The aim of our study was: to establish the effect of these changes on the revenues and income of GPs in the first decade of the 21Annual GP revenue and practice costs were collected from national institutes in the eight countries included in our study ) from 2000–2010. The data were corrected for inflation and purchasing power. Data on the remuneration systems and changes herein were collected from the European Observatory Health Systems Reviews and country experts.Comprehensive changes in the remuneration system of GPs were associated with considerable changes in GP income. Incremental changes mainly coincided with a gradual increase in income after correction for inflation. Average GP income was higher in countries with a strong primary care structure.The gap between the countries where GPs have a lower income  and the countries where GPs have a higher income  continues to exist over time and appeared to be related to dimensions of primary care, such as governance and access. New payment forms, such as integrated care payment systems, and new health care professionals that are working for GPs, increasingly blur the line between practice costs and income, making it more and more important to clearly define expenditures on GPs, to remain sight on the actual income of GPs. The remuneration system of GPs provides incentives, intended and unintended, for GP behaviour. For instance, fee-for-service payments are expected to provide incentives for GPs to treat patients in their own practice as long as possible instead of referring them to other health care providers. With salary and capitation systems there will be a risk of unnecessary referrals to other (more costly) health care providers -5. HowevConsequently, this paper will address the following questions:1. How did the income of GPs develop from 2000 to 2010 in the eight countries in our study ?2. Have there been comprehensive changes in the payment systems and did these affect the income of GPs?3. Is the income level of GPs related to the strength of primary care in these countries?We collected annual data on GP-revenues for each country in our study. We distinguish three different revenue components: total revenue, practice costs and income. The total revenue is the amount the GP receives through the remuneration system. For those countries where GPs are self-employed or entrepreneurs, practice costs  have to be deducted from the total revenue to calculate income (before taxes). In countries where GPs receive a salary, only data on salaries were collected, since the employer in that case covers practice costs. The income of a GP is presented as the income for a full-time GP after deduction of practice expenses and before income taxes and excludes income from out-of-hours care. The data come from national institutes, most of them are routinely collected data on GP revenues. National data were converted into Purchasing Power Parities US$ (pppUS$) to make the data comparable across countries while allowing for possible differences in purchasing power. The data were then corrected for inflation, with the year 2000 as reference year (Consumer Price Index). Data on pppUS$ conversion rates and inflation were taken from the OECD health data files 2010 .In this study, we distinguish two types of changes of the remuneration system: comprehensive and incremental changes. We define a comprehensive change as being introduced at a certain point in time (more or less overnight) and changing the main way in which GPs are remunerated (for example from capitation fee to fee-for-service). Incremental changes add new elements to the existing remuneration system or changes the balance between several remuneration types, which are introduced gradually, taking several years to come into full effect .A recent European wide study by Kringos  into theData on health care expenditure were retrieved from the OECD online health database. We related GP income to total health care expenditure on individual health care services  and to expenditures on basic medical and diagnostic services, both in pppUS$ per capita. For a detailed description, see the OECD website . In the For this study, we define a substantial increase in GP income as follows: when the increase is more than the GDP per capita corrected for inflation, we consider the increase as substantial. We look at the increase of GP income in two ways. Firstly, we look at the minimum and the maximum GP income in a certain country in the period under study. Secondly, for countries with comprehensive changes in the remuneration system, we look at the income in the year before the change and the maximum income in the years after the change. The average GDP per capita for the countries included in this study is 29,660 pppUS$ (price level 2000). The minimum average GDP per capita in the past decade is found in France  and the maximum in The Netherlands . For a comparison with annual wage development in the population, we used OECD Statistics, i.e. the dataset on average annual wages, in 2009 pppUS$ and 2009 constant prices. The development in annual wages was recalculated using an index with the year 2000 = 100.The countries in our studies can be divided into two groups. The first group consists of the countries that routinely collect data on GP remuneration and practice costs. This is the case in Germany (for public practice only), Finland, France, and the UK. The second group of countries  do not routinely collect these data and the income of GPs had to be calculated from other sources, such as public expenditure on GP-care and incidental studies into practice costs. For Belgium, no reliable data source for practice costs was available and thus an estimate was used. For Sweden, where multiple remuneration systems exist, only information on GPs in salaried service was available. The data used for the calculation of total revenue, practice costs and income for each country are available in Additional file et al on GP-income from 1975–2005 [Data on changes in the remuneration system for General Practitioners were collected from the Health System Review series published by the European Observatory on Health Systems and Policy and the study of Kroneman 975–2005 ,9. This Ethical approval was not required for this study.GPs in Belgium are mainly paid a fee-for-service. To strengthen primary care, in 1999 the General Medical File (GMF) allowance was introduced for patients of 60 years and older. GPs receive an allowance for all persons for whom they coordinate their medical files. In 2001 the age limit was extended to 50 years and in 2002 the entire population could apply for this GMF coordination . The GMFIn Denmark, the GPs derive their revenues from a combination of a capitation fee, which makes up one third to a half of their revenues, and from fees for services rendered . In the period from 2003 to 2010 there were no significant changes in the remuneration system but only small adjustments in the fees and the types of fees. Priority setting of certain services is introduced in the form of, for example, comparatively high fees for preventive consultations. This higher fee is supposed to encourage GPs to offer longer consultations focusing on broader health and prevention activities such as education regarding smoking or dietary habits, weight control, and so on . In 2006For general practitioners, who generally work in health centres, two payment systems exist. Traditionally, payment is mainly based on a monthly salary with additional payments based on, among other factors, seniority and skills. Work that exceeds 37 hours a week is remunerated in addition to the salary. The second system is called the personal doctor system, which is a special remuneration formula determined by a basic salary , that is supplemented by a payment per consultation for patients who consult their GP less than three times in the previous year and a monthly “capitation” payment for the so-called frequent visitors - those who visited their GP more than three times in the previous year. This programme leads to higher total revenues compared to the traditional system, but the GP is not protected by the limit of 37 hours per week, as there is no formal working week, just a requirement to offer services on weekdays. Towards the end of the decade, different local modifications of two “official” systems have become more common. Also some municipalities with the personal doctor system have decided to change back to the “traditional” system with doctors having 37 hours per week working time and receiving a salary. Comprehensive changes in the remuneration system have not taken place in the past decade. Another trend during the past 10 years in the municipal sector has been the outsourcing of GP services to private companies. Usually these private companies have their own remuneration system for doctors. Unfortunately current and comparable data on doctors’ salaries employed by these companies are not available.General Practitioners in France are mainly paid on a fee- for-service basis. In 2001 supplementary payment was introduced for GPs that registered patients for gate-keeping purposes . For each registered patient an extra fee of €46 was introduced . HoweverSince 2009 GPs may receive additional payment for practice improvement. Contracts are signed with the Social Health Insurance on a voluntary basis for a three-year period and can be terminated at any time on the doctor’s demand. The contract encourages GPs to develop prevention, to improve treatment and to follow patients with a range of chronic conditions (currently hypertension and diabetes) and to improve efficiency by increasing the rate of prescription of generic drugs. GPs are offered additional remuneration on top of their normal fee-for-service income. The additional payment takes into account the size of the population treated by the doctor and a number of quality indicators. In 2008, there were 16 indicators for which final but also intermediate targets were defined. Overall, the amount earned can exceed €7000 per year for a doctor achieving over 85% of the targets and treating more than 1200 patients. There is no penalty for GPs who do not achieve the targets.Until 2008, the payment of ambulatory physicians  used to be subject to a global spending cap tagged to the increase of the wage base from which the statutory health insurance funds received income-related contributions. This worked as a two-stage process. First, the statutory health insurance funds made total payments to physicians’ associations in the form of negotiated capitation fees for each member (insured person) of the fund. These negotiated budgets were subsequently distributed among the members of the physicians’ associations according to a uniform relative value scale. This scale contained a list of all services that can be provided by physicians for remuneration within the statutory health insurance system. Each of these services was awarded a certain number of points. Physicians invoiced their associations each quarter for the total number of points generated by the services rendered. The monetary value of the points has been derived by dividing the total negotiated budget (the budget that the GP-unions received from the sickness funds) by total number of points. The monetary value of the points is then used to calculate the physicians’ quarterly remuneration. To prevent physicians from maximising the number of reimbursable points each practice was awarded a budget according to its specialty reflecting within limits historical practice patterns. In 2009 all ambulatory physician services were awarded a Euro-value (based on the previous number of points multiplied by 3.5001 eurocent) thus transforming the uniform relative value scale into a fee schedule. The spending cap was lifted to the extent that physicians’ associations and statutory health insurance funds were collectively required to identify the required budget to cover an expected service level as defined by health risk adjustment . Prior to this, in 2008, the number of individual services that are applicable for reimbursement was reduced by bundling and the number of capitation-like compensations for a complex of physician services per case (patient/practice/quarter of a year) was increased. Besides, for each GP practice, the maximum number of reimbursable services is settled for each quarter of a year (targets). When a practice produces cases or points above its target, a reduced fee is applicable to all additional services, which are regarded as ‘overproduction’ -25.rd of the population) and privately insured patients. For publicly insured patients, GPs received a fixed capitation fee, which was differentiated by age of the patient and whether the patient lived in a deprived area. For privately insured patients, GPs charged fee-for-services (mostly consultations or home visits) to the patients, who charged their health insurance company for full or part reimbursement if GP costs were included in the coverage. Prices were fixed and set by the Dutch Healthcare Authority. After January 1st in 2006, all Dutch inhabitants had to buy the basic package of health insurance, which included GP care. The GPs became remunerated through a mixed system: GPs receive for all patients a capitation fee (which is significantly lower compared to the former capitation fee for publicly insured patients) and a consultation fee that differs for home visits, office consultations and telephone consultations. The capitation fees are higher for older patients and patients living in deprived areas. Furthermore, GPs can negotiate with health insurers for funding of activities that either increase their efficiency or substitute for secondary care. About 8-12% of the GPs revenue is generated via these negotiated activities .In 2006 the remuneration system for GPs changed substantially in the Netherlands. Before 2006, two types of patients were distinguished: patients with compulsory public insurance . The share of salaried GPs increased from 7% in 2000 to 12% in 2010 [In the Netherlands, there are self-employed GPs and GPs that are in salaried service of the independent GPs ( in 2010 . The incketen-DBC) for diabetes, COPD and CVA, consisting of a lump-sum payment for each patient with one of these diseases in the practice. With this money, all care of these patients has to be paid, also care provided by secondary health providers . Converted to an FTE GP, this results in an extra remuneration of 16.800 euro . At present, it is unclear how this money is spent in practice, and thus it is unknown what part is GP income and which part consists of additional costs.In 2010 a new type of remuneration was introduced: integrated care remuneration, the so called chain-of-care DRG  in Sweden, with all counties operating with a different mix of salary, capitation and fee-for-service for GPs, which makes it impossible to determine “the” Swedish GP remuneration system. In the period from 2000 to 2010, no major changes have taken place, at least not at national level.Before 2004, the revenues of GPs in the United Kingdom were determined by a basic allowance, supplemented by allowances based on factors including the number of listed patients, patient characteristics  and some types of services rendered. There was a slight gradient in basic allowance due to seniority (depending on the number of years a GP is registered).In 2004, the payment system changed from GP-based to practice-based, with an all-in budget . Payment was still based on characteristics of the practice”s patient list, but additional revenues could be earned when certain quality requirements were met ). For this performance payment, four domains for quality improvement were introduced: the clinical domain (with an emphasis on certain diseases), the organizational domain , the additional services domain  and finally the patient experience domain which consists of how services are provided and the involvement of patients in service development plans. The UK is the first country in Europe to use patient surveys to reward GP-practices. Revenues generated from the QOF may increase total practice revenue by 15-20% . In the There are two different contracts for GP-practices, the General Medical Services contract (GMS) and the Personal Medical Services contract (PMS). The GMS is negotiated between the British Medical Association and the NHS at the national level. The PMS is negotiated between local level health authorities  and individual GP-practices. The income of PMS contracted GPs in 2008 is on average higher compared to GMS-contracted GPs . The shCountries with a single remuneration system to pay the GP do not exist anymore in 2010. Remuneration systems for GPs have increased in complexity and detail. Even in countries where (most) GPs are in salaried service, experiments with additional payments in the form of, for example, fee-for-service have been introduced. New forms of payment that have been introduced in the past decade are the integrated care fees and the performance fees. The integrated care fee refers to a system where GPs receive an amount per patient with a certain diagnosis (for example diabetes) and this amount should be used to cover all health care costs of the specific patient, including hospital and specialist care. This is a new development, which does not (yet) form a significant share of total revenue. Integrated care fees have been introduced in Belgium, Denmark, Germany, and The Netherlands , the Netherlands (in 2006) and in Germany (in 2008), comprehensive changes in the GP-remuneration system took place. In the UK, the payment became practice based and performance payments were introduced that formed a substantial part of the practice income. In the Netherlands the difference between the payment systems for publicly and privately insured people was abolished and merged into one payment system for all citizens. For GPs it was difficult to predict what would be the income under the new system beforehand, since in the former system for the previously publicly insured population no fee-for-service existed and the existing administrative systems of the GPs did not provide insight into the income generated in the new system. In Germany, the budget cap was released, and although there are reduced tariffs above a certain number of reimbursable services, there is no limit in the number of reimbursable services anymore. In the other countries in our study incremental changes took place, varying from an increase in tariffs for certain remuneration elements to changes in the share of the different remuneration elements in the total revenue and the introduction of new remuneration elements in addition to existing elements, such as remuneration for keeping patient’s records. This was the case in Belgium and France.In Figures The total strength of the primary care sector was not related to differences in GP income Figure . When weIn 2009 (for France: 2008) GP income was moderately correlated to expenditure on individual health care services (pearson correlation coefficient = 0.60). Surprisingly, GP income was negatively correlated to expenditure on basic medical and diagnostic services (pearson correlation coefficient = −0.45). The development in GP income over the decade was strongly correlated with the development in expenditure on basic medical and diagnostic services, with correlation coefficients varying between 0.78 for Sweden to 0.98 for Germany. There were two outliers: The Netherlands (0.58) and France (0.32). For the Netherlands, the length of the time series was only four years. For France, there was a break in series that made comparison over time invalid. When looking at the development as index (2000 = 100), we see that in Belgium the GP income increased more compared to basic medical care expenditure and that in Denmark the expenditure increased stronger than GP income , followed by Belgium, Germany and the UK, respectively (more than one time the average GDP per capita). In Sweden, France and Denmark the lowest increase was found. The relative change was highest in the Netherlands and lowest in Denmark . Belgium formed an outlier: the share here is 35%. However, the estimate of the practice costs for GPs in Belgium was not based on survey or tax-based data, resulting in a less reliable estimate.When we look at the development of the income of the GPs between 2000 and 2010, several conclusions can be drawn. Firstly, the incomes of GPs in all countries except Denmark have increased (corrected for inflation), and increased more than the average income in the population. The largest relative increase was found in the Netherlands and Belgium. Secondly, the gap between the countries where GPs have a relatively lower income  and the countries where GPs have a higher income  continues to exist over time. Thirdly, the countries with comprehensive reforms are the countries where GPs received the highest payments already. The result of the comprehensive change seems to be that GP income increased substantially in the two or three years after the change. After that, the income decreased somewhat. In the UK, an increase in income was intended ,28, but Fourthly, on average, GPs working in countries with a strong primary care sector in terms of governance, workforce development, access, and coordination of care appear to have a substantial higher income than GPs working in countries with a medium or weak primary care sector. We found no association between income development and the continuity of primary care. Perhaps this can be explained by the fact that having a long-term relationship with patients, keeping medical records, and creating a feeling of trust is a universal feature of primary care and inherent to the profession of GPs, irrespective of their income level, while governance, workforce development, access, and coordination of care are largely influenced by policies and financial incentives. It is unclear why GPs in countries with a comprehensive service delivery earn less compared to their colleagues in countries with a less comprehensive service delivery. The dimension of comprehensiveness was mainly based on expert opinion, whereas the other dimensions are based on more robust data . Maybe ePolicy makers have tried to curb the unintended increases in income in the UK and the Netherlands. In the UK, the GMS contract of 2004 was valid for three years. So the first year of possible measures to curb the increase in income was 2007. In the following years, net remuneration of GPs was either frozen or increased with only a  compensation for inflation ,33. The An important limitation of this study is that we only present average incomes of GPs. The variation in income within countries in the case of non-salaried GPs are large. Evidence for this is found in Belgium , the NetA problem in calculating GP income from the total revenue is the increasing complexity of the financing of GP practices. The emergence of new payment systems, such as the integrated care fees and new health professionals working for GPs, such as nurse practitioners, make it difficult to establish the expenditure of GPs, since for instance health care consumption of specialist care of patients on the GP’s list have to be paid by the GP(−practice). There is no longer a relationship between workload (in number of patients or number of services) and remuneration. This will make it difficult to monitor GP-expenditure in the future.We have tried to relate the development in GP income to the context of primary care. However, we are aware of the fact that we only have eight countries in our study. Therefore, the results should be seen as a first indication of the association between income development and primary care context.Further limitations concern the calculation of practice costs, the method of calculating GP income before and after a drastic reform, the information on number of active (fulltime) GPs, and the income derived from services for private patients.The most important problems in calculating GP income in countries where GPs are self-employed entrepreneurs are to calculate practice costs and to define what is a full-time GP. Practice costs include salaries for practice personnel, housing, medical equipment, transportation etc.. The most reliable data on practice costs come from tax data. However, this implies that the tax office knows who are GPs and how many GPs are actively working as GP. Since this information is not always available, in some countries dedicated studies have been carried out into this matter  are not included in the calculations. However, the underestimation will not be so large, that the difference between 2005 and 2006 can be explained from this artefact. For the comparison between countries, we have to note that there is an underestimation of the income of GPs in Denmark, because the income is based on head counts of GPs in stead of full-time equivalents. There is a difference of around 20% for the three years that data are available for both full-time GP and income based on head count. However, since the number of GPs has not changed substantially over the years, we assume that the underestimation is constant over time. In the data for Belgium, Denmark and France, income from out-of-hours activities are included, whereas this is excluded in the other countries, leading to a slight overestimation of the income of Belgium, Danish and French GPs compared to the other countries.Finally, changes in GP remuneration may not be the only cause of changes in income. Other developments, such as increasing demand for GP services, ageing of the population and substitution of hospital care to primary care may also affect GP income. In the Netherlands, for instance, there is evidence that part of the increase is due to an increase in primary care use .Summarizing, we found that comprehensive changes in the remuneration system of GPs may influence GP income considerably. Incremental changes are associated with a gradual increase in income after correction for inflation, with the exception of Belgium where the incremental change coincided with a considerable increase. Beside the traditional payment systems, i.e. salary, capitation fee, and fee-for-service, new payment systems have been introduced to promote and reward quality and integration of care through financial incentives. Examples are pay-for-performance, which is most elaborated in the UK, and integrated care payment systems. The latter is still in development and is facing problems due to the differences in payment systems of the different health care providers . In counDRG: Diagnosis related groups; COPD: Chronic obstructive pulmonary disease; CVA: Cerebrovascular accident; ECG: Electrocardiography; FTE: Full time equivalents; GMF: General medical file; GMS: General medical services contract; GP: General practitioner; NHS: National health service; OECD: Organisation for economic co-operation and Development; PMS: Personal medical services contract; US$: United States dollars in purchasing power parities; QOF: Quality and outcomes framework; UK: United Kingdom (in our case: England).All authors declare to have no competing interest: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.MK drafted the manuscript, carried out the analyses and collected the data. PM carried out the calculations and analyses for Belgium. DSK provided the data on primary care dimensions and helped with the interpretation and helped to draft the manuscript. WG conducted a critical review of the manuscript and helped with the analyses. JZ initiated the study, participated in the design and helped to draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/13/436/prepubCalculation of GP income.Click here for file


The environment has an important impact on physical activity, especially walking. The relationship between the environment and walking is not the same as for other types of physical activity. This study seeks to comprehensively identify the environmental factors influencing walking and to show how those environmental factors impact on walking using the experiences of adults between the ages of 18 and 65. The current study is a meta-synthesis based on a systematic review. Seven databases of related disciplines were searched, including health, transportation, physical activity, architecture, and interdisciplinary databases. In addition to the databases, two journals were searched. Of the 11,777 papers identified, 10 met the eligibility criteria and quality for selection. Qualitative content analysis was used for analysis of the results. The four themes identified as influencing walking were “safety and security”, “environmental aesthetics”, “social relations”, and “convenience and efficiency”. “Convenience and efficiency” and “environmental aesthetics” could enhance the impact of “social relations” on walking in some aspects. In addition, “environmental aesthetics” and “social relations” could hinder the influence of “convenience and efficiency” on walking in some aspects. Given the results of the study, strategies are proposed to enhance the walking experience. A considerable number of adults throughout the world suffer from insufficient physical activity. In 2010, about 23% of adults and in 2012, about 31% of adults over the age of 15 years were physically inactive [Walking is the most usual type of physical activity for most people ,4 and caUnderstanding the factors which impact on the walking experience is necessary for providing conditions and an environment that encourages walking. Identifying factors influencing the walking experience is a multidisciplinary subject and is used in the fields of urban design and planning, health and transportation ,4,14. StStudies conducted on the influence of environmental factors on walking are mainly quantitative, while qualitative studies are complementary to quantitative studies . QualitaStudies have recommended that specific types of physical activity, such as walking, should be studied separately in relation to the context ,22. It hThe present study is a systematic review of qualitative studies that explores the influence of the environment on walking separately from other physical activities or modes of transportation. The purposes of this systematic review is to identify the environmental factors influencing walking and understand how they impact on walking based on the experiences of adults. Since the environmental requirements of adults differ from those of children and adolescents , only adThe present study is a meta-synthesis of qualitative studies on the influence of the environment on walking through a systematic review. Meta-synthesis of qualitative studies is a parallel methodology to meta-analysis of quantitative studies. In meta-synthesis, the findings of former studies on a subject are interpreted and synthesized to reach a more comprehensive and deeper understanding of the subject ,32. The During the first phase, a systematic search of different databases was carried out to find qualitative and quantitative systematic reviews about the influence of the environment on walking. The purpose of this phase was to ensure that the study has not been duplicated and to select proper keywords for the main search. During the second phase, a comprehensive and systematic search was conducted of related databases from different disciplines. Given the eligibility criteria, the papers identified were checked by reading the titles, abstracts, and full texts. Those failing the criteria were eliminated from the study. The studies selected met all inclusion criteria and did not meet any of the exclusion criteria. The eligibility criteria were established before searching and were discussed until agreement was reached. During the third phase, the eligible papers were assessed for risk of bias on the basis of a qualitative framework for assessing qualitative studies and those failing the assessment were eliminated from the study. Only studies qualified for meta-synthesis were selected. During the fourth phase, the general characteristics of the selected studies and their findings sections were extracted. During the fifth phase, the findings of the studies were interpreted and synthesized through qualitative content analysis.Studies having a qualitative research design.Studies in which the influence of environment on walking was mentioned in the findings section.Studies focusing on walking or analyzing walking separately from other modes of transportation or types of physical activity.Studies in which the participants were 18–65 years of age or the average age was within these limits.Studies which only investigated the influence of non-physical environmental factors on walking. The reason for selection of this criterion was that many quantitative studies have shown the influence of the built environment factors on walking.Studies that investigated the influence of environment on walking under conditions of intervention experience. The reason for this was the requirement that the influence of environmental factors on walking could be studied in natural conditions. Specific environmental factors should not be emphasized.Studies focused on patients or people with health conditions influencing walking, such as rehabilitation after stroke.Studies focused on non-public spaces such as offices.Seven databases of different disciplines related to the influence of the environment on walking and two journals, i.e., “Cities” and “Health and Place” were queried. The impact factors of both journals were above 1.5. The databases were Web of Knowledge, Scopus, PubMed, CINAHL, TIRS, Sport Discus, and RIBA . The RIBThe search keywords were categorized into three groups  and wereSimilar keywords relating to a group of words  and talking with them as a pleasant activity while walking ,39,41,42Common viewpoints and perceptions among community members which influenced their walking experiences constituted the meaning of public perception. Among parents, the social pressure of other parents to walk more with their children was a factor influencing walking with children. These parents felt guilty about driving their children to their destinations . The preA sense of abandonment was also a factor discouraging walking in poor areas. The reason for this was the lack of neighborhood walking facilities or their inadequate maintenance ,43. The Environmental factors which impacted on the convenience and comfort of participants while walking formed the meaning of convenience and efficiency. This also referred to environmental factors which influenced on how efficient and logical participants found walking to be in comparison with alternative activities, such as cycling.Short walkable distances to a destination encouraged transportation walking ,37,39,41The necessity of making lengthy and numerous stops while walking discouraged walking for transportation. A long wait for traffic lights to turn green was one factor causing stops during walks. Lack of harmony between adjacent traffic lights for pedestrians and multiple junctions were additional factors which required lengthy and numerous stops ,38.The maximum time limit deemed feasible for walking as transportation had a negative impact on walking. Participants accustomed to using cars had lower maximum time limits for proper and efficient walking ,30. The Vast open spaces for walking, like wide sidewalks and large open land covered with grass encouraged walking, while a lack of such spaces, such as narrow sidewalks, discouraged it ,39,41,42The lack of integration of public transportation with walking routes, such as a lack of access to public transportation stations, discouraged walking to stations ,42. LackNoise pollution caused by car heavy traffic or construction discouraged walking ,30. TrafA male participant cited listening to music as a method of reducing the effect of environmental noise and improving thinking conditions while walking . A femalFreshening facilities such as cafes and beverage shops encouraged both recreational walking and walking for transportation because participants could rest and be refreshed during walking. The availability of parking spaces at the destination also impacted on the decision to walking ,42. Bad weather and steep slopes were considered as barriers to transportation walking ,40,43. WIn qualitative studies, walking was considered to be a complex context bond and a socially and culturally sensitive phenomenon; consequently, in this meta-synthesis, social environment factors, as well as physical environment factors that influence walking, were explored. However, in quantitative systematic reviews ,6,7,23, Despite the quantitative systematic reviews ,6, the sDespite the quantitative systematic reviews ,6, all sIn quantitative systematic reviews, the influence of distance on walking for transportation was emphasized, but this was not related to recreational walking ,6. The rSpace syntax theory states that there will be higher movement density in the streets with higher connectivity ,52. The A comparison of the results of this meta-synthesis with quantitative systematic reviews showed that qualitative studies could add detailed information on what and how environmental factors influence walking. Combining the results of this qualitative systematic review with those of quantitative studies can improve understanding of walking as a complex phenomenon and help to recommend strategies to improve the physical activity and health of communities and individuals.Further discussions about results of this study are presented below. In relation to the sense of inadequate safety, the main concern was fear of accidents, which increased when walking with children in poor neighborhoods. Studies on the relationship between the sense of inadequate safety and walking with children in areas with middle class and upper class neighborhoods is recommended.In relation to the built environmental aesthetics, uncleanliness was only mentioned in areas of low economic status. Observing an industrial environment was found to be pleasant by Davies et al.  and unplThe positive influence of natural elements on walking, except dog walking, was consistently confirmed. Natural elements were also found to mitigate the negative influence of some factors on the walking experience. The presence of trees and natural light were emphasized for transportation walking and natural scenery was emphasized for recreational walking. The influence of natural elements on social relations was shown. The psychological benefits of natural elements were emphasized.In relation to have a companion for walking; in Bostock’s study, mothers had experienced walking with children as a stressful activity , while DMiddleton  reportedNeighborhood scale studies ,43 were The authors faced some limitations when synthesizing the studies’ results. No description was provided about some factors influencing the walking experience. Some factors were also compound with high level of abstraction, but their subcategory concepts had not been described. In such cases, it was difficult to analyze and interpret the factors and compare them with similar cases.The purpose of this study was to identify the environmental factors influencing walking and explore how they influence adult walking experience in qualitative studies. Environmental factors influencing the walking experience were “safety and security”, “environmental aesthetics”, “social relations”, and “convenience and efficiency”. In this meta-synthesis, the variety of both social and physical factors influencing walking were explored. The social factors and some physical factors have not been considered in recent quantitative systematic reviews.The present study examined how environmental factors impacted on walking. These environmental factors were found to relate to one another. Some factors enhanced or hindered the impact of other factors on walking. Convenience and efficiency enhanced the impact of social relations on walking in some aspects. Environmental aesthetics and social relations could hinder the influence of convenience and efficiency on walking experience. Conditions like income level could influence the impact of the environment on walking. The results of this meta-synthesis present descriptions of some discrepancies between the results of quantitative systematic reviews. In conclusion, this meta-synthesis added more variety and depth to the previous knowledge of the influence of the environment on walking.The results of this study suggest some strategies to enhance the walking experience. These included proper maintenance and adequately wide walking places such as sidewalks, increasing the population density and providing mixed land use to shorten walking distances. Combining natural elements and green spaces in the walking environment, providing sufficient variety, details, and legibility in the design of buildings and public spaces, managing and protecting view corridors from walking spaces to picturesque places are additional suggestions. The proper lighting of walking places and providing sufficient crosswalks on streets should be a priority for pedestrians. As the population density increases, traffic and insufficient walking spaces should be considered.It is recommended to carry out quantitative studies to examine the effect of the new environmental factors obtained from qualitative studies on walking. Further qualitative studies under different contexts using more sophisticated methods (such as grounded theory) are required to understand the interrelationship of environmental factors and their influence on the walking experience. In addition, conducting more qualitative research focused on issues like the influence of income level on the relation between the environment and walking experience and differences in the influence of the environment on walking alone in comparison with walking with others are recommended. The focus group method for gathering data is suggested to obtain more environmental factors influencing the walking experience.


Although there are several models of integrated architecture, we still lack models and theories about the integration process of health system responses to HIV/AIDS and NCDs.The overall purpose of this study is to design an action model, a systematic approach, for the integration of health system responses to HIV/AIDS and NCDs in developing countries.An iterative and progressive approach of model development using inductive qualitative evidence synthesis techniques was applied. As evidence about integration is spread across different fields, synthesis of evidence from a broad range of disciplines was conducted.An action model of integration having 5 underlying principles, 4 action fields, and a 9-step action cycle is developed. The INTEGRATE model is an acronym of the 9 steps of the integration process: 1) Interrelate the magnitude and distribution of the problems, 2) Navigate the linkage between the problems, 3) Testify individual level co-occurrence of the problems, 4) Examine the similarities and understand the differences between the response functions, 5) Glance over the health system’s environment for integration, 6) Repackage and share evidence in a useable form, 7) Ascertain the plan for integration, 8) Translate the plan in to action, 9) Evaluate and Monitor the integration.Our model provides a basis for integration of health system responses to HIV/AIDS and NCDs in the context of developing countries. We propose that future empirical work is needed to refine the validity and applicability of the model. Integration could also be partial or full; specific or generalized; strong or weak; localized or universal. Integration may also be classified based on the foci of integration, the units that are going to be integrated. Besides, integration can be internal (e.g. intra-program), external (inter-program), across stakeholders, across levels and with sector-wide responses.Integration is a means to an end rather than an end by itself . Based ooutput of integration, the configuration of an integrated whole, and how it works  is rapidly increasing in these countries. As HIV/AIDS and NCDs share many characteristics, an integrated approach could be a more effective and efficient alternative to curb the tide of the two epidemics. Given the political recognition of the need for integrated approach and the resource constraints in developing countries, there is an urgent need for evidence-based models for integrating the responses to HIV/AIDS and NCDs.process of integrating two or more health system response functions like that of HIV/AIDS and NCDs. Therefore, this study was designed to develop an action model, a step-by-step approach, for the integration of health system responses to HIV/AIDS and NCDs in the context of developing countries. The new model is expected to be useful for assessment, strategy development, healthcare management and in refinement of existing strategies related to integration.However, to the knowledge of the authors, there is no systematic and systemic model that could guide the scoping review of the literature to explore the rationale for integrating the responses to HIV/AIDS and NCDs in developing countries  model of integration management for the rest of the steps. We detailed the application of all the steps in using the HIV/AIDS and NCD integration as a working example.Following the generation of evidence for integration, the next logical step is communication. In order for evidence to better inform decisions, it needs to be iterative and progressive. We used descriptive, integrative and configurative evidence synthesis techniques at different levels. We considered the model to be cyclical rather than linear. The primary information sources during the design of the model were the sub-studies conducted as part of a larger research project and additional trans-disciplinary literature review.In overall, this model development process was integration managers should implement to arrive at an effective integration of functions. If integration managers use a systematic process of integration, there will be a higher chance of successful integration as compared to the use of fragmented and unsystematic processes of integration.Integration consists of a series of steps that This article describes a model for integration process of health system response functions of HIV/AIDS and Noncommunicable diseases using the acronym INTEGRATE. Each letter of the acronym INTEGRATE stands for a step in the action cycle that needs to be carried out before proceeding to the next step. The nine steps in the INTEGRATE Model are shown in the figure below.As described in the above figure, the resulting action model has five underpinning principles, five key processes, four action fields and a nine-step action cycle. These principles, key processes and steps are illustrated in the following sections.Key process I: Analyze connections between the problemssyndemic theory and ecological model, analysis of the connection between HIV/AIDS and NCDs can be conducted at three levels: Population, Problem and Individual levels.As it is the case for many other management functions, integration starts with understanding of HIV/AIDS and NCDs, more specifically the connections between them. Using the Step 1: Interrelate the magnitude and distribution of the problemspopulation level is essential to identify epidemiological overlaps between the problems. Evidence from population level overlap informs overall policy approaches and priorities. It also informs the need for a more detailed analysis. The magnitude of HIV/AIDS and NCDs can be interrelated at point in time , across time (in a time-series manner), across different geographic settings, and across different segments of a population. The interrelationships between patterns and trends of HIV/AIDS and NCDs across different dimensions could be explored using a cluster analysis, trend analysis and correlational analysis techniques.Interrelating the magnitude and distribution  of HIV/AIDS and NCDs at overlap between HIV/AIDS and Diabetes (considered as a prototype NCD) in developing countries, Diabetes was found to have higher prevalence and HIV was found to have higher disability-weight-adjusted prevalence. Diabetes had an increasing trend while HIV had a stabilizing trend. Countries with high diabetes prevalence tend to have lower HIV prevalence. Four clusters of countries were identified from the cluster analysis of the patterns in the prevalence of HIV/AIDS and Diabetes , six major pathways of linkage were found. These were direct cause-effect relationship, common underlying/background factors, lifestyle factors, treatment effects, common complications, and other disease conditions . Apart fStep 3: Testify individual level co-occurrence of the problemsThe third level in the analysis of the connections between HIV/AIDS and NCDs is their level of co-occurrence - (Comorbidity and Multimorbidity). This is analysis of individual level co-occurrence of the health problems. This evidence is important in planning and resource allocations. As most health systems in developing countries can’t afford to assign more than a single health care provider (team) to manage a patient with comorbidity and patients in those settings have the right to receive all the healthcare services they need from a single service delivery point, analysis of magnitude of co-occurrence of HIV/AIDS and NCDs is important to design effective strategies that can address the needs of multi-morbid patients.Perspectives, constructs, and methods in the measurement of comorbidity and multimorbidity are detailed elsewhere . In our Key process II: Examine the similarities and differences between responsesStep 4: Examine the similarities and understand the differences between response functionsAfter establishing the need for integrated response through analysis of connections between HIV/AIDS and NCDs, the next step is to identify eligible units for integration by examining similarities and differences between response functions. This step has four sub-steps.How health systems are responding to HIV/AIDS and NCDs? What constitutes a Health system response to HIV/AIDS and NCDs? What are the major processes/functions in a health system response? There are different classifications of the functions of a health system including the WHO Health system framework . Qualitative analysis of the similarities and differences between responses to HIV/AIDS and NCDs revealed four inter-related categories of functions .policy related functions, program related functions, institutional arrangement/coordination/ related functions, and strategic information related functions. Analysis of parallels and differences between the national responses to HIV/AIDS and NCDs yielded a fifth additional category which was labelled as management related functions. The functions under these major categories are shown in the table below.These were specialized and administrative functions get more converged. In the process of integration, these functions/processes are integrated to arrive at an integrated whole.The scope and details of the above functions would vary across the three levels of the health system: Strategic (Macro), Managerial (Meso) and Operational (Micro). When one goes upwards in a health system, programmatic/technical/functions get more Once the functions relevant for integration management are identified, the next step is to assess the relational similarities (and differences) between these functions. The basic question then will be ‘what parameters should be used to assess the similarities between response functions?’ These are the comparators, instruments for comparison. Below is a list of possible comparators. Although all these comparators may not apply to each and every function, the list is believed to include most of the relevant comparators.In a health system response to a HIV/AIDS and NCDs, it is possible for some functions to be more or less integrated than others. Though any set of functions can be assessed for degree of similarity and thus be eligible for integration management, the practice is common for parallel functions . The degree of similarity between response functions can be rated using either a dichotomous or a likert-type scale. Below is a five point likert-type scale for rating two functions using the parameters identified in the above steps. The scores can be summed up to get a single summary score.deliberative approach where a panel of experts, preferably from the concerned functions, deliberate on the similarities and provide an agreed up on score; 2) The investigative approach where an investigator assess the similarity between the functions and give a score based on the findings.Who should rate the similarities? We propose two approaches: 1) The In addition to the degree of similarity, the importance  of the similarities and differences between functions is essential for integration. Finally, the examination of similarities/differences should come up with short list of functions that can undergo the integration process.Key process III: Scan the health system environment for integrationStep 5: Glance over the Health system’s environment for integrationinternal environment – internal to the units to be integrated , the task environment , and the external environment .As integration happens in the real environment, the other major factor that is important for integration is the health system environment, the set of forces surrounding the health system that have the potential to affect the way it operates and its access to scarce resources. These include Acceptability of the level of integration by target users is also important. Other important elements are capacity for integration, external influences of different stakeholders on integration and the impacts of integration on important stakeholders.Among the prominent system factors in the context of developing countries is motivation among policy makers, health managers and providers for integration. Key process IV: Repackage evidence for integrationStep 6: Repackage and share evidence in a usable formsystem level and service level are different  integration, vertical  integration, horizontal (same level) integration, functional integration, clinical integration, and physician integration. In general, repackaging of integration related evidence should consider the audience, the content, the purpose and the method of communication.Key process V: Manage integrationStep 7: Ascertain the plan of integrationLevels of integration can be considered as parts of a continuum. There are several models of levels of integration that are developed based on health service integration . It is pPlan of integration that describes the components of responses are going to be integrated, the existing and the desired level of integration, the strategies to be used, the resource requirements, and the benefits and the risks of the integration. This will serve as a roadmap for the overall integration process. Assessment of local and global experiences and best practices relevant to the integration is essential. Communication and coordination (e.g. through consultative meetings with relevant stakeholders) is very crucial at this stage. Measurable objectives should be developed and agreed up on. Contextual factors, like personal preferences and urgency of the problem and interests of the various stakeholders involved may affect the planning and implementation integration. The required level of system integration will also depend on the type of interdependence  in the structure of the systems Gestational Diabetes screening in to HIV treatment/PMTCT HIV/AIDS, Diabetes, and Hypertension services in to a chronic disease clinic Leveraging HIV programs to support diabetes services Integrating smoking cessation in to HIV care -Integrating HIV/AIDS and Alcohol The selection of approach of integration depends of local contexts. For instance, policy integration of HIV/AIDS and NCDs can be realized in terms of one policy governing both HIV/AIDS and NCDs or a special policy guiding the integration of HIV/AIDS and NCD responses. Policy statements that support the integration of HIV/AIDS and NCD responses could also be included in both HIV/AIDS and NCD policy documents. Such policies/strategies could guide integration at program, management and information levels.Step 8: Translate the plan to actionThe action fields for Health system response are identified as policy response, programmatic response, institutional mechanism, and strategic information. The integration strategies to be used can vary based on both the action field and the desired level of integration. The common system level strategies in the implementation of health system integration include patient engagement and participation, well-developed performance management system, well-functioning information system, cohesive organizational culture, relationship development, right sizing and controlled growth, and sound financial management. The level, type and combination of strategies required are highly contextual and have to be geared towards better outcomes. System level integration may begin at any level. But it must extend to all other levels. Integration between two functions could be at the development of a plan, implementation of activities and at Monitoring and Evaluation of a program.Successful implementation of integration requires time, sufficient resources and a defined, multi-model intervention. A formal Strategic plan with measurable objectives, time lines, responsibilities, and outcomes is essential. Structural changes and resource sharing along with sufficient attention to relationships are required at all levels of a system. Flexibility of leadership is essential to adapt to the changes. Development and execution of strategies is progressive. Never expect to “finish” the integration – Integration is an on-going process .specialization barriers and political barriers. In contrast, mechanisms that facilitate the implementation of integration include standardization , direct supervision, coordinated planning, and mutual adjustment. The suitability of the mechanism of integration depends on task complexity and task interdependence  often refers to configuration. Integrated policies, integrated programs, integrated management, integrated organizational structures and integrated monitoring and evaluation systems are the outputs of strategic level integration. The changes in configurations are expected to reduce complexity but may increase connections. Configurations in most models of degree of integration consider a continuum extending from full segregation through a number of intermediate forms to full integration  and the achievement of the goals of integration (effectiveness). The change in performance of a system that could be attributed to the integration process is the effect of the integration. Accordingly, integration effectiveness can be measured at community, integration/network and organization levels  and allocative efficiency  (outcome) .Balanced Score Card (BSC). BSC is appropriate to evaluate both the implementation and impact of integration (clinical microsystem assessment tool (scale of functional integration which is validated for several forms of integration (The widely used measurement tool for integration is the egration . The secent tool . This toegration .Developing countries are facing a double-burden of HIV/AIDS and Noncommunicable diseases. As the intersection between HIV/AIDS and NCDs is significantly high, an integrated response can maximize synergy and improve efficiency of the responses. The need for integrated response is therefore clear.Integration is an iterative, dynamic and complex process. Using synthesis of evidence from various fields, we have developed an action model that could guide the integration of health system responses to HIV/AIDS and NCDs in developing countries. The model has 5 underpinning principles, 5 key processes and 9 steps. It could serve as a step-wise framework for systematic integration of health system responses to HIV/AIDS and NCDs in the context of developing countries. Although this model is prepared as an action cycle, users may use the steps out of sequence, as appropriate, depending on their context. The model can be a good basis for the development tools that could be used to operationalize the different steps stated in this model.This model is developed based on synthesis of best available evidence about integration of responses to HIV/AIDS and NCDs. The principles and the steps developed in this action model could be adapted to other disease conditions in similar contexts. This action model is conceptually enriched through a review of literature from different disciplines. However, it hasn’t yet been empirically tested. Besides, the steps in this model are stated as general guiding statement and are not operationalized in to specific tasks and activities.Therefore, we propose that future empirical work is needed to refine the validity and applicability the model. The model should also be translated in to tools that facilitate its application to meet the intended purpose. Further research work is also needed to refine this model.


Physical exercise is associated with reduced risk of heart disease, type II diabetes mellitus, and overall mortality. However, growing evidence shows that physical activity can also improve cognitive function and may lower the risk of developing dementia, but Randomized Clinical Trials gave mixed results. Aim of this article was to review the knowledge available in literature on the effects of physical activity on cognition and the suggested possible mechanisms involved in these effects. Our group have planned a trial aiming to evaluate the effectiveness of physical activity in preventing or delaying the cognitive decline in individuals at risk of developing dementia. Beside the effects of exercise on cognition are not fully defined, also the mechanisms underlying the benefits of physical activity on cognitive sphere are not completely known. Recently the SIRT1 loss is both closely associated with accumulation of beta amyloid and tau protein in AD patients. Although there is no specific exercise that can be recommended, the available evidence suggests that practicing more types of physical activity is particularly advantageous. It is important to explore further mechanisms involved in the pathogenesis of the AD in order to be able to identify new and effective target treatment, including physical activity. I.Physical exercise is associated with reduced risk of heart disease, type II diabetes mellitus, some types of cancers, and overall mortality  and beneAs cumulative neuronal loss is considered critical in the pathological process of the dementias , it has II.Exercise interventions in both healthy older adults , 23 and Verghese et al  reportedAlso Barnes et al  showed tIn contrast, Sink et al  recentlyThen starting by the evidences that still conflicting data are available in literature, our group have planned a randomized controlled (the Exercise and Prevention of Dementia [EPD]) clinical trial with the aim to evaluate the effectiveness of physical activity in preventing or delaying the cognitive decline in individuals at risk of developing dementia, namely in patients with subjective memory disorder or mild cognitive impairment (MCI), following the CONSORT recommendations. In particular, subjects older than 60 years old, consecutively admitted at the Centre for the Education and Research on Medicine for Aging (CERMI), after general and neuropsychological evaluation were randomized to undergo to active exercise or stretching. The intervention group consisted of subjects that performed aerobic controlled moderate exercise training, while the control group undergo only to stretching exercises. All study population were evaluated at 6, 12, 24, 48 months. Currently the statistical analysis is being carried out.III.Beside the effects of exercise on cognition are not fully defined, also the mechanisms underlying the benefits of physical activity on cognitive sphere are not completely known. Some studies indicate a positive correlation between exercise and hippocampal volume front . In addiRecently it was shown how the loss of SIRT1, the human homolog of Sir2, was closely associated with accumulation of beta amyloid and tau protein in the cerebral cortex of patients with Alzheimer’s disease (AD) . In factIn particular, in recent years the pathogenetic “neurocentric” hypothesis of the AD, focused mainly on the neuronal damage due to an excess of beta-amyloid, has given way to a more extended “neurovascular” hypothesis. This switch was caused by the evidence that an early vascular damage contributes to the development of the AD, and the observation that many risk factors associated with the development of AD are also known cardiovascular risk factors .In this context, it has been formulated the hypothesis that alterations of the adrenergic system, the important role of which on cardiovascular homeostasis is well known, may contribute to the pathogenesis of AD. In this sense, some evidences have showed that in course of AD the noradrenergic brain system undergoes several changes, and that in particular the stimulation of beta-adrenergic receptors is involved in the production of pathological amyloid in animal models ,48. ThisIn this scenario, physical activity may play an important role in the normalization of these molecular events, given its well-known ability to interfere favourably on adrenergic signalling in the cardiovascular system .Therefore, it is of fundamental importance to explore further mechanisms involved in the pathogenesis of the AD in order to be able to identify new and effective target treatment, including physical activity.IV.Although there is no specific exercise, which can be recommended, the available evidence suggest that practicing more types of physical activity, especially in a group, is particularly advantageous. To increase levels of physical activity in community, revitalization and other approaches, such as the establishment of local networks, including sports clubs, and appropriate interventions of public health are needed.


This extended editorial introduces the Special Issue on Suicide and Resilience in Circumpolar Regions, the results of the knowledge synthesis project by an international research team funded by the Canadian Institutes of Health Research and endorsed by the Arctic Council. It focuses on the extent and magnitude of the problem of suicidal behaviours and thoughts from a circumpolar perspective – the variation across Arctic States and their northern regions, the excess risk among some indigenous groups and their demographic characteristics. Much remains to be learned about the design and implementation of youth-focused intervention programmes, especially in a circumpolar comparative framework. Suicide among indigenous youth has emerged as a serious public health challenge in circumpolar regions over the past several decades. To date, the problem has shown no sign of abating, although much research has been done to understand its causes and various interventions have been attempted in many localities –3. A sigIn February 2011, Health Ministers and representatives from Member States of the Arctic Council signed the Arctic Health Declaration in Nuuk. It specifically pledged to “enhance mental health and prevention of substance abuse and suicide through exchange of experiences and good practices” . In 2014International Journal of Circumpolar Health presents results from the research by one of the international teams led by Susan Chatwood of the Institute for Circumpolar Health Research based in Yellowknife, Northwest Territories, Canada. The collection of papers include epidemiological analyses, a scoping review of existing interventions and a multiple case study of projects, programmes and policies in northern Canada, Greenland and northern Norway.This special issue of the IJCH has published articles on suicide prevention, including case studies and systematic reviews, as well as a special issue devoted to this topic in 2009.Over the years This introductory article to the current Special Issue sets the scene by describing the magnitude and extent of the problem from a circumpolar perspective, with special focus on the indigenous populations.First a methodological note: When comparing suicide rates , the statistical procedure of age standardization is used. It ensures that the rates are comparable across populations with widely different age structure and where certain age groups are more prone to the health problem than others. Different “standard populations” can be used. When comparing all circumpolar regions as in  and 2, tSuicide in Russia and its regions rose and peaked in the latter half of the 1990s, which appears to correspond to the substantial social and economic dislocations of the early post-Soviet era. However, the rates in Chukotka outstripped that of other regions, especially among women .Among the circumpolar Inuit, the increase in suicide rates occurred first among Alaska Natives, later in Greenland, and still later in the Nunavik and Baffin regions in the eastern Canadian Arctic , with eaIn a jurisdiction where mortality data can be segregated by ethnicity/race, as in Alaska, the excess risk of suicide in the indigenous population is clearly evident . BetweenAmong Canadian Inuit, the excessive risk of suicide is present in all 4 Inuit regions, and in both males and females . Over thThe only study on an indigenous group in Arctic Russia – the Nenets in the Nenets Autonomous Okrug in northwestern Russia – also showed a higher mortality than non-Nenets in the region . In YakuEthnic identity is not recorded in health and social databases in the Nordic countries. Information on suicide among the Sami is derived from studies where Sami identity among study participants was specifically determined based on a variety of linguistic, genealogical and socio-political criteria. Regional Sami cohorts have been assembled in Norway  coveringUnlike other health indicators, where disparities between Sami and non-Sami are very small or non-existent , there iFirearms and hanging tend to be the method of choice for suicide among indigenous people in the Arctic,15. TheSuicide is predominantly a phenomenon among men in the Arctic as elsewhere. The age–sex pattern of suicide among the Nenets in Russia is similar to that observed in other Arctic populations  Fig. 6)Fig. 6). For every successful suicide, there are many more suicide attempts, and for every suicide attempt there are numerous people harbouring suicidal thoughts –19. The The Survey on Living Conditions in the Arctic (SLiCA) among indigenous people in several regions  providesIn Canada, preliminary data from the Inuit Health Survey conducted in 2007–2008  found thThe female preponderance among those who had suicide thoughts and suicide attempts in Arctic populations is similar to that observed in other populations globally.Suicide intervention programmes come in different shapes and forms, and may range from individually focused actions such as helping those who attempt suicide, identifying and treating depression, and reducing substance use, to broader legislative actions such as those controlling firearms availability. Programme evaluation to demonstrate any measurable effect in reducing suicidal behaviours or long-term impact has rarely been performed or published, as will be made clear in the scoping review by Chatwood and colleagues in this Special Issue. The Hope and Resilience Conference presented examples of local initiatives in Alaska, Canada, Greenland and Norway . Young pEfforts need to be directed at the entire community, especially in identifying resilience and protective factors, and not only focusing on individuals who are at risk. Political self-determination is often held out as a panacea for health improvement, yet the world's highest youth suicide rates occur in Greenland and Nunavut, 2 jurisdictions where indigenous people have advanced the furthest towards self-government. Such issues are often not on the mind of youths contemplating suicide. Studies and workshops have shown that adults may identify boredom as the main reason for suicide, and the solution would be programmes offering recreational activities, job training and strengthening traditional culture. In contrast, youths may attribute suicide to stress and emphasize the need for meaningful everyday communication and interaction, more attentive parents and less alcohol abuse. There is still much to be learned about the design and implementation of youth-focused intervention programmes. It is hoped that this Special Issue will provide the impetus towards such efforts.


It is important to enhance the return to work of cancer survivors with an appropriate intervention, as cancer survivors experience problems upon their return to work but consider it an essential part of their recovery.The objective of our study was to develop an eHealth intervention to enhance the return to work of cancer survivors and to test the feasibility of the eHealth intervention with end users.To develop the intervention we 1) searched the literature, 2) interviewed 7 eHealth experts, 3) interviewed 7 cancer survivors, 2 employers, and 7 occupational physicians, and 4) consulted experts. To test feasibility, we enrolled 39 cancer survivors, 9 supervisors, 7 occupational physicians, 9 general physicians and 2 social workers and gave them access to the eHealth intervention. We also interviewed participants, asked them to fill in a questionnaire, or both, to test which functionalities of the eHealth intervention were appropriate and which aspects needed improvement.Cancer survivors particularly want information and support regarding the possibility of returning to work, and on financial and legal aspects of their situation. Furthermore, the use of blended care and the personalization of the eHealth intervention were preferred features for increasing compliance. The first version of the eHealth intervention consisted of access to a personal and secure website containing various functionalities for cancer survivors blended with support from their specialized nurse, and a public website for employers, occupational physicians, and general physicians. The eHealth intervention appeared feasible. We adapted it slightly by adding more information on different cancer types and their possible effects on return to work.A multistakeholder and mixed-method design appeared useful in the development of the eHealth intervention. It was challenging to meet all end user requirements due to legal and privacy constraints. The eHealth intervention appeared feasible, although implementation in daily practice needs to be subject of further research.Dutch Trial Register number (NTR): 5190; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5190 (Archived by WebCite at http://www.webcitation.org/6hm4WQJqC) Due to the improved survival rates for cancer in recent decades , remainiResearch done over the past 10 years has indicated that cancer survivors are more likely than cancer-free controls to be unemployed ,3 and thAn overview of the outcomes of these above-mentioned intervention studies, as well as studies of factors predicting the return to work of cancer survivors, led to the following main insights. First, it is both feasible and appreciated by cancer survivors to address the issue of return to work in an early stage of psycho-oncological cancer care ,9, althoBased on the assumption that information and support need to be tailored to the individual, a stepped-care eHealth intervention may be a suitable solution. Other advantages of eHealth interventions include that they are easy to access and to tailor to the individual, both of which are important, as information on the Internet can be overwhelming . FurtherBased on all of the above-mentioned findings, we decided to develop an intervention that would be part of psycho-oncological care and be based on the theory of self-management and integrative care management. We decided to deliver the intervention as stepped care through eHealth. In this paper, we report on this process, specifically addressing the above-mentioned challenges to eHealth interventions, including noncompliance.The objectives of this study were to develop an eHealth intervention to enhance the return to work of cancer survivors and to test the feasibility of the eHealth intervention with end users.We sought ethical approval to interview cancer survivors, employers, and occupational physicians, as well as approval for the feasibility study, from the Medical Ethics Committee of the Academic Medical Center, Amsterdam, the Netherlands, which judged that ethical approval was not required for either of the 2 studies (METC number W13_028 and W13_122). Participants (with the exception of experts) gave either their oral or written informed consent before the interview took place, or their written informed consent before participating in the feasibility study. We executed the following steps for objective 1 .We conducted a stepwise development of the intervention . We deveOur literature search was focused on self-management, integrative care management, stepped care, and eHealth in a nonsystematic manner. The aim of this search was to retrieve input on relevant intervention content and input on how to deliver the intervention. We restricted our search to MEDLINE, searching the trial register for relevant interventions. The search was carried out between March and May 2012. We completed a search for each topic using the main text words: “cancer,” “absenteeism,” “self-management,” “eHealth,” “interdisciplinary communication,” and “stepped care,” complemented with synonyms. We also searched references from relevant studies. The results of our search were analyzed on the basis of a written account of the relevant intervention content and relevant information on how to deliver the intervention.Several studies described self-management interventions that aimed to improve individuals’ skills and confidence, helping them deal with their disease more effectively in daily life . ResearcA few studies have tried to enhance collaboration between primary and occupational health care, but the level of effectiveness is still inconclusive. Some studies have shown positive results with respect to feasibility  and effeIn a stepped-care intervention, all patients start with a low-intensity intervention, with the intensity increasing only if an intervention goal is not achieved at a certain point in time . The adSeveral eHealth intervention features are related to enhanced patient compliance: peer and counsellor support, email and phone contact, updates, record keeping, and individualized feedback ,34. FurtWe approached approximately 10 experts based on the fact that they had recently developed an eHealth intervention for cancer survivors or an eHealth intervention aimed at increasing return to work of sick-listed employees. The first author (ST) undertook semistructured interviews based on a topic list. This list consisted of questions on 1) how to deliver an eHealth intervention, 2) features required to increase compliance with eHealth interventions, and 3) tips and tricks for developing an eHealth intervention. The interviews were held in August 2012. They were not audiotaped but the first author (ST) provided a written summary of the most important issues mentioned during the interview.In total, 7 eHealth experts were interviewed with the aim of 1) gaining input on how to deliver the intervention, 2) gathering tips and tricks for developing an eHealth intervention, and 3) determining features that increase compliance. These eHealth experts reported that the following elements were required to deliver an eHealth intervention: choose a modular or a structured form; and use a combination of text, film, and pictures. The following additional features that increase compliance with eHealth interventions were also suggested: sending reminders, and using blended care with a health care professional. Finally, the experts also noted that what was most important when developing an eHealth intervention was 1) to consider, before starting, what type of “track and trace data” would be required to study use and compliance, and 2) to consult an information technology expert at the beginning of the development of the intervention because they can give advice at an early phase about the functionalities that are possible given financial and practical constraints. As return-to-work trajectories vary across patients in terms of length  and needThis first draft of the eHealth intervention consisted of access to a personal, tailored, and secure website containing various functionalities for cancer survivors, blended with support from their nurse, occupational physician, and employer . We presCancer survivors were eligible to participate if they had been working at the time of diagnosis, were fluent in Dutch, and were aged between 18 and 65 years. Occupational physicians and employers were eligible to participate if they had recently encountered an employee with cancer and were fluent in Dutch. We intended to interview 10 cancer survivors, 5 employers, and 5 occupational physicians. The first author (ST) undertook semistructured interviews after the interviewees had been given a rough outline of the first draft of the intervention. They were asked whether this first draft accorded with their needs and whether they thought the design was the most appropriate to deliver the intervention. The interviews were held in March 2013; they were audiotaped but not transcribed verbatim. We analyzed the interviews using a direct content analysis  in orderIrrevocable, and assignments providing insight into the individual importance of work  draft a “tone of voice document,” which reflects the key values of the intervention, and on the basis of which the text is written, 2) to write clear and concise sentences without ambiguity, and 3) to develop the website in such a way that it is personal, for example, by using quotes from former cancer survivors that include their name, age, and occupation. The key values for this intervention were reliability, activating, personal, confrontational, serious, and directed to work and income. The design expert showed us that it is essential to match the design of the website with the tone of voice and Web text. Based on the tone of voice we wanted, the design expert created style sheets . After cBased on consultations with these experts, we built a first version of the eHealth intervention, consisting of access to a personal and secure website containing various functionalities for cancer survivors blended with support from their nurse, and a public website for occupational physicians, general physicians, and employers . FunctioAfter developing the first version of the intervention, we tested its feasibility by interviewing 1) cancer survivors, 2) employers, occupational physicians, and general physicians, and 3) social workers. All of the interviews discussed below were audiotaped but not transcribed verbatim. We intended to interview 40 cancer survivors, 10 employers, 10 occupational physicians, and 10 general physicians. We analyzed the interviews using a direct content analysis  in orderTo test the feasibility of the intervention for cancer survivors, 1) we invited cancer survivors who had taken part in previous research by our department and who had given their consent to be approached in future research on cancer and work, and 3) the treating physician also invited cancer survivors who were treated between 2012 and 2014 in the department of gynecological oncology of an academic medical center. Cancer survivors were eligible to participate if they had been working at the time of diagnosis, were fluent in Dutch, and were aged between 18 and 65 years. The patients were sent an informative letter about the study. If interested, they could return a consent form agreeing to telephone contact, whereupon 1 of the researchers contacted the patient by phone. During this conversation they could ask questions and decide whether they wanted to participate.We used the following criteria to assess feasibility: 1) appropriateness of each functionality, 2) which functionalities needed improvement, 3) usefulness of the eHealth intervention, 4) user friendliness of the eHealth intervention, and 5) whether the eHealth intervention met their expectations. We considered the eHealth intervention feasible when at least 50% of the patients responded positively to each criterion.After patients gave their informed consent, they filled in a questionnaire on their expectations of the intervention  and their need for support regarding their return to work . After completing the questionnaire, they were given access to the eHealth intervention for 6 weeks, after which they filled in another questionnaire about the usefulness and user friendliness of the intervention  and whether the intervention met their expectations  meet my expectations because...”). All of the participants who filled in both questionnaires were invited to participate in a telephone interview by 1 of the researchers (SvH) to potentially gain greater insight into the answers to the questionnaire and to ask whether they had any further suggestions to improve the eHealth intervention and its functionalities. These interviews were held in June 2015. Based on these interviews, we developed a final version of the eHealth intervention for cancer survivors.Of the 177 cancer survivors invited to participate, 39 (22.0%) filled in the first questionnaire, while 20 filled in the second questionnaire (each participant was contacted by phone to remind them to fill in the questionnaire). We used the data of the 20 participants who filled in both questionnaires for our analysis. In total, 11 participants (55%) used the eHealth intervention. The other participants did not use the intervention either because they forgot to log in or they did not have any problems at work and thus did not feel the need to use the intervention. All of the 20 participants were invited for a telephone interview and 11 participated. The other 9 participants did not participate because of time constraints, practical issues, or lack of interest. During the interviews, the participants were positive about the intervention and its functionalities. They proposed several ideas to improve the intervention, such as making it easier to log in by using less-complicated passwords or not using text message authentication, or to make the intervention accessible for vision-impaired people by making it possible to enlarge the size of the text or to have the text read aloud. For an overview of all of the ideas that were proposed to improve the intervention, see Employers were eligible to participate if they had recently encountered an employee with cancer, while occupational physicians and general physicians did not need to have recent experience with a cancer patient or the associated work-related problems. All of the participants had to be fluent in Dutch. After giving informed consent, participants visited the eHealth intervention website designed for their respective profession and then participated in a semistructured interview to gather information on participants’ experience with the intervention, its usefulness, and its user friendliness. The interviews were conducted in January and February 2015 by 1 of the authors (SvH) and they were audiotaped but not transcribed verbatim. Based on these interviews, we developed a final version of the intervention for employers, occupational physicians, and general practitioners.In total, 9 employers, 7 occupational physicians, and 6 general physicians participated in the interviews. For a full overview of the ideas that were mentioned, see When asked about the user friendliness, design, and practical usefulness of the intervention, almost all of the participants indicated that the intervention was easy to use , that the design matched the content and purpose of the website , and that they would recommend this intervention, for example, to their friends or colleagues if they had to deal with an employee, client, or patient with cancer . Thus, we made no changes regarding these aspects in the final version of the intervention see .We asked 2 social workers from a gynecology department of a Dutch hospital who had experience supporting cancer survivors in their return to work to visit the section of the eHealth intervention for specialized nurses and to participate in a semistructured interview with 1 of the authors (SvH). Based on this interview, we developed a final version of the section of the eHealth intervention for specialized nurses.A total of 2 social workers participated in 1 interview, on the basis of which we added information on financial and legal issues to the final version of the intervention in order to provide specialized nurses and social workers with access to the same information as that provided to the patients they are supporting . In thisThe objectives of this study were to develop an eHealth intervention to enhance the return to work of cancer survivors and to test the feasibility of the eHealth intervention with end users. The results of our development study show that cancer survivors particularly want to receive information and support on opportunities to return to work, and on the financial and legal aspects of their position. Furthermore, we found that the use of blended care and the personalization of the eHealth intervention are preferred features for increasing compliance. The results of the feasibility study showed that the eHealth intervention was feasible; however, we adapted it slightly by adding more information on different types of cancer and its treatment and on the possible effects of these on the return to work.The strengths of our study include the use of a multistakeholder and mixed-method design to develop our eHealth intervention. In this way, the content, design, and delivery of the eHealth intervention could best fulfill the needs of the end users and be the most suitable option to achieve the intervention goal, given Dutch law and our framework of psycho-oncological care. This also ensured that the risk of a type III error  was minimized .We did not test the feasibility of the eHealth intervention in precisely the same conditions under which the intervention is intended to be used, as the feasibility study among cancer survivors was a prospective cohort study, with a short follow-up period of 6 weeks, that started on average 3 years after diagnosis, while the eHealth intervention is intended to be used from the initial cancer diagnosis until sustainable return to work. As a result, we are unable to draw firm conclusions about the usefulness of the content of the eHealth intervention, the features that enhance compliance, and the features that enhance integrative care management. We have partly overcome this drawback by consulting the literature, and interviewing experts and end users under our first objective. However, implementation of the eHealth intervention in daily practice should be the subject of further research. We were able to test the appropriateness of all the functionalities and the user friendliness, the usefulness, and the design of the eHealth intervention, for which we found positive results, so that the criteria for feasibility were met.The employers, occupational physicians, and general practitioners who participated in the interviews and feasibility study were generally very interested in this subject for personal reasons, for example, as a cancer survivor. This was very useful for generating ideas about the content of the eHealth intervention, but it might have led to an overestimation of its future use by other members of their profession in daily practice. Implementation in daily practice should, for this reason, also be the subject of further research.Cancer survivors, employers, occupational physicians, general practitioners, and specialized nurses were generally positive about the eHealth intervention. Not surprisingly, occupational physicians saw the least added value of the eHealth intervention for their own profession, as they thought that they were already applying the content in their daily practice. However, in their experience, they believed that employers would particularly benefit from the content, as they rarely have to deal with an employee with cancer, and cancer remains a difficult topic to address in the workplace ,39. We aAlthough 97% of Dutch society has Internet access , InterneDue to legal regulations, we were obliged to add a disclaimer to two functionalities explaining the risk of using each of them and suggesting a more secure alternative, for example, in relation to inviting their employer, occupational physician, or general practitioner to view personal information via an email. The use of email is generally not considered a secure way to exchange information if you wish to keep the information completely confidential. Although we fully agree that it is our responsibility to inform patients about any possible harm, such warnings might cause unnecessary concern and discourage them from using the eHealth intervention at all, which might lead to otherwise preventable dropout. We therefore recommend that researchers engage the services of a legal adviser from the start when developing an eHealth intervention.The process evaluation of the study by Bouwsma et al , which iOne subject of further study should be the feasibility of the eHealth intervention in daily practice, and such a study should especially focus on the functionalities aimed at increasing compliance and integrative care, as we were unable to study them this feasibility study. In addition, the effectiveness of the eHealth intervention on a sustainable return to work should also be further studied, and the intermediate effect of the eHealth intervention on self-management skills and work-related self-efficacy should be analyzed . We are studying both of these in a multicenter randomized controlled trial.A multistakeholder and mixed-method design appeared useful in the development of the eHealth intervention. However, it is challenging to meet all end users’ requirements due to legal and privacy constraints. The eHealth intervention appeared feasible, although implementation in daily practice requires further research.