Taenia solium taeniasis in endemic populations. The advantage of systematic reviews over selective reporting of the research evidence is that they seek to minimize bias and use transparent methods to find all research that meets pre-defined inclusion criteria. Our systematic review used the highest quality systematic review methods [White et al. have raised a number of concerns about the findings of our systematic review . However methods  and the  methods . We beliIn relation to some of the specific points raised by White et al. we note that we have presented the meta-analysis results stratified by drug and dose to allow the reader to identify any important differences in effectiveness, which was the aim of the review. It was not possible to further stratify the results by the diagnostic test used due to the relatively small number of studies. However, more important than the diagnostic tests used is the fact that all studies had a high risk of bias due to issues such as lack of randomization, incomplete outcome data and lack of blinding of outcome assessors ; a fact T. solium scolex and egg shedding may still occur after treatment is raised by White et al. 2020, though not substantiated with research evidence. We were unable to find evidence to confirm this statement but note the findings of one study of mass drug administration (MDA) with ALB 400mg triple dose included in the systematic review that used both Copro-PCR and Co-Ag-ELISA [The possibility that albendazole (ALB) does not kill the In relation to the analysis of side-effects, White et al. 2020 quote two publications. One is a case report of neurological side-effects after MDA with 5mg/kg praziquantel  and neitWhite et al. also note that neurological side-effects would be anticipated to occur 3 to 5 days after treatment but, again, they did not cite any evidence to support this claim and we were unable to find any supporting evidence for their statement. In fact, those studies that do note the time of occurrence of side-effects generally report effects within the first 1–3 days , 10 follT. solium endemic countries need help to control the problem. To make decisions about possible solutions, they need an impartial summary of the best available evidence of effectiveness and safety, along with an assessment of other factors important for decision-making, including whether the problem is a priority, a rational assessment of the balance between desirable and undesirable effects, values and preferences, resource requirements, impact on equity, feasibility, and acceptability [We encourage constructive criticism of all research, including our own, but we suggest that this should be based on research evidence rather than reliance on perception and opinion. tability , 12.Some authors are staff members of the Pan American Health Organization. The authors alone are responsible for the views expressed in this publication, and they do not necessarily represent the decisions or policies of the Pan American Health Organization.


Asprosin is a recently discovered protein released during fasting conditions mainly by adipocytes from white adipose tissue. As a glucogenic peptide, it stimulates the release of glucose from hepatic cells by binding to the OLFR734 receptor and leading to the activation of the G protein-cAMP-PKA pathway. As it crosses the blood–brain barrier, it also acts as an orexigenic peptide that stimulates food intake through activation of AgRP neurons in the hypothalamus; thus, asprosin participates in maintaining the body’s energy homeostasis. Moreover, studies have shown that asprosin levels are pathologically elevated in obesity and related diseases. However, the administration of anti-asprosin antibodies can both normalize its concentration and reduce food intake in obese mice, which makes it an interesting factor to combat obesity and related diseases. Current research also draws attention to the relationship between asprosin and fertility, especially in men. Asprosin improves age- and obesity-related decrease in fertility potential by improving sperm motility. It should also be mentioned that plasma asprosin levels can be differentially modulated by physical activity; intense anaerobic exercise increases asprosin level, while aerobic exercise decreases it. However, further research is necessary to confirm the exact mechanisms of asprosin activity and its potential as a therapeutic target. It has long been known that adipose tissue is not only a store of fat reserves but also an extremely active endocrine organ. As a source of adipokines, it plays a role in the regulation of numerous physiological and pathological processes . NumeThe review was conducted by searching relevant studies published in Web of Science and PubMed databases from the beginning of the discovery of asprosin, i.e., from 2016 to 7 February 2021, by using “asprosin” as the search keyword. The review included studies on the discovery of asprosin and articles describing the mechanisms of its action and those assessing changes in its level in response to the effects of various factors and physiological and disease states. Only articles published in English between 2016 and 2021 (7 February 2021) qualified for the review. The exclusion criteria were as follows: language of publication other than English and nonavailability of the full-text version of the article. Letters to the editor and summaries of conference speeches were excluded from the review. Studies in which there was no separate group for a real assessment of the action of asprosin were excluded. The review was prepared following the PRISMA  guidelines.A total of 143 articles were retrieved following the search in the PubMed and Web of Science databases. After removing duplicates, 77 articles remained. On the basis of the inclusion and exclusion criteria, 41 articles qualified for review. The PRISMA diagram  shows thAsprosin is a fasting-induced glucogenic hormone that was discovered and first described by Romere et al. in 2016 . As a smThe main target organ of asprosin action is the liver, where it promotes glucose production and release ,9. As reAsprosin is an important hormone in appetite regulation. As reported by Duerrschmid et al. , asprosiAs reported by Romere et al. , in the Zhang et al.  have shoAs reported by Wei et al. , asprosiThe role of asprosin and OLFR734 in ovary function and female fertility is currently unclear. However, Maylem et al.  suggest Polycystic ovary syndrome (PCOS) is a common disease that affects nearly 6–10% of women of childbearing age; anovulation and hyperandrogenism are observed during the course of this disease, resulting in infertility disorders . The rolFBN1 gene was found not only in adipose tissue but also in skeletal muscle. Several studies have indicated that the level of this protein is modulated by physical activity. Ko et al. [As reported by Romere et al. , the expo et al.  indicateo et al.  also shoo et al.  on healto et al.  in a groo et al.  for a fuo et al. . These rThe majority of current research focuses on understanding the mechanisms of action of asprosin, the factors influencing its release, and the correlations between the level of asprosin and the occurrence of a given health condition or disease. As it is a relatively young molecule, few research teams have taken up the challenge of using asprosin as a therapeutic agent for treating selected diseases or conditions. Undoubtedly, the studies conducted thus far show the enormous potential of this molecule both in terms of its appropriate therapeutic effect and the possibility of using antibodies against asprosin in specific situations to reduce its level. In the first case, the potential of asprosin is assessed in the context of the possibility of stimulating the appetite and thus increasing body weight, which was reflected in the patent application . In the Asprosin as a newly recognized adipokine seems to be an interesting subject for future research. As a fasting-induced hormone, it regulates food intake and energy supply through a gradual increase in appetite. Its level correlates with the content of adipose tissue, which is its main source. Therefore, its increased levels are observed in obese and overweight people. As a factor that increases appetite and induces glucose release, it seems to contribute to the development of obesity, metabolic syndrome, and diabetes. On the other hand, asprosin seems to be a promising target to combat obesity and metabolic diseases by using anti-asprosin antibodies. Asprosin seems to be a multifunctional molecule , which i


Hypertension remains one of the foremost noncommunicable diseases that most often lead to cardiovascular diseases and its different complications. The prevalence of hypertension in Bangladesh has been increasing. However, there are very limited studies that have evaluated the impact of health education and awareness development in mitigating the burden of hypertension and its complications in Bangladesh.This study aims to increase awareness, enhance knowledge, and change lifestyle behaviors through health education and the use of mobile health  technology among individuals with hypertension living in a rural community of Bangladesh.A randomized controlled trial is underway in a Mirzapur subdistrict of Bangladesh. This trial compares two groups of individuals with hypertension: The comparison arm receives health education and the intervention arm receives health education and a periodic mobile phone–based text message intervention. The trial duration is 5 months. The primary end point is participants’ actual behavior changes brought about by increased awareness and knowledge.Enrollment of participants started in August 2018, and collection of follow-up data was completed at the end of July 2019. A total of 420 participants volunteered to participate, and among them, 209 and 211 were randomly allocated to the intervention group and the control group, respectively. Among them, the ratio of males/females was 12.0/88.0 in the intervention group and 16.1/83.9 in the control group. Data cleaning and analyses have been completed and the results have been submitted for publication.Periodic short education using mHealth technology in addition to face-to-face health education may be an effective method for increasing awareness and knowledge about behavioral changes and maintaining healthy lifestyle behaviors.Bangladesh Medical Research Council (BMRC) 06025072017; ClinicalTrials.gov NCT03614104, https://clinicaltrials.gov/ct2/show/NCT03614104; University hospital Medical Information Network (UMIN) R000033736, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_his_list.cgi?recptno=R000033736DERR1-10.2196/15523 Hypertension is one of the most significant modifiable risk factors for cardiovascular diseases (CVDs) worldwide , with inA review of community-based interventions for CVD implemented in low- and middle-income countries recommends that patient education can have a positive effect on treatment adherence and BP control among individuals with hypertension . The litHowever, the current status of the knowledge, attitudes, and perceptions of hypertension among participants indicates the significance of awareness buildup with respect to various features of hypertension, basic changes in lifestyle, and detailing of procedures in improving health education. Moreover, participants’ knowledge about hypertension and the benefits of lifestyle modifications by all means is important for successful management of hypertension . NeverthTo expand awareness of the target population, innovative techniques are introduced in this study. One is regular BP checkup by the use of a Portable Health Clinic system  during home visits by community health workers (CHWs), in light of the fact that a routine health checkup system at the community level is yet to be established in Bangladesh, particularly in its rural areas. For example, medical personnel such as community nurses, during their field visits, may routinely check the BP of hypertensive individuals, who do not have any BP self-checking facility at home.The second extraordinary contraptions are used to measure food and urine salinity to alert the participants. The third strategy is the persuasive motivating approach and social capacity building using mHealth technology for behavioral change.We hypothesize that awareness development and knowledge acquisition can enhance behavioral change, and periodical mobile phone–based SMS intervention will be significantly beneficial in modifying lifestyle changes among hypertensive individuals. Thus, this approach could minimize the hypertension status of participants as well as its complications.The objectives of this study are to develop awareness and enhance knowledge through health education, the use of mHealth technology, and change in lifestyle behaviors among hypertensive individuals in a rural community of Bangladesh.This is a single-center, randomized (1:1), open-label, parallel-group study, conducted in a rural community of Mirzapur, Bangladesh. The intervention period was 5 months for each individual, and the total study duration was 12 months.Individuals with hypertension living in the study site were identified as follows. One group of individuals were identified from a tertiary-level health facility . The principal investigator and CHWs visited the tertiary facility and checked the database records as well as the registered notebook including current remedies from the facility and collected household contact information  with the permission of the hospital authorities. Afterwards, CHWs visited homes of the participants and obtained their consent to participate in this study. The other group of individuals were identified from the neighborhood rural communities arbitrarily by CHWs reviewing the registered clinician’s prescriptions and current remedies by household visits, and obtained their consent for the study.A purposive sampling method was followed for enrolling study participants who met the eligibility criteria and were willing to participate voluntarily in the study.Participants who met the following criteria were eligible for enrollment into the study:Individuals of either sex who have hypertension and are aged 35 years or above, have 1-5 years of schooling, reside within a radius of 3 miles from the Kumudini Women’s Medical College and Hospital, are likely to stay in the community for the ensuing 5 months, have a personal cell phone or access to a shared phone, are open and can exchange their views freely, are willing to participate in the study, and consented to comply with the health education and periodic text messages for the entire study period.Individuals with mental illnesses or serious comorbidities such as progressive diabetes, chronic pulmonary disease, malignancy, and pulmonary tuberculosis that might cause periodic absence were excluded from this study.A randomization schedule was prepared following the permuted block randomization technique using a block size of 4 based on a computer-generated series of numbers. An experienced researcher (third party) who was not involved with the study generated the random allocation by sequence and distributed that in serially numbered sealed opaque envelopes, which are kept in locked file cabinets in a site away from the trial’s location. Sealed envelopes containing group assignment were given to the eight CHWs who were involved in participants’ enrollment under the guidance of a principal investigator.Enrollment took place during morning hours for 6 consecutive days (except Friday) in a week, and the principal investigator of the study was present at the site every day to ensure compliance with the study protocol. Once eligibility for randomization was determined, written informed consent was obtained. CHWs opened the envelope in the presence of participants. Participants were allocated to either of the groups, after enrollment, CHWs collected their demographic information and performed physical examination of the participants.To develop awareness, enhance knowledge, and motivate behavioral changes using mHealth technology, the intervention group received the 5-month health education including health education materials and SMSs . At the The control group received the same health education booklet as the intervention group at the time of enrollment. After that, CHWs visited and provided health education at participants’ households or asked them to visit the nearest health facilities such as Kumudini Women’s Medical College and Hospital or HFWC. They were followed up every month for up to 5 months (twice in the first month and once the rest of the months) for receiving health education only.Sample size calculation was based on the behavioral changes of study participants. In this study, investigators compared two interventions . Investigators expected the compliance of the intervention group to be higher than that of the control group. We assumed that the proportion of patients in compliance is at most 10%-12% better in health education with text messaging group.The sample size was calculated with a two-tailed 5% significance level and a power of 80%, with a 95% CI (1–α) to detect varying differences in the effectiveness of the two intervention groups. Adherence rates were assumed to differ by 10%-12%, that is, rates of 90% in the study group and 78%-80% in the control group, with a presumption that 6% of the participants would be lost during the follow-up . The sample size for each group was estimated to be between 153 and 210 participants. Thus, considering the largest calculated sample size, the study finally had a sample size of 210 in each group.Once the participants were made aware of the importance of lifestyle changes and obtained knowledge about lifestyle modification, they could change their lifestyles. Thus, increased awareness and knowledge was measured by the actual behavior change in them. Following the lifestyle change, their BP level was expected to decrease, the risk for complications would be reduced, and their quality of life would be improved. Therefore, we set the following end points.The primary outcome was the evaluation of the behavioral changes using the researcher-developed questionnaire .Secondary outcomes were (1) the actual salt intake  and dietary salt excretion , (2) BP value, (3) blood glucose level  and urinary protein and glucose  for checking complications, and (4) quality of life measured by EQ-5D-5L quality of life questionnaire .Primary and secondary outcomes were measured every month including baseline and up to 5 months for both intervention and control groups.As a secondary outcome, the feasibility of utilizing mobile phones in hypertensive individuals using field-testing questionnaires was checked by the researcher-developed questionnaire.Researchers have strongly recommended economic evaluation of health promotion interventions such as health education and mHealth technology . For thiCHWs were oriented on hypertension of rural community people every month till the completion of the study. Through this training, they understood the pathology and mechanisms of hypertension, dietary practices, behavioral changes, and physical activities that are needed for controlling hypertension. Moreover, they could perform physical measurements and acquire motivational skills that are useful for drug and instructional compliances by the rural community people and are essential for the prevention of complications.Health education materials were developed based on the DASH diet , with advice to walk every day for at least 30 minutes and to take medicine regularly. DASH diet and suggestions to reduce hypertension are stop smoking and drinking, walk at least 30 minutes every day, and take medicines regularly -18.An exploratory qualitative study was conducted to comprehend the knowledge level in relation to hypertension in a rural community of Bangladesh. The study assessed the level of understanding of individual’s perception regarding symptoms, causes, and consequences of hypertension, the importance of lifestyle modifications, and regular checkups. One of the critical aims was to investigate the practice of hypertension management, adherence to drugs, barriers and challenges that keep them away from seeking regular clinical consultation, laboratory investigation, and medication adherence.SMS text messages have been developed in native language by the members of the research team representing different professional backgrounds; these messages were sent to 15 people (randomly) for their comprehension and acceptability as part of the field-testing procedure. Individuals in the wired intervention group received SMS text messages, and they had the liberty to participate additionally in a two-way communication system . After receiving the feedback, messages were finalized. The SMS consisted of simple health education information to aid in the behavioral change of participants. Attempts were made so that all the participants in the study could read the SMS messages by themselves or by someone in the family who could read and explain the contents of messages to them if they do not understand. Contents of the text messages are presented in At baseline, a standardized pretested questionnaire was administered to obtain information on the sociodemographic profile such as age; gender; religion; financial dependency; educational qualification; occupation; monthly family income and expense; type of housing; possessions of household land and properties; type of family; marital status of the respondent; living arrangements; health status; health care–seeking behavior; family history; hypertension-related information; hospitalization history; food consumption practices; lifestyle behavior such as tobacco use; alcohol consumption; food habits; the level of physical activity; and mHealth-relevant information.Nutritional status assessments such as height, weight, mid-upper arm circumference, hip circumference, and waist circumference were measured by CHWs. BP, random blood sugar, urinary protein and glucose, and salinity of food and urine were measured using the standard procedure starting from the enrollment day till the end of the follow-up. Follow-up visits and physical examinations were performed at households, at Kumudini Hospital, or in the nearest HFWC.All participants were explicitly informed about the objectives, importance, and risks and benefits of the research before recruitment. Participation was completely voluntary, and written informed consent was obtained from all participants.This study was approved by the Bangladesh Medical Research Council , with Clinical Trial Registration No. NCT03614104 and UMIN Registration No. R000033736. This study was conducted in accordance with the Declaration of Helsinki and the Ethical Guidelines for Clinical Studies of the Ministry of Health, Labor and Welfare of Japan. Enrollment of participants started in August 2018, and collection of follow-up data was completed at the end of July 2019.In 5% of the study participants, the quality control team independently checked data collected on the same day using a field-tested methodology. Errors detected were corrected immediately at the field site. Later on, scoring was completed for each question of the repeated interview . The sum of all the scores was divided by the total number of questions/variables asked. The ideal score was 1 or a score as close to 1 as possible. If the score exceeded 1.5, the CHW responsible for the interview was questioned regarding the differences. The findings of the quality control team were considered for necessary corrections if any major discrepancies were found.t-test or Mann-Whitney U test. The differences in categorical variables between groups were examined using χ2 test. For primary and secondary endpoint analyses, Mann-Whitney U test was performed to assess the changes in health behaviors at baseline, and analysis of covariate was performed to assess the changes in health behaviors at baseline and 5 months after the follow-up. Analysis of covariance was used to check the correlation between a dependent variable and the covariate independent variables and to remove the variability from the dependent variable that can be accounted for by the covariates. A multivariate regression analysis was then performed to evaluate the simultaneous effects of various exposure variables after adjusting for any confounding variables. Data were analyzed using the statistical software packages SPSS for Windows version 25.0 (IBM Corp) and Epi Info version 7.0 (Centers for Disease Control and Prevention). Values of P<.05 are considered statistically significant.The intend-to-treat analysis was used to compare the outcomes of the intervention and control groups. To ensure comparability of randomized samples, all baseline indicators at the time of registration were analyzed. The data will be expressed as the mean±standard deviation or median (minimum-maximum) and cross tabulation (with the range or percentage with 95% CI where appropriate) for continuous variables and as frequencies and percentages for discrete variables. The differences in continuous variables between the groups were examined using the Currently, the study is in the active implementation phase (participants’ follow-up is ongoing) after the completion of recruitment. A total of 420 participants have agreed to participate and among them, 209 and 211 are allocated to the intervention group and control group, respectively . The proFrom August 2018 to July 2019, the following processes were completed: recruitment, intervention, and data collection. Subsequently, data cleaning was completed, and from the results, data analysis  was performed. Preliminary analytical results are presented in This paper describes the protocol for a randomized control trial that aims to develop awareness, enhance knowledge, and make behavioral changes using health education and mHealth technology among individuals with hypertension in a rural community of Bangladesh. To our knowledge, this is the first study conducted in Bangladesh to measure the impacts of mobile phone SMS as a tool for reducing the burden of hypertension. One of the most significant barriers to effective treatment of hypertension is the lack of awareness and education about hypertension, its complications, and the optimal way to treat hypertension, which can be addressed by mobile phone interventions for knowledge generation as well as awareness and behavior change communications.Bengali using Bangla alphabets, we assume that it will not be very difficult for the participants to read and understand, as the ability to read the SMS messages has been considered in the inclusion criteria. Using SMS as a tool for health education, health information and lifestyle messages can be easily disseminated by persons with minimum technical knowledge and skills.In this study, we sent SMSs to participants through mobile phones (two-way communication). As the SMS is written in Moreover, in our study, we have used the following three unique devices to improve the self-management skills of individuals with hypertension.Portable Health Clinic  is a hanThis is a handy, instant measurement device that can estimate the participant’s salt intake of the previous day at home . ParticiWe also check the participants’ food salinity as a proxy for their daily salt intake by using an electronic salinometer for measuring food (TANITA white waterproof salinometer SO-313, which has three different types of level sensors; Because of purposive sampling, this study does not represent hypertensive individuals of a rural community as a whole. To check the feasibility and reliability of urine and food salinity results, it is better to compare them with laboratory data, which cannot be evaluated in this study. CHWs were consented not to share the random allocation status of hypertensive individuals with the family members as well as their neighbors during the study period. However, chances of disclosure, although small, cannot be ruled out. Moreover, data contamination due to neighborhood as well as family members and obtaining consent from CHWs to not disclose the data may be other limitations of the study.This study was conducted in rural Mirzapur, Bangladesh. This study aimed to determine the effectiveness of SMS-based interventions for health promotion and to determine whether it will be well accepted by beneficiaries. The results of the study indicated that SMS is an effective method for building awareness toward the prevention and control of hypertension and its consequences in a rural population of Bangladesh -23.


Just a fraction of the scientific knowledge produced in laboratories reaches a lay audience. Most of our communication with the public gets lost in translation because of the difficulties that science communication poses to scientists. Among other obstacles, differential exposure to scientific and critical thinking, discrepancies with social narratives, and communication training based in the deficit model add on top of a practice established on avoiding emotionality. Just a fraction of the scientific knowledge produced in laboratories reaches a lay audience. Most of our communication with the public gets lost in translation because of the difficulties that science communication poses to scientists. Among other obstacles, differential exposure to scientific and critical thinking, discrepancies with social narratives, and communication training based in the deficit model add on top of a practice established on avoiding emotionality. In this context, effective communication requires the use of emotions, which are crucial to establishing trust. This commentary provides a rationale for collaboration with graphic design and fine arts to use emotions in science communication and education. It starts by proposing the two-way engagement model as a replacement for the deficit model. Next, it offers a neuroscientific basis for the use of emotions in establishing trust. Finally, it finishes profiling the Convergence Initiative’s efforts to establish bridges across disciplines and communicating science with the public through art. Collaborations between neuroscience, graphic design, and fine arts can help scientists to make their findings accessible to the general public through emotionality.With headlines that present ongoing research as conclusive, it is not surprising that most of our communication to the public gets lost in translation, leading readers to forget that science is a dynamic knowledge-building process. Indeed, just a fraction of the scientific knowledge produced in laboratories reaches a lay audience. The many contributing factors for this gap orbit around the difficulty that science communication poses to scientists. Scientific training can take between two to 12 years to complete. In that time, different exposure to scientific knowledge, critical thinking, and social narratives creates huge disparities between trainees and the general public. There are often discrepancies between what scientists think is important, what scientists think the public perceives as important, and what is actually important to the public . The lacFrankenstein, the arts have criticized the scientific method and warned of the moral implications of an emotionless practice of science  and the orbitofrontal cortex (OFC) are critical for our balanced experience of reason and emotions. The balance between the excitation and inhibition of these areas is crucial for decision-making in social settings . I belieThe insula, another area of the limbic system, has been linked to aversive behavior, and is known to modulate the activity of the ventromedial PFC (VMPFC) in a social context of decision making . The insSuch experiments may be able to explain why different authors state that appealing to emotions can be more influential when explaining and discussing scientific facts . It is eBecause of the direct relationship between art and emotion, the recruitment of art and design in science communication assists the public to situate themselves in the complexities of scientific inquiry. Similarly, art in popular culture has a strong influence in shaping people’s perception of science and scientists. Films, novels, comics, and illustrations are usually more appealing, eye catching, and memorable than formal scientific lectures .Over the last 30 years, several prominent organizations have demonstrated the effectiveness of art in two-way engagement. The United Kingdom Wellcome Trust’s Sciart program (1996–2006), with 118 projects and nearly £3 million in funding, illustrated how art can help to promote scientific knowledge in new and more attractive ways . ArtNeurIn practice, I think connecting emotions to scientific discoveries involves at least two steps . First, Second, using the visual form produced in step one as the new starting point, the communicators invite fine art practitioners to a two-way engagement conversation with scientists. Collaborating with artists gives scientists the chance to draw on innovative techniques to impart scientific concepts with an emotional appeal. From the neuroscience perspective, before any possible conscious reasoning takes place, the limbic system judges experiences as aversive, desirable, or rewarding. Emotions act as cues to summon memories from past events, influencing our behavior to avoid or approach new situations, or in this case, new information. Fine arts practitioners are instrumental in the process of modeling the emotive message to give science the right tone at the moment of communication. The variety and richness of approaches used by artists can help scientists connect to audiences’ narratives and transform our teaching methods into inclusive and attractive environments while paying homage to the human aspect of the scientific endeavor. We learn more about things we like, things that surprise us, things that connect to us, things that stand apart from the daily noise of everyday life.In 2016, I founded The Convergence Initiative as an organization committed to bridging neuroscience, design, and the arts. A primary activity of The Convergence Initiative has been the development and organization of a two-semester course that integrates topics in the disciplines of design, fine arts, and neuroscience. Co-designed with art educator, sci-art practitioner, and researcher Bettina Forget, the course facilitates a year-long collaboration between neuroscience graduate students from McGill University and art and design students from Concordia University’s Faculty of Fine Arts. Instead of enlisting scientists as artistic muses (like some SciArt collaborations), we encourage a horizontal partnership between the art and science students from day one to the completion of the eight-month collaboration.Using a two-way engagement approach as much as possible, we start the program by mixing our students in the same class. Neuroscience graduate students and undergraduates in fine arts and design prepare introductory exposition using the Ignite format. This presentation consists of 20 slides, which automatically advance every 15 s, creating a fast and fun 5-min presentation. These presentations start a selection process where the students form pairs by the end of the first semester. In the second semester, these pairs collaborate to develop innovative sci-art projects. During the first semester, we deliver basic concepts in neuroscience using interactive presentations, games, and experiments. We pair an artistic activity with each topic. For example, our class on the visual system is followed by a class in the theory of color where students explore the ideas of Josef Albers on the interaction of pigments. Outside of the classroom, the course includes site visits, where artists and scientists have the chance explore each other’s exclusive silos . Discussion is a requirement, and a substantial part of the class involves comparing the practices of science and art. The revision of the philosophical bases of the scientific practice and the debate of those ideas in private and public forums is also part of our program.Theoretical and practical aspects of science communication are covered side by side with non-traditional methods for science delivery. Participants explore topics such as the neuroscience of interactions between reason and emotion alongside graphic design, zine publication, podcast production, and storytelling. Cognitive bias, complexity avoidance, risk perception, as well as group psychology, are also discussed. The culmination of this training is a public science symposium where the neuroscience students use these tools and others to present their research topic in an innovative way. Over the years, our students have found numerous creative ways to communicate their research science. To mention just a few, these tools have included comics, musical composition, storytelling, and sculpture.The course concludes with a month and a half long public exhibition of art inspired by neuroscience. The art pieces are developed on the research done by each team of artists and neuroscientists during a complete semester. This process starts with the scientific research contributed by the neurosciences, followed by the artists guided inquire about aspects of the scientific process that are less obvious to the scientists. To mention a few, the teams examine the impact and purpose of the research, relation between human and non-human aspects, probable futures and questions raised by the findings, and the ethical aspects versus the benefits for the global community. The teams then established the research questions and chose the medium, materiality, and methodology to create art that explores that query. In the process, the teams ensure that the scientific aspects are respected while allowing the fluidity of the creative proceedings. Both scientists and artists are strongly encouraged to participate and explore their counterparts’ fields. This active sharing and exploration are reflected on the shared authorship of the art pieces, with no obvious distinctions on their backgrounds. By this point, we have guided our students from the first scientist-artist encounter using the two-way engagement program to produce a final multidisciplinary science-art collaboration reflected in the art pieces now delivered to the visitors of the exhibitions.Our program owes part of its success to the constant support of institutions like the Faculty of Fine Arts at Concordia University (who hosts the course), the Research Institute of the McGill University Health Centre (RI-MUHC) and its Brain Repair and Integrative Neuroscience Program (BRaIN), and the Integrated Program in Neuroscience of McGill University. This interdisciplinary support highlights the crucial role that other stakeholders play in the program, by contributing facilities, personnel, expertise, and funding.Some of the most important outcomes of the course are the new perspectives that the neuroscience students take with them. Insight into how other people in society think and operate. New understanding on the attitude of outsiders toward science. What “think outside of the box” really means. A deep appreciation for synergetic collaboration. A return to the playground.In order for scientists to connect with others, they must be flexible between feeling and reason. We must maintain an unbiased approach toward the observation of nature, but when communicating with the public, we must maintain our humanity. The benefits are quite obvious– improved appreciation for the scientific endeavor, increased public trust in science, increased scientific funding, political support for representatives who use evidence to inform their public policies. The problems that humanity faces today are multifaceted; as such, they require the expertise and contribution of many partners to reach the solutions. Science is just one aspect of that solution, recognize the help and contribution of others can help us to create better spaces to develop those future multifaceted thinkers that will finally bring us one step closer to a better world. Collaborations between scientists, designers, and artists are then more important than ever in the construction of that new fabric.


Ineffective coping has been linked to prolonged pain, distress, anxiety, and depression after a hand and upper limb injury. Evidence shows that interventions based on cognitive behavioral therapy (CBT) may be effective in improving treatment outcomes, but traditional psychological interventions are resource intensive and unrealistic in busy hand therapy practices. Developing web-based, evidence-based psychological interventions specifically for hand therapy may be feasible in clinical practice and at home with reduced training and travel costs. Hand Therapy Online Coping Skills (HOCOS) is a program developed to supplement traditional hand therapy with therapist-assisted coping skills training based on principles from CBT and the Technology Acceptance Model.This study aimed to describe the development and assess the usability of HOCOS to support hand therapists in the management of psychosocial problems.The ADDIE model  of system design was applied to create HOCOS. The usability testing of HOCOS involved a 2-stage process. In the first step, heuristic testing with information and communications technology (ICT) experts was completed using two sets of heuristics: Monkman heuristics and the Health Literacy Online (HLO) checklist. The second step involved user testing with hand therapists performing a series of online and face-to-face activities, completing 12 tasks on the website using the think-aloud protocol, completing the system usability scale (SUS) questionnaire, and a semistructured feedback interview in 2 iterative cycles. Descriptive statistics and content analyses were used to organize the data.In total, 4 ICT experts and 12 therapists completed usability testing. The heuristic evaluation revealed 15 of 35 violations on the HLO checklist and 5 of 11 violations on the Monkman heuristics. Initially, hand therapists found 5 tasks to be difficult but were able to complete all 12 tasks after the second cycle of testing. The cognitive interview findings were organized into 6 themes: task performance, navigation, design esthetics, content, functionality and features, and desire for future use. Usability issues identified were addressed in two iterative cycles. There was good agreement on all items of the SUS. Overall, therapists found that HOCOS was a detailed and helpful learning resource for therapists and patients.We describe the development and usability testing of HOCOS; a new web-based psychosocial intervention for individuals with a hand and upper limb injuries. HOCOS targets psychosocial problems linked to prolonged pain and disability by increasing access to therapist-guided coping skills training. We actively involved target users in the development and usability evaluation of the website. The final website was modified to meet the needs and preferences of the participants. Hand and upper limb injuries are some of the most common injuries in orthopedic settings ,2, and aMost studies conducted in hand therapy have focused on maximizing physical recovery and adjustments with regard to medical or occupational therapy procedures -15. InteIn hand therapy, CBT may be efficient treatment to improve pain and distress by increasing adjustment to hand injury in relation to illness perception and coping strategies ,39-41. UHagemen et al  reportedHand Therapy Online Coping Skills (HOCOS) is an evidence-based and theory-based psychosocial coping skills program based on CBT principles  and the This paper aimed to provide a brief overview of the web-based system and to report on its usability from the perspectives of information and communications technology (ICT) experts and clinicians practicing in the field of hand therapy. Usability testing is a critical step in the development of online interventions and involves obtaining feedback to understand what is positive or negative about a system and identify existing gaps in content or functionality using iterative cycles of prototype alteration .A mixed methods usability testing approach with semistructured interviews, observations, and questionnaires was undertaken, with iterative cycles to determine the usability of HOCOS and to further refine the prototype ,60. PartWeebly support (Weebly) portal to participate as heuristic evaluators in phase 1 of usability testing. In phase 2, PTs and OTs based in Ontario, Canada, and practicing in the clinical area of hand therapy were invited to participate in the study to enhance the development of HOCOS. Clinicians were messaged directly using contact details available to the public on the Canadian Society of Hand Therapy (CSHT) website. Interested participants contacted the research team directly by telephone or email and were provided with a letter of information and signed consent forms before data collection. Log-in access to the password-protected HOCOS website was provided free of charge.We recruited ICT experts online through the One of the researchers, FB, facilitated data collection by conducting interviews, taking notes, and observing participants’ behavior. Appointments were made to meet with participants at the study site or at a desired destination within 2 hours of the study site. A brief description of the study was provided to each participant, with emphasis that the evaluation was about the content and functionality of the website. An explanation of cognitive interviews and information about privacy, and protection of the data collected were also provided. Before the interviews, demographic data, including age, gender, educational level, practice area, and use of technology, were collected. All participants were identified by pseudonyms to ensure anonymity . Accordiviolations where the interface did not conform to two sets of heuristics of predetermined criteria: the Monkman heuristics [Heuristic testing is a usability inspection method completed by usability experts and involves evaluating an application to find usability problems, assigning them to a specific category of heuristics and ascribing a severity rating . ICT expuristics  and Healuristics . HLO wasuristics . The fifuristics  compriseuristics . The evathinking aloud method [User testing involved asking each participant to go through the website using the d method , followed method . First, d method ,70. The The facilitator also asked the participants to explain or demonstrate the information in the video related to the module that was reviewed, such as metal practice and breathing exercises in module 1 and module 5, respectively. The participant’s ability to follow the instructions correctly was observed, and any difficulties, doubts, and reports were documented using a 3-point scale  . At the All interviews were audiotaped and transcribed verbatim in an anonymized format. The usability testing and interview data were analyzed together using triangulation . ContentWe enrolled four ICT experts to act as evaluators during heuristics evaluation, which meets the optimal requirement for detecting all usability problems . During The heuristic evaluation of HOCOS against the HLO checklist identified violations in 15 of the 35 criteria with violations seen across all domains . Domain This included findings from the user task performance and cognitive interviews  components of usability testing of the HOCOS.assessment page to fill outcome measures. The page was accessible through the resources page, although the opening comments on the page highlighted contents on the resource page. There were 6 participants who did not realize that the workbook contained both educational information and homework despite text alongside the introduction highlighting different module assignments.We measured user performance based on ease of navigating through the site, assessing the ease of learning for a first-time user without familiarity with the interface, and the frequency and importance of errors. Errors observed during usability testing were reported in 3 categories: completed with ease, completed with help, and not completed . The perclick on the link to write your answers on the link to provide answers. Providing feedback using the website form was the most difficult task for participants. Users did not click on the next page at the end of every module where the feedback form was placed. We included a text highlighting where to find the feedback form on the module’s introductory page and on the final page of every module. Presentation errors were defined as failures to locate and properly act upon desired information or selection errors because of labeling obscurities [Control usage errors were defined as improper toolbars or entry field usage . Five pacurities .Searching was a bit of a challenge for 5 participants because they did not know what to search for, unsure of search terms to use, or struggled to come up with a health topic in the context of the website. Participants completed the 12 tasks in phase 2 at the end of the second cycle of testing.The key usability findings from the thinking aloud interviews were organized into the following themes: design aesthetics, content, functionality and features, and desire for future use. Please see part C for a deeper learning on this topic. Users also recommended that the most important message on each page should be at the top of the page. As the modules were stand-alone content, the participants suggested that a decision tree or matrix would reduce the burden of prescribing the appropriate module to patients based on their presentation and treatment goals. In response, we created a matrix with information on key learning points, indications, and contraindications for each module. For example, patients with paradoxical responses to visualization avoid thinking about their hand injury, and those focused on the loss may find mental imagery distressing. Changes were also suggested to some features to increase user interest and reduce negative responses. For example, we changed the titles Mental Practice to Picturing My Movement, Thought Reprocessing to Healthy Thinking, and Board of Directors to Thinking Traps.Overall design aesthetics was critical to enhancing engagement and motivation to use the website and related to the layout, navigation, visual assets, and appeal. Participants liked the idea of different textures, colors, and cultures represented in the graphics. It was suggested that the font sizes should be set at size 14 to 16, and a large amount of information should be grouped and broken up with visual assets (graphics and illustrations). In response, we divided the PowerPoint slides into parts A and B and/or C to reduce information overload and reduce the feeling of being overwhelmed. Part C was created as an addendum with the caption, Mental Practice to portray the multisensory nature of hand movement. HOCOS was created with a focus on understandability, and all text developed to meet grade 6 to 7 reading levels. Most participants valued this consideration and commented that the information, language level, and medical term explanations were helpful in furthering understanding of topics that were unclear or new to them. However, some of the language used still had to be changed to conjure everyday talk and meet societal norms such as changing wife/husband to spousal partner and routine to day-to-day. Several language changes were made to clarify meaning, such as changing tissues to body, thought record to thought journal, healthy to uninjured, and food for thought to pause-stop-think.Program content was described in terms of completeness, understandability, quality, credibility, relevance, and interest. The comments on program content, such as texts, images, and multimedia components, were generally positive. The layout structure of presenting information in different formats and having a summary of key points after each lesson was valued. All participants judged that the site content was relevant and credible. Generally, participants were pleased with the completeness of the website, but additional content was suggested. Examples of additions included creating reflective pieces to improve engagement with the slideshows and linking activities under Ask an Expert link to allow users to send an email question to the web developers and a goal plan journal to keep track of goals and activities. Participants suggested having features that allowed the program to support social interactions among participants, such as a discussion board. However, because of budgetary and time constraints, we were unable to include these functions in HOCOS. Other features that were introduced to help patients incorporate the new information to their daily routine was the How to Make It Work Guide.These refer to the adaptive and interactive features on the website and included module 1 to 5 audio clips, printable PDF information forms for patient and clinician users, and videos of simulated patients completing module activities. It was agreed that these features allowed for an increased level of personalization of HOCOS content to meet the individual needs of the users. To further enhance participants’ motivation and engagement, we added the following functions: interactive questions (quizzes after each PowerPoint presentation), an Overall, participants received HOCOS very well and expressed a desire to use the program in the future. It was agreed that the website would be especially useful if available to patients from initial contact for presurgical screening with surgeons or immediately after surgery in acute care. The therapists commented that they valued the fact that the site content focused on supplementing current hand therapy practice for patients struggling with psychosocial issues. The accompanying navigation of the workflow would make it easy to prioritize programs for their patients. Most participants suggested that collaboration with the CSHT and hand programs in Ontario would help facilitate increased uptake in the hand therapy community.Go to homepage tab was created as a signpost to the respective sessions after logging in, and a navigation tutorial video and informational videos on the clinical impact of psychosocial factors on hand and upper limb injuries were created. Finally, we included patient-friendly resources on chronic pain, problem solving, time management, and a sleep guide. Overall, therapists found that HOCOS was a detailed and helpful learning resource for therapists and patients. Participants liked the web layout, tabs for modules, and resource page. There were no reported harms or unintended effects on participants, privacy breaches, or technical problems during usability testing. Overall, HOCOS system usability improved from good to excellent based on adjective rating scale described by Bangor et al [The SUS scores from both cycles of usability testing are listed in or et al .The final version of HOCOS was built on the Weebly platform, customized and styled using platform add-ons and publicly available pictures on Creative Commons. The platform included a landing page, a resource library, tabs for each of the modules, a feedback page, an assessment page, a goals page, and therapist- or patient-specific resources . MultimeThe overall objectives of this paper were to provide an overview of HOCOS and report the findings from usability testing with ICT experts and clinicians practicing hand therapy. HOCOS is designed to help patients with hand and upper limb injuries learn how to better manage psychosocial issues. The uniqueness of HOCOS is an interface design that offers learning opportunities to both clinicians and patients. Overall, therapists were pleased with the objective and content of HOCOS and found it a useful resource for meeting patients’ needs in hand therapy.Formal usability testing is a key process required to ensure the relevance of content and make the website easy to use, learn, efficient, and acceptable to users . UsabiliThis study contributes to the dearth of literature on the usability testing of web-based portals developed for managing psychosocial factors in orthopedic hand and upper extremity services. Chad-Friedman et al  reportedDissemination of evidence-based therapies remains poor in routine practice . AlthougOur study should be viewed with consideration of certain limitations encountered. The study was conducted among hand therapists in Ontario, and most participants were comfortable using the computer and the internet, which limit the generalizability of the study results. This may not be representative of the end users, such as patients seen in most hand therapy clinics. In recruiting participants for this study, we chose snowball sampling, a form of convenience sampling. This increases the risk of compiling a nonrepresentative sample. We planned to create an online platform that is user friendly for a significant portion of patients with hand and upper limb injuries who are mostly elderly , low skiThe presence of one of the researchers (FB) during the usability testing sessions may have affected the behavior of end users conducting the testing. The participants may have felt reluctant to be critical despite encouragement to highlight both weak and strong features of the website. Furthermore, we were unable to test the HOCOS website in the context of the patient-user’s experience to gain a comprehensive view of the system’s functioning in a clinical setting because of financial and time constraints. This needs to be addressed in future research by examining the effectiveness of HOCOS in a randomized controlled trial to determine if the present system design can contribute to improved outcomes in practice.User testing of an online intervention should include the ultimate end users, including patients, to allow for the examination of factors related to participants , disease (severity and duration of symptoms), and experience (access to and comfort with using the internet and computers) ,98. On tThis study provides initial support for the usability of HOCOS. Ensuring that therapists were involved in the design and development process of HOCOS enhanced the user-centeredness and user-friendliness of the website. Usability testing during the formative stage of eHealth intervention development is necessary to ensure that online interventions are effective and acceptable to potential users. HOCOS has the potential to increase access and acceptability of coping skills training programs for many individuals with hand and upper limb injuries who are not able to receive hospital- or clinic-based treatment psychotherapy. We plan to conduct a pilot study to determine the feasibility of the website for adults with hand and upper limb injuries and further refine the tool for a fully powered randomized controlled trial. If effective in improving outcomes, this program could be used as a template to develop more interventions targeting the psychosocial challenges confronting individuals with hand and upper limb injuries.


The use of Patient Reported Experience Measures (PREMs) has great potential in healthcare service improvement, but a limited use. This paper presents an empirical case of PREMs innovation in Italy, to foster patient data use up to the ward level, by keeping strengths and addressing weaknesses of previous PREMs survey experiences. The paper reports key lessons learned in this ongoing experience of action research, directly involving practitioners.The aim of this paper is to present the results of an ongoing action research, encompassing the innovation of PREMs collection, reporting and use, currently adopted by 21 hospitals of two Italian regions. The continuous and systematic PREMs collection has been implemented between 2017 and 2019 and includes: a continuous web-based administration, using web-services; an augmented and positive questionnaire matching standard closed-ended questions with narrative sections; the inclusion and benchmarking of patient data within a shared performance evaluation system; public disclosure of aggregated anonymized data; a multi-level and real-time web-platform for reporting PREMs to professionals. The action research was carried out with practitioners in a real-life and complex context. The authors used multiple data sources and methods: observations, feedback of practitioners, collected during several workshops and meetings, and analysis of preliminary data on the survey implementation.A continuous and systematic PREMs observatory was developed and adopted in two Italian regions. PREMs participation and response rates tend to increase over time, reaching stable percentages after the first months. Narrative feedback provide a ‘positive narration’ of episodes and behaviours that made the difference to patients and can inform quality improvement actions. Real-time reporting of quantitative and qualitative data is enabling a gratifying process of service improvement and people management at all the hospitals’ levels.The PREMs presented in this paper has been recognized by healthcare professionals and managers as a strategic and positive tool for improving an actual use of PREMs at system and ward levels, by measuring and highlighting positive deviances, such as compassionate behaviours. As the most important stakeholders in the healthcare system, patients can play a crucial role in healthcare services’ organizational design, management, and policymaking . MonitorThe patient perspective measured in terms of experience provides clear factual and reliable results that can stimulate and inform quality improvement actions , 8. PatiThe use of PREMs as institutional accreditation  and perfDespite this evidence, the use of PREMs data is still to be improved, and their full potential has yet to be exploited , 22–25. Recently, Gleeson and colleagues  and FlotSampling is a cost-effective and easy method to carry out population surveys. Conversely, collecting patient experience data from a broader patient population , 26, on The various methods for administering surveys present different strengths and weaknesses , 26: poswww.nhs.uk) [An advanrage of web-based surveys is the reduction of the time needed to collect and report patient data. Timeliness is, conversely, a barrier in using patient data obtained by postal and telephone surveys , 31. Rec.nhs.uk) . However.nhs.uk) .Providing measurable and actionable indicators from patient surveys is fundamental to the success of survey . CliniciPatient surveys usually include standard measures of patient experience to allow the benchmarking within and among healthcare organizations , 37, 38.Healthcare professionals prefer micro-level data reported by patients cared in their ward, in order to link this data to their ‘real-life’ work , 26, 39.As mentioned above, timeliness is another factor affecting the use of patient data for quality improvement . Having Finally, the method of communicating data to managers, clinicians and staff is crucial: the volume and variety of patient data collected and reported can be overwhelming and lead to fatigue, adversely affecting their perception of the usefulness and the actual use of PREMs . Clear PThe above issues can contribute to explaining the limited use of PREMs data to improve healthcare service delivery, and to monitor the implementation and effectiveness of improvement efforts .The aim of this paper is to present the results of an ongoing action research , which iThe authors used an approach based on multiple sources and methods. Observations of real-life events were combined with feedback by practitioners, collected during workshops and meetings.Descriptive statistics were performed on the preliminary data by using the STATA.15 software.Italy has a public and universal healthcare system, financed by general taxation, largely free of charge at the point of delivery, and regionally managed. Healthcare services are provided by Local Health Authorities (LHAs), which directly manage hospitals among other suppliers, and Teaching Hospitals (THs), which have also the mission of training healthcare professionals and advancing research. The context of this paper is the Italian regions of Tuscany and Veneto. These regions share a common healthcare Inter-Regional Performance Evaluation System (IRPES), designed by the Management and Healthcare Laboratory (MeS) of the Scuola Superiore Sant’Anna and implemented for the first time in 2005, in Tuscany. The IRPES indicators measure and monitor quality, efficiency, appropriateness, as well as patient and staff satisfaction , 54, 55.Between 2017 and 2019, Tuscany and Veneto implemented a continuous and systematic digital collection and real-time reporting of PREMs regarding inpatient care experience, called PREMs Observatory and carryed out in collaboration with the MeS. This PREMs model was first implemented in 2017 by eight Tuscan public accredited private hospitals, which are part of the Italian Association of Private Hospitals (AIOP). In 2018, 18 public hospitals in Tuscany and seven in Veneto joined the PREMs program. Between January and February 2019, another two LHA hospitals and one teaching hospital joined the Observatory. At the time of this research (March 2019), the program had completed the design phase and had begun the data collection from a total of 26 healthcare suppliers that refer to 21 hospitals. In tables and figures included herein, the hospitals directly managed by LHAs are indicated by the code H, while the Teaching Hospitals by the code TH. Overall, six healthcare organisations were involved, including both LHAs and THs. The full deployment of the PREMs Observatory in Tuscany and Veneto is expected in 2019. Another Italian region is also working with the MeS to implement the PREMs model in 2020.The action research is based upon the identification of a need for improvement in PREMs use by the same practitioners. As mentioned above, managers and healthcare professionals reported a low knowledge and use of PREMs in answering to the last organizational climate survey. The innovations to the PREMs methodology have been proposed by the researchers, then defined in detail and implemented with policy makers and technicians in Tuscany and Veneto, and top-level and mid-level health care managers, including nurses coordinators and ward managers. Their involvement in the pilot stage of this innovative PREMs was continuous, leading to a ‘feedback loop’ . In the In the Table The innovations illustrated in this paper combine the strengths of traditional survey methods with advancements in the PREMs methodology aimed at overcoming some limitations that the same methods pose.Key aspects retained from the previous PREMs experiences are: the standard questionnaire of patient experience evaluation; the inclusion of PREMs in the multi-dimensional health care performance evaluation system (IRPES); benchmarking within and among healthcare organizations/hospitals using the quantitative patient data from the standard questions; public disclosure of the PREMs results.Reducing sampling limits by systematically proposing participation in PREMs survey to all hospitalized patients: a sort of census survey, which allows for a detailed data reporting, particularly in reference to wards;Adopting an augmented traditional survey that combines standard closed questions with narrative sections to capture what was relevant in the individual patient’s experience;Using a web-based questionnaire and a fully digital administration method, in order to limit the costs of the survey and to avoid risks of errors in the data collection and data entry;Collecting data regarding the hospitalization directly from patients immediately following their discharge;Providing a real-time online tool of PREMs reporting that completely avoids a time gap between data collection and reporting, allows for benchmarking among hospitals, departments and specialties, and allows different access levels to level-specific data, from the ward to the regional level.The main innovations implemented in the PREMs to overcome some of the limitations of the traditional approach are the followings:The PREMs were implemented as a systematic, continuous and census-like survey. In Tuscany and in Veneto, during the hospital stay, every patient is informed by the healthcare workers about the possibility to take part in the survey. Informational material, such as posters and flyers, are kept available in the participating wards. An informative document explaining the initiative, its goals and the data protection and privacy policy is given to each patient by healthcare personnel. It includes information on the anonymity of the survey, because no identification data are collected, and answers to closed-ended questions are reported in aggregated form. The informative document explains that responses to the open-ended questions are voluntary and individually reported to healthcare managers and professionals, without making change or anonymizing them. The informative document asks patients not to add identifying information, because names or other details that can allow identifying patients or healthcare professionals are not deleted. The same information is mentioned in the questionnaire, at the beginning of every open-ended questions’ section. The informative document also clearly explains that data are reported by the researchers to the healthcare organizations for internal use , according to the different levels of responsibility, and that data will be used for the annual performance evaluation within IRPES.Patients can decide to take part to the survey, and leave their contact information  for sole purpose of the PREMs survey. 24 h after the discharge, the patient receives via text message and/or email a unique personal link to access the online questionnaire. A reminder email/text message is sent to the patient five days after the invitation. The link expires in one month after it has been sent.The administration method is based on web services. PREMs’ continuity is based on the modification of the electronic medical record (EMR) software, that requires the inclusion in the EMR of a specific PREMs section, where healthcare workers input patient contact information for the purposes of the survey. The list of patients’ telephone numbers and email addresses is collected through a continuous data flow based on an Application Programming Interface (API) established between each hospital’s EMR and the MeS server. This data flow also contains some pre-existing EMR data, namely: the hospital provider; date and ward of admission; date and ward of discharge; wards of transition during the hospitalization; additional patient data, if available .The data flow does not contain the first or last name of patients. If the patient does not wish to participate, contact information is not collected in the PREMs section of the EMR, and, as a consequence, the record is automatically not included into the data flow.The delivery via e-mail and/or text message of the invitation to take part in the survey is automatic and based on web services enabled by the data flow from the hospitals. The questionnaire is only available online. Patient’s contact information is automatically deleted five days after the reminder, or right after the completion of the questionnaire, whichever occurs first.As previously mentioned, healthcare workers and professionals are in charge of informing patients of the survey and collecting their contact details. In Tuscany, two indicators measuring participation and response rates were added in the IRPES. Targets and incentives are linked to these two indicators, with the aim to avoid biases attributable to practitioners by discouraging opportunistic behaviours (i.e. selection of patients), preventing scepticism or embarrass of in proposing the participation to PREMs and encouraging to enroll all patients .i)the general approach of the questionnaire;ii)the typology of questions;iii)the order of the questions;iv)the length of the questionnaire.Four aspects of the PREMs questionnaire were revised with regard to the original version used in Tuscany in previous PREMs experiences , 21:i)t(i)The closed-ended questions are aimed at investigating the standard dimensions of the patient experience  . Because(ii)The adopted questionnaire combines the standard questions with a narrative section to describe what and who were relevant to the patient during the hospital stay. This augmented survey allows patients to an in-depth and personal assessment and description of their experience. Patients can indicate the healthcare workers’ behaviours that met their needs, for example in terms of compassion, respect and humanity: these aspects are not well addressed by the closed-ended questions . The mea(iii)The questions, traditionally grouped in homogeneous domains , have been re-organized in order to follow the various phases of thepatient experience journey during the hospitalization. The questionnaire was divided into sections, accordingly: the first section refers to the admission process; the second, to the experience in the ward; the third, to the discharge phase. The first question refers to the individual actually filling in the questionnaire, in order to understand if the patient was assisted by a caregiver. The health-related and socio-demographic characteristics of the respondents are collected in the last section A briefer questionnaire was used with respect to the questionnaires used in previous PREMs experiences , in ordeEach element is addressed below.The patient survey is completely managed by the MeS, which, as an external third-party, assures the confidentiality of the survey, and provides a yearly benchmarking of results within the IRPES Fig. . Data coAmong the innovations encompassed by the PREMs Observatory, the day-by-day online reporting of real-time data is one of the most important. This data reporting is in addition to the annual evaluation that is in benchmarking as mentioned above, but it vertically permeates the healthcare organisations form the ward to the system Fig. . Indeed,Real-time reported data are not made available to the public. Conversely, PREMs indicators encompassed by the annual evaluation are publicly disclosed on the IRPES website.The participation rate, measured as the ratio between the number of invited patients and the number of discharged patients, has increased over time Table .Table 2Overall, the trend of the average participation rate for LHAs depends mostly on the PREMs deployment date in their directly managed hospitals. The first start-up period was characterised by a variable percentages of patients’ participation, mainly due to technical fine-tuning activities. Thereafter, the PREMs participation rate became stable around 30%, and in some cases overcoming 80% of the inpatient population . On average, 4616 questionnaires were collected by the hospitals in the first year  of the PREMs Observatory, with a mean of more than 380 questionnaires per month. As reported in the Table A care worker understood my discomfort without me saying anything… and spontaneously washed my hair.”“As a family member (daughter), I have been allowed to keep our daily habits, like sitting on a chair to have breakfast with my father.”“While I was walking with my husband in the hall, a nurse made my bed. I really appreciated this act of attentiveness.”“The personnel managed my anxiety very well. In particular, a nurse kindly touched my shoulder, giving me attention and a sense of protection. I really thank her...”“Narrative feedback was left by almost all responding patients, to least one of the open-ended questions. The majority of their feedback was positive. Several patients wrote their stories about healthcare professionals and workers, also referring to them by name. If patients could not remember names, they sometimes referred to the other details, such as the healthcare workers’ duty shift. Patients often reported specific episodes that can allow learning-by-excellence processes of quality improvement. Such comments highlighted that the compassionate behaviours of healthcare workers made the difference in the hospitalization experience. Feedback can add relevant information regarding the service organization and on staff behaviours, for example:As shown above, patient comments were related to the positive behaviour not only of the doctors and nurses, but also of the care assistants as well. During workshops and events held for the presentation of preliminary data Table , practitWhen sharing these early results with managers and professionals of participating hospitals, both during meetings with managers and during extended workshops, participation and response rates were partially explained by the role of healthcare workers: their being convinced of the usefulness and innovativeness of the initiative, the clarity and quality of communication with patients, and the time they devoted to speaking to patients about the initiative. The importance given to PREMs by the management was reported as being key in creating a positive perception of this innovative survey, and fostering greater trust in its results, which led to healthcare workers being proactive in encouraging patients to share their experience through PREMs. Managers and professionals believe that participation and response rates are higher when healthcare workers take the initiative to promote the PREMs.Additionally, the creation of a patient contacts list was already a routine activity for the healthcare workers, who already collect such data for other purposes. Therefore, the administrative tasks were not perceived as increasing with PREMs, as stated by the the same healthcare workers who participated in the workshops. This made it possible to implement PREMs as a census-like survey. During workshops and collective events, healthcare professionals also reported improvements over time in the healthcare workers’ ability to inform patients about PREMs. This led also to the creation of a new routine activity, which coul increase participation and response rates over time.Clinicians and managers recognized the joint and real-time reporting of PREMs data as meaningful, because they have timely access to quantitative measures and qualitative feedback of their own patients at ward and hospital levels. A timely access to the real-time platform was considered crucial: a delayed sharing of PREMs data, due to a delayed distribution of credentials for accessing the platform, was reported as a factor negatively affecting practitioners’ contribution to the PREMs initiative. Not having a timely access to the web platform discouraged practitioners in informing and enrolling patients. Moreover, practitioners indicated that having PREMs data available enhance the staff’s ability to improve patients’ experiences, with respect to waiting times at the admission, communication, team coordination, and other key dimensions of the patient experience, which are measured by the closed-ended standard questions. Additionally, practioners stated that, through an in-depth analysis of the experiences described in the narrative sections, positive and negative issues in daily practices could be confirmed, identified, and addressed. Healthcare managers, particularly at ward level, were sometimes so positively surprised by the quantity of positive feedback from patients that they would immediately report the results to their team. This suggests an immediate gratifying effect of the patients’ positive narration, particularly about competences, skills, kindness and compassion of all the healthcare workers, including the care assistants. In this respect, healthcare professionals and managers recognised the unique possibility, given by this tool, to monitor the behaviours of hospital staff at the lower levels of the organizational structure. Measuring care assistants’ contribution to the positive experience of patients has traditionally been very difficult to monitor. Hence, this innovative PREMs model was recognized by the practitioners as an effective support to people management within hospitals and wards, across all organizational levels. In particular, the innovations implemented in the PREMs allow the identification and acknowledgement of the healthcare workers who were mentioned by patients for the positive difference that their compassionate behaviour made in the patient experience. This makes it possible to convey the importance and value that their work and behaviours had (and can continue to have) to patients, to all the personnel, including care assistants.The access to the beta version of the platform was granted, generally, during the first presentations of the preliminary results. This allowed practitioners to contribute in revising the dashboards. Thanks to the healthcare professionals’ involvement, the graphic representation of data evolved in the first months of the initiative. Practitioners can directly and autonomously choose the graphic representation of data among bar, pie and area charts. Stacked bar charts were added into a section of the platform, comparing the patients’ answers to the PREMs questions among suppliers, according to granted permissions . In addition to the available time-period selection function, a trend visualisation of specific dimensions of patient experience is currently under development, so that changes over time in the patient perception of care quality would be readily visible and quantifiable.Currently, the narrative comments can be consulted using a key-word research, by open-ended question, or transversally among all the five questions. Some basic statistics were added  have been added to this section. The development of an algorithm for a real-time sentiment analysis is ongoing, with the goal to integrate it directly into the platform. Other basic statistics were integrated in order to better monitor the initiative .According to literature , this PRThe ongoing initiative, currently implemented in Tuscany and Veneto, continuously collects patient experience data in a systematic way, providing: (i) standard experience data for trend monitoring and benchmarking within and among healthcare organizations and regions, in the multi-dimensional IRPES; (ii) real-time narrative feedback, to bring out episodes, people and behaviours that made the difference to the patients’ experience and that can be used by the healthcare organizations to value people and learn by what worked.This innovative PREMs model represents the first example of patient survey that achieves such detail, by collecting and reporting patient measures in real-time and up to the ward level. A scaled-down survey instrument , like thThe integration in the standard questionnaires of narrative sections allows reporting both qualitative  and quantitative feedback (big data) . AccordiIn this regard, another potential use of PREMs data concerns the patients’ acknowledgement and value of healthcare workers directly reported by the patients. This was a critical aspect to be addressed in some healthcare organizations of Tuscany and Veneto, where the healthcare workers expressed the need for being more and better valued. According to the practitioners’ feedback, the volume of positive feedback provided by patients can be a lever to encourage, motivate and value clinicians, nurses and care workers. It allows for the monitoring of the care assistants’ contribution to the positive experience of patients, which is usually difficult to measure. Further research could focus on the ability of PREMS to measure and have an impact on healthcare and care assistants’ practice.With the innovations introduced, the PREMs have moved from the exclusive focus on ‘what’s wrong’, to the recognition and celebration of what worked well and of those who made a positive difference in the experience of patients, in order to make their care even better , 84. A gThe integration of PREMs in a performance evaluation system, publicly disclosed and effectively disseminated among healthcare professionals, was proved to have an impact on their daily practice and behaviours, positively affecting the patient experience . In the This paper presents an action research in which researchers and practitioners of two Italian regions worked in designing, implementing and monitoring a PREMs continuous and systematic observatory. The PREMs Observatory exploits to the greatest extent possible the strengths of traditional patient surveys, and addresses several of the issues and limitations in using patient survey data.According to the preliminary results and practitioners’ feedback, the PREMs initiative presented in this paper can improve the use of PREMs in the day-by-day practice of healthcare managers, professionals and workers in general, and support patient-driven mechanisms of quality improvement, as well as of cultural and behavioural change, due to several innovations that it encompasses. The combination of the PREMs integration into the multi-dimensional performance evaluation system and the operational and positive people management and quality improvement tool is consistent with healthcare managers’ and professionals’ goals of rapidly deploying sustainable quality improvements, by focusing more on an appreciative and positive approach.Additional file 1. Questionnaire.


Training started with a workshop on participatory diagnosis of working conditions. Once teams had conducted the participatory diagnosis in the rural communities, they designed in a second course an active teaching intervention. The intervention was targeted at the main occupational health problem of the community. After implementation of the intervention, teams evaluated the program. Evaluation results were very positive with an overall score of 9.7 out of 10. Teams reported that the methodology enabled them to visualize hazardous working conditions. They also stated that the training improved their abilities for problem analysis and preventive actions. Aspects like time constraints and difficult geographical access were mentioned as challenges. In summary, addressing occupational health in primary care through targeted training modules is feasible, but long-term health outcomes need to be evaluated.Integrating basic occupational health services into primary care is encouraged by the Pan American Health Organization. However, concrete initiatives are still scarce. We aimed to develop a training program focusing on prevention of occupational risks for primary healthcare professionals. This train-the-trainer program was piloted at four universities in Chile and Peru. Occupational health or primary healthcare lecturers formed a team with representative(s) of one rural primary healthcare center connected to their university (N Globally, work activities in rural areas are mostly linked to the use of natural resources. Examples of such work activities include small-scale mining, fishing, livestock, and agriculture . In agriIn addition to these work-related characteristics, poverty, cultural aspects , geographical features, and limited access to health services and to formal education are challenges for rural populations’ health ,4,8,9. WIn the framework of the sustainable development goals (SDGs), decent work and good health and well-being are two of the 17 goals. These 17 objectives are closely related and improving one will also have positive effects on the others . Decent Since its Global Plan of Action on Workers Health for 2008 to 2017, the World Health Organization (WHO) considers the integration of BOSH into primary health care (PHC) as a strategy to universally address workers’ health ,19,20. TIn many Latin American countries, providing health care services in rural areas is an obligatory part of internships for health care students . HoweverThe rest of the paper is divided as follows: We first describe the methodology of the training program. After that, the evaluation strategy is explained. In The train-the-trainer program was developed and implemented between January to December 2018. It is based on a blended-learning concept (here: online and onsite training) with a theoretical and practical component. The program was piloted at four universities collaborating with the Center for International Health (CIH). The CIH is a training network on health-related aspects coordinated by the Ludwig-Maximilians-Universität in Munich, Germany. It is funded by the German Federal Ministry for Economic Cooperation and Development  “Higher From 2015 to 2019, the CIH annually offered parts of its funds as competitive research and training funds for the seven partner universities, associated teachers, and alumni from LMICs. The call was open for any research or training project relevant to the SDGs and in the scope of the CIH’s vision “we empower health professionals”. The project had to be completed within a maximum of 12 months. In 2017, the authors of this paper, together with the four collaborating universities, successfully applied for these funds (number of projects received: 25 of which 6 received funding). The authors of this paper are all lecturers within the CIH training programs in Latin America who jointly designed and carried out the program. In addition, four of them accompanied the participating universities throughout the training program as “tutors”.The collaborating universities were one CIH partner university and three universities at which CIH alumni are teaching. At all of them, medical or nursing interns provide health services to rural communities. At this stage, we restricted participating universities to two universities located in two geographical regions of Chile  and two universities in Peru, one located in the coastal region, the other in the Andean region. This was done in order to limit the travel expenses of the workshops and at the same time, pilot the program in different cultural settings. The universities were informed about the initiative and invited to take part in the training program. All invited universities agreed to participate. Each university was encouraged to participate with a team of lecturers in occupational health and/or PHC and with at least one PHC representative of a rural community (named “team of trainers” herein). The community was selected by each university from those in which the universities’ interns are involved in primary healthcare. The selection was based on the preference of the universities.The program was taught in two phases  and can ® . Therefore, these efforts imply additional commitments, especially if a greater impact to be achieved”.“I think skills for this kind of work could be strengthened in the healthcare team.”“… I think it is necessary to incorporate follow-up and to develop other instances of intervention, like networking and intersectoral work.”Lack of financial support for teaching interventions .Some teams partly overcame the shortcomings as a result of the positive relationship with the community, management, and commitment of some local authorities. A trainer said:“We had constant support from the university… this allowed us to have sufficient teaching hours, finance travel costs, coffee breaks, materials… Local primary healthcare center contemplated the necessary professional hours, as well as time for coordination of actions with social and institutional organizations.”4.TrialabilityBased on their experience, trainers considered applying this methodology to address different health problems and rural communities as feasible. An initial approach to recognizing community health problems and prioritizing more effective measures would be facilitated. Nevertheless, due to the diversity of factors involved in the problems, interventions beyond education should be considered. A trainer mentioned:“Since the disease model in general has changed, it is important to consider social factors in interventions. Participatory diagnosis and educational intervention models in communities are useful for the development of respectful strategies in which the community is involved.”5.ObservabilityThe local communities’ situation and the internal dynamics of the formed work teams became visible. Through this experience, both the teams of trainers and communities were able to recognize the health problems of the community’s workers, possible solutions, and the obstacles to overcome. Likewise, institutional support facilitated the work of the teams:“I think we should work with local authorities on a results basis to achieve greater impact.”“… for the community, the problems arising from the current legislation are more complex …”Ten trainers  participated in the final evaluation workshop. All declared that the objective of the training program was fulfilled although one of the teams could not complete the teaching intervention. Reasons for this were mainly the geographical distance from the community and difficulties of the team to carry out meetings (time and distance). A trainer mentioned:“In general, the objectives were achieved, it was possible to make diagnosis of the community’s health problems and their occupational risks. No intervention was carried out.”Factors mentioned to facilitate the achievement of the program’s objectives were related to the motivation of all involved parties as well as the learning methodology. Hindering aspects were time, geography, limited knowledge, and lack of awareness of occupational safety and health, as well as little institutional support .Based on the Pan American Health Organization’s (PAHO) strategy to integrate occupational health services into primary healthcare, we developed and pilot-tested a train-the-trainer program to address occupational risk prevention in rural communities of Latin America. The program was conducted as a combination of online training, face-to-face learning, and implementation practice carried out in two phases: risk assessment and intervention. Community participation was considered at all stages. Overall, evaluation results were positive and implementation was successful in three out of four communities. Three of four teams continued occupational safety and health activities in the communities after the end of the project. One university implemented the program into regular training of medical interns.As a result of the participatory diagnosis, knowledge was generated regarding the health of workers in rural areas, both for the trainers and for the communities. Musculoskeletal disorders and mental distress were identified as the main work-related health problems and thus, the major rural work-related problems worldwide were targeted ,49,50. TJoint efforts between communities and teams resulted in teaching interventions based on community needs. Socio-demographic characteristics , the use of local languages , and the low educational level of many community members were challenging. However, for the successful implementation of the program it was important to consider them as it is known that innovations become more widely adapted when they are socio-culturally accepted  (p. 15),Our program raised awareness about the association between work and health and the prevention of occupational risks in the community. Previous studies suggest that the community-based approach taken contributed to the success of the program ,31,33,56Lack of public policies, missing involvement of authorities, and lack of intersectoral action became the main factors of complexity. According to the International Labour Organization (ILO), low social security coverage is a major shortcoming in terms of access to decent work in rural areas; cross-ministerial policies encompassing the scope of occupational safety and health in rural development are needed . Some coAs a limitation, the methodologies and strategies used might not be suitable in all parts of rural Latin America. However, the multi-national team of authors of the program , the involvement of trainers’ teams from northern Peru to the central south of Chile, as well as the flexibility of the used methods are promising for its implementation in other contexts. The project duration was also a limitation, especially for trainers’ teams as they had to organize the workshops in the communities. Likewise, the duration of the project, limited financial resources, and lack of experience with research of most of the participating teams did not allow evaluation of the impact of the actions on communities’ health. In addition, no control group was included. Furthermore, not all trainers completed the evaluation form or took part in the final workshop. Although all participants were invited, participation was voluntary, respecting the personal decisions of the trainers and their availability of time. While we cannot know to which degree the written evaluation was representative, members of all four teams took part in the final evaluation workshop. Therefore, we expect selection bias to be small. Reporting bias might have played a role especially in the final workshop; however, as there was an atmosphere of trust and respect built over the training program, we do believe that this had only a minor impact on the results.We have successfully developed a train-the-trainer program on occupational risk prevention and have shown the feasibility of its implementation in rural areas of Latin America. The cornerstones are its participatory community-based approach and active learning methodology combining classroom teaching with guided practice. In the next step, we need to test its medium- and long-term impact on communities’ health. After successful evaluation, it can be used as a tool to implement occupational safety and health in rural areas. For this, we consider cooperation with relevant intersectoral stakeholders and institutional support to be crucial.