Fruit and vegetable (FV) intake in children in the Netherlands is much lower than recommended. Recurrent appraisal of intake levels is important for detecting changes in intake over time and to inform future interventions and policies. The aim of the present study was to investigate differences in fruit and vegetable intake, and whether these could be explained by differences in potential determinants of FV intake in 11-year-old Dutch schoolchildren, by comparing two school samples assessed in 2003 and 2009.For 1105 children of the Pro Children study in 2003 and 577 children of the Pro Greens study in 2009 complete data on intake and behavioural determinants were available. The self-administered questionnaire included questions on children's ethnicity, usual fruit and vegetable intake, mother's educational level, and important potential determinants of fruit and vegetable intake.Multiple regression analysis was applied to test for differences in intake and determinants between study samples. Mediation analyses were used to investigate whether the potential mediators explained the differences in intake between the two samples.In 2009, more children complied with the World Health Organization recommendation of 400 g fruit and vegetables per day (17.0%) than in 2003 . Fruit consumption was significantly higher in the sample of 2009 than in the sample of 2003  grams/day). This difference was mainly explained by a difference in the parental demand regarding their child's intake (23.6%), followed by the child's knowledge of the fruit recommendation (14.2%) and parental facilitation of consumption (18.5%). Vegetable intake was lower in the 2009 sample than in the 2003 sample . This difference could not be explained by the assessed mediators.The findings indicate that fruit intake among 11-year-olds improved somewhat between 2003 and 2009. Vegetable intake, however, appears to have declined somewhat between 2003 and 2009. Since a better knowledge of the recommendation, parental demand and facilitation explained most of the observed fruit consumption difference, future interventions may specifically address these potential mediators. Further, the provision of vegetables in the school setting should be considered in order to increase children's vegetable intake. A healthy diet, including an ample intake of fruit and vegetables, is part of recommendations for a healthy diet and may be especially important in youth . Fruit aThe World Health Organization (WHO) and Food and Agriculture Organization (FAO) recommend a daily intake of 400 grams of fruit and vegetables . The DutSimilarly to other countries in Europe ,12 and eSchoolgruiten programme; there are initiatives to implement the programme nationwide, and the European Commission is encouraging similar promotion of fruit and vegetable consumption across Europe [A main focus of such projects is increasing the availability and accessibility of fruit and vegetables at school by providing children with free servings of fruit and/or ready-to-eat vegetables during school hours. Some also use specific school lessons to increase knowledge, for example, or promote taste testing to enhance preferences, and parental activities to improve parental support ,17. Somes Europe .To explore trends in intake, inform decisions about continuation of the aforementioned interventions or develop future programmes and policies, it is important to gain insight into present intake levels and correlates of intakes as compared with the period before most intervention activities were launched .Therefore, the objectives of the present study were to explore differences in the fruit and vegetable consumption and their determinants between two national representative samples of 11-year-old schoolchildren in the Netherlands in 2003 and 2009. In addition, it was assessed whether differences in the presumed determinants explained the potential differences in intake levels between the two samples. Finally, it was tested whether differences between the samples were modified by gender, ethnic background or parental educational level.Representative samples of 11-year-olds in the Netherlands were derived from the Dutch cross-sectional survey data of the Pro Children Study in 2003  and the The methodological build-up was identical in both studies and has been described in more detail previously . The datPrimary outcome measures were the total intake of fruit and vegetables in grams on the day prior to the day of the data collection. Fruit and vegetable intakes were analysed separately because previous studies have shown that these are distinct behaviours  with theIn summary, the 24 h recall is an instrument that identifies all vegetables and fruits consumed during the day prior to the completion of the questionnaire. Questions were asked about the fruit and vegetable intake in three different time intervals: (1) before school, (2) during school time and lunch, (3) after school, at supper and after supper. Amounts were indicated in terms of the number of slices, portions, or pieces eaten and standards were defined for these units [For descriptive purposes only, intake levels were dichotomized according to whether children met the WHO recommended daily amount of fruit and vegetables of 400 grams/day and whether the children met the Dutch recommendations .Potential mediators of interest were previously identified determinants of fruit and/or vegetable intake. These potential mediators were assessed for fruit and vegetable intake separately by a questionnaire that had previously shown acceptable to good test-retest reliability (12 out of 15 fruit and vegetable questions had an intra-class correlation coefficient (ICC) > .0.60) . A rangeAge, gender, ethnic background of the children and their mother's educational level were assessed as potential confounders or effect modifiers. Mother's educational level was categorized according to years of education: fewer than 12 years and 12 and more years.Children's ethnic background was defined in three categories according to Statistics Netherlands: native Dutch (both parents were born in the Netherlands), non-Western (at least one of the parents was born in a non-Western country) and western ethnic background (at least one of the parents was born outside the Netherlands but in Europe (excluding Turkey), North America, Oceania, Japan, or Indonesia). Children's ethnic background, gender, and age as well as their mother's educational level were respectively obtained from the child and parent questionnaires.As can be seen in the flow diagram Figure , a totalDescriptive statistics were calculated for the key variables. Student's t test, the chi-square test or the non-parametric Mann-Whitney U test were applied to compare crude differences in intake levels and potential determinants between the two study samples.The 24 h recall data showed a considerably skewed distribution, because many children reported that they had not eaten fruit or vegetables on the day prior to the survey and thus many zeros were scored. A log transformation (ln(x+1)) did not result in a normal distribution. Therefore, analyses for all outcome variables were carried out on non-transformed data. The distributions of the residuals from the regression analysis were checked for all analyses and found to be acceptable. Since the 'allowing' variables were highly skewed to the right, they were categorized as 'negative', i.e. taking 'strongly disagree' and 'disagree' together; 'neutral', and 'positive', i.e. taking 'strongly agree' and 'agree' together. Likewise, the 'bringing vegetables to school' variable was dichotomized into a low  and a 'neutral/high' category, including the neutral and two positive answer categories.All analyses with fruit and vegetable intake and potential determinants as dependent variables and the two samples (coded zero and one) as an independent variable were conducted with linear or binary logistic regression analyses. First, effect modification by age, gender, ethnic background of the child and/or the mother's educational level was assessed by including the interaction terms between the group variable and the potential moderator. Children's age, gender, mother's educational level and ethnic background of the child were included as covariates in the adjusted models to account for potential confounding.et al. [i*bi)/c for all determinants together. For both fruit intake and vegetable intake two mediation models were run; the first model including all presumed mediators and a second model including only the variables that were identified as significant mediators in the first model.Second, it was explored whether the differences in presumed determinants could explain the differences in intake between the samples . Mediation analyses were applied in accordance with MacKinnon et al.  and follet al. . Brieflyet al.  was thenet al. . The proAll analyses were conducted with the PASW Statistics 18 program (IBM). A p-value ≤ 0.05 was considered to be significant. Numbers included in the specific analyses differ slightly because of missing values on one or more variables.As shown in Table As can be seen in Table Table Table As can be seen from Table That the 2009 sample had a lower vegetable intake than the 2003 sample could not be completely explained by the assessed potential mediators, since the direct effect (path c') was still significant after the potential mediators were taken into account. Results from the mediation analyses indicated that parental demand acted as a suppressor in the relationship between cohort and vegetable intake, meaning that the association between cohort and vegetable intake became stronger after the 'demand' variable was taken into account. The variables with a negative association with the cohort variable  did not show significant mediating effects.portions or pieces of fruit, whereas the WHO recommendation combines fruit and vegetable intake and uses total grams per day. Additional analyses revealed that the 2003 children reported a higher consumption of tangerines than did the 2009 cohort. Whereas one tangerine counted as one piece of fruit, in the calculations for grams per day it was considered to contribute 50 grams and most other popular fruits such as apples, pears and bananas were estimated to weigh 100 grams per piece. That the 2003 cohort ate more tangerines is in line with the season of measurement; in September and October these kinds of fruit are widely available in the Netherlands.The aim of this study was to assess differences in fruit and vegetable consumption and their potential determinants between two samples of 11-year-old schoolchildren in the Netherlands measured in 2003 and 2009. Overall, the results indicated that the mean fruit intake of the children measured in 2009 was higher than that of the children measured in 2003, independent of their gender, ethnicity and maternal level of education; however, vegetable intake was somewhat lower in 2009 than in 2003. Also more children from the 2009 cohort met the WHO recommendation. However, the observation that more children from the 2003 cohort met the Dutch recommendation for fruit intake may be a result of the different definitions. The Dutch recommendation states a minimum of two Regarding the presumed mediators, significantly more children in 2009 knew about the recommended fruit intake levels than in 2003, and some positive trends for other potential determinants of fruit and vegetable intakes were also found.The finding that the schoolchildren in 2009 on average reported eating more fruit than in 2003 is encouraging. From the mediation analyses it appears that knowledge of the recommendation, parental demand and parental facilitation explains most of this difference. This may indicate that school programmes were indeed able to improve the children's knowledge of the recommendations for fruit intake and that this influenced their intake. It further suggests that the school programmes or other media activities were able to reach the parents, who subsequently changed their parenting practices regarding fruit intake. It is, however, surprising that liking or school availability could not explain the differences between the two samples. Most school-based programmes not only addressed the knowledge of the recommendations but also individual level determinants such as liking . Resultset al. showed that in Denmark fruit intake improved between 2002 and 2006 among 11-, 13- and 15-year-olds; in all age groups among girls the proportion which state to eat fruit at least once per day improved from between 52% and 58% in 2002 to between 62.9 and 69.8% in 2006 [Our results regarding fruit intake are somewhat similar to the very few earlier studies that are available for approximately the same period of time. Rasmussen  in 2006 . Howeveret al. showed that a feeding strategy in which children could make choice regarding when and what vegetables to eat, was positively associated with their vegetable intake [The results further indicate that 11-year-olds in 2009 did not eat more vegetables than 11-years-olds in 2003. On the contrary, the 2009 sample reported a lower vegetable intake than the 2003 sample. This finding is consistent with results from previous research, indicating that increasing intake levels of vegetables of children is more difficult than improving fruit intakes. Children have higher preferences for fruit , and in e intake . In addiThe fact that many factors that have been found to be significant correlates of fruit and vegetable intakes appeared to be more favourable in 2009 than in 2003 is encouraging. The fact in particular that in 2009 children more often agreed that there are fruits and vegetables available at their school may indicate that schools have changed their policies or have participated in programmes that facilitate availability and accessibility, such as the Schoolgruiten project . AnalyseThere was one potential determinant that showed a negative trend: fewer children in 2009 than in 2003 reported that they were allowed to eat as much fruit and vegetables as they wanted. It may be that parents have become stricter in controlling their children's eating behaviours. It could also be a statistical artefact since in 2003 the scores were high and could only go down (regression to the mean), but this is mere speculation and should be further explored in additional research.A strength of this study is that it used representative samples for the Netherlands, using the same validated methodologies , that weSecond, the Pro Greens questionnaire slightly differed from the one used in Pro Children in the assessment of fruit intake, i.e. a separate question for berries was added. Although it was just a minor adaptation, a sensitivity analysis was conducted. There were doubts as to whether children might have thought that they had to state pieces of berries eaten instead of portions of berries eaten, because there were high intake numbers on this item. Therefore, under the assumption that the children reported pieces of berries instead of portions, the numbers were recalculated into portions eaten to check if it would make a difference in the number of children who reached the recommended intake. Results from these analyses showed that the reported differences between the two samples were not caused by this extra questionnaire item (data not shown).A final limitation was the use of self-reported measures. Self-reported intake levels may be biased, but a previous study showed acceptable validity of the questionnaire used in the present study. Furthermore, any bias because of self reports is likely to be the same in the two study samples, and will therefore not be of limited influence on the comparison between the two samples.Taking the limitations into account, the present study does provide an indication of the current situation compared with a period in which interventions and policies aimed at improving schoolchildren's fruit and vegetable intakes were not omnipresent. Although the effect size may not be clinically relevant for individuals, there is a likely relevance for public health, because many children can be reached by school-based interventions and small changes in a large proportion of the population can have an important impact on health indicators, as recently shown in an epidemiological modelling study . In the The outcome of the present study suggests that there was a small improvement in fruit consumption in 11-year-olds between 2003 and 2009, whereas the intake of vegetables was lower in the more recent sample. Children reported in general more knowledge of recommended intake levels and more favourable scores on other potential determinants of fruit and vegetable intakes in 2009 than in 2003. Improved knowledge, parental demand and parental facilitation explained the differences in fruit intake which suggests that these factors should be addressed in future intervention programmes or strategies.The authors declare that they have no competing interests.AY, JB, SJtV designed the study. CF, NIT and SJtV conducted the analyses. CF drafted the manuscript. All authors provided feedback on the manuscript and approved the submitted version.


Perinatal mortality is an important indicator of obstetric and newborn care services. Although the vast majority of global perinatal mortality is estimated to occur in developing countries, there is a critical paucity of reliable data at the local level to inform health policy, plan health care services, and monitor their impact. This paper explores the utility of information from village health registers to measure perinatal mortality at the sub district level in a rural area of Indonesia.A retrospective pregnancy cohort for 2007 was constructed by triangulating data from antenatal care, birth, and newborn care registers in a sample of villages in three rural sub districts in Central Java, Indonesia. For each pregnancy, birth outcome and first week survival were traced and recorded from the different registers, as available. Additional local death records were consulted to verify perinatal mortality, or identify deaths not recorded in the health registers. Analyses were performed to assess data quality from registers, and measure perinatal mortality rates. Qualitative research was conducted to explore knowledge and practices of village midwives in register maintenance and reporting of perinatal mortality.Field activities were conducted in 23 villages, covering a total of 1759 deliveries that occurred in 2007. Perinatal mortality outcomes were 23 stillbirths and 15 early neonatal deaths, resulting in a perinatal mortality rate of 21.6 per 1000 live births in 2007. Stillbirth rates for the study population were about four times the rates reported in the routine Maternal and Child Health program information system. Inadequate awareness and supervision, and alternate workload were cited by local midwives as factors resulting in inconsistent data reporting.Local maternal and child health registers are a useful source of information on perinatal mortality in rural Indonesia. Suitable training, supervision, and quality control, in conjunction with computerisation to strengthen register maintenance can provide routine local area measures of perinatal mortality for health policy, and monitoring of newborn care interventions. Similar efforts are required to strengthen routine health data in all developing countries, to guide planned progress towards reduction in the local, national and international burden from perinatal mortality. Reliable measures of stillbirths and early neonatal deaths  are necessary for planning and evaluation of prenatal, obstetric, and newborn care services. It has Measures of perinatal mortality can be derived using data from vital statistics, routine health services data, or sample surveys. Of thesSample surveys estimate perinatal mortality based on retrospective complete birth histories from women of reproductive age. Recent surveys indicate that perinatal mortality in Indonesia has remained stagnant at around 25 per 1000 live births over the past decade. HoweverWith the shift to district level decentralised health service provision in Indonesia, there isThis paper describes research undertaken in a rural district in Indonesia, to study the utility of local health registers on pregnancies, births and deaths in measuring perinatal mortality at the local level. Information from health service registers was triangulated with information from a range of other sources that record deaths, to estimate perinatal mortality rates at the sub district level in Indonesia. The study findings were compared with local vital statistics, as well as with the data on pregnancies and perinatal deaths reported for the study population by the Maternal and Child Health Program. This research demonstrates the feasibility and potential in using locally available health services data to improve perinatal mortality measurement in Indonesia.The study was conducted in Pekalongan district, Central Java Province, Indonesia. Pekalongan was selected as three of its subdistricts  were involved in a pilot field project being conducted to strengthen mortality registration and vital statistics systems in Indonesia. Initialpuskesmas), which deploys a government midwife to each village within the sub district to provide maternal and child health services. The field research team comprised a group of four research staff from the School of Population Health, University of Queensland, working in collaboration with local government health personnel in Pekalongan district.The three sub districts include a total of 34 villages. Each sub district is served by a government health centre ,a) pregnancy registration and antenatal care services (partus register), andb) birthing support services including record of birth outcomes (bayi kohort registers)c) infant health services including immunization and growth monitoring  collated all records to develop a complete list of deliveries that occurred in 2007. The key variables that were used to match records across registers were the name of the mother & father (and child if available), date of birth, and where applicable, the date of death, and age at death. Village midwives were consulted to verify unmatched pregnancy and birth records, leading either to reconciliation since they actually pertained to a single event or to their identification as truly unique pregnancies in the perinatal cohort. For each pregnancy, the date of delivery, duration of gestation and birth outcome was recorded based on data available from the three registers. We applied the stillbirth definition prescribed by the World Health Organization for reporting perinatal mortality for international comparison  ; to enabFor some pregnancies, the outcome was not recorded in the pregnancy register or the delivery register, but was identified as a live birth since the child received immunization as recorded in the infant register. In other instances for which no register entry was available indicating the outcome, midwives were asked to consult their informal notes, or local traditional birth attendants who had assisted with the concerned delivery, and complete the record. This component of data collection was termed 'Midwife follow up of health registers'.All live births were followed up in the infant register to trace and record survival or death in the first week of life. Survival was confirmed by an entry for immunization at four weeks age. Missing entries were investigated as per the register follow up method described above, and in case of death, the exact age at death in days was recorded in the study dataset. In addition, local death registers maintained by the village administration or the health centre were consulted to identify deaths in the first week as well as stillbirths, and these were used to verify entries in registers, or complete records, as necessary.Following collation of all records with suitable data linkage, a comprehensive electronic database was created to enter the records pertaining to each pregnancy, its outcome and if a live birth, its survival through the first week, for each study village. Key variables captured for each record from different data sources include identification variables, date of birth, birth outcome, length of gestation, and date of death, among others. The complete set of variables collected for each record from each data source is listed in Additional File Ethics clearance for the study was obtained from the Institutional Review Board at the University of Queensland, and from the Ethical Review Committee at the National Institute of Health Research and Development, Ministry of Health, Indonesia. Local permission and oversight of the field study was provided by the District Health Office in Pekalongan.The data were first scrutinised to assess the completeness of information recorded in key fields in each health register, such as birth outcome, date of birth, birth weight, and duration of gestation. The completeness of pregnancy registration in each register was evaluated as a percentage of the entire cohort. Identified perinatal events were triangulated with data from other sources of information on vital events, to develop a comprehensive list of still births, live births and early neonatal deaths, to derive measures of perinatal mortality rates for each sub district. Finally, data on perinatal deaths (i.e stillbirths at > 28 weeks gestation plus deaths in the first week of life) were used to calculate perinatal mortality rates for the study population.Bahasa Indonesia). Electronic audio tapes were then transcribed and translated into English, providing a verbatim note of what was said. The themes explored in the discussions included enquiry into their work practices, their interaction with Traditional Birth Attendants, and their opinions on the strengths and weaknesses of existing recording and reporting systems. Coding or indexing was done for specific themes and probes used to facilitate the discussion, and provide a framework for thematic analysis. In this paper, we only report specific issues that provide insight into the errors in register maintenance, and the reasons for such error.The study included the use of qualitative research methods to study the experiences of midwives in recording and reporting perinatal deaths. In each sub district, midwives from all villages included in the study attended a focus group discussion held at the health centre, lasting about 90 minutes each. Informed consent was obtained from each participant, and discussions were conducted in the national language , non-availability of registers for 2007 (2 villages), absence of midwives during the period of contact due to personal reasons (3 villages), and in the remaining 2 villages, midwives were involved with other health program activities, and could not participate in the research.Overall, the scrutiny of health registers indicated a uniformly poor quality of data recording of birth outcome and date of birth in all villages included in the study. Table A total of 1759 pregnancies that resulted in delivery were identified after data linkage across the three health registers. The distribution of pregnancies across the registers is illustrated in Figure The recording of perinatal deaths can be expected to vary across registers. For instance, pregnancy registers should at least record all stillbirths, delivery registers could be expected to record all stillbirths and at least early neonatal deaths within the first few hours of life; and the infant registers will not include records of stillbirths, but could be expected to record all early neonatal deaths. As described in the Methods, we also pursued a range of additional sources to identify perinatal deaths that could have occurred in the study population during the reference period. Again, appropriate matching was conducted to develop a final unique list of perinatal deaths.Table Table Qualitative research identified that the majority of women in Pekalongan deliver at home, attended by the trained health centre midwife. Several health centres have delivery rooms, but these are not used. Some women prefer a Traditional Birth Attendant, but the trained midwife is also present. In case of complications, the case is shifted to the district hospital. A small number of women attend private health facilities in the town or capital cities. In all such cases of delivery in health facilities, the details of delivery are recorded on discharge cards, and these details are entered in the local village delivery register. The above variations in birthing circumstances had an obvious influence on the manner in which data were recorded in the registers. In addition, the qualitative research identified several other reasons for the inconsistent register maintenance. These could be largely described in the following categories:a) High workload on midwives, with little time for routine documentation. This is coupled with a lack of awareness about the importance of data accuracy for health monitoring and health services planning. This causes the midwives to maintain informal notes in handbooks (rather than the bulky registers), which they later use to update the main registers in the immediate period prior to submitting monthly returns. This results in losses during transcription due to use of shorthand, misspellings, illegibility, inaccurate memory, and other oversight while recording data in handbooks.b) Individual variations and inconsistencies in accessing local health services during pregnancy, childbirth and post partum. This leads to duplication of records or losses to follow up, hence complicating records maintenance which compromises data accuracy.c) Absence of any local supervision in an environment where data in the monthly report is used to measure accomplishment of service targets set for local staff, which leads to inconsistencies between data in the registers and the data in the summary monthly reports.d) Inadequate collaboration and data sharing with local Traditional Birth Attendants, who also provide birthing and post natal services to the community.rukun tetanga/rukun warga).This results in discrepancies between data recorded in the different data sources maintained at the local level.e) Lack of coordination with other responsible stakeholders within the community who are also responsible for gathering/reporting information on vital events e.g. village administration; community volunteers  in only 23 cases. Of the remaining 27 cases, we were able to confirm gestation ≤ 6 months in only 17 cases, while in the remaining 10 cases, the exact gestational age at fetal death could not be determined. In our analysis, we chose to classify these 10 cases as miscarriages. This could have resulted in under estimation of stillbirths, as a result of improper application of the 28 week definition.Further, the absence of reliable information on birth weight precluded the possibility of applying more sensitive criteria such as the 1000 g threshold for stillbirths. It has been observed that on average, fetal weight at 28 weeks exceeds 1000 g . Hence, There is also potential for bias from misclassification between stillbirths and early neonatal deaths, however, the perinatal mortality rate adequately accounts for such misclassification. At the same time, it has been recommended to present data on stillbirths and early neonatal deaths separately, given their distinct epidemiological differences and health service implications. TherefoA recent evaluation of community based interventions to improve the quality of newborn care and reduce perinatal mortality identified that the interventions were partially successful, resulting in significant reductions in stillbirth rates, but without any impact on early neonatal deaths . This suAlso, declines in under-five and infant mortality rates lead to increasing proportionate mortality during the neonatal period, most of which occurs within the first week of life,24. SuchIn the current environment, there appears to be a growing need and demand for local measures to assist planned health care delivery. Vital sThe authors declare that they have no competing interests.LB participated in the data collection, analysis, and drafted the initial version of the manuscript. DS, KM and SM participated in data collection and analysis, and contributed to individual sections of methods, results and discussion sections of the manuscript. CR, TA and CE conceptualised the research study, provided guidance on the field data collection and analysis, and provided critical appraisal and revisions to the manuscript prior to submission. All authors read and approved the final version of the manuscript.The field research conducted by LB, DS, KM and SW was supported by a research grant from the Australian Agency for International Development (ROU 13652), which included support to the University of Queensland staff (TA and CR). CE is a government employee of the District Health Office, Pekalongan, Indonesia. The funding body did not have any role in the study design, data analysis, or manuscript preparation and submission.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/11/20/prepubTable S1: Principle variables collected from local health registers and additional sources.Click here for file


This project occurred during the course of the Translating Research in Elder Care (TREC) program of research. TREC is a multilevel and longitudinal research program being conducted in the three Canadian Prairie Provinces of Alberta, Saskatchewan, and Manitoba. The main purpose of TREC is to increase understanding about the role of organizational context in influencing knowledge use in residential long-term care settings. The purpose of this study was to evaluate healthcare aides’ (HCAs) perceptions of a one-page poster designed to feed back aggregated data (including demographic information and perceptions about influences on best practice) from the TREC survey they had recently completed.A convenience sample of 7 of the 15 nursing homes participating in the TREC research program in Alberta were invited to participate. Specific facility-level summary data were provided to each facility in the form of a one-page poster report. Two weeks following delivery of the report, a convenience sample of HCAs was surveyed using one-to-one structured interviews.One hundred twenty-three HCAs responded to the evaluation survey. Overall, HCAs’ opinions about presentation of the feedback report and the understandability, usability, and usefulness of the content were positive. For each report, analysis of data and production and inspection of the report took up to one hour. Information sessions to introduce and explain the reports averaged 18 minutes. Two feedback reports (minimum) were supplied to each facility at a cost of CAN$2.39 per report, for printing and laminating.This study highlights not only the feasibility of producing understandable, usable, and useful feedback reports of survey data but also the value and importance of providing feedback to survey respondents. More broadly, the findings suggest that modest strategies may have a positive and desirable effect in participating sites. Integration of research findings into practice is dependent, in part, upon researchers presenting and disseminating findings in an effective manner. Concern regarding communication of research findings is underpinned by evidence of the extent of the research–practice gap -11. In hFrom the knowledge-translation literature, evidence on the effectiveness of audit and feedback suggests that feedback of audit data has the potential to be effective in improving the practice of healthcare providers . HealthcThe present report describes the development and evaluation of a feedback intervention for HCAs. This project is designed to link directly with and complement the Canadian Institutes of Health Research-funded Translating Research in Elder Care (TREC) program of research, a multilevel and longitudinal research program being conducted in 36 nursing homes across the three Canadian prairie provinces: Alberta (n = 15), Manitoba (n = 8), and Saskatchewan (n = 13) -23. The i.e., whether the content could be comprehended); (3) assess the usability of the feedback reports—the preferred method of data presentation ; and (4) evaluate the usefulness/utility of the content of the feedback reports .The purpose of this study was to evaluate healthcare aides’ perceptions of a one-page poster designed to feed back aggregated data (including demographic information and perceptions about influences on best practices) from the TREC survey they had recently completed. The objectives of this project were to (1) evaluate the feasibility of providing feedback reports (process and format); (2) assess the understandability of the feedback reports (The project had two distinct phases: (1) development of the report and (2) evaluation of the report.The design of the feedback reports was guided by recommendations of a feasibility assessment undertaken in one long-term care facility in Alberta. That assessment was designed to determine the needs of HCAs with respect to the content and presentation of the feedback report and involved consultation with HCAs, care managers, and a site administrator to identify data of most interest and relevance for feedback purposes. The feasibility assessment indicated that a poster format, presenting the results from four survey variables in a graph form with minimal explanatory text and at a Flesch-Kincaid reading level of grade 8 or less, was optimal for this HCA population.e.g., information sessions). In developing the feedback reports, we adhered to general principles for presentation of data, including promotion of visual appeal  and making the content understandable (clear and concise presentation of information) and relevant to the HCAs. Guided by recommendations from the feasibility assessment, a one-page, legal-sized poster format was adopted for presentation of the results , frequency, content (which variables to report), and supporting processes  surveying (administered using one-to-one structured interviews) HCAs to elicit their opinions about the understandability, usability, and usefulness of the feedback reports and (2) collection of logistical data . While all facilities (n = 36) participating in the TREC research program received HCA feedback reports, a convenience sample of approximately 50% (n = 7) of the participating Alberta nursing homes (n = 15) was invited to participate in the evaluation of the HCA feedback reports.Once permission was granted by the facility administrator, the research assistants (who had administered the TREC survey approximately two weeks prior and were therefore well known in the facilities) arranged a suitable time with the unit managers in order to deliver the reports and provide a brief (15-minute maximum) information session for HCAs to explain the purpose and content and respond to questions about the report. Following each information session, the research assistants completed a brief evaluation form to document the number of HCAs in attendance and record the questions posed. At some of the larger facilities, more than one information session was required in order to access HCAs in each unit. In one province, an investigator also attended some feedback sessions. We recognized that delivery of feedback sessions required well-developed communications skills and careful preparation to ensure sensitive and appropriate responses to questions. To this end, standardized training , a training manual, and preparation time were provided to all research assistants.Approximately two weeks following delivery of the feedback reports, HCAs who had previously completed a TREC survey in each of the participating facilities were invited to complete the evaluation survey. At each site included in the present study, 27 to 73 HCAs responded to the TREC survey, representing 39% to 96% of HCAs per site. We estimated that inclusion of 10 to 20 TREC survey respondents from these sites would be sufficient to achieve the objectives of this project. Across all 36 sites included in the TREC research, 9 to 164 HCAs per site responded to the TREC survey, representing, on average, 52% (range: 28%–96%) of HCAs at each site.Our experience in TREC was that face-to-face structured interviews were the optimum method of survey data collection from HCAs. We found that this approach maximized data validity and minimized missing data. Hence, research assistants conducted short 5–10 minutes), one-to-one structured interviews with HCAs. The research assistants arranged a convenient time two weeks following delivery of the reports to conduct the structured interviews with HCAs. Written, informed consent was obtained prior to each interview, which was conducted in a quiet, private location in each facility. Structured questions elicited HCAs’ opinions about understandability of information included in the feedback reports; whether information was presented in a usable manner, that is, in a format that could inform practice or influence change; whether content of the report was relevant and useful to policy and practice; whether the report delivery process was appropriate in terms of timing and access to the report; and whether the accompanying information session was accessible and helpful. When a respondent identified deficits or weaknesses in the reports, the research assistants asked the HCA for suggestions or recommendations to improve the report. Examples of interview questions for each evaluation parameter are provided in Table 0 minutesEvaluation of the reporting process involved collection of logistical data on (i) time spent analyzing relevant TREC survey data and report production, (ii) time spent providing information sessions to introduce and explain the reports, (iii) the number of reports required by each facility, (iv) the most appropriate report topics, and (v) the cost of printing reports. Research assistants monitored the time invested for each activity and recorded these data in a spreadsheet on an ongoing basis as the study progressed.Human Research Ethics Board (HREB) approval for the conduct of this study was received from the University of Alberta, and permission of individual facility administrators was obtained to conduct the study in the respective facilities. In accordance with Tri-Council standards for research  and the The evaluation survey data were double entered into a Statistical Package for Social Sciences (SPSS) version 17  database for analysis . DescripIn total, 123 HCAs completed the evaluation survey (structured interview). On average, we surveyed 43% (range: 31%–70%) of the respondents to the TREC survey at each of the sites. The majority (94.3%) of respondents were female. On average, respondents had worked as a HCA for 9 years, had worked in the respective facility for 6.5 years, and 40% reported English as their second language (ESL)  = 14.97, p <.000). Specifically, fewer people with ESL were satisfied (approximately 50%) with the quantity of text in the poster when compared with the number of people with English as their first language who were satisfied (84%). However, a clear trend in the opinions of those with ESL about whether too much (as reported by 21% of ESL respondents) or too little text (as reported by 27% of ESL respondents) existed was not evident. Significant associations were also found between ESL and likelihood of the results to influence practice  = 23.44, p <.000), likelihood of the results to influence thinking  = 9.12, p = .011), perceptions of usefulness of the feedback in general  = 22.17, p <.000), and usefulness of the feedback in their role  = 24.70, p <.000). Specifically, a greater proportion of individuals with ESL indicated the results were likely to influence their practice and their thinking and reported that the information, in general and in their role, was useful.Given that a large proportion of respondents reported having ESL, we tested for an association between language status and perceptions of the feedback report. After categorizing responses to the question about quantity of text into “too little,” “satisfactory,” or “too much,” the chi-square test for independence indicated a significant association between language status and perception of the quantity of text in the report  had attended one of the information sessions at which the feedback reports were presented. Of these individuals, 61.5% reported that the information presented was either very useful or extremely useful. With regard to understandability, 40% reported that the information was easy to understand, and 48% reported that it was very easy to understand. We also analyzed the data for differences in perceptions of the feedback report based on attendance versus nonattendance at the information sessions. No statistically significant differences in perceptions were found between the two groups. Research assistants reported that, overall, the information sessions were well received by the HCAs and acted as a venue for HCAs to raise questions. Further, it was noted that HCAs expressed their gratitude towards the researchers for making the effort to return to the facility in order to feed back some of the study findings.On average, up to one hour in total was spent by data analysts and investigators in analyzing the relevant TREC survey data for inclusion in the report and producing and inspecting the report for each facility. A minimum of two feedback reports (posters) per facility were supplied, and one additional poster was also supplied for every 50 beds in excess of 100 beds. Posters were produced in tabloid size (27.9 by 43.2 cm) and were laminated. The cost per poster for printing and lamination was CAN$2.39. In total, 7.35 hours were spent delivering the information sessions (n = 25) to facility staff, and the sessions averaged 18 minutes (range: 5–45). On average, four (range: 1–9) information sessions were conducted per facility.Feedback represents an important part of the translation phase of the research process and has a range of potential benefits, including promoting the translation of evidence into practice and engagement of participants in future research. To enable feedback initiatives as part of the research process, the cost of providing feedback should be built into research budgets. In the following, our discussion will center on the consequences for practice and research and the feasibility of providing feedback to survey respondents.Our broad purpose was to develop a knowledge-translation intervention that would assist in reducing the research–practice gap. Feedback of relevant data and presenting them in a format that is easily understood has the potential to facilitate ownership of the results and promote the implementation of research-based changes in practice. Further, other researchers report that engagement of and ownership by care providers is an important element in motivating practice change based on research evidence -29. WhilWe were cognizant of the fact that we had to be careful and respectful about the type of information we were feeding back. In the feedback report development phase we consulted with HCAs, research assistants who were working closely with HCAs during the TREC study data collection, and facility managers. We asked them to consider and advise on which variables would be appropriate, of interest, and relevant to HCAs. Variable selection was therefore guided by their recommendations as well as our judgment regarding the potential sensitivity of the data. For example, we were careful to avoid reporting on variables such as leadership and staffing levels, which could have reflected negatively on a facility or could have been inflammatory or have caused controversy.HCAs expressed gratitude for the investigators’ efforts to provide feedback on the survey results. This undertaking was perceived as evidence that the investigators considered the HCAs important to the TREC research. This finding resonates with literature that has identified survey respondents’ dissatisfaction with not receiving feedback about study results, which, in turn, can prompt a sense of exploitation by researchers and potentially can lead to apathy about or disinterest in participating in research in the future ,31. OtheThe feedback of research findings has implications for the wider research domain. The provision of feedback acknowledges respondents’ contribution to the research and, in the course of a study that has two or more data collection points, can be an important strategy to promote goodwill, future participant engagement, and trust. However, consideration needs to be given to the effects that such an activity may have on future data. Feedback may alter behavior and may, therefore, influence study findings, potentially confounding them. The purpose of the study will likely determine whether it is appropriate to feed back findings during the conduct of the research. In the case of the TREC program of research, an integrated approach, involving the knowledge users, was adopted. We recognized that our feedback could influence healthcare aides’ behavior, thereby influencing future results. However, we weighed this against the specific requests from HCAs for feedback and considered that failure to provide feedback could be detrimental to our research relationship and credibility and that this may negatively affect healthcare aides’ willingness to participate in future surveys in the TREC program of research. In the process of delivering feedback, careful consideration should also be given to the potential effects of feedback that might be perceived in a negative light. Such feedback should be delivered sensitively, and researchers should be cognizant that negative feedback may adversely affect future response rates.We aimed to develop a cost-effective feedback mechanism that conveyed relevant data in a clear, useful, and usable format. The poster approach, which provided data in a visual display with the minimum amount of explanatory text required to describe the results, was well received. We found that once the initial feedback report poster template had been developed, the poster could be produced with ease, was inexpensive, and was a useful means of presenting information in an accessible manner. In all, investment of time and money to produce the posters and provide the information sessions was outweighed by the benefits of satisfying survey respondents through the delivery of feedback and enhancing the chances that they would respond to future surveys. A range of approaches could be adopted for the delivery of feedback. In deciding which approach to adopt, researchers should carefully consider the target audience and the context in which the findings are being delivered and then tailor their approach accordingly. The significant associations that we found between ESL and characteristics of the feedback point to the importance of considering the needs of audiences for whom English is not their first language when delivering feedback. Additionally, researchers should consider and monitor the resource requirements associated with delivery of the feedback .There are some limitations associated with this study. In particular, the study was set in a small number of long-term care facilities in a single Canadian province. Therefore, while we achieved the number of responses for which we had aimed at the outset of the study, our data represent a limited number of HCAs working within a distinct setting. Given these constraints, we recommend caution when generalizing the study findings to other settings.This project was designed to explore feedback reporting for the communication of survey data to HCAs. The delivery of feedback in a poster format presenting information graphically and with the minimum amount of text required to explain the results was positively received in the HCA sample included in this study. The importance of providing feedback to research participants was reinforced by the responses of participants at the information sessions, who expressed their gratitude for the feedback and their keen interest in how the findings of the TREC study would be used to influence policy and practice.The authors declare that they have no competing interests.AMH designed the study, provided leadership for the study, and lead the manuscript development. NBG provided valuable advice during the design of the study, managed the data collection phase, and contributed to the manuscript development. LC assisted in data collection and analysis. AMB contributed to the design of the feedback reports and manuscript development. GC is provincial site lead for the TREC research program in Alberta. PN is co-lead investigator for project one of the TREC research program. CAE is the principal investigator for the TREC research program and conceived the HCA feedback study. AMH, CAE, and GC participated in securing the funding for the project. CAE, GC, and PN provided commentary on the final submitted manuscript. All authors read and approved the final submitted manuscript.


The prevalence of breast cancer in developed countries has steadily risen over recent decades. Immediate and long-term health needs of patients, including preventive care and screening services, are receiving increasing attention. A question still unresolved is whether breast cancer survivors should receive mammographic surveillance in the clinical or screening setting and, thus, whether they should be excluded from, or invited to, organised mammography screening programmes. The objective of this article is to discuss the many contradictory aspects of this matter.Problems with mammographic surveillance of breast cancer survivors include: weak evidence of a reduction in mortality; lack of evidence in favour of one setting or the other; lack of evidence-based guidelines for the frequency and duration of surveillance; disproportionate emphasis placed on the first few years post-treatment, probably dictated by surgical and oncological priorities; a variety of screening policies, as these women are permanently or temporarily or partially excluded from many - but not all - organised screening programmes worldwide; an even greater disparity in follow-up protocols used in the clinical setting; a paucity of data on compliance to mammographic surveillance in both settings; and a difficulty in coordinating the roles of health care providers. In the future, the use of mammography in breast cancer survivors will be influenced by the inclusion of women aged > 69 years in organised screening programmes and the implementation of multidisciplinary breast units, and will probably be investigated by research activities on individual risk assessment and risk-tailored screening. In the interim, current problems can be partially alleviated with some technical solutions in screening data recording, patient flows, and care coordination.Mammographic surveillance of breast cancer survivors is situated at the crossroads of numerous different specialist areas of breast cancer control and management. The solutions for current problems probably lie in some important modifications in the conventional screening procedure that are underway or under study. These developments appear to be directed towards a partial modification of the screening rationale, with an adaptation to meet the diversified breast care needs of women. The complexity of the matter constitutes a call to action for several entities to eliminate the barriers to effective research in this field. The prevalence of breast cancer (BC) in developed countries has steadily increased over recent decades due to improvements in detection and treatment of the disease. The immediate and long-term health needs of patients are receiving increasing attention. This is also the case for preventive care and screening services.The subject of this article is the unresolved question of whether patients treated for BC should receive mammographic surveillance in the clinical or screening setting and, thus, whether they should be excluded from, or invited to, organised mammography screening programmes for the general female population. Up until recently this question was seldom raised ,2, but wThe many correlates of this problem should be placed in the wider context of cancer survivorship research. This area of translational research, which covers a broad range of topics including preventive measures and screening for patients with a history of cancer, is growing exponentially and is expected to translate into new evidence-based health care models and programmes. The development of rational approaches to continued breast surveillance is a key element of breast cancer survivorship agenda.The problem of who should be responsible for the mammographic surveillance of BC survivors involves several specific points of interest. First, it is related to some emerging research subjects in the area of BC screening, such as the idea of risk-tailored screening. Secondly, and from a larger perspective, establishing whether women with a history of BC should be excluded from organised screening programmes is correlated with numerous aspects of BC control and management. Due to this multifaceted profile, the provision of mammographic surveillance for BC survivors raises wider questions concerning the incorporation of screening into primary care services and the interaction between public and personal health services.The objective of this article is to discuss the many and contradictory aspects of this matter and the possible solutions. The basis for the discussion is an international overview of screening guidelines and practices for BC survivors. The work is directed at health policy makers, health managers, screening authorities, and primary care physicians. However, given the (problematic) interrelationship between mammographic surveillance and clinical follow-up for BC, it might also be of interest to oncologists and other hospital specialists. The article specifically addresses population-based, organised mammography screening programmes , as implemented in public, tax-financed health care systems. However, some of the information reported here comes from private insurance-based health care systems.The points dealt with in the article are the following: the size of the problem, including the prevalence of BC and the risk of ipsilateral relapse and new contralateral cancer; the benefit of mammographic surveillance; the published guidelines for its frequency and duration; the strategies currently being used in organized screening programmes and in the clinical setting; the current levels of compliance with mammographic surveillance in either setting; considerations that may contribute to the rationale behind the decision-making on the provision of the service; the current challenges and potential developments that may be expected in the future; and the practical solutions that can be implemented to improve the situation in the short term.To calculate the complete prevalence of BC and to identify all prevalent patients, a long history of cancer registration and follow-up for vital status is needed. In the great majority of countries and regional areas with organised screening programmes, this requirement is not or only partially met. An alternative approach is to use statistical models such as those based on equations that relate mortality and prevalence to incidence and survival probabilities. Observed and estimated data provide a fairly consistent picture of current prevalence of BC among women living in the western world. In the United Kingdom , the NetThe incidence of ipsilateral relapse after breast-conserving surgery and radiotherapy is in the range of 0.5-1% per year -10. ThisAmong women aged above 50 years, a personal history of in situ or invasive BC conveys a risk of second contralateral invasive cancer of 1.5-1.75 relative to women with a negative history. This is equivalent to saying that the risk of second contralateral BC is greater than the familial risk of primary BC .The evidence that mammographic surveillance for early detection of ipsilateral breast relapse or new contralateral cancer reduces the risk of death among BC survivors is less than one would expect. No randomized studies have been conducted, and observational studies have often been hampered by small sample size and low quality of design . Their rThe value of routine clinical examination in detecting a relapse in the ipsilateral breast or axilla or a new contralateral cancer is not certain. Patients with clinically detected ipsilateral breast relapse have a poorer survival than those whose relapse is detected by mammography or breast self-examination. Moreover, the proportion of relapses detected on routine clinical examination has decreased over time, from 45% according to reports published before 2000 to 15% according to more recent data. In other words, the contribution of mammography shows increasing importance because of technical improvements and quality assurance . As a coBreast self-examination continues to have a role in the follow-up of BC patients. The proportion of relapses detected by patients themselves is still about 35%. However, breast self-examination detects more ipsilateral relapses than contralateral relapses, which suggests a lack of patient awareness that the risk increase applies to both breasts .There are no studies showing treatment or survival benefit from an earlier detection of asymptomatic relapse of BC using magnetic resonance imaging . SimilarCentral to the present discussion is the lack of evidence that the effect of regular mammographic surveillance varies between the clinical and the screening setting. It has never been demonstrated that BC survivors cannot be screened successfully in an organised screening programme . MoreoveDue to the lack of evidence-based data on the most appropriate protocols for breast surveillance of BC patients, published practice guidelines give somewhat conflicting information. No consensus exists about how frequently patients should undergo mammography and clinical breast examination (if any), for how long they should be seen at short intervals, and whether or when it is appropriate for them to return to normal screening ,10,21,22For example, the United Kingdom NHS National Institute for Health and Clinical Excellence guidelines of 2009 recommend that patients with early BC, including ductal in situ carcinoma, be offered annual mammography until they enter the national screening programme. Patients who are already eligible for screening should have annual mammography for 5 years. For patients who reach the screening age as well as those who complete 5 years of annual mammographic surveillance, it is recommended that the screening frequency be stratified according to the patient risk category [The British Association of Surgical Oncology recommends that patients be followed-up for 5 years, although this period may vary with local protocols. As far as the frequency of mammography is concerned, the Association refers to the guidelines from the Royal College of Radiologists which suggest 1- to 2-year intervals for up to 10 years .The 1998 clinical practice guidelines for the care of BC from the Canadian Steering Committee , as wellThe 2006 update of the American Society of Clinical Oncology guidelines recommend that all patients have a careful history and physical examination every 3 to 6 months for the first 3 years, every 6 to 12 months for years 4 and 5, and annually thereafter, and that a mammogram be obtained at least 6 months after completion of radiation therapy and every year thereafter . It is o" ... may ..." be excluded from the programme. In other words, and contrary to a widespread belief, the exclusion of BC survivors from organised screening programmes is presented as an option, not a necessity.Finally, the European guidelines for mammography screening recommend that screen-detected BC patients have annual mammography  or perioA Table in the Additional file One key point should be noted here. Most guidelines place emphasis on providing frequent mammography and clinical examination in the first 3 to 5 years after diagnosis, and suggest that follow-up may be less frequent or even terminated thereafter ,18. ThisThis explains why most guidelines pay so much attention to the frequency of follow-up mammography and so little to the complementary question of which health setting is most appropriate. The option of providing mammographic surveillance through organised screening programmes is simply not taken into consideration.The inconsistency of practice guidelines, their emphasis on the early post-treatment phase, and their ambiguity and omissions are among the major reasons why BC survivors are permanently or temporarily or partially excluded from many - but not all - organised screening programmes worldwide. It is important to note that there is also a lack of consistency and clarity in policies and procedures within the same countries.In 1999, a survey of organised screening programmes and mammography registries in 25 member countries of the International Breast Cancer Screening Network was performed. The objective was to determine what specific data relating to screening monitoring were collected. Information on whether women attending screening had a history of BC was available from 15 countries. Most of the national representatives of these countries stated that women with a history of BC were specifically not invited to screening .In Sweden, for example, women who ask to be excluded and women with previous BC are not invited, and this is also the case for women with newly diagnosed, screen-detected cancer . In PolaThe Italian Group for Mammography Screening guidelines do not establish a management standard for women with a history of BC. However, they state that only patients who are known with certainty to be followed-up in the clinical setting can be excluded from an organised screening programme, and that the exclusion criteria should be clearly defined during the planning phase . As the There are important organised programmes that use different, if not opposite, approaches. For example, it is not the policy of the United Kingdom NHS Breast Screening Programme to exclude BC survivors. The only women who are discontinued from the programme are those with bilateral mastectomy, those who are considered by general practitioners to be medically unsuitable due to terminal illness, and those who have explicitly asked not to be invited. In all other circumstances, women have the opportunity of making an informed choice about whether or not to accept a screening invitation on each and every occasion it is made . The UniIn Denmark, all women aged between 50 and 69 years at the start of an invitation round are invited to screening unless they have specifically asked to be excluded .The basis on which women are eligible for screening must be clear and unequivocal". On the website of the BreastScreen Australia programme, it also reads that "Generally there is no dispute about a women's age..." and that "Any policy is only effective if it is able to be implemented" [In Australia, the national mammography screening programme selects women on the basis of age alone (50-69 years) because "...emented" . This isi.e. exclusion or inclusion. It must be borne in mind that organised screening programmes no longer have a static design. It may happen that BC survivors are systematically invited and managed with non-standard procedures. One of these is the so-called early or short-interval rescreen, an opportunity that may be extended to inadvertently invited BC survivors (when their status is unknown to the service). Early rescreen may be used for several other conditions including poor technical quality of mammograms, high levels of mammographic breast density, hormone replacement therapy use, and family history of BC [The screening management of BC survivors is not a binary option, ry of BC -49. Wherry of BC . In nortry of BC  showed try of BC .Another hybrid model of BC survivor management, which combines screening with a clinical service, has been developed in the health care district of Rome. Apart from some exceptions, all women receive a personal invitation to participate in the organised screening programme. BC patients who are not followed-up elsewhere are asked to contact the screening centre to arrange a follow-up visit that is equivalent to an assessment for a positive mammography result, after which they are referred for specialist oncology consultation .These are only a few examples of the solutions that have been adopted for the provision of mammographic surveillance of BC survivors. Given the fact that organised screening activities are highly decentralised in most countries, it can be assumed that the way in which BC survivors are managed varies to a far greater extent than is suggested by the information available.Variability in approaches to breast surveillance of BC survivors is not confined to organised screening, but is also observed in the clinical setting . A surveIn England and elsewhere, the degree of within- and between-centre variation in follow-up strategies has probably increased over time because of a qualitative change in the service workload. In all populations targeted by screening, the growth in the number of BC patients to be followed-up is associated with a broadening range of clinical situations due to the fact that the presence of screen-detected cancers amplifies the heterogeneity of biological characteristics of the disease . This, iUncertainties about the optimal setting for mammographic surveillance, together with the variability of practices, may create confusion among BC patients invited to screening or referred to the clinical setting. In turn, this may adversely affect their compliance, especially in the medium-long term .To the author's knowledge, there are no data on the proportion of BC survivors excluded from an organised screening programme who present for mammographic follow-up in the clinical setting. The only available studies on attendance of BC patients at clinical breast imaging units are from the United States, where approximately 80-85% patients with early BC return for mammography examination within 1 -55 or 2 It is curious to note that one of the suggested explanations for mammography underuse among BC survivors is that their concern about cancer recurrence is greater in the first years after treatment . Whilst i.e. after their return to the organised screening programme [Data are also lacking on the response rate of BC patients invited to organised screening at both short and standard interscreening intervals. A single, large study from the United Kingdom reviewed a cohort of BC survivors after 5 or more years of survival, rogramme . These wrogramme .A similar paucity of data extends to the health outcomes of these patients. The exclusion of BC survivors from organised screening programmes is based on the assumption that they will have an advantage from undergoing clinical mammography in the sense that a second BC would theoretically be detected at an earlier stage. In actual fact, the only available tumour stage data are from selected clinical series . PopulatThere are several other considerations that may contribute to the rationale behind the decision-making on the provision of mammographic surveillance for BC survivors.Oncologists and other hospital specialists tend to retain direct control over the clinical investigations that are indicated to detect a cancer recurrence, and this is also the case for follow-up mammography. As intensive screening for asymptomatic metastatic relapse is not recommended because it does not improve survival or quality of life ,61, the Objectives #1 to 6 require a patient-physician interaction, which can take place in a hospital outpatient oncology or surgery clinic or, after the transfer of responsibility, in the primary care setting or elsewhere in the clinical health care environment . This isBC patients' views should be given closer attention when planning post-treatment follow-up. A systematic review of qualitative studies reporting on patients' views and preferences about follow-up for any type of cancer has shown that they attach importance to the regularity of follow-up appointments, expertise of specialists, rapid access to tests, and continuity of care and information . There iThe exclusion of women with BC from an organised screening programme involves the identification of all prevalent as well as incident BC patients. The latter should also be promptly notified to the screening service. This is impossible to achieve in several countries and regional areas due to the absence of cancer registration or limitations in geographic coverage or time coverage. Additional problems may be caused by the latency time of cancer registries, legal restrictions of access to their files, and poor quality of record linkage procedures.Many mammographic surveillance protocols recommend that BC patients be returned to normal screening after some years  of exclusion . It is ii.e. different types of management being adopted by the same service for patients with the same condition. This is unacceptable in principle, may negatively affect the image of the screening programme, and may be associated with medico-legal hazards. BC patients excluded from organised screening programmes are subject to further inequalities when they present for mammographic follow-up in the clinical setting. As pointed out above, the current multiplicity of different recommendations results in an extreme diversity of protocols in use [The health inequalities facing BC patients during post-treatment breast surveillance are not adequately perceived. The limitations of cancer registration translate into a mixed practice of both exclusions and inclusions from organised screening, s in use .It has been suggested that excluding BC survivors from organised screening programmes would be justified if their rate of abnormal mammograms requiring subsequent recall for diagnostic work-up was significantly greater than that of the general target population. If this was the case, the level of inconvenience for these women would be excessive and immediate evaluation in a diagnostic setting would appear more appropriate .Theoretically, patients treated with conserving surgery and radiotherapy are expected to have an increased prevalence of mammographic abnormalities because they have an altered breast architecture which changes over time and causes difficulties in radiological interpretation . To whate.g. in cross-national and international comparisons of screening results. This problem, however, can be overcome by excluding women with a personal history of BC from data reports and analyses. There is no "statistical" need to exclude them from screening. This approach, which has been proposed by the European guidelines for mammography screening [Despite the lack of information, it should be taken into account that including BC survivors in the target population may influence the results of an organised screening programme. In particular, this may be the case for indicators related to the prevalence of mammographic breast abnormalities and of BC. The biasing effect of the presence of BC survivors could be considered, at least in part, a disadvantage from a quality monitoring point of view, creening , is currcreening .Economic evaluations have concentrated on comparing follow-up, including mammographic follow-up, of BC in primary care versus secondary or specialist care ,65. The Important changes are either underway, in preparation or at the research stage in procedures for BC screening and post-treatment management of women with BC. These developments have a potential to affect the way in which the problems with mammographic surveillance of BC survivors are perceived and treated.Preventive health care needs of BC survivors are a specific topic of BC survivorship research. The term cancer survivorship encompasses the many physical, psychosocial, and economic sequelae of cancer diagnosis and treatment as well as the related short- and long-term needs of the patients. Cancer survivorship research aims at developing an evidence base for optimal follow-up care practices using a multidisciplinary approach.The most important objective remains the achievement of a higher level of evidence of effectiveness of mammographic surveillance of BC survivors in reducing mortality. Other major issues to be addressed include the effectiveness of surveillance as specifically provided in the screening setting  and the Obtaining access to appropriate care services through delivery systems that are complementary and not duplicative  is a priA patient's family members are considered part of the survivorship experience. Indeed, post-treatment care is increasingly viewed as a spectrum of interventions aimed at improving the health and lives of cancer survivors and their families . On the The expansion of BC survivorship research will help us to understand and control the effects of socio-economic factors on patient attendance at post-treatment mammographic surveillance. The observed underuse of mammography is mostly related to clinical and medical factors such as advanced patient age, comorbidities, late disease stage of primary cancer, insufficient teamwork between oncology specialists and primary care physicians ,68, and The feasibility, cost-effectiveness, and potential benefits of different risk-based protocols for mammographic follow-up in the clinical setting are important areas of clinical research. Efficient protocols could facilitate the discharge of low-risk patients to the organised screening activity. Many tumour-related risk factors for local recurrence have been identified which could be used to modulate the duration and frequency of mammographic follow-up. A small number of breast imaging units are already using one or more of these factors to schedule appointments .Further research in the form of a controlled trial is necessary to determine optimal surveillance regimens. In this respect, however, a problem exists in that obtaining ethical approval may be difficult. Although there is no evidence to support current guideline recommendations for annual mammography, it could be deemed unethical to randomly assign patients to receive a lower level of surveillance .Inviting BC survivors to participate in an organised screening programme inherently conveys the innovative and controversial concept of tailoring the screening procedure to the personal risk of disease. This would involve the implementation of risk assessment in screening facilities  and majoSuch a perspective warrants a research effort. In a parallel line of investigation, it has been hypothesised that quantifying both the individual risk of multiple BC and the familial risk, as well as their interactions, in populations exposed for extended periods to organised screening programmes could be helpful to identify optimal preventive strategies ,73.In the Netherlands women are routinely invited to organised screening programmes up to 75 years of age, in France and Sweden up to 74 years. The extension to 73 and 74 years is being planned in the United Kingdom and some Italian administrative regions, respectively. Recommendations on how long to continue screening mammography on a spontaneous basis are also expected to evolve.Raising the upper age limit for organised screening may influence the mammographic surveillance of BC survivors in two ways. First, assuming that they are not invited, it is reasonable to expect that they will be followed-up in the clinical setting at least until the age of 74. A survey of breast imaging units in England has shown that variability in the duration of mammographic follow-up is especially pronounced for patients aged 70 years or older, with a range of 0 to 15 years . The cesSecond, the inclusion of women aged 70 years or older in organised screening programmes may facilitate the inclusion of BC survivors themselves. An Australian modelling study aimed at estimating the costs and benefits of continuing screening mammography after 69 years of age concluded that a benefit is more likely in women who are at high risk of death from BC and those at low risk of death from other causes . In the Consultation with primary care physicians is important for all elderly women, with or without a personal history of BC. Both populations need to be provided with guidance on mammography, regardless of whether they will be screened in the clinical setting or in an organised screening programme. In the latter case, however, a subtle change in the design of screening inevitably occurs. As the participation of elderly women is dependent on an assessment of life expectancy performed by primary care physicians, it can be said that they are screened for eligibility before undergoing screening for BC. This two-stage procedure is equivalent to a selective screening for women who have low competing risks of death and a potential for benefit from mammography.Medical organisations are increasingly recommending that breast diseases be cared for by specialists working as a team in multidisciplinary breast units. The section of the European guidelines for mammography screening which defines the ideal requirements for breast units introduces a new concept of the interrelationship between population-based screening activities and clinical breast care services . It is sThis model of provision of breast care, in which the separation of screening from clinical breast services is no longer straightforward, may also have implications for breast surveillance of BC survivors. European guidelines recommend that such patients be followed-up in a breast unit under the direct supervision of one of the surgeons, and that any necessary imaging be carried out at the same visit. In line with these criteria, but also with the aim of optimising the use of resources, it could be proposed that patients be followed-up in the clinical setting of the breast unit but using the personal call/recall service of the organised screening programme. This would improve attendance rates and would facilitate the subsequent return to the programme.The process of the establishment of breast units in Europe is in its initial stages, and their organisation varies greatly between countries . It is pWhere there is a policy to exclude BC survivors from organised screening programmes, such individuals need to be systematically identified. In turn, this makes it necessary to improve the spatial and temporal coverage of cancer registration.The introduction of a screening programme provides the motivation for expanding a general cancer registry or for implementing a special, screening-oriented BC registry, although optimal results are impossible . HospitaOngoing and potential developments in the area of BC cancer screening and care might offer solutions to problems arising from current patterns of breast surveillance of BC survivors. However, this is not expected to happen in the near future. In the interim, there are some practical corrective measures that could be implemented.Many studies on the provision of mammographic surveillance have concluded that the coordination between the services involved needs to be improved. To this end, the first step is to better define the role and responsibilities of primary care physicians ,68. In hAnother option to improve the coordination of care for BC survivors, including breast surveillance, would be to introduce practice guidelines and, more specifically, flow charts on a local basis. These would be designed to assist all health care providers in the implementation of follow-up, would illustrate the crucial points in patient management, and would eliminate redundant or inappropriate actions.The implementation of a population-based screening programme, which increases the number of BC survivors and creates new inequalities, offers a unique opportunity for local public health authorities to promote the development and adoption of flow charts for mammographic surveillance. As research evidence of the effectiveness of different protocols is lacking, flow charts should be based on empirical experience. A realistic consensus between practicing physicians at the community level, with the identification of distinct roles for the screening service and clinical practitioners, would be much easier to achieve than a large-scale consensus between experts. Moreover, a local approach would offer the advantage of greater flexibility in the application of health regulations from higher levels of government.In a population targeted by an organised screening programme, screen-detected patients account for approximately half of BC incidence. By definition, they are known to screening centres and can immediately be excluded from subsequent screening rounds. It seems more reasonable, however, for the mammographic follow-up of this subset of BC patients to take place in the same setting in which they were diagnosed. For example, accreditation standards recently introduced in an administrative region of northern Italy stipulate (1) that all organised screening centres should offer annual follow-up mammography to patients with screen-detected BC, (2) that these should receive personal ad-hoc invitation letters, and (3) that their mammographic follow-up status should be checked at regular intervals by the same staff who check whether women with a positive basic screening result have undergone diagnostic assessment .It is doubtful whether this policy could be implemented, in its entirety, in other health systems and under different health regulations, especially with respect to the status and role of primary care physicians. However, this model illustrates the growing idea that breast cancer screening should comprise multiple surveillance procedures aimed at subsets of the population with different risk levels.The proportion of BC patients who participate in organised screening programmes, either because of incomplete exclusion or because they are invited by design, is probably much greater than is commonly assumed. However, there are no reliable data to confirm this. The status of cancer survivors is seldom recorded in mammography databases, and there may also be some confusion as to when to enter these women as clinical cases and when to include them again in the basic screening population. The return to basic screening has been called "a grey area" , which hIn Europe, there is increasing awareness that the functions of the computer systems used in screening activities need to be improved. This also applies to completeness and consistency of the recorded items . Until tUntil ongoing and expected modifications in BC cancer screening and care provide substantial solutions to problems with breast surveillance of BC survivors, it is the author's opinion that many shortcomings could at least be mitigated by the adoption of an organisational model in which: (1) the primary care physician retains (or regains) full accountability for the follow-up care of BC patient; (2) the whole target population is invited to the organised screening programme; (3) the primary care physician advises the BC patient to decline the invitation to screening in the event of a recent or imminent clinical mammography; (4) otherwise, and after assessment of life expectancy and competing risks, he encourages the patient to participate; (5) after her first screening mammography, the patient is re-invited annually until the standard age of cessation; and (6) the mammography report is forwarded to the primary care physician, who supervises follow-up.This approach has analogies with that being used in the United Kingdom NHS Breast Screening Programme. Its rationale is that: (1) it leaves unchanged the existing information flows to cancer registries; (2) it avoids inequalities in the public provision of mammography service; (3) it is in keeping with the view that patients who are not known with certainty to be followed-up in the clinical setting cannot be excluded from an organised screening programme; (4) it extends the provision of a fail-safe mechanism against discontinuation of mammographic surveillance; and (5) it decreases the likelihood of over-investigation.BC survivors are still a small but no longer negligible minority of women in the age range targeted by organised mammography screening programmes. Due to their increasing numbers, the problem of determining the most appropriate setting in which to carry out their mammographic surveillance can no longer be ignored. This article, that is based on an international comparison of policies and practices for such women, documents a poor level of evidence-based information, an absolute lack of consistency and clarity, and several points of irrationality. Breast surveillance of BC survivors, like other needs of this growing population, has not been addressed in a satisfactory manner and must be given a higher rank in the cancer survivorship research agenda.The main aspects of the problem include: weak evidence that mammographic surveillance decreases mortality; a lack of objective evidence in favour of one setting or the other; a lack of evidence-based guidelines for the frequency and duration of surveillance; a disproportionate emphasis being placed on the first few years after treatment, probably dictated by surgical and oncological priorities; a variety of screening policies, as these women are permanently, temporarily or partially excluded from many - but not all - organised screening programmes worldwide; an even greater disparity of follow-up protocols being used in the clinical setting; a paucity of data on compliance to mammographic surveillance in both settings; and difficulty in coordinating the roles of health care providers. The problem of where and how to provide mammographic surveillance for BC survivors is situated at the crossroads of numerous different specialist areas of BC control. A solution will be found only by expanding the conventional theoretical boundaries of secondary prevention of BC.Following this line of reasoning, it is probable that novel approaches to coping with mammographic surveillance for BC survivors will emerge from some important modifications in the conventional screening procedure that are underway, such as the early rescreen practice and the implementation of breast units, or are still undergoing research, such as the hypothesis of risk-tailored screening. Taken as a whole, these developments are directed towards a partial integration, at the functional or structural level, between BC screening and clinical breast services. This would necessarily involve modifications of the traditional screening rationale, with an adaptation to meet the diversified breast care needs of women.Such a complexity constitutes a call to action for health policy-makers, screening authorities and specialists to eliminate the barriers to effective research into innovative models for breast surveillance of BC survivors. Until these models are developed, there are technical solutions in patient flow and care coordination that can alleviate the most serious shortcomings. A collective commitment to a comprehensive approach to these problems is needed.BC: breast cancer; NHS: National Health Service.The author declares that he has no competing interests.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/11/249/prepubSummary of selected breast surveillance guidelines for breast cancer survivors. A table provides a summary of the type, frequency, and duration of breast surveillance for breast cancer patients according to practice guidelines from selected organisations.Click here for file