Telemedicine has been successfully used to provide inflammatory bowel disease (IBD) patients with health care services remotely via the implementation of information and communications technology, which uses safe and feasible apps that have been well accepted by patients in remission. However, the design of telemedicine apps in this setting involves difficulties that hinder the adherence of patients to the follow-up plans and the efficacy of these systems to improve disease activity and quality of life.This study aimed to evaluate the development of a Web platform, Telemonitoring of Crohn Disease and Ulcerative Colitis (TECCU), for remote monitoring of patients with complex IBD and the design of a clinical trial involving IBD patients who received standard care (G_Control), nurse-assisted telephone care (G_NT), or care based on distance monitoring (G_TECCU).We describe the development of a remote monitoring system and the difficulties encountered in designing the platform. A 3-arm randomized controlled trial was designed to evaluate the effectiveness of this Web platform in disease management compared with G_NT and G_Control.According to the schedules established for the medical treatment initiated , a total of 63 patients (21 patients from each group) answered periodic questionnaires regarding disease activity, quality of life, therapeutic adherence, adverse effects, satisfaction, work productivity, and social activities. Blood and stool analyses  were performed periodically. On the basis of the results of these tests in G_TECCU, alerts were generated in a Web platform with adapted action plans, including changes in medication and frequency of follow-up. The main issues found were the development of an easy-to-use Web platform, the selection of validated clinical scores and objective biomarkers for remote monitoring, and the design of a clinical trial to compare the 3 main follow-up methods evaluated to date in IBD.The development of a Web-based remote management program for safe and adequate control of IBD proved challenging. The results of this clinical trial will advance knowledge regarding the effectiveness of TECCU Web platform for improvement of disease activity, quality of life, and use of health care resources in complex IBD patients.ClinicalTrials.gov NCT02943538; https://clinicaltrials.gov/ct2/show/NCT02943538 (Archived by WebCite at http://www.webcitation.org/6y4DQdmt8)RR1-10.2196/9639 Inflammatory bowel disease (IBD) comprises ulcerative colitis (UC) and Crohn disease (CD). The incidence of IBD is increasing gradually , and theChanges in information and communications technology (ICT) over the last 10 years have affected the management of chronic diseases. Telemedicine is an ICT application that provides remote health care services, that is, without the need for direct contact with the patient. It has been associated with a high degree of satisfaction in patients with chronic diseases such as chronic obstructive pulmonary disease, diabetes mellitus, and congestive heart disease -9.Telemedicine apps have been used to improve adherence to treatment and patient education in IBD (teletraining) . SeveralCurrent evidence suggests that the use of ICT is a safe way of monitoring patients with IBD, mainly UC in remission or with mild activity ,16-18. HTelemonitorización de la Enfermedad de Crohn y Colitis Ulcerosa and the clinical trial protocol for evaluation of the intervention compared with nurse-assisted telephone care (G_NT) and standard care (G_Control). Moreover, we detail the selection of indices and questionnaires used to measure the study outcomes, the patient population, and the difficulties found in the design and implementation of the trial, with the aim of helping other investigators in the development of telemonitoring interventions in the setting of complex IBD.Therefore, this study addresses the main questions related with the use of a Web telemonitoring program in patients with complex IBD, a difficult context in which telemedicine has not been previously used and requires a closer follow-up. We describe the development of the remote monitoring platform We developed a Web-based telemanagement system—TECCU—for patients with complex IBD. To evaluate the effectiveness of the Web app for control of disease activity, we designed a randomized controlled clinical trial comparing follow-up of patients through the Web-based app (G_TECCU) with G_NT and G_Control. Eligible patients were randomized to 1 of the 3 groups in a 1:1:1 ratio using a Web-based tool to generate the random allocation sequence and ensure allocation concealment. All patients attended study visits at baseline and at 12 and 24 weeks, in addition to routine visits to the IBD clinic or telephone consultations based on group assignment at randomization . DiseasePatients were recruited from the IBD unit, La Fe University and Polytechnic Hospital , Valencia, Spain. The reference population was 320,000 inhabitants in 2016, although the IBD unit was available to patients from the whole Autonomous Community of Valencia. Thus, the potential population comprised 640,000 inhabitants. The hospital serves more than 1500 patients with IBD , has 2 specialist IBD nurses, and provides an email and telephone consultation structure for IBD patients to contact the hospital.The study participants had been diagnosed with IBD at least 6 months previously according to internationally accepted criteria ,20 and hTo evaluate differences in the percentage of patients in remission and changes in the score of activity indices between the 3 groups, we calculated that a sample size of 60 patients (30 CD patients and 30 UC patients) was necessary. During the study period, patients were included consecutively from the outpatient clinic of the IBD unit or the gastroenterology department if they had been admitted for a flare-up. A total of 68 IBD patients who met selection criteria were invited to participate in the study. Of these, 4% (3/68) declined to participate owing to inaccessibility to the internet at home and 3% (2/68) did not meet the inclusion criteria. The remaining 63 eligible patients provided their informed consent and were randomly assigned to G_TECCU, G_NT, and G_control (21 patients in each group). All patients enrolled were included in a likelihood-based analysis.Patients were included consecutively from the outpatient clinic of the IBD unit or the gastroenterology department if they had been admitted for a flare-up of IBD. During the visit, the inclusion and exclusion criteria were verified and the patient was informed about the study through the patient information sheet. If the patient agreed to participate, he or she signed the informed consent document. Patients were assigned to the different groups using a secure and independent randomization tool. Once a number was assigned, it could not be reassigned.Eligible patients were assigned to the groups through a computer platform that ensured that the researchers could not modify a patient’s group. This process was performed using a block randomization method between the groups (1:1:1) with concealed allocation of participants. The blocks were numbered and ordered using a randomly generated sequence. Members of the research team who were in contact with patients did not have access to the randomization tables or lists.The trial had 3 arms with 3 different interventions :G_control: Patients in the control group received the usual care provided in the IBD unit (outpatient clinic) to patients with moderately to highly complex IBD. We also provided on paper all educational material about IBD available for the remote monitoring patients as well as information on prevention and written action plans in case of flare-up to make the 3 groups more comparable. Moreover, the clinical status of patients was recorded weekly during the first 12 weeks and subsequently every 2 weeks until the end of the follow-up in a diary designed on paper. This care was complemented by ad hoc hospital care in the case of flare-ups or if patients’ health deteriorated for any reason. Ad hoc intensive care was maintained until patients’ condition stabilized, at which point he or she returned to follow-up based on standard care in the unit. The intervention was limited to recording of baseline variables, follow-up for identification of end points, and administration of activity indices and questionnaires on HRQOL, satisfaction, and work productivity.G_NT: Patients in this group were asked about their health through a telephone call from nursing staff in the IBD unit, and we provided these patients with all educational elements and action plans available in the other 2 groups. Telephone assessment was performed periodically using structured interviews to evaluate clinical status with intensified schedules, in a similar manner to the G_control. The actions carried out depended on the results of the interview and the intervention protocol.G_TECCU: Follow-up and monitoring in this group were performed telematically using the integrated platform for management of chronic patients NOMHADchronic, which was set up to meet the specific needs of IBD patients. Patients connected to the platform via the internet using a computer or an app on a mobile phone or tablet and had to complete questionnaires (both scheduled questionnaires and those requested by the patient at other time points) and introduce relevant follow-up data . They also received advice, reminders, educational material about their disease, and information on prevention. Case managers received the information from each patient, which was filtered using an intelligent prioritization system and generation of alerts and push notifications according to an integrated intervention protocol. Physicians from the IBD unit were also able to access individual patients’ data and received referrals about alerts and push notifications that had to be managed by medical staff.The NOMHADchronic platform is an innovative technological system that was designed to boost the rollout of services for the management of chronically ill patients. The platform covers the needs of patients, professionals, and the organization managing the care process and coordinates the work of the professionals involved. This efficiency-based multiplatform system provides a flexible, integrated solution that can be adapted to provide various services. Artificial intelligence enables it to provide support for decision making. It was developed following the Health Level 7 (HL7) version 3 standard, thus enabling its easy integration with the electronic clinical history. It can be set up in such a way that plans and thresholds can be personalized according to each patient’s profile. The system also makes it possible to create combined alerts using several variables, thus facilitating a holistic approach to the patient and not only to the specific diseases diagnosed.This program was initially designed to manage patients with other chronic diseases such as cardiovascular diseases or diabetes mellitus. The telemanagement care system was developed in collaboration with La Fe telemedicine unit, Tecnología Salud y Bienestar SA, and patients from our IBD unit. With the aim of adapting the platform to the particular needs of complex IBD patients, we performed consecutive meetings with patients and researchers to modify the original modules of NOMHADchronic. We changed the elements of the platform to monitor disease activity and other clinical outcomes with specific indices, the normal values, and parameters recorded in the blood tests and fecal calprotectin as well as the follow-up schedule according to clinical guidelines in the management of IBD patients. Moreover, we incorporated educational elements to improve disease knowledge of patients and empowerment through interactive materials.NOMHADchronic comprises NOMHADcore (the nucleus of the platform), the workstation , the response center (case managers), and the patient station . The solution involves various modules to cover all aspects of management of chronically ill patients: clinical information relative to patients’ status, support for coordination of the different health care providers, logistics management, human resources management, and integration with monitoring devices and accessories . The tooResearchers designed the follow-up protocol according to national and European guidelines -21 and sComponents of the development of the telemonitoring of Crohn disease and ulcerative colitis (TECCU) platform:Detailed monitoring planDefinition of the main indicators and alarmsSpecific interventions for the patientSpecific interventions for health professionalsConfiguration of the user environment in the health professional’s appConfiguration of the user environment in the patient’s appIrrespective of the study arm, the patients included followed a periodic monitoring program adapted to the type of medication they were taking . In the case of combined treatment with immunosuppressants and biologics, the follow-up program was similar to that of patients who were taking immunosuppressants alone. Furthermore, patients from the 3 arms who took the same type of drug underwent identical monitoring, which was performed along a time line for patients treated with immunosuppressive drugs and another for patients treated with biologics . The difPatients monitored via the Web-based system used NOMHADhome, which was installed from a page that was supplied to the patients and could be accessed via the internet. The resources of the NOMHADhome platform were also available on the NOMHADmobile app, which patients could download onto their mobile phone. After inclusion, these patients automatically received an email with a personal access code that enabled them to access the NOMHADhome platform. Each patient profile contained the following data: contact information ; active IBD medications; testing schedule (blood and stool tests); log of disease activity, medication use, body weight, vital signs, and quality of life; alerts and action plans; progress of inflammatory activity and vital signs in the form of graphs; electronic messaging to the study nurse coordinator and the health care provider; and educational tips  and 5.Formative sessions of 30 to 60 min were performed with patients and investigators to improve practical utilization of the platform before starting follow-up. During telemonitoring, patients accessed via the internet the Web platform with their personal password and responded to different aspects of their disease. In all checkups, they introduced their vital signs, IBD symptoms to measure disease activity, medication adherence, and adverse effects to medication. In the main menu of the platform, patients accessed the questionnaires by clicking on the specific icons designed for this purpose and could then answer the multiple choice and yes or no questions needed to complete these items. When it was necessary to fulfill the results of blood tests or fecal calprotectin performed in their medical center, patients could introduce their results in different text boxes for each parameter similarly. Thus, the patient was able to self-complete all the clinical and analytical variables necessary to evaluate his or her disease status at each of the checkups programmed in their follow-up time line. In addition to these fixed monitoring points, the patient could complete the questionnaires voluntarily if his or her clinical status deteriorated.To assess disease activity, CD patients calculated their modified HBI via text messaging. The HBI is a validated activity index that has been shown to correlate well with the criteria of the standard instrument for assessing disease activity for CD, the CD activity index . The HBIAfter completion of a scheduled or voluntary monitoring questionnaire, a personalized action plan was designed depending on the results obtained. On the basis of the responses to the different outcomes evaluated, the platform stratified patients in the professional workstation according to the severity of their health status in different levels of severity. Health care providers were then able to respond to patient needs according to each health status. The platform proposed a specific intervention according to preestablished algorithms and medical providers, in coordination with case managers, and finally implemented a customized action plan for each case as described in the following section.Educational materials were also included in a specific section available in the main menu of the platform. At any time, patients could review the information adapted by our research group and they could answer different questions related to the information provided to check their IBD knowledge. Moreover, the platform allowed the interaction with health care providers through a messaging menu to contact case managers and medical providers as needed. Patients could ask questions related to their disease evolution or treatment by texting a message with the keyboard. These messages were frequently reviewed so that they were answered by our medical or nurse staff after 24 to 48 hours.We established individualized alerts and action plans based on the answers to questions about the activity index, adverse effects, and results of blood and stool parameters. A scale of values was assigned for each alert depending on severity . For example, according to the activity index score , the patient is categorized in the green, yellow, orange, or red zone, and the health professional can select 1 or several actions to immediately begin self-testing  and 2. ETo ensure that patients in the G_TECCU arm adhered to the requirements of remote monitoring, 2 days before each monitoring date, they received a message via email if they were using the NOMHADhome app or a message via their mobile phone if they were using NOMHADmobile. Similarly, the patients were sent a reminder if they did not enter their data on the scheduled date.Furthermore, all patients had access to tools that taught them about their disease. In G_TECCU, information was available on the NOMHADhome platform itself; in the G_Control and G_NT arms, the patients received written documents with the same information.TECCU Web platform protects the confidentiality of health data. The access to patient station and to workstation requires a personal password only known by the patient and health care providers, respectively. Moreover, health care providers register patients in the platform with a generic name and a code only identifiable by investigators. Finally, to avoid data correlation by a nonauthorized person, data included in the Web platform are not connected to other hospital information systems. Thus, only case managers and health professionals can see all the clinical history separately.TECCU is a minimal risk system. The characteristics of the interventions in this study mean that patients are not expected to experience direct adverse effects. The interventions were proposed to control and achieve longer remission periods in patients with IBD. Therefore, they cannot cause lesions or damage the patients’ health, since we did not test a new experimental drug; on the contrary, we used a Web-based telemonitoring system to give indications when flare-ups are detected or when these become more severe. With respect to the platform, a risk minimization study was performed to ensure the accomplishment of ethical norms and that the appropriate ethics committees approved the study. In any case, we recorded all adverse events occurring from the moment the patient gave his or her consent to participate in the study until 28 days after the study finished.It was decided that the most efficient means of determining differences between the 3 groups  was by contrasting differences in activity indices for the diseases treated (CD and UC). Given that the scales differ, the analysis was stratified by performing a comparison for patients with UC and another comparison for patients with CD. The sample size was calculated by estimating that to detect a difference of 3 points in the HBI, taking into account an SD in the index of 4, a power of 80%, and an alpha significance level of .05, a total of 30 patients with CD (10 per arm) would be needed. Moreover, for a difference in the Mayo index of 2 points, taking into account an SD of 2.5, a power of 80%, and an alpha significance level of .05, a total of 30 patients with UC (10 per arm) would be needed. Therefore, the overall sample size was 60 patients (20 per arm).We also stratified patients globally (CD and UC) by comparing those in remission or with inflammatory activity, irrespective of severity .P for removing variables=.10), although we tried to include the previously removed variables after each exclusion (P for including variables=.05). The yield of the models was evaluated using the coefficient of determination and, in the case of logistic regression, by evaluating its discriminative capacity (C-statistic) and calibration (Hosmer-Lemeshow test). The statistical analyses were performed using R version 3.5.1 . The analysis was performed on an intention-to-treat basis.First, we described the characteristics of patients in the test and control groups (by applying appropriate estimators according to the type of variables with their respective CIs for means or proportions) and evaluated possible differences between the groups using tests to assess differences in means or proportion. Second, we evaluated differences in the main outcome measure and in the secondary outcomes, again using tests to assess differences in means and proportions, as applicable. We then used linear regression models (or logistic regression models) to evaluate the significance and magnitude of the effect of the intervention while controlling for possible differences in the characteristics of patients from both groups. We generally used backward-forward models by initially constructing complete models and excluding nonsignificant variables one by one . We followed the protocol, the principles of Good Clinical Practice, the guidelines of the International Conference on Harmonization, and the official regulations of the participating centers. The study protocol was reviewed and approved by the local independent ethics committee of La Fe University and Polytechnic Hospital, Valencia, Spain , the regional independent ethics committee , and the Spanish Agency of Medicines and Medical Devices . The study was carried out by persons with the appropriate scientific and medical qualifications. The benefits of the study were proportional to the risks. The rights and well-being of the participants were respected at all times. According to the physicians involved in the study, the risks did not outweigh the potential benefits, and each participant provided his or her informed consent without coercion. The trial was registered at clinicaltrials.gov with the identifier NCT02943538. The results will be published according to the CONSORT guidelines.Participants attended study visits at baseline, 12 weeks, and 24 weeks, in addition to routine visits scheduled for their clinical care. The variables measured at baseline were sociodemographic variables, disease activity, HRQOL, adverse events, adherence, and patient satisfaction. The results were recorded on a paper case report form designed ad hoc for the study. The same approach was used at 12 and 24 weeks. In addition, the hospital information system was consulted to collect data on mortality and variables associated with the consumption of hospital resources . This information was used in the cost-effectiveness study, which was based on direct health care costs.The primary objective of the study was to evaluate clinical remission at 24 weeks. In addition, clinical disease activity was evaluated at each of the checkups scheduled in the patients’ time line. Remission was evaluated using the HBI for patients with CD . In the Patients with CD and an HBI <5 were considered to be in clinical remission, whereas patients with scores of 5 to 7, 8 to 16, or >16 were classed, respectively, as having mild, moderate, or severe activity . For remLaboratory parameters were measured at baseline and at each subsequent visit according to the individual patient’s schedule and included complete blood analysis with nutritional profile and C-reactive protein (mg/L) and fecal calprotectin (µg/g) to assess inflammatory activity. The results obtained could lead to changes in the medication prescribed. The alert generated led to an intervention. Fecal calprotectin was assessed at baseline and 12 and 24 weeks after inclusion, although their values did not lead to a specific intervention.The HRQOL of the patients at inclusion and at week 24 or at the end of the follow-up visits was evaluated using the following 2 tools: a specific questionnaire, the IBD Questionnaire 9 (IBDQ-9), and a generic questionnaire, EuroQol-5D (EQ-5D). IBDQ-9 has been validated for IBD and correlated extremely well with clinical activity . The SpaFurthermore, the impact of disease on work productivity and activities of daily living was evaluated using the Work Productivity and Activity Impairment questionnaire, which patients completed at baseline and at week 24. The questionnaire comprises 6 questions on the effect of the disease on work and activities of daily living during the previous 7 days. The greater the score on the questionnaire, the greater the effect is on work and daily activities. The Spanish version has been validated and has been shown to be reproducible in patients with CD .Adherence was evaluated using the Morisky-Green index , which hFurthermore, patients responded to a series of questions related to the onset of specific adverse effects to the drugs they were taking at the time. These checkups reflect the adverse effects of immunosuppressive or biologic agents, as preestablished by the research team in the NOMHADchronic app.We recorded information from each patient on the use of health care resources, specifically the number of unscheduled visits to the outpatient clinic, visits to the emergency department, and nonscheduled admissions to hospital. This information was recorded using the hospital information system, Orion Clinic, which has been certified by the Health Information and Management Systems Society and is used in daily clinical practice in La Fe University Hospital. We also recorded the following: the reason for the visit to the outpatient clinic, visit to the emergency department, or hospital admission; whether or not IBD-related surgery was necessary; and the total length of hospital stay. In addition, we recorded all deaths during the study (whether related to IBD or not).Patient satisfaction with the care received was evaluated at 24 weeks using an adapted version of the Client Satisfaction Questionnaire, which comprises 6 questions on the quality, usefulness, and viability of the care received as a result the intervention .This project was funded in 2012, and the platform was installed and configured from 2013 to 2014. Enrollment started in October 2014 and it finished in June 2016. At the time of this protocol’s submission, data analysis was underway, and the first results are expected to be published in 2018.Efforts, to date, have focused on telemonitoring systems in an attempt to positively influence adherence to treatment and knowledge of the disease in the follow-up of patients in remission or with mild-to-moderate disease ,16. ThisThere is still little evidence on the role of telemedicine in monitoring health outcomes and reducing health care costs in the IBD setting. In 2001, Robinson et al  successfconstant care was introduced for patients with UC. A randomized controlled trial comparing Web-based monitoring and standard follow-up was carried out with 333 patients with UC treated with 5-aminosalicylic acids (5-ASA) at hospitals in Denmark and Ireland. The remote care method was safe and feasible. The authors observed a trend toward higher adherence in patients managed using a Web-based system and that the duration of relapses was shorter than that in the G_control. These findings were associated with the ability of the Web-based program to empower patients to self-initiate 5-ASA in case of flare-ups. Moreover, in the experimental arm, patients made more phone calls and sent more emails but attended fewer face-to-face visits, and cost savings per patient-year were recorded.Web-based programs are a new and easy-to-use approach in telemanagement. The implementation of such programs reduces the costs of telemanagement because home installation is not required. Elkjaer et al  performeGiven that telemonitoring apps are well accepted by patients and seem to be a safe approach for follow-up of patients with less complex IBD (in remission or with mild activity), we designed a controlled, 3-arm clinical trial to compare the effectiveness of G_TECCU for the monitoring of inflammatory activity in patients with IBD of moderate-to-high complexity with G_control and G_NT. Our study enabled us to compare the main strategies applied to date in the follow-up of patients with IBD (standard or telephone support by a nurse) with remote monitoring. In particular, an easy-to-use Web-based program with a Web app (NOMHADchronic) would likely improve health outcomes and reduce costs more than other systems for remote management of the disease  .Another critical issue was the selection of activity index and biological tools for measuring disease activity and secondary outcomes remotely. We used clinical activity indices  to evaluate the primary objective of the study. The SCCAI was previously used to evaluate the ability to control disease via telemonitoring systems  and was Regarding the development of the TECCU Web program, the main difficulties were related to the design of an easy-to-use system, which is compatible with a broad group of devices. We designed an interactive tool, which allows patients to register their evolution at each moment, through a simple and structured main menu containing all relevant aspects to control IBD activity. A practical problem with the use of TECCU was its incompatibility with Microsoft Internet Explorer Web browser, but patients and researchers were able to open the TECCU platform using Mozilla Firefox or Google Chrome, and there was a version available for Windows and Mac operating system computers and Android or iOS mobile phones. Another issue was the absence of videoconference, but the electronic messaging and the intelligent alert plans included in the platform allowed coordination of health care providers to provide response to medical problems after 24 to 48 hours. Our study is subject to a series of limitations. First, we included patients with IBD managed at a tertiary referral hospital, and the exclusion of patients with suspicion that monitoring will not be completed is subject to difficulties in determining the ability and willingness to use ICT in each case, which represent a potential source of bias. According to guidelines for management of IBD, patients evaluated at referral centers often have more complex disease, are often more difficult to treat, and need aggressive therapies. Patients treated in community hospitals, on the other hand, generally have milder disease and require less aggressive treatment. However, the NOMHADchronic program may also help community physicians to be more aware of the guidelines, and it could even be more effective in patients who can self-manage with less aggressive treatments, which may be easier to implement. Second, we did not perform colonoscopy in all patients because it would increase the costs of the clinical trial, and colonoscopy is not performed routinely in all patients in clinical practice. Nevertheless, we intend to analyze the subgroup of patients who underwent routine colonoscopy. Third, due to the kind of interventions assessed, neither the patients nor the researchers were blinded with respect to the intervention, but the results were analyzed by an independent statistician who was blinded to group identification.In conclusion, the development of a Web-based program for the management of patients with IBD proved challenging in terms of providing adequate remote monitoring of the disease and acceptance of the system, mainly as a result of including patients with moderate-to-severe disease. We describe the difficulties we faced during the design of a randomized clinical trial to compare Web-based monitoring of patients with standard face-to-face monitoring and telephone monitoring. We aimed to aid other investigators in the development of telemonitoring interventions and the selection of methods to measure health outcomes remotely as well as the groups of patients who benefit from this approach during the design of future studies in the IBD setting. The results of our trial will show the impact of the TECCU telemonitoring system on disease activity, quality of life, and health care costs through continuous care and patient empowerment. Future studies are necessary to validate the NOMHADchronic remote monitoring program in other, specific groups of patients, namely, those with noncomplex disease, those with limited access to medical care or social support, and patients who may not be able to attend a clinic with specialized IBD care.


Ambitious overseas recruitment targets have been set by the UK government to help alleviate the current GP shortage. European Economic Area (EEA) doctors can join the UK’s GP register under European law. Non-EEA doctors must obtain a Certificate of Eligibility for General Practice Registration (CEGPR), demonstrating equivalence to UK-trained doctors. CEGPR applications can be time-consuming and burdensome. To meet overseas recruitment targets, it is important to facilitate the most efficient route into UK general practice while maintaining registration standards and patient safety.To develop a methodology to map postgraduate GP training and healthcare contextual data from an overseas country to the UK.Desk-based research and stakeholder interviews.Four stages were undertaken: 1) developing a data collection template; 2) conducting a case study ; 3) refining the data collection template; and 4) creating a mapping framework. The case study used the 2016 curricula for the UK and Australia.Five ‘domains’ were identified: healthcare context, training pathway, curriculum, assessment, and continuing professional development (CPD) and revalidation. The final data collection template comprised 49 mapping items across the domains. The methodology incorporated the application of a red, amber, or green (RAG) rating to indicate similarity of data across the five domains. Australia was rated ‘green’ for training pathway, curriculum, and assessment, and ‘amber’ for healthcare context and CPD and revalidation. The overall rating was ‘green’.Implementing this systematic methodology for mapping GP training between countries may support the UK’s ambitions to recruit more GPs, and alleviate current GP workforce pressures. In the context of GP workforce challenges and efforts to recruit doctors from overseas, this is the first study specifically focusing on developing a methodology for the comparison of international postgraduate GP training and healthcare context with that of the UK. The test case of Australia was used in order to develop a systematic approach that would stand up to academic scrutiny. The research provides information to guide future decisions, and direction about determining the most efficient and least burdensome route for overseas doctors to enter UK general practice while maintaining patient safety and registration standards.1Since 2017 there has been a revised target from NHS England to recruit an additional 5000 GPs, with 2000 of these GPs to come from overseas.2 Further, it has recently been agreed that, in fact, 6000 GPs are now needed.4These targets come in the context of falling numbers of GPs, failure to fill training posts currently available, and wider workforce challenges in the UK.6The UK is currently experiencing a shortage of GPs, as are many countries worldwide.7 The training of EEA doctors is recognised in the UK under European law, and these doctors are given automatic recognition which allows them to join the UK GP register. However, doctors from non-EEA countries are currently required to obtain a CEGPR in order to join the GP register.8Overseas recruitment of GPs entails a process for international doctors to apply to join the GP register of the UK’s General Medical Council (GMC), the organisation which sets the standards for delivery of medical education and training.9 but most exceed this.The CEGPR application processThe combination of the burden of current CEGPR requirements and ambitious targets for overseas GP recruitment prompted NHS England (working with the RCGP and the GMC) to review assessment processes for GPs trained outside of the EEA. Their aim was to identify whether the GP registration process could be streamlined for doctors from non-EEA countries with training and experience that are seen as largely similar to the UK GP programme. A streamlined CEGPR process for non-EEA GPs would aim to make the application process quicker and less burdensome for applicants and assessors, without compromising patient safety and GP registration standards, and to enable timely recruitment of overseas GPs to help ease the overall system-wide pressures currently experienced in UK general practice.10 to the authors’ knowledge, no prior work has explored the potential for mapping GP training between different countries and the UK. The Primary Care Research Group, within the University of Exeter Medical School, worked collaboratively with the RCGP to develop and pilot a methodology to map GP training and other relevant healthcare system-contextual data from another country to the UK. The aim of the research was to provide information to guide future decisions, and direction about determining the most efficient and least burdensome route for overseas doctors to enter UK general practice, while maintaining patient safety and registration standards.Although published work exists relating to comparison of primary school education curricula in England to those of other countries,This article reports the development of a screening tool to determine a) whether there was sufficient evidence of equivalence for a country to be considered for a streamlined CEGPR process; and b) if so, to identify the specific areas of similarity and difference, to help inform the content of the streamlined process for that country.The methods involved a rapid review of existing policies, procedures, and publications that were relevant for designing a practical approach to assessing the comparability of GP education and training of another country with the UK. A test case  was used to refine the methodology and to assess its plausibility.A four-stage approach was taken to develop, pilot, and refine the mapping methodology . The worThree activities were conducted to identify what elements of general practice needed to be included in the mapping:A list of draft mapping questions and topics was provided by the RCGP which included: GP training pathway, assessment during GP training, clinical competence and experience with population groups during and after training, CPD requirements, and revalidation systems.Key documents and web-based resources were identified through internet-based searches to help ensure any further key areas of interest were identified. Published academic and grey literature was searched using the bibliographic database PubMed and Google Scholar search engine. Internet searching was used to identify governmental and non-governmental organisations and agencies with a remit in the area of primary care, GP training, assessment, and revalidation in the countries under review.Stakeholder interviews were conducted to further inform the development of the preliminary template. Stakeholders were identified by the research team and invited, by email, to interview. Telephone interviews were conducted with six stakeholders, purposively sampled based on their role within the RCGP, the GMC, Health Education England (HEE), or a deanery. A semi-structured interview schedule was developed following review of the draft mapping questions document and identification of key areas of interest from the initial document-scoping exercise. Additional participant-specific questions were added to this generic schedule. Broadly, interviewees were asked what they would expect to see included in the mapping questions to feel confident in the final mapping framework. Interviews were audio-recorded (with permission) to aid notetaking and transcription. Formal qualitative analysis was not conducted due to the small sample and the time-limited nature of the work. Key topics were extracted from the interview notes and transcripts, using the categories and questions from the interview schedule and the additional issues identified by the interviewees.A preliminary data collection template was developed using the elements identified in the steps above. Guidance on the use of this template was developed, as well as a rating system for reviewing the alignment between the UK and the other country for each mapping topic. The alignment rating system used a four-point scoring system for each question, and a RAG rating for each domain and for the country overall .A case study was conducted to pilot the data collection template, guidance, and rating system. It was agreed by stakeholders that the pilot be completed using Australia as the country to be compared with the UK. Australia was selected for reasons including: the spoken language is English, training systems and approach to family practice were anticipated to be broadly similar to the UK, and the RCGP had some evidence that some Australian GPs would be interested in working in the UK.The case study involved desk-based research and interviews with key informants. Desk-based research was conducted by four members of the study team. Researchers were asked to a) answer the mapping question for the UK, b) answer the question for the comparison country, c) provide a commentary on the key differences and similarities between the two countries, and d) assign alignment scores and RAG ratings. Use of tables and diagrams aided this process for many of the questions, enabling direct visual comparisons to be made. An audit trail of data sources was kept, to record how easy or difficult it was to collect the data for each mapping question, and to record how confident the researcher was that the question had been fully answered. These details were used to help refine the data collection template in stage 3.Key informant interviews were conducted by two members of the study team, to clarify understanding and to address questions that could not be answered through desk-based research. Key informants were identified for each country using the research team’s professional networks and through official websites. Interviewees were selected purposively and invited by email. The interview schedule was structured to address the specific outstanding mapping questions and answers, and the key informant’s area of expertise. Interviews were conducted by telephone or Skype, and were audio-recorded (with permission) to aid notetaking.The mapping questions within the data collection template were refined and reworded in an iterative process during the course of, and following completion of, the case study. The researchers discussed their experiences of completing the case study at team meetings, and used these discussions to agree the refined template and associated guidance and ratings.The mapping domains and questions from the refined template were used to produce the overlaying mapping framework. Two alternative frameworks were also offered for consideration.Findings arising from review of the RCGP draft mapping questions, from document scoping and from stakeholder interviews, informed the domains and questions included in a preliminary data collection template. Five key domains were identified: healthcare context, GP training pathway, GP training curriculum, GP training assessment, CPD and revalidation .There was agreement between the research team and the RCGP that each of these domains should be included in the mapping process. Further discussion identified specifically how the curriculum and how requirements for remaining up-to-date should be mapped.11 and that the UK’s current CPD and revalidation requirements would be used.12 It was acknowledged that CEGPR applicants were likely to have qualified under older curricula, but the rationale for selecting only the most recent curriculum included: a) that it was not feasible within the time-frame of this work to map past curricula or other requirements in addition to the current ones, and b) local CPD and revalidation (or relicensing) requirements should ensure that a GP is up-to-date and fit to practise. As such, the use of the current curriculum in conjunction with CPD and revalidation requirements was deemed to provide an indication of a GP’s current knowledge and skills (at time of CEGPR application), rather than those gained on initial completion of their GP training. Mapping the current standards and requirements to practise would therefore give an indication of whether streamlining of the CEGPR process was suitable for each country mapped.Discussion centred around which curriculum version GPs had qualified under and how to accommodate different cohorts of qualifying GPs. It was agreed that the most recent GP curriculum in the comparison country would be mapped to the most recent version of the UK GP curriculum from 2016,11 2) professional modules,10 and 3) clinical modules.10 Stakeholder interviewees emphasised the importance of mapping the breadth of the curriculum, and the necessity of focusing on the core statement.A further issue relating to the curriculum domain was the level of detail that the mapping would include. The RCGP curriculum (2016) consists of 1) core statement: being a general practitioner,might be included in the GP role, but that the list (while comprehensive) is not explicitly intended to be exhaustive.The detailed results of the case study are beyond the scope of this paper. However, the process of completing the case study enabled the researchers to pilot and refine the methodology, including the application of the alignment scores and RAG rating processes. For example, mapping questions that were very similar or related were combined, and alignment scores and RAG ratings were applied at the level of each individual mapping question to help with applying scores and RAG ratings at the level of overarching domains. The alignment rating provided a RAG rating for each of the domains and for the country overall. The results for Australia were green RAG ratings for the domains of: GP training pathway, curriculum, and assessment; and amber RAG ratings for the domains of healthcare context, and CPD and revalidation. Australia had an overall RAG rating of green, suggesting it was suitable for consideration of a streamlined CEGPR process.Review and refinement of the mapping questions produced a refined data collection template with clear question parameters, appropriate sections and subsections, and no extraneous questions. All of the five original domains were retained and a total of 49 mapping questions were generated across the domains (further information available from the author on request).The refined template, the mapping questions, and the RAG rating system were used to generate the proposed final mapping framework . The fraIn addition, two further alternative mapping frameworks, both based on the one presented in this publication, were created for potential use in any future mapping work: 1) a simplified framework, and 2) a framework that included mapping of each domain in more detail. The three frameworks together offer potential flexibility of the mapping methodology.At a time of increased, targeted international recruitment of GPs, any changes to equivalence routes to the UK’s GP register must be informed by robust methods of comparison between different countries and the UK. The authors developed and reported a screening tool to help inform specifically whether a country could be considered for a streamlined CEGPR process, using a comprehensive yet easily interpreted and illustrated RAG rating system. A rapid review was undertaken of existing policies, procedures, and publications relevant to informing the design of a practical approach to assessing the comparability of GP education and training in another country with the UK. A test case was used to refine the tool and to assess its plausibility.9 provides evidenced foundations for the formation of streamlined CEGPR requirements. The authors believe that the methodology described is scalable, and that the comprehensive and detailed exploration of country domains is fair. Fairness and reliability could be further explored through an assessment of inter-rater reliability of the alignment and RAG ratings scoring, and the use of a country expert to review and comment on a country’s case study results.The final version of the tool provides an indication of issues and topics that might require more or less evidence and exploration within a streamlined CEGPR decision for an individual country. This, in conjunction with the known generic reasons why some candidates are unsuccessful in their CEGPR application,The main strength of this work was the use of an experienced academic team who were able to ground the project in clinical, primary care, educational, international, and methodological expertise. This work offers a robust methodology to support the agenda of international recruitment of GPs. The team achieved rapid turnaround of the work, aided by effective communication and collaborative working with the RCGP. The team also considered whether the mapping framework could be applied to other countries and has identified, in advance, issues that might arise when, for example, mapping a country where comparable healthcare context statistics are difficult to find, or where there may be sensitivity in approaching expert key informants. A potential limitation of this work was the necessity to focus on England, rather than reporting separately on each of the UK’s four nations, where different health systems have evolved since devolution .13 and also relating to comparison of healthcare workforce metrics from international perspective,14 but to the authors’ knowledge, no prior work has explored the potential for mapping GP training between different countries and the UK.Published work exists relating to comparison of primary school education curricula in England to those of other countries,Reporting the complexity of UK healthcare context had to be carefully managed through use of clear questions and informed decisions about the scope and requirements of the work. In addition, although both countries involved in this work had English as their first language, care had to be taken to avoid any misinterpretation of language and concepts across cultures. Consequently, it is recommended that any future application of this work also includes a review of each country’s mapping report by a country expert. An additional challenge for any further application of this work is accommodating potential changes within the domains being explored. For example, current changes to CPD requirements , and known future changes to curricula (UK) illustrate the need for detailed and current country-level understanding.14 In addition, at a time of changing workforce dynamics globally, it will be important to open up these practical issues to academic rigour.The aim of a streamlined CEGPR process for GPs from non-EEA countries would be to make the application process quicker and less burdensome for applicants and assessors, without compromising patient safety and GP registration standards. Enabling timely recruitment of overseas GPs could, in turn, help to ease the overall system-wide pressures currently being experienced in UK general practice. An increase in doctors coming into the UK from overseas could also provide greater opportunities in the future for senior UK doctors to deliver training and mentoring support, thus expanding their role and contribution to the workforce. This work provides reassurance that a systematic methodology for mapping GP training between different countries and the UK has been developed, with the potential for these methods to be applied to other specialties looking to recruit internationally. The methodology developed may also be of use in the context of recent work by WONCA (World Organization of Family Doctors) Europe and its teaching organisation, EURACT, to define the general practice/family medicine specialty within the EU region.Any changes to the current CEGPR and overseas GP recruitment processes will have implications for the key statutory, regulatory, and professional agencies responsible for medical training and registration and, as such, these agencies would need to have sight and input into any future policies in this area.


Badan Penanggulangan Bencana Daerah [BPBD] or local disaster management agency) and the disaster risk index. In addition, surveys were undertaken in which the respondents were the key officers in the BPBDs who are responsible for the budget and programmes to obtain detailed information about how the local government prepares their budget for disaster. By employing the Pearson’s chi-square test and the Pearson correlation test, this study revealed no significant statistical relationship between the disaster budget and the level of disaster risks among districts or cities in the Aceh province, northern Indonesia. However, results show that the total budget of the local governments has a significant positive correlation with the disaster budget. The surveys also confirm the correlation between the total budget of the local government and disasters as the same budgeting procedure is applied. The result generalisability might be limited as this study only focused on one of Indonesia’s provinces, Aceh.This study investigates the correlation between disaster budget, index of disaster risks and the population of 23 districts in the Aceh province, northern Indonesia. It also explores how the budget for disasters is proposed and prepared by Indonesian local governments. A descriptive quantitative approach is used to examine this relationship. Data were collected from the budgets of local governments (disaster risk; disaster relief planning; disaster budget; local government; tsunami; Indonesia. Indonesia is well known for high disaster risks, particularly over the last two decades. Its demographic, geological and geographical situations could be the main reasons why the country with a population of more than 240 million experiences various disasters. The country is situated in the highest disaster risk area known as the Pacific Ring of Fire where the three tectonic plates of Indo-Australia, Eurasia and the Pacific are located  programme has been called for by experts and the international community  as the government department responsible for the DM. In addition, this study is conducted at the local government level because they know more about their citizens and situation compared to other actors, that is, central government  which is managed by a ministry-level organisation called the National Agency for Disaster Management . Simarmata and Suryandaru   No. 22/2008 concerning funding and disaster relief management.The GR 22/2008 classified three types of DM funds, namely contingency funds, ready-to-use  funds and social assistance funds , each BPBD is the main actor of the local government DM budget. However, it is argued that Indonesian local governments do not have sufficient capacity to reduce disaster risks and respond to disasters  or only in a special agency that is responsible for disaster recovery. Research on this topic is limited and particularly with respect to how the government decides how much money needs to be allocated for disaster recovery and mitigation efforts. In the context of Indonesian local governments, Dartanto et al.  found thAnggaran Pendapatan dan Belanja Daerah [APBD], Indeks Risiko Bencana [or disaster risk index {DRI}]) and statistics reports published by the Indonesian Statistics Bureau. The operationalization of the variables can be found in This study employed a quantitative approach to analyse the association between DB, disaster risk and the population of 23 districts in the Aceh province, northern Indonesia, for the periods of 2014, 2015 and 2016 . The data were gathered from the local government budgets . The expected results are a range of relationship levels between 0 and 1. The higher the correlation value, the stronger the relationship among the variables. Later on, we conducted indirect interviews with senior officers by sending them a list of questions. Only three senior officers from the BPBDs returned their answers, that is, BPBA (Aceh province), BPBD Sabang and BPBD Aceh Besar. Based on their responses, the disaster budgeting process of the three local governments can be analysed.Data dan Informasi Bencana Indonesia [DIBI]), from 1815 to August 2018, a total of 1148 disasters have occurred in Aceh. The most frequent disasters are floods (479 occurrences) and fires (243 occurrences). Tsunamis have occurred four times, but the fatalities are higher than the other disasters, that is, 166 201 deaths. Thus, this province is among the provinces with one of the highest disaster risk levels in Indonesia. Additionally, the Aceh government has received special autonomy since 2008 from the central government. This has made Aceh as one of the provinces with the biggest budget in Indonesia.Indonesia is naturally a disaster-prone country. It has 34 provinces and Aceh is one of the provinces that was significantly affected by the Indian Ocean earthquake and tsunami disaster back in 2004. This made the region one of the most disaster-prone areas in Indonesia. According to the Indonesian Disaster Data and Information database  2 537 036 291.00 (or $195 157.00) to IDR 59 567 791 659.00 (or $4 582 138.00). The average value of DB is IDR 10 575 949 895.00 (or $813 534.00). The proportion of DB from the district budget is relatively very small. The highest DB portion is only 0.18, whereas the smallest portion is 0.85 with the average value being less than 1% (or 0.85). This portion is very small and this fact might indicate a weak motivation of the local governments in their programme of budgeting for a disaster.Meanwhile, the DRI of the studied districts is relatively high . The lowr = 0.005, p = 0.318). Similarly, the correlation between the DB and population showed an insignificant correlation . The same result is also found for the relationship between the DB proportion and DRI  and between the DB proportion and population . The only correlation that was confirmed is between DISBUGT and the total budget . Thus, the present study indicates that DB has a positive significant correlation with the total budget of the studied local governments. This can be interpreted as a larger DB being found in the local government with a bigger budget. In this case, local governments with a higher budget have a higher budget for disaster.Furthermore, by employing Pearson’s chi-square test and the Pearson correlation test , the DRITo obtain a more detailed understanding of disaster budgeting, a survey that involved key officers in the budgeting of three BPBDs was conducted. The process of disaster budgeting was obtained based on the survey result. Firstly, the disaster budgeting (BPBD budget) process is similar to the budgeting in other departments. Each BPBD proposes an annual budget to the BAPPEDA. The BAPPEDA compiles the proposed budget from all departments and, later on, they make the local government budget. Because of financial constraints, the proposed budget from the BPBDs and other departments is evaluated and rationalised. Consequently, BPBDs mostly receive less budget than what they have proposed:It follows a standard budgeting process regulated by the central government. Starting from determining long-term and short-term planning, followed by the proposed program. Secondly, the amount of local budget allocated for BPBDs is relatively small and not sufficient to cover the proposed BPBD programme. The reason could be that the district has a small total budget and the department is relatively new:Our budget is still very limited. What we can do is to facilitate coordination when a disaster happens. The budget amount is not really optimal. However, the province’s BPBD received a more ideal budget. The main reason is that the provincial BPBD has a more complex responsibility than the district BPBDs. It is responsible for any disaster that is categorised as a regional disaster. For example, an earthquake affects more than two or three districts, and therefore, it is categorised as a regional disaster; the Aceh province BPBD has to cover emergency and (partly) recovery programmes that are needed. Meanwhile, the district BPBDs are only responsible for coordination in disaster recovery and mitigation in their areas:(The budget is) very ideal. In fact, the budget of BPBD of Aceh province is among the biggest compared to BPBD of other provinces in Indonesia. Thirdly, the amount of the budget is mainly determined by the total budget of the local government. The portion seems too small compared to the budgets for other departments. This might indicate a lack of awareness and commitment of the local government as well as the political support of local parliament members on disaster mitigation and response issues.The results of this study are consistent with those of Oktari et al.  who founThe result of the present research does not confirm the results of the study by Dartanto et al.  where itFurthermore, the budget procedures and regulations for BPBDs are similar to other departments or local government institutions. The main determinant of the DB could be the total budget of the local government instead of the potential disaster risk of each region or district. In fact, the BPBD programme seems to not be at the top of the list of priorities in local government budgeting. The main possible explanation is that BPBD is a relatively young and new government institution that leads to less concern, trust and respect from the local government structure . The present study demonstrates statistically an insignificant correlation between disaster budgeting and disaster risk index (DRI) in the local governments of the Aceh province, northern Indonesia. However, there is a significant positive correlation between DB and total budget of the local government. Hence, it can be concluded that the DB is not formulated based on the possibility of a disaster occurrence in the districts or on the population, but rather it is based on the total amount of budget of each local government (proportionately). In addition, this study reveals that the DB is prepared in a similar manner to other department budgets. The main actors are BAPPEDA and the local government budgeting team as they decide the approved budget for all departments. The possible determinants of DBs could be the total amount allocated to local government budgets, politics and the commitment of government and legislation on DRR, the complexity and scope of BPBD duties and accountability of previous budget spending. These potential determinants should be tested in further research. This study has some limitations, namely, a small number of data samples for analysis, a short period of observation and minimal data analysis. It is imperative to re-assess the correlation between DB and DRI in bigger samples or to examine the determinants of the DB in the Indonesian or cross-country setting. Therefore, it is imperative to conduct similar research using a bigger sample, for example, all local governments throughout Indonesia.


BASE jumping is an extreme adventure sport which consists of jumping from a fixed object with specially adapted parachutes. A few studies of the personality of BASE jumpers have been conducted, but little is known about how the women in this sport compare to the men. The purpose of this study is to compare the personality traits among a sample of men and women who are experienced BASE jumpers, as this provides an interesting and important opportunity to better understand the motivation for extreme sports. Eighty-three participants completed the Temperament and Character Inventory the day before the jump at the New River Gorge Bridge Day BASE Jumping event, West Virginia, United States. The sample included 64 men and 19 women. Results show that men and women BASE jumpers shared similar personality traits both in terms of temperament and character, except for the character trait of cooperativeness on which women scored higher than men. This suggests that the basic drive for participation in extreme sports is self-regulation of personal emotional drives and needs for self-actualization, rather than to oppose social pressure or cultural bias against female participation. These findings are discussed in relation with other studies conducted among extreme athletes and in terms of congruence between personality and activity. They also need to acquire knowledge about their own reaction under extreme conditions in order to make the right decisions and maintain safe behavior throughout the jump.BASE jumping is an extreme adventure sport which consists of jumping from a fixed object with specially adapted parachutes. “BASE" is an acronym for the four categories of fixed objects from which one can jump: Building, Antenna, Span  and Earth . This sport developed out of skydiving and is considered as one of the most dangerous extreme sports because of the risk of accident or death involved in the practice . The injExtreme athletes have often been described as persons who tend to search for high risk experiences involving elevated levels of sensation, physiological arousal, and novelty , 2014. TAccordingly, personality studies have demonstrated that most BASE jumpers were both high on the temperament traits of novelty and sensation seeking and low on harm avoidance. Temperament traits refer to automatic responses to emotional stimuli whereas character traits refer to voluntary goals and values. Novelty seeking is an automatic and biased response to novelty which is moderately heritable and which is reflected by impulsive decision making, active avoidance of frustration, extravagance in approach to cues of reward, and quick loss of temper. Whereas novelty seeking is a heritable bias in the activation of behaviors, harm avoidance is a heritable bias in the inhibition or cessation of behaviors and it is reflected through pessimistic worry, passive avoidance behaviors, shyness with strangers, and fatigability . ConsequIn addition, extreme athletes may also pursue higher-level motives, such as goal achievement, mastery-seeking, social motivation, connection with the natural environment, feeling of pleasurable bodily sensations, achievement of unselfconsciousness . As an eHowever, studies conducted among BASE jumpers and other extreme sports usually don’t consider gender differences and little is known about female participants of extreme sport. As a matter of fact, women are even sometimes excluded from the studies on high-risk sports because of their low frequency . 90% of The differences of prevalence between men and women in extreme sports are not really surprising. On the one hand, women have for a long time been less involved than men in sport and extreme sports because of culture and gender roles . On the The gender difference in the prevalence of BASE jumping provides an interesting and important opportunity to better understand the motivation for extreme sports, as has been considered for personality disorders and alcohol use disorders in other work . What isGender differences is a field of widespread interest in which the differences have been viewed from several perspectives, including evolution , biologyFrom an evolutionary perspective, differences between men and women have been explained in terms of sexuality and natural selection . For insAlthough there may have been different pressures shaping the personalities and biology of men and women over evolutionary time, the roles of women and men in society are much more similar now. As a result, women now have the same access to extreme sports that men do. Some laws such as the federal antidiscrimination law (title IX in 1972 in the United States) and the Amateur Sports Act of 1978 have contributed to open access to women in sport. Those laws came along with the recognition of sport benefits in terms of physical, mental, social, and spiritual health of women . For exaStill, little is known about female BASE jumpers or other populations of extreme sportswomen. Interestingly, available studies have shown that women who are experienced in extreme sports may be similar to the men . For exaHowever, very few studies have investigated such gender differences among extreme athletes using a comprehensive model of personality, and, to our knowledge, no study comparing men and women have been conducted among BASE jumpers. The purpose of the study is to compare men and women who are experienced BASE jumpers using the Temperament and Character Inventory (TCI), a comprehensive model of personality.Novelty seeking is viewed as a heritable bias in the activation or initiation of behaviors in response to novelty ; Harm avoidance is viewed as a heritable bias in the inhibition or cessation of behaviors ; Reward dependence is viewed as a heritable bias in the maintenance or continuation of ongoing behaviors ; and Persistence corresponds to perseverance despite frustration and fatigue.The TCI is an inventory for personality traits for Cloninger’s psychobiological model of personality , which eSelf-directedness which refers to the ability of an individual to control, regulate and adapt behavior to fit the situation in accordance with individually chosen goals and values, and which encompasses traits such as purposefulness, responsibility. Cooperativeness refers to the identification with and acceptance of other people and is related to agreeability, empathy, helpfulness to others without selfish domination. Self-transcendence is viewed as the identification with everything conceived as essential and consequential parts of a unified whole. It corresponds to a unitive perspective or consciousness where the person is simply aware of being part of a greater whole, and it can be described as acceptance, identification, or spiritual union with nature and its source  and the 2014 (n = 100) Bridge Day events. Unique identifying codes, based on name initials and dates of birth were utilized to ensure participant data was not collected twice in 2008 and 2014. The overall number of participants at each event was around 400 participants. Participants were excluded from the study because of missing data on the TCI and 24 participants because of missing data on previous experience in BASE jumping . Participants who had done less than 10 jumps prior to the event were excluded from the study (n = 46) in order to consider only regular BASE jumpers. The final sample was comprised of 83 participants, including 64 men (77%) and 19 women (23%) (see Table 1). The participants were between 20 and 79 years old  and women were slightly older than men . Most of the participants came from the United States and some others came from United Kingdom, Canada, Israel, and South Africa. In average, participants had been practicing BASE jumping for 6.7 years (6.1 [SD = 5.5] for men and 8.2 [SD = 7.7] for women) and the average number of jumps among participants was 132 (SD = 302.7). Men had experienced many more jumps than women in general (M = 159.0 [SD = 340] for men and M = 43.5 [SD = 43] for women).One-hundred and sixty-two participants from different countries at two distinct Bridge Day events volunteered to participate in the study. All participants gave a written informed consent before completing the questionnaires. Data were collected from the 2008   .Data for the study was collected from the New River Gorge Bridge Day BASE Jumping event, both in 2008 and 2014. This is an annual event in October in Fayetteville, WV, United States where participants jump from a bridge 876 feet above the New River. The researchers discussed the nature and purpose of the study at this event and invited voluntary participation from attendees. Participants completed several paper questionnaires the day before the jump without remuneration, as described in prior work . The parStatistical analyses were carried out using SPSS for Windows, version 22.0. The Wilcoxon Mann–Whitney test was used as a non-parametric test for independent samples to compare the two samples of men and women because samples were small when divided by gender, and scores were not normally distributed.Data collected in 2008 and in 2014 were combined in all analyses.Table 2).BASE jumpers in this study scored above average on Novelty Seeking, Self-Directedness and Cooperativeness, and below average on Harm Avoidance, Reward Dependence and Self-Transcendence .Results showed that men and women had similar scores on all of the TCI dimensions, except for the trait of cooperativeness where women scored higher than men . Institutional Review Board approval was obtained prior to commencement of the study from the University of North Carolina at Chapel Hill Written consent was obtained from those who agreed to participate in the survey in accordance with the stipulated IRB procedure and in accordance with the Declaration of Helsinki.EM and RC contributed to analysis and interpretation of data. AH, EM, and OM-D to data collection. All the authors to review and approval of the final manuscript.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.