuals with Alzheimer's disease and their communication partners but did not include a quantitative change in the verbal communication of the affected individual with a conversational partner. Rather, these studies used language measures that do not capture communicative interaction , or measured aspects of caregiver communication or knowledge of recommendations. In order to convincingly demonstrate the effectiveness of interventions in improving the communication of individuals with Alzheimer's disease, future studies must include measures that reflect the communication abilities of the affected individual.As well, among the studies that met the criterion of having a communication outcome, there were only four randomized control trials addressing this issue, and three were considered lower quality. It must be acknowledged that it is often difficult to conduct an RCT within the field of communication disorders and, as such case-studies and single-subject designs have traditionally been used. However, due to their ability to better control threats to internal validity, RCTs are regarded as the gold standard in determining the clinical efficacy of an intervention. To this end, it is suggested that future studies investigating the efficacy of recommended techniques to improve communication of persons with AD follow the RCT protocol when possible, including those criteria necessary to be considered a high-quality RCT . In light of the above, and the fact that there were only a few studies meeting the inclusion criteria for selection, the majority of which had compromised internal validity due to methodological limitations, one must be cautious about generalizing the results of this review to clinical practice. Nonetheless, bearing in mind these methodological limitations , trends in performances did emerge allowing us to suggest the following recommendations.  Memory aids demonstrated the clearest effectiveness in improving patients' discourse related to the particular topics that were linked to the memory-aids. These tools appear to be effective in enhancing topic maintenance, as evidenced in improvement in time on topic, words per topic, and fewer topic changes. This suggests that these interventions are addressing verbal attention and helping individuals focus their thoughts. However, memory aids did not appear to encourage generalization to other conversational topics. As well, participants' performance decreased over time where followup training was not provided. This latter finding underscores the importance of continuing training for communication partners using these tools.Studies of combined memory aids were carried out primarily with nursing assistants and patients. Memory aids have received only limited testing with family caregivers . On the one hand, memory aids and training may be more or less effective when used by family caregivers compared to formal caregivers. Family caregivers may already be familiar with the content of memory books  and therefore able to initiate related conversation without them. On the other hand, memory books may cue the family caregiver to converse on specific topics, and these conversations may benefit from the in-depth shared knowledge of these topics. Further research on this intervention with family caregivers is recommended.The “Family Visit Intervention Program”  could noOnly two studies of activity-based programs that included evaluation of communication outcomes were identified in our search. The Breakfast Club intervention  demonstrOur results build on those of Zientz et al.  by demonThis systematic review was carried out using recommended methods including a search strategy designed by a research librarian, and selection of studies and extraction of data by two independent reviewers. One important limitation of the review was that effect sizes could not be calculated for all outcomes due to the data presentation limitations within the original studies. Opening the inclusion criteria to allow for studies using a wide variety of experimental designs  allowed us to consider the findings of a greater number of studies. However, conclusions from studies with different levels of validity may be misleading. To counteract this possibility, we indicated where the recommendations were supported by evidence from an RCT.This systematic review of the efficacy of techniques used to improve communication between individuals with AD and their caregivers indicated the highest level of support for the use of memory aids combined with caregiver training. High-quality RCTs examining these interventions are still rare. Future high-quality studies of these interventions, incorporating measures of communicative interaction and measures of topic maintenance, are recommended.


Alberta Context Tool (ACT) was developed to assess the relationships between organizational factors and research utilization by a variety of healthcare professional groups. The purpose of this paper is to present findings from a pilot study using the ACT to elicit pediatric and neonatal healthcare professionals' perceptions of the organizational context in which they work and their use of research to inform practice. Specifically, we report on the relationship between dimensions of context, founded on the Promoting Action on Research Implementation in Health Services (PARIHS) framework, and self-reported research use behavior.Research utilization investigators have called for more focused examination of the influence of context on research utilization behaviors. Yet, up until recently, lack of instrumentation to identify and quantify aspects of organizational context that are integral to research use has significantly hampered these efforts. The A cross-sectional survey approach was employed using a version of the ACT, modified specifically for pediatric settings. The survey was administered to nurses working in three pediatric units in Alberta, Canada. Scores for three dimensions of context  were used to categorize respondent data into one of four context groups . We then examined the relationships between nurses' self-reported research use and their perceived context.A 69% response rate was achieved. Statistically significant differences in nurses' perceptions of culture, leadership and evaluation, and self-reported conceptual research use were found across the three units. Differences in instrumental research use across the three groups of nurses by unit were not significant. Higher self-reported instrumental and conceptual research use by all nurses in the sample was associated with more positive perceptions of their context.Overall, the results of this study lend support to the view that more positive contexts are associated with higher reports of research use in practice. These findings have implications for organizational endeavors to promote evidence-informed practice and maximize the quality of care. Importantly, these findings can be used to guide the development of interventions to target modifiable characteristics of organizational context that are influential in shaping research use behavior. Journal of Continuing Education in the Health Professions (JCEHP) and Nursing Research were dedicated to advancing the theory and science of knowledge translation and research utilization by the healthcare professions with the ultimate aim of improving health outcomes. The JCEHP issue emphasized that the transfer and uptake of research findings in healthcare settings remains slow and unpredictable, despite considerable investment of public funds into healthcare research,[Nursing Research special issue advanced the science of KT by using the Promoting Action Research in Health Services (PARiHS) framework [In 2006 and 2007 respectively, special issues of the research, describiramework  to frameramework . In contramework , which wPromoting Action on Research Implementation in Health Services (PARiHS) framework[The aim of this paper is to report findings from a pilot study assessing the ACT, an instrument designed to measure modifiable dimensions of organizational context and self-reported research utilization. Specifically, we describe the relationship between three dimensions of context  as defined by the framework, and resSince its first publication in 1998, the PARiHS framework  of reseaInstrumental research utilization is the direct or concrete application of research findings, often identified as the application of clinical practice guidelines, procedures and clinical protocols. Conceptual research utilization occurs when research serves an 'enlightenment' function [Persuasive or symbolic research utilization is when research findings are used as a tool to advocate for a certain procedure or practice. Generally speaking, overall research utilization can be defined as the use of research findings in any and all aspects of one's work [Research utilization, a specific form of knowledge utilization, is a complex process in which research findings are transformed from one or more studies into instrumental, conceptual or persuasive utilization . Instrumfunction ,13: thatfunction . Persuase's work .Poor uptake of research in clinical practice has largely been attributed to individual characteristics such as a practitioner's inability to understand research , age, or attitude toward research -17. ConsPrevious work demonstrates that even if clinicians have adequate and recent research-based knowledge they do not automatically use it in practice . There iDespite organizational context being consistently identified as an important factor influencing nurses' use of research, it has not been well studied ,27. KitsChild healthcare settings are not immune to the challenges of applying the best available research evidence in clinical practice. Thus, ensuring research is used to inform clinical practice is of central importance. Effective research utilization is fundamental to ensuring that the best available research evidence informs the health and healthcare of infants, children, youth and families. Research shows that provision of research-informed care to children not only improves health outcomes, but also reduces healthcare utilization -35. Yet,To date, information about research utilization among child healthcare professionals  is lackiWe used a cross-sectional survey design to elicit health professionals' opinions about aspects of the organizational context in which they work and the extent to which they use research evidence to inform their practice.Nurses, managers, clinical specialists, doctors and allied healthcare professionals working in one of three pediatric units  located in two university affiliated hospitals in Alberta, Canada were invited to participate in this study. For this study we analyzed data only from the nursing sample.The Alberta Context Tool (ACT), conceptually framed by the PARiHS framework, was used to collect the data. The index version of the ACT was developed for use in acute care settings and comprises a suite of survey instruments designed to assess modifiable characteristics of organizational context and self-reported research use . The refFinally, measures of instrumental and conceptual research utilization, the dependent variables in this study were developed and validated by Estabrooks ,30,42,43The ACT was pilot tested in adult acute care settings and factor analytic procedures demonstrated that almost 70% of the variance in the context construct was accounted for in a sample of nurses, clinical specialists, managers, doctors and allied healthcare professionals working in four major teaching hospitals . The inspatient was substituted with patients and families; the examples which preceded questions were revised to ensure relevance to the pediatric setting. The culture, leadership and evaluation dimensions of organizational context were again found to be reliable with Cronbach's alpha scores of .71, .90 and .87 respectively [For the current study some adaptation was made to the ACT to ensure the language and content were appropriate to the pediatric setting. Specifically, the word ectively .Ethical approval to conduct the study was received from the University of Alberta Health Research Ethics Board. Operational and administrative approval to conduct the study was also attained. The surveys were completed anonymously and confidentiality of the data was maintained.We used a modified Dillman  approachhttp://www.uofaweb.ualberta.ca/prl/index.cfm was contracted to prepare and administer the electronic and paper-based surveys. All healthcare professionals who were eligible to complete the survey were provided with a personalized survey package. The package contained a letter to introduce the study, a business card providing the Uniform Resource Locator (URL) for the survey and a unique password, information detailing how to complete the survey online, a signed continuing education certificate, and a five-dollar gift certificate. PRL assembled the packages, which were either hand delivered to each eligible staff member on the three units or placed in their work setting mailboxes. Consistent with a modified Dillman [This study was undertaken in 2007. Data were collected using paper-based and electronic survey methods. University of Alberta Population Research Laboratory (PRL)  Dillman  approachDrawing on the approach used by Wallin et al.  and Cummhigh context. Those who reported a high score on any two context variables and a low score on any single variable were categorized as working in a moderately high context. Those who scored high on any single variable and low on the two remaining variables were categorized as working in a moderately low context. Finally, those who scored low on all three context variables were categorized as working in a low context. Grouping the respondents in this manner enabled us to examine their self-reported research use behaviors in relation to their perceptions of organizational context.In order to sort nurses into the four contextual groups, we needed to effectively divide the number of respondents into high and low on each dimension and therefore required an appropriate cut point between high and low mean scores on each of the 5-point leadership, culture and evaluation scales. In our earlier work ,30 the 4The instrument was offered to 362 nurses, including registered, graduate and licensed practical nurses. A response rate of 69% was achieved for a total sample size of 248. Internal reliability for the culture, leadership and evaluation scales was acceptable with Cronbach's alpha scores of .688, .898, .849 respectively.The demographic characteristics of the nurses from each of the three units are reported in Table Table Table all nurses combined, did not follow this pattern. For all nurses combined, those reporting the organizational context as 'low' reported fractionally higher conceptual use of research than did nurses perceiving the organizational context as 'moderately low'. On Unit B, nurses who perceived the organizational context as 'low' reported higher conceptual research use than did their colleagues who perceived the organizational context as 'moderately low' or 'moderately high'.The pattern for conceptual research use and organizational context categories was slightly different. While nurses on Units A and C reported steadily higher conceptual use of research in conjunction with more positive perceptions of the organizational context; conceptual research use reported by nurses on Unit B, and for The appropriateness of the unit of analysis at individual or unit levels for research use was assessed using interclass correlations. Table 4Figure These data illustrate a positive trend in the relationships between organizational context and research utilization. That is, more positive perceptions of organizational context were generally associated with higher self-reported instrumental and conceptual research use. We have organized our discussion around three key points: 1) the nature of the relationship between instrumental research use and organizational context, 2) new insights into the potential appropriate 'level' of analysis  of the concepts studied , and 3) the establishment of a methodological 'cut off' point for distinguishing between 'low' and 'high' contexts.First, our findings are consistent with Wallin et al.  and CummOur findings provide further empirical support for the context dimension of the PARiHS model ,9,28. SpSecond, our findings using the three contextual dimensions aggregated to the unit level suggest that they behave appropriately as unit level variables - both by the near linear trends in relationships with research use and the consistently small standard deviations across units Table . Our aggThird, the results of this pilot study lay the foundation for future studies. Literature on dichotomizing continuous variables suggests the importance of establishing cut points because prior work can be invalidated if cut points change . We estaThe sample is drawn from university hospitals only and these hospitals are linked operationally. The sample includes healthcare professionals from pediatric intensive care units and therefore the results cannot be generalized beyond this setting. This was a pilot study hence the sample size is small and this has restricted the degree of analysis that could be undertaken.Overall, the results of this study lend support to the claim that more positive organizational contexts influence greater use of research in practice in child health settings. These findings have important implications for organizational endeavors to promote evidence-informed practice and maximize the quality of care. Importantly, these findings can be used to guide the development of interventions to target modifiable characteristics of child health organizational contexts that are influential in shaping research use behavior.The authors declare that they have no competing interests.GGC led the design and interpretation of statistical analysis and development of the manuscript. AH contributed to the interpretation of statistical analysis and manuscript development.SS contributed to the design and conduct of the study as the Alberta site investigator, and through interpretation of statistical analysis and manuscript development. PN contributed to manuscript development. CAE is the Alberta lead investigator and as such secured resources, led the design and conduct of the study and provided guidance on manuscript development. All authors approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/10/168/prepub


Recently, cancer mortality has been compared to research spending by the National Cancer Research Institute (NCRI), whose research budget is approximately £250 million. The analysis shows a mis-match between mortality and research spending. As well as crude mortality rates, other measures of cancer burden should be considered because they contribute additional information. ‘Years of life lost’ (YLL) summed over each individual dying after a diagnosis of cancer represents a population-based mortality indicator of the impact of that disease on society. Years of life lost divided by the number of deaths for each cancer site produces an additional statistic, the average years of life lost (AYLL), which is a measure of the burden of cancer to the individual patient. For 17 cancer sites where data are available, four tumour sites have a rather large difference in mortality, comparing YLL to crude mortality. Years of life lost shows the population burden from cancers of the ovary, cervix, and CNS to be rather larger than suggested by crude mortality, despite screening programmes for cervix cancer. Using YLL, the underprovision of funding for lung cancer research is similar to that reported using percentage mortality. Breast cancer and leukaemia receive a relatively higher research spend than the population burden of these cancers, and the spending on leukaemia is quite extreme. Prostate cancer has a low per cent YLL but attracts a moderate amount of research spending. The use of AYLL as an indicator of individual cancer burden considerably changes the ranking of the mortality from different tumours. The mean AYLL is 12.5 years. Prostate cancer has the lowest AYLL, only 6.1 years; brain tumour patients have the highest, at just over 20 years. Comparing AYLL to research spending suggests four ‘Cinderella’ cancer sites with high individual cancer burden but low research spending: CNS tumours, cervix and kidney cancers, and melanoma. Breast cancer and leukaemia have roughly average AYLL but a considerable excess of research spending. YLL emphasises the discrepancy between research spending and mortality, and may be helpful for decisions concerning research support. Avearage years of life lost measures the burden to individual patients and may be helpful where individuals’ needs are relevant, such as palliative care. As well as crude mortality, more subtle and comprehensive calculations of mortality statistics would be useful in debates on research funding and public health issues. Measures of mortality from all types of diseases are clearly important for public health considerations. With regards to cancer mortality, data are important to monitor the effects of screening programmes, efforts at earlier diagnosis and treatment, and the effects of environmental and other causative factors such as smoking. Recently, mortality from cancer has also been compared to research spending by the National Cancer Research Institute (NCRI) as a means to gauge the appropriate relative level of expenditure for different tumour sites, and to inform debate about the distribution of funds .The latest figures on cancer mortality from Cancer Research UK  suggest There have been valuable efforts by the NCRI to review funding in relation to mortality, leading to the publication of a strategic analysis . This stSimple percentage mortality expresses the number of deaths from an individual tumour type divided by the total number of deaths from cancer as a percentage. However, another important mortality statistic that complements crude mortality indicators is ‘years of life lost’ (YLL). This is calculated for each individual dying after a diagnosis of cancer by subtracting the actual survival since diagnosis from the individual's life expectancy at the time of diagnosis, based on appropriate life tables. The YLL for a specific cancer site in a population is obtained by summing all the individual years of life lost through deaths from the cancer of interest, in that population in a specific time period. This can then be expressed as a percentage, that is, the years of life lost from a specific cancer as a percentage of the total number of years of life lost from all cancers.Therefore, YLL is a population-based mortality indicator, which gives more weight to those diseases that kill early or are incurable. Thus, weighting is given to cancers that affect patients at a young age and who die as a result. It also counterbalances the weighting given to common cancers in older patients by simple percentage mortality. This combination of factors allows YLL to give an indication of the impact of the disease on society, that is, it represents the population burden for individual cancers.Data from the East Anglian Cancer Registry for the 5-year period 1990 to 1994 were used to calculate YLL. No cutoff for age was used for the calculations. Although a cutoff at age 70 years has been suggested , censoriData for 17 tumour types are available, which account for 84% of the total YLL from cancer. The figure for colo-rectal cancer also includes anal tumours. Specific YLL data for liver cancer, and head and neck cancers are not available but they represent only 2% each of simple mortality . UnspeciFigures for YLL can be used to produce an additional mortality statistic, the average years of life lost (AYLL). Average years of life lost is simply an average derived by dividing YLL by the actual number of deaths for each cancer site, over the defined time period. This parameter is interesting because it provides a measure of the burden of cancer to the individual patient, rather than the population as a whole. Effectively it shows, on average, how much a patient's life is likely to be shortened by their cancer.vs percentage mortality, for 17 cancer sites where YLL data are available. The majority of points lie close to the line of equality. This graph shows absolute differences in percentage for the two mortality indicators. Since most of the tumour sites lie relatively close to the origin, the absolute differences between them are quite small. Therefore, a helpful way to express the difference between per cent YLL and per cent mortality is to show the difference as a ratio.The YLL for an individual cancer site can be expressed as a percentage of the total years of life lost from all cancers, so it can be directly compared with percentage mortality. In The diagram shows the outlier tumour sites clearly, but as with The use of AYLL to indicate the impact of a tumour type on individual patients considerably changes the ranking of the mortality from different tumours . The meaIn Of the four ‘Cinderella’ cancers, cervix is notable because of the high AYLL despite cervical screening. Melanoma is noteworthy because the percentage YLL is relatively modest for this tumour type, accounting for only 1.4% of YLL, whereas the AYLL of just over 15 years indicates that the impact per patient is rather high. It is also increasing in incidence. However, perhaps the most striking of all is that tumours of the brain and CNS have the highest AYLL of all 17 tumour sites, but a rather modest 1.5% of NCRI research spending. The ratio of research spending to AYLL is shown in Using the YLL parameter, to represent population burden from cancer, emphasises the discrepancy between research spending and mortality. Although slightly more difficult to compute than simple percentage mortality, this parameter has added value in demonstrating the effect on the population for individual tumour sites. The absolute differences between YLL and mortality are comparatively small except for colo-rectal and breast cancers, and to a lesser extent bladder and lung cancers. However, the relative differences are much larger for many of the less common tumours . ConsideIt may be that other public health decisions, such as the provision of hospice care, would benefit from consideration of YLL as a mortality indicator. For example, the biggest difference between YLL and simple mortality applies to CNS and cervix cancers, which have a substantial incidence in younger patients. This might suggest the need to consider palliative care resources for younger patients. These two tumour types also account for the highest individual cancer burden, quantified by AYLL. Other measures of social and personal burden, including quality of life, might also be considered as part of a comprehensive review of services.The different indicators of cancer deaths, and cancer burden, show different aspects of mortality, and are complementary. Analysis of these together can identify tumour types with extreme impact, either on society, for example through a high incidence, or on individual patients as a result of relatively low cure rates. Extreme tumour types, expressed by either statistic, may need special consideration.This analysis illustrates the value of considering different mortality statistics, which include measures of the burden of cancer deaths on both the population and individual patients. It also demonstrates that inequity in resourcing research goes well beyond the underprovision for lung cancer research. Overall, this analysis suggests that a more subtle and comprehensive calculation of mortality statistics would be useful in relation to research funding, and debate on public health issues.