Access to facilities, services and socio-economic opportunities plays a critical role in the growth and decline of cities and human settlements. Previous attempts to explain changes in socio-economic indicators by differences in accessibility have not been convincing as countries with highly developed transport infrastructure have only seen marginal benefits of infrastructure improvements. Australia offers an ideal case for investigating the effects of accessibility on development since it is seen as home to some of the most liveable cities in the world while, at the same time, it also has some of the most isolated settlements. We investigate herein the connectivity and accessibility of all 1814 human settlements (population centers exceeding 200 persons) in Australia, and how they relate to the socio-economic characteristics of, and opportunities in, each population center. Assuming population as a proxy indicator of available opportunities, we present a simple ranking metric for a settlement using the number of population and the distance required to access all other settlements (and the corresponding opportunities therein). We find a strikingly unequal distribution of access to opportunities in Australia, with a marked prominence of opportunities in capital cities in four of the eight states. The two largest cities of Sydney and Melbourne have a dominant position across all socio-economic indicators, compared to all the other cities. In general, we observe across all the settlements that a decrease in access to opportunities is associated with relatively greater socio-economic disadvantage including increased median age and unemployment rate and decreased median household income. Our methodology can be used to better understand the potential benefits of improved accessibility based on infrastructure development, especially for remote areas and for cities and towns with many socio-economically disadvantaged population. Accessibility generally describes “the degree to which a product, device, service, or environment is accessible by as many people as possible” , or, froRemoteness can be defined as the inverse of relative accessibility. The concept of remoteness, and hence accessibility, is an important dimension of policy development in Australia. Access to available services and opportunities is a major issue ,12 becauLack of adequate infrastructure hinders access to markets ,15. In sWhen a government prioritizes the socioeconomic development of a given area, it typically invests to build new transport infrastructure. For instance, to link the dispersed populations and remote businesses of Northern Australia, the Australian Government is establishing a $5 billion infrastructure plan to provide loans for the construction of major infrastructure , with an additional $600 million for constructing new roads . HoweverBefore investing heavily on infrastructure development, the important questions to address are: (a) to what extent the access to services exist in those remote areas related to the more developed regions, and (b) what are the prevailing impacts of such differences?-2 whereas global average for desert area population density was around 24 persons km-2.Australia offers an ideal case for investigating the effects of such inequalities in regional development and accessing opportunities as it has some of the most liveable cities in the world  , and, atThe role and impact of transport infrastructure in regional development are not clear, and sometimes the direction of causality is questionable . PreviouUnderstanding the effects of inequality in accessing opportunities in Australia now may have lessons for other places and the world at large in the future. In 2014, 54 per cent of the world’s population was living in cities. The compounding urban agglomeration effects point to a projection that 66 per cent of the world’s population will be living in cities by 2050 . As a reThis paper presents an overall picture of the connectivity and accessibility of all human settlements in Australia, ranked nationally and by state, and relates their accessibility rating to the socio-economic characteristics of each community. This is an important step towards a more explicit or expansive consideration of the influence of improving accessibility and prioritizing transport infrastructure investment into towns and communities that are relatively more socioeconomically disadvantaged than others.Ai is the accessibility of region i; L is the service center category of region j to be reached from region i; Wj is the measure of opportunity/activity, here the size of population to be reached in region j from region i; dij is the distance to be covered to go from i to j; L , in Australia . Accessibility has been a well known concept in regional science and has various formulations ,12,23–25tegory L . The negthat the nearby places have greater influence than the remote ones, andthat the areas will be treated differently by its service center category and categories with greater average distance generally implies less number of those service centers but having greater influence .This accessibility index was selected because:We want to reflect the amount of opportunities and services available in different regions which are currently measured by populationWe want to look at the influence of not only the nearest region but all regions. But since with increasing distance the influence tends to decrease, we use an exponential function to penalize regions with longer distance. In other words, nearby regions have higher influence than the remote ones.We want to differentiate the influence of different types of regions. Hence, we categorize all the regions by the type of service centers and use the mean distance for that type of service center in the exponential function. In particular, we use the ratio between the distance of a region and the mean distance from all the regions to the nearest region of that particular type.First, we present a general picture of the connectivity of different UCLs with road networks. Figure A in The spatial distribution of the accessibility values of the UCLs are shown in We then create a ranking analysis of the UCLs based on their accessibility values. For ranking purpose, we normalize the accessibility values in a scale from 0 to 100. We consider the highest value for the accessibility index as 100  and compute the accessibility values of other UCLs as follows:Among different Australian cities, Sydney, Melbourne and the UCLs around them have very high accessibilities (above 80). Newcastle, Geelong, and Canberra have high accessibilities (60 to 80). Brisbane, Gold Coast, Sunshine Coast and the UCLs around them have moderate accessibilities (40 to 60). Adelaide and Perth and the UCLs around them have low accessibilities (20 to 40). Cities such as Townsville, Cairns, Hobart, Darwin and the UCLs around them have very low accessibilities (below 20).In order to assess the socio-economic impacts of the unequal access to opportunities across Australia, we correlate different variables including median age, median household income, median rent, median mortgage repayment, unemployment rate and the Socio-Economic Indexes for Areas (SEIFA) of the UCLs with the corresponding accessibility values. SEIFA is developed by the Australian Bureau of Statistics (ABS) to rank areas in Australia according to relative socio-economic advantage and disadvantage . The SEIIntuitively, the consequence of unequal access to services and opportunities will also be reflected in income distribution. But as we plot median household weekly income against the accessibility values in A significant portion of household income is spent on rent or mortgage repayment. Access to opportunities should have an important influence on unemployment rates. The Socio-Economic Indexes for Areas (SEIFA) set indicates the socio-economic conditions of an area created using census data. There are four SEIFA indexes available for analysis:The Index of Relative Socio-Economic Advantage and Disadvantage (IRSAD)The Index of Relative Socio-Economic Disadvantage (IRSD)The Index of Education and Occupation (IEO)The Index of Economic Resources (IER).Each index is a summary of a different subset of census variables and focuses on a different aspect of socio-economic advantage and disadvantage. We plot these 4 SEIFA indexes of the UCLs against their corresponding accessibility values. dragon kings [Our analysis of the relative accessibility of all the significant human settlements in Australia provides a better understanding of the hierarchical ranking among Australia’s cities and towns, and how these relate to socio-economic development factors. It shows the dominant position of its two largest cities, Sydney and Melbourne, across all performance indicators, compared to all the other cities, in support of the concept of on kings ,28, likeon kings . This hion kings ,30. Our on kings ,32, incoon kings , prefereon kings  and highIn relating the accessibility values of the UCLs with their socio-economic characteristics, we observed the following:There is an increasing trend of accessibility values originating from the eastern coast cities, particularly, from Brisbane, Sydney, and Melbourne. A similar pattern is observed in Western Australia with Perth as the source of the trend.There is a strikingly unequal distribution of the access to opportunities in Australia. Unlike the south-eastern and the south-western regions, there such a trend is not observed in Northern Australia. Investing in road infrastructure in Northern Australia could start a similar trend of increasing accessibility from a major city center (such as Darwin) potentially leading to improvements in socio-economic development and feeding the growth pattern in the region. The assessment of such development options should, however, be undertaken balanced with their potential impacts on the environment and/or ecological services.Unequal access to opportunities has a strong association with socio-economic characteristics, particularly for the dispersed and remote areas. With decreasing accessibility, median age and unemployment rate tend to increase and median household income tends to decrease.island effect in Australia’s regional development. Regional cities/towns benefit from the services and opportunities available to the nearest major capital cities  of investment (or investment options) on infrastructure, and/or in identifying what investment is needed to stimulate regional development . This is particularly relevant to its stated vision of developing the communities, economies and businesses in Northern Australia. First, our results  especialS1 File(DOCX)Click here for additional data file.S2 File(CSV)Click here for additional data file.


Practice-based learning and improvement is one of the six core competencies listed by the Accreditation Council for Graduate Medical Education (ACGME) for residency programs . ACGME defines practice-based learning and improvement as "an ability to investigate and evaluate the care of patients, appraise and assimilate scientific evidence, and continuously improve patient care based on constant self-evaluation and life-long learning".Autopsy has long been recognized as an important tool for learning and quality improvement in clinical practice. Physicians often utilize autopsy findings for evaluating the accuracy of their clinical diagnosis, identifying any unsuspected conditions, and establishing a cause of death. To reiterate the importance of autopsy in medical education, we performed a study through a retrospective chart review of 141 autopsies conducted at our institution between January 2011 and May 2015. We measured the level of agreement between the clinical cause of death established by the treating clinician and the cause of death listed by the pathologist after autopsy using Kappa coefficients. We found there was poor agreement between the clinical and autopsy diagnosis, especially among cases of pulmonary embolism and liver cirrhosis, while there was moderate agreement among cases of myocardial infarction. Our findings were consistent with the available literature.Despite the well-established role of autopsy in learning, institutions have failed to establish it appropriately into the medical curriculum. Hence, the autopsy rates have declined significantly in the past few decades. According to Hull and colleagues, the current autopsy rate is approximately 5% at community hospitals and 10% at academic hospitals, which is far less than approximately the 70% rate at teaching hospitals in the 1960s.,In academic institutions, residents are closely involved in patient care and have an opportunity to secure consent from a patient's family for an autopsy. Based on our experience and studies in the literature, it is evident that residents lack skills and knowledge for requesting an autopsy. For example, studies on resident perception of autopsy importance and procurement showed that both internal medicine and pathology residents agree that autopsies are an important learning tool, but feel they do not have adequate knowledge and skills about the requisition process and technical aspects of an autopsy.We realize there is an unmet need for training and educating residents about the autopsy process and implementing measures to improve autopsy rates. In order to assess feasibility of introducing a program, we analyzed the number of monthly autopsies conducted at our hospital for five consecutive years. We found there is a high likelihood that each resident would be a part of this learning experience at least once during their 3-year residency period. Additionally, since each resident is required to complete an intensive care unit (ICU) rotation every year, there is ample opportunity to complete this exercise.Since building teams for practice-based learning are part of our residency curriculum, the critical care fellow, senior resident, and interns (first-year resident) rotating in the ICU would be responsible to complete an online training before starting the rotation. The training would address the difference between a usual case and coroner case along with how to communicate with the coroner's office. Furthermore, each resident will learn how to introduce the autopsy consent form, discuss the goals of life and end-of-life decisions with the patient's family, break the bad news at the time of demise, obtain consent for autopsy from family members, and educate the families about the process and technical details of an autopsy. After completion of the autopsy, residents would be required to fill out an Autopsy Self-Reflection Forms, in which the resident would document his or her learning experience from participating in the autopsy process. This would include comments from the resident explaining specific points learned from the autopsy that added to the resident's medical knowledge and clinical experience. In addition, the resident can suggest what could have been done differently in the future to improve outcomes. These forms would be included in the portfolio of the resident and evaluated by the program director at the end of the year to assess resident performance. We believe that implementing these measures in the residency curriculum will be a substantial resource for learning and self-reflection for residents, will provide evaluators with a tool for assessing practice-based learning and improvement competency, and will also increase autopsy rates at our institution.Through the development of the Autopsy Learning Module, we learned that in addition to clinical experience, house staff should be given an opportunity to self-reflect on the patients they care for during their training. Furthermore, we have understood that self-reflection resonates within the resident and has a positive effect on their life-long learning practices.While resident physicians are in strategic positions to interact with patient families, they often lack the prerequisite skills and experience in the autopsy consent process, which may lead to poor self-assurance. The Autopsy Learning Module allows residents to actively participate in the autopsy process. Through this experience, residents gain confidence in both securing consent from families and communicating with the coroners and pathologists. In addition, a completed module allows program residency directors the tangible means to assess a resident's competency in practice-based learning and improvement.The authors declare that they have no conflict of interest.


The Greek Taxon Information System is an initiative of the LifeWatchGreece Research Infrastructure (ESFRI) that is resuming efforts to compile a complete checklist of all species reported from the Greek territory. Such an effort is necessary as a requirement for all signatories of the Convention on Biological Diversity (Greece is a signatory since 1994). Over an estimation published in 2004 according to which 50,000 species are present in Greece, belonging to most kingdoms except bacteria and viruses, a list of 35,000 valid species (and subspecies) has been assembled from previous national and European initiatives and specialized databases on various groups. A new database will be progressively set up in the LifeWatchGreece Infrastructure within the near future. Before the dissemination of this dataset, it is important that the checklists will be validated by specialists for each taxonomic group. The first step already accomplished was to build and publish Preliminary Checklists for some taxonomic groups of marine fauna, which have been validated by specialists on the basis of their expertise and secondary literature. The publication of these Preliminary Checklists is expected to increase the visibility and usability of the database in the future not only to the scientific community but also to the broader domain of biodiversity management, especially in cases where no such checklists have been published yet. The guidelines used to test the first taxonomic groups are presented in this paper.Biodiversity, global species databases, biodiversity management, data managementLWG) aims at building a research e-infrastructure for biodiversity data  including data from observatories, which is composed by a suite of electronic services (e-Services) and virtual laboratories (vLabs). Data will cover the terrestrial and freshwater life zones of Greece, while data for the marine life zone will cover the entire Mediterranean Sea. A portal is providing access to data and to the e-Services and vLabs. Like in all biodiversity information systems, a taxonomic backbone is essential . The project was set up in MS-Access and included approximately 23,000 taxa. With the addition of 3,500 marine species and using extrapolations, it was calculated that the total number of animal species reported from Greece would reach 40,000-50,000 species  led by A. Legakis, as the Editor-in-Chief. Although GTIS does not form a formal follow-up of the previous projects, as it uses advanced methodologies and procedures, the data content is primarily based on them. A new database in PostGreSQL will be set up as an application in the LifeWatchGreece Portal, and some parts of the content will be also disseminated as a Scratchpad. The "Greek Biodiversity Database" did not meet these conditions of sustainability . The next step will be to elaborate Annotated Checklists based on primary literature including all comments about the taxonomy and the status of occurrence in Greece.Ascidiacea, Brachiopoda, Cephalopoda, Chaetognatha, Cumacea, Lophogastrida, Mysida, and Porifera) and will be applied for the future lists in the taxonomic scope of the GTIS . A number of Preliminary Checklists will be published within the present LifeWatchGreece online collection of papers in Biodiversity Data Journal. Specific details will be added in each checklist paper by taxonomic group. Some groups are already covered by recent annotated checklists  and will not be the subject of a Preliminary Checklist, but they will be included in the database with the proper bibliographic reference. This work also suggests that this type of publications is still needed to support the correct citations of databases.This paper presents the main guidelines and workflow for the production of the Preliminary Checklists. They have been currently tested on some marine taxonomic groups  and for the ce WoRMS  for the In total, only 7 scientific publications cited the Greek Biodiversity Database since 2010 indicating that stable paper-published references are still needed for crediting information systems in addition to the website itself.The geographic area covered Fig.  is compoThe Preliminary Checklists were plugged into the classification of Creation of the listAlgae, FishBase " was secondarily used for further dissemination, and will be integrated subsequently in the LifeWatchGreece Portal. The Greek Biodiversity Database was managed under MySQL as the back-end of the Content Management System Drupal. The new database is currently managed locally under MS-Access and will be eventually moved to the LifeWatchGreece infrastructure under PostGreSQL. The technical details of the database structure will be detailed in a further paper.The species and name lists were firstly stored in a relational database used for construction and validation. A scratchpad entitled "Species List of Greece . As far as possible, feed-backs were sent to the managers of those databases when issues were raised during the comparisons.The followed classification below order rank was checked against reference databases such as Taxon names and their authority were matched against and corrected from the reference databases. Non-accepted names were kept in our internal database when they were used to report a species in Greece in a scientific publication but were not listed in the Preliminary Checklists.References reporting species presence since 2000 were also researched (previous available checklists and new records). These were published in (a) the reference database for animals assembled by the Zoological Museum of the University of Athens and the Hellenic Zoological Society , (b) GreOccurrences from Greek geographic areas were also searched in Global Species Databases which provide distribution data by country. However, point data with geocoordinates were not reported in this Preliminary Checklist step.Validationsensu stricto. In cases of lack of a national expert we invited international taxonomists to examine the lists in collaboration with Greek colleagues who could follow up and continue their updating in the future. Specialists who validated the checklists will be main authors of the respective published lists and cited as taxonomic editors for every record in the database as well.Individual checklists were exported from MS-Access as worksheets in MS-Excel files: one with the species list itself, one with the main relevant and potentially useful references. The files were sent to specialist taxonomists for a thorough examination of the lists for possible errors and omissions, with a request for relevant secondary literature. Several rounds of "listing – validation – corrections/additions" were sometimes needed until Preliminary Checklists were considered validated. For most taxonomic groups, we consulted Greek colleagues with a particular expertise in the fauna or flora of Greece, even if they were not taxonomists VocabularyStatus of occurrence in the countryThe following terms are used in the database and the Preliminary Checklists for the status of occurrence of species:Present (including non-indigenous species recorded in Greece);Possible: this term can be used for doubtful reports , or for species present in Europe/Mediterranean but not reported in Greece so far;Absent for mistaken records and misidentifications included in previous databases or publications. All species wrongly reported from Greece will be stored in the database as mistakes so that such errors will not be disseminated anymore.Reported - recordedThroughout the initiative, we will use the following terms consistently:Reported: a species observed or collected in the country’s territory, whatever the validity of that report.Recorded: the report of the species has been positively confirmed. The set of recorded species represents the fauna and flora of the country that is currently known to occur in Greece. The "Recorded" status of a species can be subsequently changed back to "Reported" when a new doubt about the presence of the species is raised.To summarize: {Recorded} = {Reported} - {Possible, Absent}. The status Present is then equal to the status Recorded. The two terms are used in different context: the vocabulary {Reported, Recorded} makes reference to an action of observation, while the {Present, Possible, Absence} lists the statuses of occurrence in the country.The Greek Taxon Information System in LifeWatchGreece is an initiative with a complementary role to previous individual projects on biodiversity databasing which had never been integrated or systematically updated at least within an organized national framework. A notable example is the Greek Biodiversity Database and its website that had not been widely known and used given the surprisingly low number of citations for such an initiative. This was also apparent during the checklist validation process as most of the contacted specialists were not aware of the existence of this database although the majority of collaborators came from Greece. We expect that the publication of taxonomic papers (e.g. Preliminary Checklists) in scientific journals will increase the visibility and usability of such type of biodiversity data, not only to the scientific community but also to the broader domain of biodiversity management, especially in cases when checklists had not been previously published. Online databases, like scratchpads (e.g. SpeLoG application within LifeWatchGreece) provide the ability for users to download species lists, match name lists from their own work, or report errors and additions. Although online databases make data accessible to a wide range of end-users, they are still problematic in terms of referencing, because electronic data are volatile compared to data listed in scientific publications. So, readers should be encouraged to check active online databases for their updated content.Lepidoptera, Pisces, Mammalia); (b) not recently updated ; (c) never listed before although sporadic records have been published in scattered literature sources (e.g. Chaetognatha); and (d) never studied , due to the taxonomic impediment . All groups of biota will be progressively listed and published under GTIS. Preliminary lists have been already tested for some marine taxonomic groups, such as Ascidiacea, Brachiopoda, Cephalopoda, Chaetognatha, Cumacea, Lophogastrida, Mysida, and Porifera. Preliminary Checklists will not be compiled for well-covered groups with checklists recently published such as Pisces  well-covered  checklists compiled from individual sources required thorough taxonomic updates; (b) Global Species Databases do not necessarily report species by country; (c) specialists are lacking in Greece for a number of groups; (d) voluntary scientific work is challenging. The publication of checklists and data papers could be an immediate reward to collaborators who validate the Preliminary Checklists: a publication still constitutes a better credit than just citing their name in the database/scratchpads records to which it will be associated in all cases.A gap analysis for taxonomic groups that could not be validated, combined with the collaboration of local and international scientists, could stimulate future research on understudied taxa. A strategic plan should be developed to fill the gaps including the involvement of research/academic authorities, scientific societies and citizen science initiatives for completing the study of the taxonomy for all species present in Greece. Local experts do not need to be taxonomist specialists of a given group, but may be good experts of the local fauna and/or flora , and serve as national experts and focal points for given groups; they could then ensure the monitoring of the knowledge for these groups in Greece. For this reason, the LifeWatchGreece Infrastructure involves a wide network of research and academic institutions all over Greece. The overall GTIS initiative is open to collaboration with taxonomists from the Greek, European and World scientific community who are interested in contributing to this effort.


The Internet has become a common and global medium. It contains vast information resources and a wide range of communication instruments. One of the communication channels are social media, which increasingly are also used in the business field. Social media combined with mobile technology introduced new challenges to marketing activity. This trend is also observed on specific and highly regulated drug market. The aim of this article is to describe the perspectives for the use of social media in e-pharmamarketing. We find that this require personalized communication, the use of online promotion tools, in order to perform advertising in contact with a demanding client. Currently pharmaceutical companies use social media to communicate basic information on their life, but they still do not appreciate it sufficiently as a tool to build the image of company or products. It is therefore considered that these companies should attach greater importance to the presence in this type of media, especially in the light of dynamic changes in the way people communicate. The Internet has revolutionized the world and is growing rapidly, the same as possibilities of using it in the functioning of society and business. Better access to the global network increases the number of users . The trSince the introduction of e-mail, new media  and social networking  the ways of human communication have changed noticeable. These changes are observed regardless of the age of Internet users. This is obviously more popular among the younger generation but it is used increasingly among the elderly as well . PopularThe use of modern technology in the pharmaceutical market is not only the implementation of modern production techniques and supply of consumers with innovative medicinal products. The dynamic development of interactive electronic media of a social network gives also a huge field of possibilities for the use of innovative methods of selling and building market position of companies operating in the pharmaceutical industry. Thus is created e-pharmamarketing. It is an activity of a pharmaceutical company aimed to promote and sell its products and build a relationship with the customer or selected groups of recipients, conducted via the Internet . The purMarketing of pharmaceutical companies in social media can rely on generating Internet traffic by the use of social networking sites. It enables direct contact with a target group, also reducing marketing costs. It aims at formation of relationship between a pharmaceutical company and doctors or patients. This is not a method to achieve rapid sales growth, but it is to become a partner for dialog. The goal is to influence positive image of a company and, at the same time, to encourage customers to share information with friends. Social media marketing relies on effective fanpage management of a brand or a company. This is public relations and marketing operation. Pharmaceutical companies may place counseling articles on social networking sites. The topics may cover health, medicine, lifestyle, nutrition, etc. Photos, videos, commercials, and short text messages can be also published.The authors of this article conducted a survey on 50 biggest pharmaceutical companies operating in Poland . The obtA vast majority of pharmaceutical companies benefit from the YouTube platform as well. YT has already over 1 billion users in the world . 70% of Video marketing and discussion forums are much less used. Blogging is not popular. None of companies used chat. While social networking, the companies: provide information reference (56%), try to build the company image (54%), communicate professional staff and consumer (28%). 26% of surveyed companies want to increase sales of their products. Only few of them (8%) use social media to strengthen brand awareness.Unfortunately, microblogs are still less popular than social networking among pharmaceutical companies. Microblogs provide the opportunity for pharmaceutical companies to submit short entries, slogan, logo, links to other reference sites or articles. Microblog’s entries are only to encouraged to click on a link and read full content on a website or enter into a discussion. The companies often indicate briefly on a received award, sponsored events, study on a new product, a new drug registration and others.E-pharmamarketing in social media is not without disadvantages. Among the most important are the lack of immediate results and difficult measurability. It is because similar types of activities are carried out in an integrated promotional activities of pharmaceutical companies . It is aNot without significance is the lack of full acceptance of social media. There is relatively low confidence in the network and the Internet users dislike impudence spam; . The oveA significant difficulty is in final subordination of distributed content to legal and ethical requirements in different countries and cultures, which reduces the possibility of full universalization of globally distributed content.Nevertheless, there are a lot of potential benefits: high interactivity, knowing competition and customer expectations , possibin = 2; 4%) and the ability to control competition. As burdensome is perceived the need to constantly monitor the content or possibility of losing the positive company image, as well as lack of control over the content being placed. As a result, companies operating in the pharmaceutical industry tend to remain at least one step behind the technological progress in the field of communication tools, losing the ability to generate available benefits. One example of this may be Polish pharmacies. According to conducted monitoring in social media by the Institute of Media Monitoring (IMM) in the first half of 2016 only 20% requests for pharmacy recommendation received answers within the first 36 h after publication. So 80% of pharmacies lost the possibility of contact with the client in the network . Most of the large pharmaceutical companies, operating on corporate principles, are involved yet in corporate social responsibility (CSR) and for this purpose they reserve certain budgetary measures. By communicating via social media, companies can rapidly engage the local community for various rescue operations, supporting them financially and materially. Through such activities they gain synergy and their aid is effective and not anonymous. Therefore, companies can expect positive effects in the dimension of public relations.Pharmaceutical companies can achieve many different goals through the use of social media. They can improve the level of knowledge; build relationships; increase sales of its own products and finally serve general social purposes. As they seem not to take the possible advantages arising of e-pharmamarketing yet, it should be recommended they clearly re-orientate their marketing activity toward new instruments of communication available via Internet to stay up to date with the dynamic changes appearing in the social life and communication channels.MS-Ś conceived the study and prepared draft of the paper. MS-Ś and PR contributed to paper preparation and study. EP provided new information necessary to revise the paper.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Sickle cell disease (SCD) is of major public health concern globally, with majority of patients living in Africa. Despite its relevance, there is a dearth of research to determine the socio-demographic distribution and psychosocial impact of SCD in Ghana. The objective of this study was to examine the socio-demographic distribution and psychosocial consequences of SCD among patients in Ghana and to assess their quality of life and coping mechanisms.A cross-sectional research design was used that involved the completion of questionnaires on socio-demographic characteristics, quality of life, coping mechanisms, anxiety and depression. Participants were 387 male and female patients attending a sickle cell clinic in a public hospital.Results showed that majority of the patients were single, female, less than 39 years old and had attained secondary school level of education or less. Also, patients were more satisfied by the presence of love, friends and relatives as well as home, community and neighbourhood environment. While pains of varied nature and severity were the major reasons for attending hospital in SCD condition, going to the hospital as well as having faith in God was the most frequently reported mechanisms for coping with an unbearable SCD attacks. Results of multiple regression analysis showed that some socio-demographic and quality of life indicators had strong associations with anxiety and/or depression.It is recommended that a holistic intervention strategy incorporating psychosocial dimensions should be considered in the treatment and management of SCD. Sickle cell disease (SCD) is a genetic disorder found in individuals who have inherited an abnormal gene in the haemoglobin from either parent . The disThere is a pattern in the socio-demographic distribution of SCD globally. For instance, a previous study found that majority of their sample were females, had high school education, were between 25 and 34 years old and were single . LevensoIn terms of the psychosocial consequences of SCD, several studies have found that SCD, which is a life-threatening disease, has severe psychosocial consequences on individuals –15. AccoHealth-related quality of life (QOL) refers to the effects an illness has on the subjective well-being of patients . This inIndividuals with SCD use various mechanisms to cope with the disease, which largely includes pain management. Coping mechanism involves constantly changing cognitive and behavioural efforts to manage internal or external demands on individuals’ personal resources . AttendiIn spite of these, not much is known about the present socio-demographic distribution and psychosocial consequences of SCD in Africa and Ghana in particular. Much is known about the psychosocial response of other diseases such as diabetes than for SCD in Ghana. Furthermore, although treatment advances greatly improve the quality of life as well as the lifespan of patients, exploring the present treatment and quality of life outcomes would help in the management of the patient. The purpose of this study was to examine the present socio-demographic distribution and psychosocial consequences of SCD and to incorporate these into the management of SCD in Ghana.A cross-sectional survey design was used in the study. The population consisted of SCD patients at a sickle cell clinic in a major hospital in Accra. About 24,010 patients attend this hospital in a year, 100 to 120 patients (both old and new) attending daily. A simple random sampling technique was used to select patients, from a list, who attended the hospital within the 2-month period of data collection. Those willing and able to participate in the study and signed an informed consent from were recruited for the study. In all, 387 patients participated, comprising of 180 males and 204 females with a mean age of 24.34 (SD = 6.59) years.Four different assessment instruments were used in this study. These are the Beck Depression Inventory, the Beck Anxiety Inventory, the quality of life index, and the structured clinical interview. These measures were appropriate for SCD patients in Ghana. Although these measures were developed outside Ghana, cross-cultural studies have found that the Beck Depression Inventory (BDI), for example, is satisfactory for measuring cross-cultural depression . A crossThe BD)  was usedThe Beck Anxiety Inventory (BAI)  is a 21-The QOL index is a measure of an individual’s quality of life through self-report of the importance they attach to each of 16 life domains on a 3-point rating scale as well as their current satisfaction with each domain on a 6-point rating scale . The impThe structured clinical interview (SCI) is an instrument that helps a clinician to formulate questions to fit the patients understanding, to ask additional questions that clarify ambiguity, to challenge inconsistencies in responses provided and to determine the seriousness of symptoms presented. It is subjective and limited to diagnostic evaluations, research and the training of health professionals. The SCI used in the present study sought information about major complaint, presenting problems, psychosocial history, individual medical history, family medical history, previous treatment and current medical treatment. It was also designed to elucidate the coping strategies of the patient.Prior to sampling participants, G*power  was usedTable Table The patients were asked to indicate their level of satisfaction or dissatisfaction in 16 different dimensions of quality of life. The patients were generally dissatisfied with their quality of life, and this was highest for health, self-esteem, goals and values as well as money Fig. . The levThe patients reported they were more satisfied than dissatisfied with the love received and with friends. They were however more dissatisfied with their children and helping relationships Fig. . Also, tTable Seeking help at the hospital was the main coping mechanism whenever patients had a crisis Table . HoweverMultiple regression analysis was used to test if the socio-demographic characteristics and quality of life indicators significantly predicted patients’ anxiety. The results indicated that the predictors explained 36% of the variance. Level of education, quality health, number of children and a conducive neighbourhood significantly predicted anxiety Table . This inResults of multiple regression analysis showed that the predictors explained 21% of the variance. Age, health, money, learning and creativity significantly predicted depression Table . This inThe aim of this study was to examine the socio-demographic distribution and psychosocial consequences of SCD among patients in Ghana. The results showed that majority of the participants were females, between 20 and 39 years old, had secondary/vocational school level of education and were single. These findings are generally consistent with findings of previous studies that have examined the socio-demographic characteristics of SCD patients in other parts of the world . Life exThe results also showed that most of the participants were females. Gender role socialisation and expectations may have accounted for more females reporting SCD and its associated complications. In Ghanaian culture, males are expected to show bravery, strength and endurance during times of crisis and are expected to be the bread winners, to be leaders in their family and to endure pain . This isMajority of the participants in this study had attained secondary/vocational school education or less, consistent with findings of previous studies , 12. TheIn relation to the findings on marital status, majority of the participants reported that they were single and this is compatible with previous findings . It is pIn relation to quality of life, the results of the present study showed that patients were more satisfied with their ability to work, learn, play, be creative and be happy with friends, which is consistent with findings of previous studies. For example, Dampier et al.  found thOur findings are similar to those in previous studies that also found that the main reason why SCD patients visit the hospital was because of pain. Bloom , for exaWith regard to the association between quality of life and anxiety and depression, good health and ability to learn had negative associations with depression. Creativity and money on the other hand were positively associated with depression. It is known that depression has a positive association with functional impairment and a negative association with quality of life , 47. LowThis study has some limitations that is worth mentioning in order to serve as a guide for the design and conduct of future studies. First, given the relatively large number of patients who visit the hospital annually, selecting a much larger sample would have increased the generalisability of the findings of the study. Nonetheless, the sample size used for this study was enough with respect to statistical requirements. Second, the study would have benefitted from a more objective assessment of quality of life to corroborate the subjective assessment of satisfaction or dissatisfaction. Also, self-report measures, as was used in the study, may cause systematic measurement errors (methods variance), and responses given by participants may not have been accurate. Finally, not including a control group as a basis to compare differences and relationships among the study variables limits the ability to generalise the findings therefore interpretation of the results should be done with due cognisance to this fact.This preliminary study reveals that socio-demographic characteristics and quality of life play a major role in SCD and these have serious psychosocial consequences, especially anxiety and depression, on SCD patients. These factors—age, levels of education (income), gender and social relations —should be considered seriously in the management of SCD to facilitate healing and restoration of quality of life. More of such studies are needed in Ghana to gain a better insight into the impact of the psychosocial life of SCD patients and their families.


Hospital emergency departments (EDs) are a place where many Americans seek treatment of dental conditions. Racial and ethnic minorities consistently have higher rates of ED utilization than whites for dental conditions. The reasons for these disparities and significant public health concerns are investigated less often. In this paper, we measure trends in racial disparities in ED discharges for dental conditions in Maryland from 2010 to 2013. To understand these disparities, we also describe differences between racial groups in age, gender, income, location, payer, comorbidities, and the availability of dental care.2010–2013 State Emergency Department Data for Maryland were used in the analysis. Rates per 100,000 of the population are calculated using information from census population estimates. Cost-to-charge ratios are used to estimate the costs of ED discharges. Dental/oral health-related conditions (DOHRC) are defined as discharge diagnoses of ICD-9-CM codes 520.0 through 529.9. Descriptive statistics and fixed effects logistic regression models with a rare event correction are used to analyze the data.Blacks, especially females aged 25–34, have larger proportions of total ED discharges due to DOHRC, and higher population rates of DOHRC, than any other racial or ethnic group. In 2013, Blacks represented 30% of Maryland’s population and accounted for 52% of ED costs for DOHRC. Hispanics and those of other races have much lower rates of DOHRC discharges. The regression results show that the high proportion of DOHRC discharges among Blacks may be explained by the concentration of Blacks in low-income central cities with less access to dental care.There are significant racial disparities in the ED utilization for DOHRC in Maryland. These disparities reflect the lack of access to dental care due to both cost and geographic limitations. This results in high healthcare costs and ineffective solutions for patients. Addressing oral health disparities will require policy solutions that are targeted to the populations most at need, and action plans that combine community and state level efforts. Americans increasingly utilize hospital emergency departments (EDs) for the treatment of dental conditions , 2. ThesRacial disparities in the utilization of EDs for dental conditions are a consistent finding in research about this public health concern. Evidence from Wisconsin, New Jersey, and Maryland demonstrates that Black Americans, especially those with no or public insurance and of low socioeconomic status, have higher rates of ED visits than whites –10. The In this paper, we assess racial disparities in ED discharges for dental conditions in Maryland from 2010–2013. We chose to focus on Maryland for several reasons. First, recent public and policy attention in Maryland has been focused on reducing disparities in access to oral health care . Second,The data used in this paper come from the 2010 to 2013 State Emergency Department Databases (SEDD) of the Healthcare Cost and Utilization Project (HCUP) for Maryland. A dataset that pooled discharges from the 2010 through 2013 datasets was created to facilitate comparisons over time. These data and analysis are representative of the total population of ED discharges over this period. When reported, rates per 100,000 of the population were calculated using information from county level population estimates . InformaDental/oral health-related conditions (DOHRC) are defined as diagnoses of ICD-9-CM codes 520.0 through 529.9. Variables indicating preventability and severity of DOHRC were created using a schema that classifies ICD-9-CM dental diagnosis codes based on the severity of the condition and the likelihood that the conditions were preventable through normal dental care . In ordep value cutoff of <0.05. Results of these descriptive statistical tests are presented in Appendix S1 in Supplementary Material.When conducting descriptive analysis, Chi-square tests are used to determine if there are differences between expected and observed distributions of the independent variables and the dependent variables. The statistical significance of individual cells of data is determined by the contribution of that cell to the overall Chi-square using a A fixed effects logistic regression model that contrasts DOHRC discharges with other discharges is estimated. These models “fix” or control for the effect of time, producing estimates that show year over year averages. The relatively rare nature of DOHRC discharges in the full sample necessitates the use of a rare event correction to ensure accurate predictions. The rare event correction is performed by randomly selecting a 5% subsample of non-DOHRC discharges to create a balanced sample and then a correction for the resulting sample selection bias .Two models are estimated. The first estimates the effect of race on the odds of being discharged with a DOHRC relative to any other condition. The second model adds variables that may mediate the relationship between race and odds of having a DOHRC discharge, as identified by the descriptive analysis. These variables include a gender by age interaction, the rate of dentist per 100,000 of population in the county, location of residence, and median household income in the county of residence.Dental/oral health-related conditions discharges are not evenly distributed by race Table . For allThis concentration of inappropriate and ineffective ED treatment among a single racial group has implications beyond the disservice to the patients involved. In total, $15.7 million was spent in Maryland in 2013 treating dental conditions in the ED, an increase of $4 million from 2010, adjusted for inflation . Regardless of race and ethnicity, those discharged with a DOHRC are less likely to have a chronic comorbidity that would complicate treatment than those discharged with a medical condition, with 22% or less having one or more. In addition, there are no differences in the preventability or the severity of dental conditions that are diagnosed in the ED that would explain the differences in rates seen across racial groups .To test our hypothesis that disparities in ED discharges by race are due to residential segregation into high- and low-income areas with differential access to dentists, we estimate two fixed effects logistic regression models that estimate the odds of being discharged with a DOHRC relative to any other condition Table . The firThe second model in Table When these variables are added to the model, the variable for Blacks becomes non-significant. This indicates that the difference between Blacks and Whites in the proportion of ED discharges that are due to DOHRC is caused by the relative disadvantage of Blacks in terms of income, location, and access to dental care. On the other hand, the variables for Hispanics and those of other races continue to be significant and with no or small reductions in magnitude. Therefore, the lower proportion of DOHRC for these groups is not associated with their relatively privileged position on the variables in the model.In this paper, we identified significant racial disparities in ED discharges for DOHRC in Maryland between 2010 and 2013, with Blacks having a larger proportion of total ED discharges and higher population rates than any other group. Black females between the ages of 25–34 have by far the highest rates in the population. This disparity is not strongly related to worse overall health or different patterns of diagnoses in this population. Instead, as established in our regression models, it is associated with a lack of access to dental care due to cost and availability because of a concentration of this population in low-income and central city areas. Our findings are consistent with previous research that a higher level of ED utilization for dental conditions among Blacks is due to a lack of access to dental care. Our findings also support research documenting the better overall and oral health of Hispanics , 15, whiWhile the analysis presented here provides systematic evidence of racial disparities in ED utilization for dental conditions, there are obvious limitations. Because administrative data are used in the analysis, there is relatively little information on the patient themselves. Better information on the patient overall oral health status, dental insurance coverage, and their values related to oral health would provide more complete explanations of the reason and solutions for these racial disparities.The ED is not the place for treatment of dental conditions for anyone. Costs are high and the care provided is palliative at best. The disproportionately high level of DOHRC discharges for Blacks in Maryland create high costs for Medicaid and ineffective solutions for patients. The disparities revealed in this paper highlight the importance of solutions targeted to the populations most at need. Any solution is going to need to combine community and government action to deal with lack of access to dental care due to location and cost. The proposed restoration of an adult dental care benefit for Maryland residents would allow Medicaid beneficiaries to seek dental care in more appropriate, and cost effective, settings , 26. ProNC developed the concept and design of the study; NC contributed to the acquisition of data, analysis, and interpretation of data; NC made contribution to drafting and revising the article and the final approval of the version to be submitted.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Background: More and more institutions worldwide and in German-speaking countries are developing and establishing interprofessional seminars in undergraduate education of health professions. In order to evaluate the different didactic approaches and different outcomes regarding the anticipated interprofessional competencies, it is necessary to apply appropriate instruments. Cross-cultural instruments are particularly helpful for international comparability. The Interprofessional Education working group of the German Medical Association (GMA) aims at identifying existing instruments for the evaluation of interprofessional education in order to make recommendations for German-speaking countries.Methods: Systematic literature research was performed on the websites of international interprofessional organisations , as well as in the PubMed and Cinahl databases. Reviews focusing on quantitative instruments to evaluate competencies according to the modified Kirkpatrick competency levels were searched for. Psychometrics, language/country and setting, in which the instrument was applied, were recorded. Results: Six reviews out of 73 literature research hits were included. A large number of instruments were identified; however, their psychometrics and the applied setting were very heterogeneous. The instruments can mainly be assigned to Kirkpatrick levels 1, 2a & 2b. Most instruments have been developed in English but their psychometrics were not always reported rigorously. Only very few instruments are available in German.Conclusion: It is difficult to find appropriate instruments in German. Internationally, there are different approaches and objectives in the measurement and evaluation of interprofessional competencies. The question arises whether it makes sense to translate existing instruments or to go through the lengthy process of developing new ones. The evaluation of interprofessional seminars with quantitative instruments remains mainly on Kirkpatrick levels 1 and 2. Levels 3 and 4 can probably only be assessed with qualitative or mixed methods. German language instruments are necessary. Interprofessional collaboration in health care is growing in importance in German-speaking countries. At the same time, more and more institutions are establishing interprofessional teaching and learning scenarios in the education of health professionsWith a history of merely 25 years, interprofessional education is a relatively new field in teaching and affiliated research using different teaching and learning approaches with respect to methodology (e.g. joint seminars or project work), seminar and course composition  and content . The special edition of the GMS Journal for Medical Education  providesPrior to applying instruments, it needs to be decided which instrument is suitable for which learning outcome. In this respect, the Kirkpatrick four-level framework for evaluating the results of educational programmes serves as orientation. For the evaluation of interprofessional education , 5], th, th5], tIn order to be able to assess interprofessional teaching quality, it is necessary to use reliable and valid instruments. In a first step, existing instruments were to be identified in the literature and assessed regarding their basic, but also specific suitability for use in the German-speaking countries. Due to the manifold and heterogeneous publications in this field, it was decided not to consult individual studies but rather reviews.  Identified suitable instruments will then be made available for German-speaking countries. Based on the results, a practice-oriented handout with instruments for the evaluation of interprofessional seminars and projects shall be provided in the years to come. The following research questions were derived from these considerations: Which instruments are recommended in the summarized review literature for the evaluation of interprofessional teaching on which Kirkpatrick evaluation level?Which instruments are available in German and which can be recommended for translation into German respectively?A two phase methodological approach was necessary. As the field of interprofessional collaboration and teaching is developing rapidly, the websites of the relevant national and international interprofessional networks  were scanned systematically for instruments for the evaluation of teaching activities.In order to further address the research questions, the aim was to compile a systematic literature review. As mentioned in the Research Objective section, this systematic review was not to be based on individual studies, but rather on a meta-synthesis of reviews. The main focus was on review articles of instruments for evaluation as assessment tool, not for evaluation as complete control cycle. The evaluation tools were to be suitable for use on the teaching level, not on the collaboration level. PubMed/Medline and CINAHL were identified as suitable literature databases. Database-specific search strategies were determined, including the search keys “review”, “evaluation” and “interprofessional education”  independently checked the reviews being determined this way and included in the study by means of criteria stipulated in the Critical Appraisal Skills Programme Checklist . The reTwo independent working group experts  subsequently assessed the information on the test quality of the individual studies in the respective reviews. A brief characterization describes the suitable instruments determined this way. An adequate test quality description contains comprehensive details on objectivity, reliability, validity and on diagnostic psychometric properties (such as sensitivity and specificity).Particularly successful tools as well as German-language tools were individually and critically discussed again and presented.The scanning of the interprofessional networks yielded two repositories for evaluation tools:Canadian Interprofessional Health Collaborative  National Center for Interprofessional Practice and Education .Both collections comprehensively present tools, but also show limitations. They do not only focus on interprofessional education, but also consider instruments for evaluating interprofessional collaboration. The access to these databases is rather open, enabling a free download of tools. However, the integrated tools are not subject to critical evaluation and quality management, rendering their validity and reliability uncertain. The review at hand therefore does not include any tools of these databases. The PubMed search produced 24 hits while the Cinahl search produced 49 hits see . After sThe working group assessed the six remaining reviews using the CASP checklist and went through the full text in search of valid and suitable tools , University of the West of England Interprofessional Questionnaire (UWEIPQ), Interprofessional Socialization and Valuing Scale (ISVS) and Team Climate Inventory (TCI). The already existing online repositories of tools for evaluating interprofessionalism have shown that it is inevitable to focus on specific questions and quality assurance regarding usability and transparency. The present review reveals that the unsystematic approach in the scanned reviews and thus the missing critical assessment of the studies included in the reviews proved to be problematic. In conclusion, the heterogeneous situation regarding the quality of the reviews included in this study only allows for a limited recommendation. From the test theory perspective, the recommendation of Havyer et al.  should bVarious instruments are available measuring interprofessional education by evaluating outcomes on different Kirkpatrick levels. Outcome and Kirkpatrick level have to be considered when selecting or applying an evaluation instrument. Only a few reliable and valid instruments are available yet. Assigning an outcome to a competency framework may be helpful when choosing an instrument.Moreover, not all Kirkpatrick levels can be mapped by quantitative assessments. It seems to be necessary to include qualitative evaluation as well.TCI and ISVS are mentioned in various reviews. Oates and Davidson  describeFinally, the ISVS is the only instrument to be recommended from a test theoretical perspective at the moment. As this high-quality tool is already available and does not need to be redeveloped, the working group is currently translating and localizing the ISVS. It will also validate the German version. The results of this review show that the transition from education to practice also needs to come more into focus. This includes evaluations on team level, an analysis of the transition and the development of suitable instruments and benchmarks for ensuring business success and organizational modifications .Another working group of the GMA Committee for Interprofessional Education is currently working on a German competency framework for interprofessional education. After the compilation and approval of this competency framework, the suitability of the recommended instruments shall be reviewed again. Afterwards, it can be decided on whether renewed, adapted recommendations or new instruments appropriate to the complexity shall be developed. 1 In this context, health professions comprise professions in the fields of medicine, dentistry, nursing, therapy and diagnostics.The authors declare that they have no competing interests.


We sought to analyse the impacts found, and the methods used, in a series of assessments of programmes and portfolios of health research consisting of multiple projects.We analysed a sample of 36 impact studies of multi-project research programmes, selected from a wider sample of impact studies included in two narrative systematic reviews published in 2007 and 2016. We included impact studies in which the individual projects in a programme had been assessed for wider impact, especially on policy or practice, and where findings had been described in such a way that allowed them to be collated and compared.Included programmes were highly diverse in terms of location (11 different countries plus two multi-country ones), number of component projects (8 to 178), nature of the programme, research field, mode of funding, time between completion and impact assessment, methods used to assess impact, and level of impact identified.Thirty-one studies reported on policy impact, 17 on clinician behaviour or informing clinical practice, three on a combined category such as policy and clinician impact, and 12 on wider elements of impact . In those multi-programme projects that assessed the respective categories, the percentage of projects that reported some impact was policy 35% (range 5–100%), practice 32% (10–69%), combined category 64% (60–67%), and health gain/health services 27% (6–48%).Variations in levels of impact achieved partly reflected differences in the types of programme, levels of collaboration with users, and methods and timing of impact assessment. Most commonly, principal investigators were surveyed; some studies involved desk research and some interviews with investigators and/or stakeholders. Most studies used a conceptual framework such as the Payback Framework. One study attempted to assess the monetary value of a research programme’s health gain.The widespread impact reported for some multi-project programmes, including needs-led and collaborative ones, could potentially be used to promote further research funding. Moves towards greater standardisation of assessment methods could address existing inconsistencies and better inform strategic decisions about research investment; however, unresolved issues about such moves remain.The online version of this article (doi:10.1186/s12961-017-0191-y) contains supplementary material, which is available to authorized users. AThis paper describes the methods used in two successive comprehensive reviews of research impact studies, by Hanney et al.  and RaftFor this paper, we deliberately sought studies that had assessed the impact of all projects in multi-project programmes, whether coordinated or not. We focused on such multi-project programmes because this approach offered the best opportunities for meaningful comparisons across programmes both of the methods and frameworks most frequently used for impact assessment and, crucially, of the levels of impact achieved and some of the factors associated with such impact. Furthermore, such an approach focused attention on the desirability of finding ways to introduce greater standardisation in research impact assessment. However, we also discuss the severe limitations on how far this analysis can be taken. Finally, we consider the implications of our findings for investment in health research and development and the methodology of research on research impact.The methods used to conduct the two previous reviews on which this study is based , 9 are dBox 1 Search strategy of two original reviewsFor the current study the main inclusion criterion was studies that had attempted to identify projects within multi-project programmes in which investigators had claimed to have made some wider impact, especially on policy or practice, and/or for which there was an external assessment showing such impact. We included only one paper per impact assessment and therefore, for example, excluded papers that reported in detail on a subset of the projects included in a main paper. We did not include studies that reported only on the total number of incidents of impacts on policy claimed for a whole programme, rather than the number of projects claiming to make such impact. We included only those studies where the findings were described in a way that allowed them to be collated with others, then analysed and presented in a broadly standardised way. This meant, for example, that the categories of impacts described by the study had to fit into at least one of a number of broad categories.We defined the categories as broadly as possible to be inclusive and avoid creating overlapping categories. Following an initial scan of the available studies we identified four impact categories that were broadly compatible with, but not necessarily identical to, the impact categories in the widely-used Payback Framework , 15 and Studies were included if they had presented findings in one or more of these categories in a way that could allow standardised comparison across programmes. In some cases, the studies presented findings solely in terms of the numbers of projects that had claimed or been shown to have had impact in a particular category. These had to be standardised and presented as percentages. Each study was given the same weight in the analysis, irrespective of the number of individual projects covered by the study. For each of the four categories of impacts we then calculated the median figure for those studies showing the percentage of projects that had claimed to make an impact in that category. We also presented the full range of percentages in each category.We extracted data on methods and conceptual frameworks for assessment of research impact described in each study, and on categories of factors considered by the authors to be relevant for the level of impact achieved. In identifying the latter, our approach was informed by a range of international research literature, in particular the 1983 analysis by Kogan and Henkel of the importance of researchers and potential users working together in a collaborative approach, the role of research brokers, and the presence of bodies that are ready to receive and use the research findings , 17. OthThirty-six studies met the inclusion criteria for this analysis , 32–66. The studies came from 11 different countries, plus a European Union study and one covering various locations in Africa. The number of projects supplying data to the studies ranged from just eight in a study of an occupational therapy research programme in the United Kingdom , to 22 oIn terms of the methods used to gather data about the projects in a programme, 21 of the 36 studies surveyed the researchers, usually just each project’s Principal or Chief Investigator (PIs), either as the sole source of data or combined with other methods such as documentary review, interviews and case studies. Six studies relied exclusively, or primarily, on documentary review and desk analysis. In at least three studies, interviewing all PIs was the main method or key starting point used to identify further interviewees. The picture is complicated because some studies used one approach, usually surveys, to gain information about all projects, and then supplemented that with other approaches for selected projects on which case studies were additionally conducted, and often involved interviews with PIs. In total, over a third of the studies involved interviews with stakeholders, again sometimes in combination with documentary review. Many studies drew on a range of methods, but two examples illustrate a particularly wide range of methods. In the case of Brambila et al.  in GuateIn 20 of the 36 studies, the various methods used were organised according to a named conceptual framework  of projects that reported having achieved some such impact is set out in Table improved reporting of unintentional child injury cases and liaison between the Hospital Authority Informatics and Accident and Emergency” .Illustrating the combined category, Milat et al.  used a cFor each category, apart from the combined one, there was a wide range in the proportion of studies per programme that had demonstrated (or claimed) impact in each category.Most included studies had considered key factors that might help explain the level of impact achieved  of projects in the nine included HTA programmes , 55, 66 a high level of engagement of the researchers with potential users of their research findings”  . In quite a few of the individual impact assessments this limitation was reduced because more detailed case studies were also conducted on selected case studies. These were often reported to provide examples of the significant impact. However, in our current analysis, any supplementary case studies were not included in the data used to construct Table “(i) relevance , (ii) timeliness, and (iii) formulation of policy reflecting community values by a local representative committee” mittee” .rocess” .the results of 17 out of 18 user-initiated studies were translated into action” . As was noted, some individual studies provided lessons for the specific funder on whose research they focussed as to how that funder might best use its research resources. Some more general lessons could also be drawn in terms of the types of research programmes, for example, needs led and collaborative ones, that seem to be more likely to lead to impacts, though it is widely understood that overall it is desirable for there to be a diversity of health research funded. Additionally, the growing body of evidence about the impacts that come from health research could potentially be used to promote research funding along the lines argued in the World Health Report 2013 .Lessons can also be learnt from the review about the range of methods and frameworks available to conduct health research impact assessments. Furthermore, in addition to continuing refinement of existing frameworks, for example, of the Canadian Academy of Health Sciences’ framework in Canada , there aSome ideas about standardisation, as well as some potential dangers, might come from recent experience in the United Kingdom where many research funders are now using a standardised approach called Researchfish® . This is an on-line survey, originally developed with the United Kingdom’s Medical Research Council, that an increasing number of research funders are now sending annually to the PIs of all the projects they support. It asks for information on outputs, outcomes and impacts (see Raftery et al.  for a moHow best to address these issues when seeking more standardised approaches could be of interest to the newly established WHO Global Observatory for Health Research and Development . FurtherThe quite high proportion of projects that reported making an impact from some multi-project programmes, including needs-led and collaborative ones, as well as the demonstration of the monetary value of a programme, could potentially be used to promote future research funding along the lines argued in the World Health Report 2013 [In addition to being of value to research managers in identifying factors that might lead to increased impact, this review of impact studies also demonstrates the range of methods and conceptual frameworks that can be used in conducting such studies. However, weaknesses in some studies, and diversity between studies in terms of methods and timing used, reduces the value of some individual studies and the ability to make comparisons within the full suite of 36 studies.A standardised approach to assessing the impact of research programmes could address existing methodological inconsistencies and better inform strategic decisions about research investment in order to enhance impact. However, experience from the United Kingdom shows that moving towards such standardisation can itself generate further difficulties. There could be a role for the newly established WHO Global Observatory for Health Research and Development  in both


Large-scale educational assessment has been established as source of descriptive, evaluative and interpretative information that influence educational policies worldwide throughout the last third of the twentieth century. In the 1990s the Brazilian Ministry of Education developed the National Basic Education Assessment System (SAEB) that regularly measures management, resource and contextual school features and academic achievement in public and private institutions. In 2005, after significant piloting and review of the SAEB, a new sampling strategy was taken and Prova Brasil became the new instrument used by the Ministry to assess skills in Portuguese (reading comprehension) and Mathematics (problem solving), as well as collecting contextual information concerning the school, principal, teacher, and the students. This study aims to identify which variables are predictors of academic achievement of fifth grade students on Prova Brasil. Across a large sample of students, multilevel models tested a large number of variables relevant to student achievement. This approach uncovered critical variables not commonly seen as significant in light of other achievement determinants, including student habits, teacher ethnicity, and school technological resources. As such, this approach demonstrates the value of MLM to appropriately nuanced educational policies that reflect critical influences on student achievement. Its implications for wider application for psychology studies that may have relevant impacts for policy are also discussed. In Latin America, most educational assessment systems were established during the 1990s, either as an unfolding of accumulated experience in assessments for specific purposes or as part of education reform programs that were common in that decade. Those national systems vary largely in terms of their institutional framework; technical, financial, and operational provisions, as well as the social, economic, and political ambiance in which they operate. Economic fluctuations and political instability affect national educational assessment systems differently, and it has been recognized that those systems supported by institutions that are independent of education ministries—and thus enjoy greater technical and management autonomy—tend to be more stable Ferrer, . That isCreated in the late 1930s as a research and consulting agency to support the Brazilian educational system, INEP began to play a strategic role in the 1990s, as the education reform established systematic, comprehensive, large-scale educational assessments with increasingly important effects over educational policies in the following decades. It's relative independence and accumulated experience warranted INEP to consolidate and refine techniques that now directly influence all agents involved in the teaching-learning process that takes place within the scope of the national education system: government, schools, teachers, parents, and students.Sistema de Avaliação da Educação Básica-SAEB) was first administered by INEP to a sample of public schools in 25 Brazilian states to produce in-depth understandings regarding the outcomes of teaching and learning processes in the national education system  by national law in 1990. In the same year the National System for Educational Assessment (Lei de Diretrizes e Bases da Educação-LDB) in 1996, SAEB gained a strategic role in guiding policies aimed at enhancing the quality of education in Brazil. Following provisions of the new Constitution, LDB established not only a universal and decentralized educational system, but was also required to develop a National Plan for Education that would set forth guidelines, goals and strategies for educational policy every 10 years , that addressed management aspects and was sample based, and the National Student Achievement Assessment  or Prova Brasil. Prova Brasil benefited from successive improvements to its SAEB predecessor and, by being census and not sample based, allowed the creation of achievement indicators for individual schools, municipalities, cities, states, and Brazil as a whole. Therefore, Prova Brasil introduced accountability into Brazil's educational scenario.SAEB underwent important transformations in each subsequent edition , comprising technical improvements  and broadening of the scope of information collected to cover more academic subjects and aspects of school and family context. In 2005, SAEB went on to encompass two major assessments: the National Basic Education Assessment . Teachers and school principals participate in data collection by completing questionnaires regarding school infrastructure and working conditions, as well as personal and professional background information.Prova Brasil, national, regional, and local statistics are now being generated, which allow direct comparisons that provide the government with relevant information that could be used for the development and monitoring of educational public policies. The Basic Education Development Index (Índice de Desenvolvimento da Educação Básica—IDEB), launched in 2007, introduced a sophisticated informational tool to guide political action by combining proficiency indicators from Prova Brasil with information about students  into a single scale that ranges from 0 to 10. IDEB facilitated the monitoring of schools with low student achievement and, as an accountability device, was used as criterion for providing technical and financial resources based on these schools' development plans  for 2011–2020 was for the IDEB to reach a national score of 6 by 2021, which would place Brazil at the same level of current academic achievement of developed countries that are members of the Organization for Economic Cooperation and Development–OECD. The current national public system IDEB score, calculated in 2013, was 4.9 in the early years of elementary school (0.2 above what was projected) and 4.0 in the final years . Students were mainly from public schools , and the 10-year-old group was the most frequent . The majority of students were from the Southeast , followed by the South , Northeast , North , and Midwest  regions. Although the relative frequencies for the sample differ from that ones observed for the population, the rank order remains the same, i.e., in the population, the Southeast was the region with more students answering Prova Brasil, the same occurring in the sample. The same pattern was repeated for all regions.The total number of participants for Mathematics was 7726 schools, 11,421 classes and 127,256 students, and for Portuguese was 7688 schools, 11,361 classes, and 126,527 students. With regard to the total amount of observations after listwise deletion, most of the sample was composed by females , and which of the aforementioned variables are the best predictors of academic achievement.This study aims to identify how much of the variance in academic achievement of fifth grade students on The variables presented in this study are those deemed statistically significant for both Mathematics and Portuguese. Also, these variables are the ones that have the largest chi-square, corroborating the decision above.Prova Brasil itself. The students' questionnaire has 54 items concerning sociodemographic background characteristics and also the engagement of students and their parents in education-related activities. This questionnaire is completed by students right after Prova Brasil has been administered. The teachers' questionnaire is comprised of 119 items concerning their background, pedagogical practices, and their socioeconomic and cultural profile. It also contains items regarding the classes attending the exam, such as availability of essential academic resources. Each school is assessed by two separate instruments; the first has 72 items and focuses on the characteristics of the school. The second has 212 items and is also completed by the school principal, who reports data related to school infrastructure, resources and available materials, school safety and school conservation status, as well as the practices and attitudes of teachers and students. Lastly, Prova Brasil has two parts of 22 items each for Portuguese and Mathematics, based on specifications of the Brazilian National Education Curriculum. Prova Brasil scores are based on the SAEB proficiency scales, which split the achievement levels into different categories regarding distinct levels of cognitive ability. The Portuguese scale is comprised of nine categories, with scores ranging from 0 to 350. The Mathematics scale is bit larger and is divided in 12 categories, ranging from 0 to 425.This study used data from five different instruments. Four questionnaires are designed to assess sociodemographic characteristics of schools, teachers, and students. The fifth measure is This study utilizes secondary datasets obtained from the Brazilian Ministry of Education website  started to be widely used in education as a technique for the prediction of academic achievement. Three hierarchies, also known as levels, were defined for null model, which does not consider the independent variables at any of its levels and therefore does not explain any variance in the dependent variable; it only estimates the partitioning variance of the dependent variable due to each of the levels considered. The second was a conditional model, which is drawn from the null model, with the independent variables for each level being added in order to explain part of the total variability.Academic achievement measures the extent to which students perform in different academic subjects. For this study, it is set as the dependent variable, and the variables investigated at the three levels of the MLM are the independent ones. Two types of models were tested in this research. The first one was a Yijk) is predicted from the sum of the average of their class (βjk0) with the error (eijk), which represents the distance between their score and the average of their class. In addition, the student's class average will be predicted at Level 2, from the student's school average (γk00) plus a random effect (ujk0). Finally, the student's school average will be predicted at the Level 3, from the student's school overall average (π000) plus a random effect (rk00). All random effects are assumed to be normally distributed, with mean equals zero, and variance σ2. The three-level null model with random intercept is shown in Equation (1).For both null and conditional models, only random intercepts were considered in this study. In effect, for a three-level null model with random intercepts, the student's achievement  The log-likelihood ratio, which tests the hypothesis that the variance in achievement between subjects on the same level is zero. Also, it assumes the existence of effects of higher levels within the individual level. Log-likelihood statistic is calculated using an adaptive Gauss-Hermite approximation; (b) The Akaike's Information Criterion (AIC), which compares the models being tested to a hypothesized true distribution. The lower the AIC value, the better the model; and (c) BIC, Bayesian Information Criterion, which can be interpreted in the same fashion as the AIC, but the fitted models are based on the posterior probability distribution. The more probable the model, the more defensible it is;To investigate whether the residuals follow a normal distribution. Moreover, both class and school effects must also be significantly different from zero;To estimate three different random intercept conditional models considering the selected variables for each level using the Restricted Maximum Likelihood method;To calculate the three statistics introduced at the second step for each conditional model in order to compare the deviance between the models. Again, the smaller the model deviance in comparison to others, the better its fit;p-value which assess the significance of the variable to the model as a whole.For each variable to be considered in each conditional model, the following statistics are produced: Chi-square, the regression Beta, and a t estimate. The Chi-square is interpreted as a deviation of group means from the grand mean and it gives the test statistic for each variable in the model. The Betas have the same interpretation as in standard regression, the average increase in the dependent variable given a one point increase in the predictor. The t statistic is used to obtain a Mean scores for Portuguese Language and Mathematics are presented in Table The first stage of the model selection procedure consisted of assessing the influence of higher levels on individual scores based on statistics of likelihood ratio and explained variance. This analysis guided the decision concerning which levels would be included in the MLM. A total of three models were tested, with all combinations of models containing two and three levels.Although, the variability of academic achievement accounted for by the 2 two-level models tested are similar  for Mathematics was 1322197 , whereas the ML deviance for the three-level model  was 1321171  and gender . The results indicate that better achievement is obtained when teachers are white and male.The first two variables to have a significant relationship with academic achievement in Mathematics and Portuguese are teacher ethnicity  was also significantly associated with student achievement. The worst performing group in both subjects were those students taught by teachers who worked “30 h per week.” The structure of the response options themselves must be addressed, since the choice of defining some categories as intervals and others as a single value might add unaccounted bias to the results. Moreover, the item also referred to the total amount of time devoted exclusively to teaching, not accounting for administrative work or time spent preparing classes.The amount of time that the teacher worked per week . With the exception of Portuguese teachers working at four or more schools, working in more schools was associated with worse student achievement. This pattern can be explained by increased stress and less time available for class preparation and further qualification of the teacher  and their relationship with academic achievement are displayed in Table p < 0.001; p < 0.001] and school support programmes focused on tutoring and learning difficulties monitoring . Over the last two decades, far-reaching welfare measures and social programmes were developed to eradicate extreme poverty, most of which have contributed significantly to preventing school dropout and supporting families who consistently send their children to school. Some national programs, such as Brazil's National School Feeding Programme and Bolsa Familia have also helped reduce the school dropout rate. According to the INEP Bolsa Familia alone has been responsible for a decrease of as much as 36% of school dropout rates.The school level variables that most impacted achievement were that ones related to national programmes aimed at the reduction of school dropout . The National Program of Educational Technology (ProInfo) is one of the most important policies focused on promoting the educational use of information technology by students in public schools. Federal government provides states or municipalities with the equipment needed to set up computer labs, which in turn contribute with the necessary infrastructure and faculty training on how to use the technology.The presence of regional and national school support programs has led The relationship between infrastructure  has been extensively investigated. Research in developed countries indicate that infrastructure does not have a significant effect on the academic achievement  in order to reflect the within school complexities of educational interactions—a common critique of school effectiveness studies that do not employ this methodology . These results both refine and advance the current research on school effectiveness studies in the developing world. While they find some basis in international trends  were utilized to compensate or identify occasional differences in how subjects are taught to students.Another relevant structural limitation concerns the absence of variables that seek to assess individual characteristics on a personal level. According to Soares and Alves , personaAs this study addresses a wide range of variables that influence academic achievement from a broader perspective, only random intercept models were utilized for achievement prediction. Random slope and multilevel models with interactions between variables were therefore not considered. Moreover, only the overall scores for the whole of the country were taken into account, but not scores by regions or states. Considering these limitations, future research exploring further relations among variables from different levels and focused on states and regions is recommended.As the first author, IM contributed to organize and write all the sections of the paper. SS contributed to organize the literature review, discussion, and conclusion. VD collaborated to carry out the data analysis and to describe the results. TV and EF collaborated to write the results and discussion. CP as a specialist in educational policies was responsible to review the whole of the paper and to contribute to the discussion and conclusions. KR was responsible to discuss educational policies in light of his experience on this topic and contributed to the whole of the paper.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.