Meningiomas are among the most common primary adult brain tumors, which arise either spontaneously or secondary to environmental factors such as ionizing radiation. The latter are referred to as radiation-induced meningiomas (RIMs) which, while much less common than their spontaneous counterparts, are challenging from a management point of view. Similar to spontaneous meningiomas, the optimal management of RIMs is complete surgical resection. However, given their high grade, multiplicity, tendency to invade bone and venous sinuses, and high recurrence rate, this cannot always be accomplished safely. Therefore, other therapeutic modalities, such as stereotactic radiosurgery, have emerged. In the current review, we provide an overview of the historical outcomes achieved for RIMs through radiosurgery and microsurgical resection. Furthermore, we provide a discussion of clinical and radiological parameters that affect the decision-making process with regard to the management of RIMs. We also provide an outline of recent changes in our understanding of RIMs, based on molecular and genetic markers, and how these will change our management perspective. We conclude the review by summarizing some of the current obstacles in the management of RIMs with SRS and how current and future research can address these challenges.  Meningiomas are the second most common adult brain tumour, typically presenting in the 5th-6th decade of life . MeningiIn comparison to spontaneous meningiomas (SMs), patients with RIMs are typically of a younger age at diagnosis, tend to present with multiple lesions, and demonstrate a higher recurrence rate , 6. HistThe available evidence suggests that RIMs differ biologically and clinically from SMs. Likewise the management of RIMs presents unique challenges and merits special discussion. In this review, we will provide a brief overview of outcomes currently achieved through various modalities utilized in the management of RIMs with a focus on the role of radiation therapy (RT) and predominantly in the form of stereotactic radiosurgery (SRS) and how these compare with SRS outcomes in SMs and microsurgical outcomes with RIMs. Subsequently, we will provide a discussion on clinical and radiological factors that must be considered as part of the decision-making process in the management of RIMs. Further, we will describe some of the molecular and genetic discoveries that have transformed our understanding of these lesions. We conclude by exploring some of the challenges associated with the use of SRS in the management of RIMs and how current and future research may address some of these questions.Similar to SMs, the first approach in the management of RIMs has typically been complete surgical resection, including resection of the associated dura and bone (Simpson Grade I) . HoweverThe tumor control rate seen with RIMs is roughly similar to that reported for SMs treated with SRS. Depending on the grade and location of the lesion, the reported 5-year tumor control rates of SMs with SRS have ranged from 86 to 99% –20. The The recurrence rate of RIMs managed solely through surgical resection has ranged from 0 to 43%, depending on the length of follow-up and whether radiotherapy (RT) was used concurrently  5, 30–3–330–33. Although complete surgical resection, to the safest extent possible, has traditionally been the first line approach for both RIMs and SMs, the improvement of radiosurgical instruments has shifted the management paradigm to include both modalities as required. In the following section, we will review and critically analyze factors that should be considered in deciding upon one management modality over another or in combinations, as deemed necessary.As with other pathological entities in medicine, an accurate history and physical examination is the cornerstone of the decision-making process in the management of RIMs as well. Patients with RIMs are typically divided into those with histories of low, medium, and high dose radiation . As discThe age at presentation is important as well. While multiplicity is common with RIMs, patients presenting at a younger age have been found to be at a greater predisposition , 40. TheClinically, it is important to correlate the lesion(s) with symptom presentation and to assess the risk of surgical intervention. In patients in whom a gross total resection (GTR) may be a high risk endeavor, it may be prudent to proceed with a planned subtotal resection (STR) followed by adjuvant therapy. The overall status of the patient is important as well. In particular, but not limited to, the status of the patient scalp is essential: given the history of prior radiation, the scalp of some patients is thin and prone to necrosis, dehiscence, and CSF leakage, increasing the overall risk of complications of surgical intervention . UltimatRadiological parameters that can be used to identify the lesion(s) that are more actively growing include the degree of T2 hyperintensity within the lesion(s), surrounding edema, absence of calcification (as seen on CT), or evidence of rapid enlargement on serial imaging , 42. In The invasion of major venous sinuses by RIMs and their multiplicity is a major obstacle to intervention, whether in the form of surgical resection or SRS. However, advances in SRS technique that have been applied in the management of challenging SMs offer hope. Recently, Deibert and Kondziolka have reported the case of a patient presenting with a large recurrent meningioma invading the posterior two-thirds of the superior sagittal sinus, extending 16 cm in its greatest length . This paTraditionally, meningiomas have been grouped based on the most recent WHO classification . HoweverAlthough RIMs are relatively uncommon, they represent a challenge from a therapeutic perspective. In addition, the increasing survival of patients with childhood malignancies implies that the prevalence of RIMs is likely to increase in the near future. The fact that there is a long delay in occurrence of RIMS suggests that there is memory of radiation injury or long-term molecular alterations that result in RIM formation. Therefore, understanding the molecular alterations induced by radiation therapy is critical in the prevention of RIM formation. This is a disease model that lends itself ideally to research, and understanding of its molecular pathophysiology can provide insights and a better understanding of meningiomas in general with ultimate therapeutic targets being identified.The role of adjunctive medical therapies is also an area for further investigation. To date, several agents—such as hydroxyurea—have been attempted with variable success rates . RecentlWith an increased understanding of RIMs and an expansion of the available therapeutic armamentarium, clinicians may be able to gradually push the envelope when it comes to the multimodal management of RIMs. SRS has been shown to represent a safe and efficacious option in the management of RIMs implying that radical surgical resection may be gradually replaced by a planned STR that is safe, followed by adjuvant SRS therapy. The detection of markers that predict a greater likelihood of recurrence will also help decide upon the optimal follow-up routine and the need for adjuvant therapy. The role of therapeutic drug agents targeting aberrant molecular pathways is paramount as well. While many obstacles remain when it comes to the management of RIMs, great strides have been made. It is essential to learn from past experiences while remaining open to the integration of new treatment strategies and targets.


To understand healthcare professionals’ perceptions of the benefits and potential harms of integrated care pathways for end-of-life care, to inform the development of future interventions that aim to improve care of the dying.Qualitative interview study with maximum variation sampling and thematic analysis.25 healthcare professionals, including doctors, nurses and allied health professionals, interviewed in 2009.A 950-bed South London teaching hospital.4 main themes emerged, each including 2 subthemes. Participants were divided between (1) those who described mainly the benefits of integrated care pathways, and (2) those who talked about potential harms. Benefits focused on processes of care, for example, clearer, consistent and comprehensive actions. The recipients of these benefits were staff members themselves, particularly juniors. For others, this perceived clarity was interpreted as of potential harm to patients, where over-reliance on paperwork lead to prescriptive, less thoughtful care, and an absolution from decision-making. Independent of their effects on patient care, integrated care pathways for dying had (3) a symbolic value: they legitimised death as a potential outcome and were used as a signal that the focus of care had changed. However, (4) a weak infrastructure, including scanty education and training in end-of-life care and a poor evidence base, that appeared to undermine the foundations on which the Liverpool Care Pathway was built.The potential harms of integrated care pathways for the dying identified in this study were reminiscent of criticisms subsequently published by the Neuberger review. These data highlight: (1) the importance of collecting, reporting and using qualitative data when developing and evaluating complex interventions; (2) that comprehensive education and training in palliative care is critical for the success of any new intervention; (3) the need for future interventions to be grounded in patient-centred outcomes, not just processes of care. Qualitative research has an important role in shaping complex interventions to ensure that these are appropriate, acceptable and feasible in the chosen setting, but such approaches can be undervalued. This in-depth qualitative study examines healthcare professionals’ perceptions of the benefits and harms of integrated care pathways for end-of-life care in order to inform the development of interventions to improve care for the dying.We interviewed healthcare professionals from different grades of medical, surgical and allied specialties, and have developed detailed insights into the factors associated with successful implementation of integrated care pathways for end-of-life care.By using data collected in 2009, we are able to understand the views of healthcare professionals in the period before the media controversy surrounding the use of the Liverpool Care Pathway and Neuberger review.We interviewed a disproportionately large number of staff members from the intensive care unit, and participants were from a single tertiary referral centre, which may not be representative of the wider clinical setting.Qualitative research, including exploration of patient, carer and healthcare professional perspectives, has an important role in shaping complex interventions to ensure that these are appropriate, acceptable and feasible. In the context of controlled trials, qualitative research can be used to understand the complexity of interventions and the context in which these are tested.2The Liverpool Care Pathway for the Dying Patient (LCP), an integrated care pathway for end-of-life care, was developed in England in the late 1990s.5The aim of any integrated care pathway is to improve patient outcomes by promoting consistency and streamlining the processes of care.10The extent to which healthcare professionals were aware of and in agreement with the potential harms exposed by the media and Neuberger review is unclear. Healthcare professionals’ views around the LCP were studied prior to the Neuberger review, but these studies cited mainly positive attitudes towards the impact of the LCP on the processes of care, for example, improvement in communication, continuity, documentation and as an educational tool.Understanding the a priori reservations of healthcare professionals regarding potential harms of integrated care pathways for end-of-life care would help inform the implementation of the LCP outside the UK where it is still being used,This was a qualitative analysis of interviews with healthcare professionals. The data were collected as part of a study which followed guidance for the development and evaluation of complex interventions from the Medical Research Council ,The setting was two adult ICUs in a 950-bed South London teaching hospital, serving an area characterised by social deprivation and with culturally and ethnically heterogeneous populations. At the time of the study, the LCP had been implemented across much of the hospital, but was not used routinely in the intensive care setting.Maximum variation sampling was used to select potential staff participants to gain perspectives from a broad range of healthcare professionals by taking into account age, gender, profession and experience, and included both ICU and other hospital staff. Staff were identified through discussions with key staff members, and approached by letter or email. Written informed consent was gained from each participant prior to the interview. Twenty-five participants were interviewed: 13 nurses (junior to senior), 6 ICU doctors (junior to senior), 1 transplant coordinator, 2 social workers, 2 senior physicians and 1 senior surgeon. Three participants had extensive palliative care experience. All participants had some familiarity with integrated care pathways for end-of-life care, including the LCP, though experience varied by clinical settings and their grade. Interviews were carried out in 2009.An interview time convenient to the healthcare professional was arranged . Interviews were conducted in a confidential setting away from the clinical workplace unless the participant preferred not to. Interviews lasted 30–60 min and were conducted face-to-face with one of two trained interviewers (Dr Cathy Shipman (MSc), a senior research fellow and an experienced qualitative researcher, with an interest in non-specialist provision of palliative care; CR, a clinical research associate trained in qualitative methods). No relationship had been established prior to the start of the study, and there were no non-participants present. Topic guides were developed from a literature review; initial observations and discussions with service users, and explored perceptions, recommendations and views on integrated care pathways for palliative and end-of-life care (including the LCP); processes of decision-making; and experiences of palliative and end-of-life care. Although the study was based in the ICU, questions were more generally focused on the use of integrated care pathways. Questions were open-ended, and were piloted and revised. No repeat interviews were carried out. All interviews were digitally recorded and transcribed verbatim. The data were anonymised and code numbers allocated to each case. Themes were fed back and data were discussed with the project advisory group and with participants.We used thematic analysis to inductively identify patterns and themes within the data. This approach utilises five related steps of: familiarisation, coding, theme development, defining themes and reporting.The primary data coder was KES. Specialist software was not used. To address issues of analytical rigour and trustworthiness, a subset of transcripts were double-coded by KB. A reiterant process of discussing areas of agreement and disagreement took place between KES and KB to achieve consensus. Alternative interpretations were incorporated into the analysis. The analysis was further tested during discussions with colleagues, and meetings of the project advisory steering group. We also paid attention to non-confirmatory cases where emerging themes contradicted more common ideas. Quotations were chosen to illustrate the themes, and to include a range of study participants.Four themes were identified from the interview transcripts, each including two subthemes. Participants were divided between those who cited mainly benefits of integrated care pathways, and those who talked about potential harms. In addition, integrated care pathways for dying appeared to have a symbolic value, acting as a signal that the focus of care had changed. Underlying this were comments relating to the context and infrastructure within which care was provided .I think perhaps it does mean that everybody has a clear picture as to what we are doing and not doing. (Senior nurse)Many participants cited benefits of integrated care pathways for dying with respect to processes of care. The LCP provides a structured single record with prompts to guide care, and nursing staff, in particular, appeared to value the structure that integrated care pathways provide. There was frequent mention of improved clarity about the care which was to be provided.The biggest challenge I find as a nurse is not really knowing where you stand sometimes with treatment with, you know, perhaps the weekend…that's why I think the pathway is a good thing because it gives people guidance and gives us nurses something to follow. (Senior nurse)Integrated care pathways were felt to make care of the dying more consistent and comprehensive, and were felt to be particularly valuable in situations where continuity was compromised, for example, out of hours or when turnover of staff  was high.So having a form…can make sure that everybody involved can see where you are, what your aims are and what the plan actually is,…rather than having to, to discuss the plan for 10 minutes and tell the new person, you know…if there's a form then everybody can just see, sort of what we're doing. (Senior ICU doctor)An extreme view was that integrated care pathways for end-of-life care could provide a substitute for face-to-face handover between healthcare professionals changing shifts.so it's clear on every patient this is what we're going to do, this is the process. (Junior nurse)From many study participants there was a sense that integrated care pathways provide absolute clarity about processes of care. Much of the language used was of process and protocol, rather than uncertainty or grey areas.But I think it provides clear guidelines, in my experience, for junior staff to follow and it is very clear and easy to follow and I think it provides a nice framework. (Junior doctor)Several participants thought integrated care pathways for dying people were particularly beneficial for the more junior or inexperienced healthcare professionals. Again, this was particularly related to processes of care: care pathways provided clarity and structure to the care delivered.I think pathways…give some kind of guideline which is helpful for people but often it is particularly young colleagues, it is something which makes them more inflexible…in the way that the most important thing if you work with pathways is to identify patients who don't fit in to the pathways because otherwise you make wrong decisions based on your pathways. (Senior surgeon)However, a minority of interviewees expressed a different view: that integrated care pathways may be particularly poorly used by inexperienced staff. For example, a consultant surgeon spoke about care pathways being used too rigidly by inexperienced colleagues.In this study, it was uncommon for staff members to talk about the impact of integrated care pathways on patient outcomes, and no participant spoke about integrated care pathways as improving the quality of patients’ deaths. Where outcomes were discussed, these related to the potential for harm. The words ‘dangerous’ and ‘danger’ were used. Integrated care pathways were not thought to be intrinsically bad, but were susceptible to poor use.but it is documentation so it doesn't do the care for you,…and there's still an awful lot of thought and…work that you know needs to go into giving that care,…so it's not a tick box exercise,…and I think there's just a danger of that. (Senior nurse)The distinction between processes of care and patient outcomes was highlighted clearly by one participant.Whatever care pathway there is, I'm always worried about people switching off their brains. Tick-boxing. Putting down on paper what they have to to fill in the paperwork. (Senior ICU doctor)Several study participants expressed concern that end-of-life care needs to be individualised, and that the structure of integrated care pathways, which in the case of the LCP included 4 and 12 hourly prompts, can inhibit the necessary flexibility required to provide good care to the dying. One participant spoke about integrated care pathways promoting tick-box care and inhibiting thoughtfulness.I think it's dangerous at the moment at times because that clinical decision-making doesn't happen, it isn't documented and in some instances the pathway, and that's not the intention of the pathway and the people who developed the pathway, but the presence of the pathway, the options of the pathway actually seems to absolve people from that. (Senior physician)Another participant with extensive experience in palliative care spoke about the tension between providing holistic end-of-life care and following a pathway, and suggested that integrated care pathways may absolve healthcare professionals from clinical decision-making.When it does become a focus issue we very quickly get the paperwork out of the stationery cupboard and put it there [by the bed]. (Senior nurse)Several participants described integrated care pathways for end-of-life care in a way that suggested a symbolic value. Pathways were considered to be a useful signal, even before the paperwork was filled in, to herald the change in focus of care from active to palliative treatment. For example, the presence of the paperwork at the bedside was described as a non-verbal form of communication that the focus of care had changed.The availability of integrated care pathways for end-of-life care was felt to have a value in legitimising death as an outcome in hospital, providing an acceptable alternative to aggressive medical care. One ICU consultant spoke about integrated care pathways providing a positive focus to the change in patient care by highlighting the care which will be provided, rather than aspects of care that are thought to be no longer appropriate.I always joke about departments where, yes, the Liverpool Care Pathway is used in the department, do you know exactly what happens, by that stage you've switched off and you've handed the patient over, I think that's the honest truth. (Senior physician)There was a sense, however, that the use of integrated care pathways may promote a binary attitude towards the dying: integrated care pathways are either used or not used; therefore, patients are either dying or not dying. This perceived clarity regarding the change in focus of care may give some clinicians permission to distance themselves from the patient's care entirely. One senior physician talked about ‘switching off’ when the LCP is used.things like the Liverpool Care Pathway and things like that, I think they are a distillation of what I personally have been taught piecemeal over 10, 11 years now since graduation, and even before. (Senior ICU doctor)Education and training in palliative care were commented only occasionally. A few study participants volunteered that they had received palliative care training, and for those who had, this had often focused more on how to use the LCP paperwork than generic palliative care skills. For one participant, the LCP itself appeared to act as an educational tool.There is no evidence. It's not a validated tool. (Senior physician)Only one study participant spoke about the evidence base for the LCP. This participant expressed concern about the lack of strong evidence of the benefits of the LCP, and the lack of awareness among other medical colleagues about the paucity of evidence.The four main themes outlined above are illustrated in This study demonstrates that in the years preceding the Neuberger review, healthcare professionals were conscious of both benefits and harms of integrated care pathways for end-of-life care. The benefits related to streamlined processes of care, and were experienced by the healthcare professionals themselves. Potential harms related to applying the pathway inflexibly or without thinking, leading to poor clinical decision-making, and were reminiscent of criticisms subsequently published by the media and the Neuberger review.It is notable that no participant in this study cited benefits regarding improved outcomes for patients. This does not mean that integrated care pathways do not have the potential to improve the quality of patients’ end-of-life care, but it does suggest that healthcare professionals using them may lose sight of the ultimate goal of care: a good death for the patient and improved outcomes in bereavement for their carers. The LCP audits, which measured success of implementation based on process measures and not patient-centred outcomes, may have reinforced this aspect.20The LCP was not intended as a protocol, but as a guide.23Although the LCP was intended simply as a guide to care, it fulfilled additional roles. An integrated care pathway for end-of-life care acted as a symbol to herald the change from curative to palliative treatment, to signal to others that the focus of care had changed and to legitimise that change. Indeed, for some clinicians, the perceived clarity of this switch in the focus of care appeared to allow them to distance themselves from the patients’ care entirely.One of the main criticisms made by the Neuberger review was the lack of prospective testing of the LCP. It is interesting that only one healthcare professional in this study cited the importance of knowing the evidence base for such a pathway. Professionals may consider research evidence less important or relevant when people are dying, and this may be compounded by the historical paucity of research funding for palliative care.The strengths of this study are that a large number of people were interviewed, from different grades within several medical, surgical and allied specialties. By using data collected in 2009, we are able to understand the views of healthcare professionals in the period before the media controversy and Neuberger review.This study has limitations. The original study focused on those dying in the ICU, where rapid changes in health status and prognostic uncertainty are common. The disproportionately large number of staff members from the ICU in this study may, therefore, not be representative of the wider clinical setting. Attitudes towards integrated care pathways for end-of-life care were just one part of the original study and the interview schedule.This study has important implications for the future development of interventions to improve end-of-life care. First, it demonstrates the importance of collecting, reporting, and using qualitative data during the development of complex interventions.Second, the study emphasises the importance of investment in education and training in palliative care. The enthusiasm for what was perceived to be a protocol for end-of-life care indicates a need for improved understanding of how to care for the dying. Without these generic skills, it is unlikely that staff members would be able to use any such tools well or to recognise when these tools are being used poorly.Third, the study identifies the importance of grounding the development of any future tools to improve care of the dying around patient outcomes, not just processes. Measuring processes of care is often more straightforward than measuring outcomes. However, reliance on process measures not only meant that it was impossible to demonstrate whether the LCP improved quality of care for patients and families,


Background: postnatal depression (PND) is defined as a psychological mood disorder that occurs in a mother within 6 weeks of her giving birth. It refers to an episode that causes mood disturbance and it could begin in, or extend into, the postpartum period. It is thought to have a high impact upon the mother's health as well as the family's functioning and the child's development. Socio-demographic, psych-social, and physical activity factors may all contribute to postpartum mood and ability to cope with responsibilities. The primary aim of this study was to determine which of these factors predicted PND in postpartum women. A secondary aim was to identify the socio-demographic and psycho-social predictors of physical activity in postpartum women.Methods: The study used a cross-sectional correlational design. A sample of 150 postpartum women was sent a package of six standardized questionnaires.Results: There was no association between physical activity and PND; however, older mothers, mothers of younger children, mothers who are less reluctant to ask for help, and mothers who are more satisfied with the help they get experience lower levels of PND. Mothers of older babies, mothers with more children, and less educated mothers are more likely to engage in caregiving activities, whereas mothers with fewer children and higher levels of partner support are more likely to engage in occupational activities. None of the socio-demographic factors or any of the parenting factors predicted levels of sporting activity. Approximately 13 per cent of childbearing women around the world suffer from depression , levels of physical activity , social support, partner support, and parental confidence are associated with PND. An additional aim of the study was to determine whether the socio-demographic factors, partner support, and parental confidence are associated with levels of physical activity in the four domains.A cross-sectional correlation design was used.A sample of 150 postpartum women were involved in the study. To be eligible for the study mothers had to be within 6–52 weeks postpartum, live in the Perth metropolitan region of Western Australia, not use a wheel chair or have a physical/medical problem that prevents undertaking moderate to vigorous physical activity, be able to read or respond in English, and not have a baby with disabilities or a premature baby of less than 35 weeks gestation.The Postpartum Lifestyle Questionnaire (PLQ) is a 14-page instrument designed to collect details on physical activity participation, parenting confidence, social support, barriers of exercising, screening of PND, partner support, and personal demographics including age, ethnicity, education, income, type of accommodation, and occupation. The statement “your postpartum lifestyle” appeared on the front cover of the PLQ in order to make a good connection between participants and research goals. The PLQ is made up of the following scales and surveys:The Edinburgh Postnatal Depression Scale  and data collection commenced in March 2010 and concluded in July 2010. Six hundred questionnaires were distributed in the metropolitan areas of Perth  to child health clinics.The PLQ was distributed in the form of a package that contained the participant's information sheet and a reply paid envelope for the participants. In addition, nurses were provided with an instruction package that included a checklist, advertisement sheet and another reply paid envelope so they could return details of the number of questionnaires distributed to participants (mothers in the 6–52 weeks postpartum period during the time of participation). Postpartum women recruited to the study by the metropolitan child health clinics, and provided active consent before being given the PLQ package.The means and standard deviations for the key variables are listed in Table SPSS version 20 was used to test two hierarchical multiple regression models. Our primary research goal was to examine the relationships between PND and 21 potential predictors. We partitioned the predictors into socio-demographic variables , social support variables , parenting variables , and physical activity variables . Our original intention was to test a hierarchical linear regression model in which the socio-demographic predictors were entered on Step 1, the social support predictors on Step 2, the parenting predictors on Step 3, and the physical activity predictors on Step 4. Inspection of Pearson and Spearman correlations, however, concurred that two of the socio-demographic predictors  and all four physical activity predictors  were not significantly correlated with PND. These predictors were therefore dropped from the regression model. We then tested a three-step hierarchical regression model in which a reduced set of socio-demographic predictors were entered on Step 1 , the social support predictors on Step 2, and the parenting predictors on Step 3. The scatterplot of standardized predicted values against standardized studentized residuals showed no evidence for violations of the regression assumptions of linearity, normality, and homoscedasticity; Cook's Distance values were all less than one indicating that no participant had a disproportionate impact on the regression solution; and tolerance values ranged between 0.463 and 0.989 indicating that multicolinearity was not a problem. The results of the regression analysis are reported in Table r = 0.188, p = 0.022) indicating that mothers of younger children engaged in lower levels of physical activity in the living domain compared to mothers of older children. Four predictors were correlated with caregiving  and two with occupation . Multiple regression analyses were therefore conducted for caregiving and occupation. For both regression models: The scatterplot of standardized predicted values against standardized studentized residuals showed no evidence for violations of the regression assumptions of linearity, normality, and homoscedasticity; Cook's Distance values were all less than one indicating that no participant had a disproportionate impact on the regression solution; and tolerance values ranged between 0.923 and 0.991 indicating that multicolinearity was not a problem. The results of the regression analyses are reported in Table Our secondary research goal was to examine the relationships between levels of physical activity and seven potential predictors. We partitioned the predictors into socio-demographic variables  and parenting variables . Our original intention was to test four hierarchical linear regression models—one for each of the four domains of physical activity, namely, living, sport, caregiving, and occupation. In all models, the socio-demographic predictors were to be entered on Step 1 and the parenting predictors on Step 2. Inspection of Pearson and Spearman correlations, however, concurred that not all of the seven predictors were correlated with all of the activity domains. No predictors were correlated with sport. Only one predictor (age of baby) was correlated with living  of PND severity. These results highlight the role of social support in predicting PND and are consistent with findings which establish PND as a reason for poor quality interaction with others  or any of the parenting factors  predicted levels of sporting activity.less active in the caregiving domain with a consequent increase in activity in the living and occupation domains. Not surprisingly, mothers with more children were more active in the care-giving domain and less active in the occupation domains.Mothers with older babies were more active in the caregiving, occupation, and living domains. These findings are consistent with those of Sampselle et al.  which shLess highly educated mothers were more active in the care-giving domain, which might be due to their inability to find well-paid employment—a state of affairs that would lessen the incentive to work outside of the home. This idea is supported by studies that have found a link between income and physical activity in the postpartum period (e.g., Eyler et al., There was no association between parental confidence and physical activity in any of the four domains. Our failure to find a link between parental confidence and activity in the occupation domain is inconsistent with the finding that feeling more confident and able to cope with maternal roles was associated with less participation in occupational activities (Blum et al., There were some limitations for the current study such as the size of the sample, a lack of clinically depressed mothers in the sample and the duration of the study. Increasing the size of the sample, thus ensuring greater statistical power, might result in the capture of associations that the current study missed and resolve some of the disagreement between different studies. In addition, the inclusion of greater numbers of clinically depressed mothers in the study, while methodologically challenging, would strengthen the findings and perhaps add statistical support for the hypothesis that exercise can help to mediate the effects of PND.The study findings suggest that there is no association between physical activity participation PND following childbirth; however, older mothers, mothers of younger children, mothers who are less reluctant to ask for help, and mothers who are more satisfied with the help they get, experience lower levels of PND. In addition, mothers of older babies, mothers with more children, and less educated mothers are more likely to engage in caregiving activities, whereas mothers with fewer children higher levels of partner support are more likely to engage in occupational activities. Further research is needed in order to further investigate the relationship between exercise and postpartum mood. The factors that enable exercise need to be investigated during pregnancy and the prenatal period to facilitate postnatal exercise and encourage more participation in postnatal exercise classes, as women appear to be mostly inactive during this time, possibly due to adapting to their new role and responsibilities. In addition, qualitative approaches are required to inform the development of structured exercise programs that are tailored to new mothers' specific needs and maintain their participation.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Communities of practice (CoP) can facilitate collaboration between people who share a common interest, but do not usually work together. A CoP was initiated and developed including stakeholders from clinical, research, community and governmental backgrounds involved in a large multidisciplinary and multi-sectorial project: the Rehabilitation Living Lab in a Mall (RehabMaLL). This study aimed to evaluate the structure, process and outcomes of this CoP. A single case-study, using mixed-methods, evaluated the RehabMaLL CoP initiative after one year, based on Donabedian’s conceptual evaluation model. Forty-three participants took part in the RehabMaLL CoP with 60.5% (n = 26) participating at least once on the online platform where 234 comments were posted. Four in-person meetings were held. Members expressed satisfaction regarding the opportunity to share knowledge with people from diverse backgrounds and the usefulness of the CoP for the RehabMaLL project. Collaboration led to concrete outcomes, such as a sensitization activity and a research project. Common challenges included lack of time and difficulty finding common objectives. A CoP can be a useful strategy to facilitate knowledge sharing on disability issues. Future research is necessary to determine strategies of increasing knowledge creation between members. Researchers in the field of rehabilitation are increasingly interested in finding mechanisms to ensure their research is relevant and applicable for front-line health care professionals and community partners, with the ultimate goal of increasing social participation of people with disabilities. Models describing the complex process of bringing different types of knowledge into action, such as the Knowledge-To-Action (KTA) model , highliget al., [Despite this growing interest in including relevant stakeholders in the KTA process, difficulties in involving them in research remain. This gap between the research being conducted and the needs and realities of stakeholders, has been identified for different groups, including clinical practitioners ,4,5, comet al.,  have thu. As well, through the ongoing discussions that take place in a CoP, participants can build up a stock of knowledge and resources from which they can draw when needed [Communities of Practice (CoP) have been presented as a KTA strategy that can facilitate recognizing and supporting the use of different types of knowledge and evidence, such as tacit or explicit knowledge from a variety of stakeholders ,15. A Con needed . Grol ann needed  suggest There seems to be an increasing interest in using CoPs in general , and in A single case-study, triangulating both qualitative and quantitative data, was used to evaluate the RehabMaLL CoP initiative. www.crir-livinglabvivant.com), a large multidisciplinary and multi-sectorial research project initiated by the Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR). The RehabMaLL has established partnership with an international real-estate promoter and owner of a Montreal downtown shopping mall, local community groups, as well as local, national and international research, clinical and industry partners. The RehabMaLL is the first environment of its kind, designed to study how to best address the needs of persons of all ages with physical, sensory and cognitive disabilities. It aims to promote their social participation by creating an inclusive mall environment where numerous interactions and daily activities typically take place. Due to the complexity of this project and the multiple stakeholders involved, a strategy was needed to facilitate collaboration between all partners. The CoP was thus created to implement, support and structure knowledge creation and translation, to best ensure the progress of the RehabMaLL project. Its development and accompanying evaluation was led by two researchers, , from the RehabMaLL. A CoP was initiated in May 2013 to facilitate mutual sharing of ideas and experiences between stakeholders from research, clinical, community and governmental milieus involved in the Rehabilitation Living Lab in the Mall , process  and outcome (the effects of care on patients and population). Notions of quality and performance are directly linked to the organizational structure of the health system and to its management of processes. The outcomes correspond to the quality of care offered to the patients and to the performance of the health system in offering this care. In order to assess and evaluate the CoP, Donabedian’s conceptual evaluation model for quality of care  was seleIn this study, data from the online platform were collected over the first 15 months, from May 2013 to July 2014. Following completion of this first portion of the analysis, administration of questionnaires and telephone interviews with the participants was conducted from August to December 2014. A log and notes from the in-person CoP meetings were maintained throughout. Questionnaire on communities of practice. The CEFRIO, a research network interested in the use of technologies to foster innovation, developed a questionnaire specifically for examining different facets of CoPs. It was developed in the context of a study where multiple CoPs in different sectors were initiated and evaluated [valuated ,34. The Newman’s survey for online communities. Four additional questions based on a questionnaire developed by Newman et al. [et al. had been developed to evaluate an online conference and was based on Salmon’s [n et al.  were alsSalmon’s  five staData from the online platform were collected over the first 15 months of the CoP and included: number of discussion topics and comments, number of comments made by each participant and broad content of discussions. Interviews with CoP participants were conducted in French or English by two independent interviewers familiar with the RehabMaLL project, but who had not been part of the CoP activities. Interviews included six open-ended questions for researchers and seven for other participants. Themes addressed were: positive and negative aspects of collaborating using the online platform and during in-person meetings, changes in perspective on research and usefulness of the CoP for research activities, as well as impact of the CoP on their own knowledge and activities. The seventh question addressed participant’s (other than researchers) interest to take part in future research activities following their experience in the RehabMaLL CoP. Participants took part in the phone interview at a time convenient to them and all interviews were recorded. The CoP facilitator kept a log throughout the first year of the RehabMaLL in order to collect data on the original structure of the RehabMaLL and changes to the structure over time, as well as the activities of the CoP and regular meetings between the facilitator and the main researchers , who insured the governance of the project. Summaries of meetings were also produced and shared with CoP members, by email and on the online platform. Participants who attended could give feedback on the exactitude of the notes, and they helped those who had been absent keep up-to-date with the activities.A summary of the data collected, using the structure, process and outcome dimensions of Donabedian’s model, as applied to the CoP, is presented in p < 0.01 level of significance was used. All analyses were done using SAS Software. Answers were regrouped  in order to allow us to identify trends. Descriptive analysis using frequencies were conducted per item, for each individual and for categories of participants. A Fisher’s Exact Test compared scores between categories of participants. To control for multiple comparisons, a i.e., topic name, participant code, date of comment, and the participant’s comment). Comments were then categorized into themes according to its content. Some themes were also subdivided. Comments may have been included in more than one theme. This process was validated by the research team . Themes were chosen based on a classification proposed by Connected Educators, a group interested in innovations seeking to foster knowledge sharing using social media and online connections . They include: Practice, Resource, Advice, Collaboration, Novel Ideas, Summary, Vulnerability, Asking, and Appreciation . Results from the quantitative and qualitative data are presented in the following section according to the dimensions of Donabedian’s model: structure, process and outcomes. The number of participants in the CoP varied over time due to the nature of the group which has ongoing recruitment and involvement that can depend on the participant’s interest in the topic of discussion or activity. Forty-three participants were included in the online data collection and 28 participants took part in the questionnaire and interviews . Elements considered to inform about the structure of the CoP include characteristics of the members and of the platform being used, as well as the structure of the online discussions, meetings and activities. Data sources include facilitator’s log and interviews. Fifty people were contacted to take part in the CoP, of which 43 participated at some point, including researchers in rehabilitation, clinicians, members of community organizations, people living with a disability and family members, as well as representatives of governmental agencies . The majwww.cnphi-rcrsp.ca). This platform has been in development for over 10 years to facilitate sharing of information between healthcare professionals throughout Canada. It includes a news board, discussion forum, library, list of members and an event calendar. Each CoP member had a username and password to access the platform. As a strategy to engage participation, monthly newsletters and summaries of meetings were sent out through the online platform and by email. Two short online surveys were also conducted using the online platform to determine participants’ interests and to help organize CoP activities. The RehabMaLL CoP was designed to evolve through in person meetings, as well as through an online collaborative platform, with the support of a facilitator. The online platform was offered to facilitate ongoing exchanges between members regardless of availability and location of the participant. Following an in-depth review of available online platforms, the platform chosen for this CoP was created by the Canadian Network for Public Health Intelligence , the main researchers for the CoP  and the scientific directors of the RehabMaLL . All but two (out of the 43) members participated in at least one of the in-person meetings. Participants in the in-person meetings were involved in research presentations, small working groups, discussions, and planning of community activities.Online participation was sporadic in most cases. Of the 43 participants who took part in the CoP activities over the first 15 months, 60% were active on the online platform at least once . On averThe number of monthly comments did not display a visible pattern, with peaks in July (47), October (54) and November (33), 2013. An important decline can be observed after a few months following the creation of the CoP . Different types of participants tended to post about certain themes. Aside from vulnerability, the facilitators were the most frequent contributors for each theme. When facilitators were removed, clinicians were most likely to give advice (n = 16) and discuss practice (n = 14), while community organizations most often expressed appreciation (n = 16), asked questions (n = 11) and shared resources (n = 11). Examples of topics addressed online are: the use of public places like the shopping mall in the rehabilitation process, phone applications to evaluate the accessibility of public places, accessible tourism and leisure, and ways of sensitizing storeowners about accessibility. The most popular topics and the ones that could be linked to research in the RehabMaLL were discussed more in-depth during the meetings. * in Results from the questionnaires administered to CoP members are presented in Data collected during the interviews also provided insight into the process of the CoP. In particular, questions addressed the preferred mode of collaboration of members, either online or in-person, as well as positive or negative aspects of both. Participants who had used the online platform reported some advantages regarding the platform as compared to in-person meetings, including the possibility to discuss and share resources on an ongoing basis, as well as it being a central place to keep track of information. Difficulty accessing and using the platform, either because of its design or from lack of familiarity with technology, was mentioned as an obstacle. Limited participation of members online was also perceived as an issue, making discussions less dynamic than they would have liked. Finding the time to go online is the most common obstacle expressed by participants during the interviews. Questionnaire results show that 29.6% of participants agree that their participation in the CoP requires too much time. In-person meetings, on the other hand, facilitated discussion and sharing with the other members, according to participants’ interviews. It allowed for dynamic and stimulating exchanges, leading to new reflections and increased awareness of different perspective. The meetings were also the occasion to network and forge collaborations. However, some participants reported that it was sometimes hard to find a focus to the meetings or specific discussions that would be relevant to everyone. There was a clear preference for collaborating during the in-person meetings, rather than online, although a few participants noted that if exchanges were dynamic on the on-line platform, it would be best to communicate both in-person and on-line. Based on the questionnaires, few obstacles to participating in the CoP received high scores. Results of the interviews indicate that time is the main factor limiting participation in the CoP. Elements considered to inform us about the outcomes of the CoP include member satisfaction, achievement of personal and group objectives, development of new initiatives, as well as change in individuals and organizations. Data sources include questionnaires, open-ended interviews, logs and minutes of meetings. Both online and during the in-person meetings, the diversity of the members and the opportunity to share different points of view on a variety of relevant issues were much appreciated, as expressed during the open-ended interviews. Results from the questionnaires show that 100% of participants agree that members have something to offer each other. Overall, 55.6% of participants reported satisfaction with their own participation in the CoP.Participants highly agree that the CoP allows them to exchange information with people working in the same field as them (92.3%), to speak about their own experiences (88.5%) and to see the advantage of working together with others in similar organizations (88%). With regards to learning from the CoP, members agree they learned on a personal (77%) and on a professional (70%) level. However, only 66% agree that it has helped them reduce professional isolation. Open-ended questions indicated that exchanges in the CoP had led some participants to reflect on new ideas or projects, and that the CoP was a good place to share information.In relation to research activities, 100% of members agree that the CoP is useful for the RehabMaLL project (100%), and that the CoP has achieved its goal (87.5%). Open-ended questions reveal that researchers and participants in the category “other” also highly value the contributions of the RehabMaLL CoP for validating their research results and building collaborations. Some of them recommend working in smaller groups on targeted topics. For other members , the RehabMaLL was an opportunity to gain a better understanding about research, to build collaborations and gain access to researchers. In some cases, the RehabMaLL CoP has been an incentive to participate in upcoming research activities. There were no significant differences between type of participant on any items from the questionnaire. etc. according to their own perspectives. In many cases, the participants engaged discussion with store owners and workers. Collaboration within the RehabMaLL CoP has also led to new projects such as a sensitization activity regarding accessibility. This activity was organized by RehabMaLL CoP members, in collaboration with a Montreal community organization, also a collaborator in the RehabMaLL CoP. It corresponded to one of the goals that participants had mentioned throughout the meetings to help sensitize storeowners and workers to disability and universal accessibility. During the activity, teams including people with and without disabilities, whether members of the CoP or not, visited 54 stores to rate a variety of accessibility facets, such as the doors, washrooms, counters, The CoP participants also contributed to a specific research project led by one of the members, who is a clinician and a graduate student. The project received funding to survey current clinical practices and needs regarding the use of the shopping mall environment to facilitate the rehabilitation process. Through this project, focus groups were conducted with clinicians working in rehabilitation and people with disabilities and a short video was produced based on the results to sensitize clinicians about the importance of including the community setting in their practice. The CoP members were solicited to participate in the discussion groups as well as to inform the video creation in order to ensure it addressed different potential audiences. This study addressed the structure, process and outcomes of a CoP using multiple data sources and perspectives. Overall, participants were active either online and/or in the meetings. The vast majority of respondents were positive about the opportunity to communicate and collaborate with others from different backgrounds and settings to discuss social participation for individuals with a disability. Participation online was quite low and was mostly used to ask questions and share information. Approximately half of the CoP members attended each in-person meeting and results indicate that participants appreciated the richness of these discussions over on-line communication. In the following section, results are discussed with respect to the current state of knowledge regarding CoPs. versus discussions in the meetings. As addressed in previous studies [This CoP has used both online and in-person means of communication and collaboration, as do most CoPs in the healthcare sector . However studies , facilitet al. [et al. [Another factor that had been identified to explain levels of sharing of knowledge using online technology is trust between members . In partet al.  also higet al. ,40 or seet al. . Having  [et al.  have shoDespite these different levels of participation online and in-person, the dynamics observed in this CoP seem to be consistent with the model described by Wenger and Wenger-Trayner , which iOverall members did show appreciation for many aspects of the CoP, although they were generally not satisfied with their participation, as expressed by low results to the question “I am very satisfied with my participation in the CoP”. This question obtained only a 55.6% agreement rate. The explanation for this relatively low level of satisfaction is unclear. According to interview findings, it may be attributed to personal factors, such as dissatisfaction with their own level of engagement, in particular because of lack of time to participate, or due to some other factors. Other facets of dissatisfaction include the ease of use and function of the online platform. Future studies should examine strategies that can help overcome these common barriers in different types of CoPs. One of the strong points attributed to the RehabMaLL CoP by members is the diversity of its composition and sensitization to different points of views. This advantage was observed throughout the discussions and the activities, in particular for knowledge sharing across sites and backgrounds. However, this facet of the CoP might also be responsible for some of the challenges met . In partDespite the growing interest in CoPs, there is still a lack of research looking at the outcomes of such initiatives and offering validated tools and frameworks for this assessment ,25. It rThe evaluation focused on collaboration and outcomes of the RehabMaLL CoP, but did not address outcomes of the larger RehabMaLL project, including accessibility and use of the mall for people with disability. In that sense, it would have been interesting to include questions regarding the access to or use of the Mall space in the qualitative interviews, and get greater feedback on the topic from CoP members, in particular participants with a disability. Understanding the process, structure and outcomes of the RehabMaLL CoP can be useful to those interested in developing a similar group. The first 20 months of this CoP show positive outcomes of collaboration between members of different backgrounds interested in social participation of people living with disabilities. Results also suggest some challenges, in particular in regards to online participation. Future research is needed to better understand ways of increasing collaboration in a CoP with participants from such a wide range of different backgrounds and settings.


Reason for Erratum:Immobilization of Laccase was published incorrectly. The correct sentence should read:Due to a typesetting error, the first sentence, in the section In general, laccase immobilization by adsorption was carried out (Hong et al., The publisher apologizes for this mistake, the original article was updated. This error does not change the scientific conclusions of the article in any way.


Universal Health Coverage (UHC), referring to access to healthcare without financial burden, has received renewed attention in global health spheres. UHC is a potential goal in the post-2015 development agenda. Monitoring of progress towards achieving UHC is thus critical at both country and global level, and a monitoring framework for UHC was proposed by a joint WHO/World Bank discussion paper in December 2013. The aim of this study was to determine the feasibility of the framework proposed by WHO/World Bank for global UHC monitoring framework in Kenya.The study utilised three documents—the joint WHO/World Bank UHC monitoring framework and its update, and the Bellagio meeting report sponsored by WHO and the Rockefeller Foundation—to conduct the research. These documents informed the list of potential indicators that were used to determine the feasibility of the framework. A purposive literature search was undertaken to identify key government policy documents and relevant scholarly articles. A desk review of the literature was undertaken to answer the research objectives of this study.Kenya has yet to establish an official policy on UHC that provides a clear mandate on the goals, targets and monitoring and evaluation of performance. However, a significant majority of Kenyans continue to have limited access to health services as well as limited financial risk protection. The country has the capacity to reasonably report on five out of the seven proposed UHC indicators. However, there was very limited capacity to report on the two service coverage indicators for the chronic condition and injuries (CCIs) interventions. Out of the potential tracer indicators (n = 27) for aggregate CCI-related measures, four tracer indicators were available. Moreover the country experiences some wider challenges that may impact on the implementation and feasibility of the WHO/World Bank framework.The proposed global framework for monitoring UHC will only be feasible in Kenya if systemic challenges are addressed. While the infrastructure for reporting the MDG related indicators is in place, Kenya will require continued international investment to extend its capacity to meet the data requirements of the proposed UHC monitoring framework, particularly for the CCI-related indicators.The online version of this article (doi:10.1186/s12939-014-0123-1) contains supplementary material, which is available to authorized users. Universal Health Coverage (UHC) has been defined as providing access to needed health services without incurring financial hardships for the whole population , and is UHC is increasingly embraced at a global level as a priority in the post-2015 development agenda ,7. HealtTo progress towards UHC, countries will need to concurrently undertake health financing reforms as well as comprehensively address health systems service delivery challenges ,10. AccoFor WHO, monitoring progress towards UHC is one of its research priorities, and will facilitate assessment and tracking of strategies implemented and their outcomes. A global monitoring framework will allow joint learning and sharing of experience and knowledge on UHC implementation across different contexts, and a common and comparable approach in assessing UHC progress is currently being developed ,13.In recent years, consultative meetings have been conducted to develop a common mechanism of monitoring progress towards UHC. These meetings addressed the concepts of UHC that will be measured, and described the potential indicators to be utilised -16. TherRecent studies on the measurement of UHC progress have explored possible indicators for UHC, the availability of the indicators in low income countries, and validity of commonly proposed indicators and the data sources -19. The Kenya is a low income country, with slow economic growth. The main economic sectors include agriculture, tourism and service industry . The popThe country grapples with a high disease burden, of which the traditional communicable diseases are the major cause . The GloIn Kenya health services are provided by four main sectors: public, private, faith-based and non-governmental organisations (NGOs). The private and faith-based institutions are a mix of profit and not-for-profit agencies. The public sector operates the largest share of healthcare facilities in the country, and is the major health service provider in the rural areas ,28. As sWHO has described six health systems functions i.e. health financing, service delivery, health workforce, information, medical products, vaccines and technologies, leadership and governance, defining the desirable attributes of a health system to facilitate adequate service coverage . The KenDraft for comprehensive global monitoring framework and targets for the prevention and control of noncommunicable diseases (NCDs), which further developed indicators for NCDs [This study utilises three documents to benchmark Kenya’s capacity to report on UHC monitoring indicators: the proposed WHO/World Bank UHC monitoring framework , the subfor NCDs . Togethefor NCDs ,15. The for NCDs .Table 3A comprehensive literature search was undertaken to identify literature describing UHC in Kenya and to identify potential sources for monitoring UHC. The search was done in two phases. The first phase captured literature that addressed the two UHC components  in Kenya. The second phase captured literature that addressed the measurement of UHC indicators. Table Published in the year 2000 onwardsPublished in English LanguageResearch studies conducted in KenyaLiterature addressed health service coverage, financial risk protection, measurement of UHC and health information systemsKenyan Government policy documents and reports that addressed access to health services and health information systemsThe search was conducted purposively to identify key relevant resources to answer the research objectives. The abstract and summaries of the identified articles and reports published in English were reviewed to determine the relevance of the documents in relation to the research question. A total of 228 documents were retrieved into Endnote referencing software. The retrieved documents were then reviewed to identify and exclude duplicates, and then to select the sources providing information on relevant potential data sources, using the following inclusion criteria:A total of 25 documents were included in the study, listed in Additional file Since commencing the study, the WHO/World Bank framework was recently revised to capture the feedback received from various stakeholders . The priThis study utilised both versions of the joint WHO/World Bank framework ,34, togeKenya is in the initial stages of implementing UHC ,35. The Kenya Health Policy 2012–2030 is the most detailed policy document that addresses certain aspects of UHC [to attain universal coverage of critical services that positively contribute to the realisation of policy goals” provides a documented commitment to achievement of UHC for all Kenyans [The country has yet to establish a formal policy declaration on UHC that is entrenched in legislation. The current s of UHC . The pol Kenyans . Similar Kenyans ,43. The  Kenyans ,44. The  Kenyans ,44. Alth Kenyans . DiscussFrom critical examination of the literature, Kenya has the capacity to report on the majority of the proposed indicators for MDG related service coverage. The capacity to report implies that the country has established a network for reporting the MDG-related in the public sector, some health workers are trained on the reporting process. However, several challenges exist in relation to quality, timeliness of the data generated currently exist ,45. Key The current frequency of generating these indicators varies, depending on the data source and funding. Table Measurement of the equity indicator for MDG-related service coverage will be possible from the following surveys: Kenya AIDS Indicator survey (KAIS), Kenya demographic health survey (KDHS), Kenya service provision assessment survey KSPA and the census-collect primary data on the socio-economic status of the respondents ,39. ThisThe revised WHO/World Bank UHC monitoring framework has broadened the dimensions of equity measures to include place of residence and gender in addition to the wealth quintile. But in the country’s current reporting processes, most data from facilities are aggregated at district level. Information available at national level will therefore be aggregate district measures, and further information on place of residence may be more cumbersome to retrieve. Furthermore, due to the frequent mobility of Kenyans in both urban–rural migrants and the pastoralist communities, the place of residence may be difficult to ascertain for the purposes of measuring equity .National Integrated Tool for reproductive health, HIV/AIDS, Malaria, TB and Child Nutrition (MOH 711B) form and Monthly Workload Report for Hospitals (MOH 717 form) do not capture this information, and it is unlikely that the primary data for this indicator is compiled and reported to the national level consistently. To obtain data for the percentage of women screened for cervical cancer would therefore require physical retrieval of data from the postnatal registers [The country has very limited capacity to report on the potential CCI related service coverage indicators. There is a paucity of CCI indicators in the country’s health sector. Table egisters . Even wiKenya Household Health Expenditure and Utilisation survey” to generate the estimate values of the proposed indicators [The country has the capacity to report on the three proposed financial risk protection indicators. Table dicators . InstituThe implementation of the proposed UHC monitoring framework hinges on the functionality of the country’s health information system, which will play a critical role in generating valid and reliable data that can be benchmarked and tracked to monitor UHC progress ,54. CurrGood quality data is critical to the success of monitoring progress towards UHC. The five key critical dimensions of quality include accuracy, completeness, timeliness, consistency and accessibility ,55. BaseThe available indicators are captured across several data sources and programmes within the country’s health information system. The donor investments in monitoring of the health MDGs resulted in several parallel reporting channels created to meet various donor reporting needs. However, there is limited coordination across the various reporting channels . In certThe national surveys are often a preferred data source since they provide better quality data and are more generalizable to the whole population. However, the frequency of conducting these surveys is varied and hence has an important implication on the availability of data. These surveys are conducted in the country on average every 3–5 years. Furthermore, the roll out of individual surveys and the frequency of these surveys are not synchronised ,46. ResuThe WHO/World Bank focus on developing a comprehensive monitoring framework for UHC within the Sustainable Development Goals has exposed not only the weaknesses of the health information systems in developing countries, but also the vulnerabilities of the health systems that underpin them. The aspiration to provide access to health services to all Kenyans in a bid to spur social and economic development has been articulated in several government policies. The Ministry of Health has undertaken several piecemeal strategies to facilitate the expansion of service delivery and affordability of health services ,30,43. HThe problem for Kenya—and many other low and middle income countries—is cyclical. The implementation of an effective monitoring framework to monitor progress towards UHC assumes a functioning health system that can sustain effective health information data collection and reporting. There needs to be political commitment to the concept of UHC before this can happen: data collection, particularly where it is of dubious quality, will at best point to weaknesses, but not drive their reform. Lack of strong stakeholder engagement and commitment to achieving UHC remains an important impediment to Kenya’s progress ,21. CounIn Kenya, the agenda to achieve UHC has largely been driven by the Ministry of Health, but the Ministry does not have sufficient direct influence on the country’s budget, development or political agenda to bring about the whole of government changes required for UHC . The MinThe results of this study have clear implications: with the global MDG focus on HIV/AIDS, tuberculosis and malaria, the monitoring and reporting mechanisms for those conditions have been developed and institutionalized. In contrast, the systems for reporting on chronic conditions and injuries are ad hoc, uncoordinated, inconsistently reported and not always representative. Extending the success of MDG monitoring will require not only improvements in health information systems, but the comprehensive development of strategies to address this growing non-communicable burden of disease. This has implications not only for Kenya, but also for the international community.The implementation of MDG programmes and the internationally driven national surveys such as the KDHS, KAIS and the Kenya Malaria survey have established an infrastructure for reporting on most of these indicators. The surveys have the potential to be adapted to include CCI indicators, financial risk protection and the specific equity measures, but financial considerations will limit the frequency of their application. There is a need to set up additional routine mechanisms for monitoring CCI indicators, extending monitoring into the private sector, and investing in the health information system to enhance the generation of good quality data. This will be critical for supporting a meaningful and informative UHC monitoring and policy decision processes.With aggregated reporting recommended in the evolving WHO/World Bank UHC monitoring framework , care neThese results are consistent with the findings of other studies that have been conducted on monitoring UHC: other low income countries share Kenya’s limited ability to report on the indicators for CCIs ,19. Yet As global discussions on UHC and post 2015 development agenda are ongoing, it will be critical to make plans on how the required data can be generated by Kenya and other developing countries in similar scenarios. Post-2015 planners now need to be considering how low-income countries will be supported in terms of technical expertise, financial resources, and the extensive sensitisation and training of primary data collectors on the new framework. The WHO and World Bank, if they see the need for such a level of reporting for UHC, need to consider the implications of development assistance required for such substantial infrastructure—even in emerging middle income countries like Kenya. The global community will need to engage with individual countries to establish to what extent each can realistically report on the framework, and to identify the extent of investments required.The implementation of the proposed UHC monitoring framework in Kenya will be beneficial for the country to assess its progress. To some extent, the global focus will drive domestic planning and investment for the indicators not currently available in Kenya. Kenya, like any country, will have to make policy decisions and trade-offs on how to approach the expansion of UHC to suit its context . The mon


Continuity of care is an essential aspect of quality in general practice. This study is the first systematic follow-up of Finnish primary care patients’ assessments with regard to personal continuity of care.To ascertain whether patient-reported longitudinal personal continuity of care is related to patient characteristics and their consultation experiences, and how this had changed over the study period.A 15-year follow-up questionnaire survey that took place at Tampere University Hospital catchment area, Finland.n = 97 468) were analysed. Continuity of care was assessed by asking the question: ‘When visiting the health centre, do you usually see the same doctor?’; patients could answer ‘yes’ or ‘no’.The survey was conducted among patients attending health centres in the Tampere University Hospital catchment area from 1998 until 2013. From a sample of 363 464 patients, a total of 157 549 responded. The responses of patients who had visited a doctor during the survey weeks  during the study years. The sense of continuity was linked to several patients’ experiences of the consultation. The most prominent factor contributing to the sense of continuity of care was having a doctor who was specifically appointed .Continuity of care was proven to enhance the experienced quality of primary care. Patients felt that continuity of care was best realised when they could consult a doctor who had been specifically appointed to them. Despite efforts of the authorities, over the past 15 years patient-reported continuity of care has declined in Finland. Continuity of care is an essential aspect of good-quality primary care, as is involving patients in assessing, developing, and improving it.Continuity of care constitutes an indicator of quality in general practice.18et alet alA review by Starfield strengthens the doctor–patient relationship and the sense of partnership in care;improves diagnostic and communication skills;enhances trust and empathy;improves the coordination and integration of care.12For the GP, continuity of care:According to the European Definition of General Practice/Family Medicine, a GP is responsible for the provision of longitudinal continuity of care, as determined by the needs of the patient.21Patients are increasingly perceived as clients in healthcare services and experts in their own care and, as such, GPs must make additional efforts to recognise patients who are chronically ill as partners in care.23There is extensive literature on the benefits of continuity of care for patients, professionals, authorities, and healthcare systems. The personal continuity of consultations in primary care in Finland is decreasing; this is a matter of concern. This study shows that having a specific named doctor generates continuity and patients experience better quality health care as a result.Despite many positive findings in this dimension of general practice, there is ongoing debate as to whether, and to whom, the continuity of care really matters.Finnish healthcare services offer universal coverage for a comprehensive range of care, which is delivered primarily by organisations that are publicly owned and operated;Only about half of health centres have a personal list system, with all patients allocated to a named family doctor. In addition, free occupational health services also play an important role in Finnish health care by providing primary care to the employed population. In Finland, patients can choose to consult a doctor either in a health centre or in occupational health. They are also able to choose a private doctor, for which they will have to pay extra. In the past 10 years, the authorities in Finland have sought to improve the quality of primary health care, increase its resources and integration of care, and emphasise patients’ roles in their own care.34how personal, longitudinal continuity of care is related to certain patient characteristics; andwhat were patients’ experiences of consultations with doctors working in Finnish primary care centres.To the authors’ knowledge, prior to this investigation, there have been no systematic longitudinal studies measuring continuity of care in Finland. The aim of this study was to ascertain:How the patient-reported, personal, continuity of health-centre doctors had changed over the study period was also examined.The Department of General Practice at the University of Tampere sent a questionnaire (available from the authors on request) to 65 primary healthcare centres in 1998, 1999, 2000, 2001, 2003, 2005, 2007, 2009, 2011, and 2013. In every study year, the questionnaire was given to patients attending for treatment during one particular week. The questions were based on international studies35The questionnaire was piloted in the Pirkanmaa area in 1998, given to 19 399 patients and 9276 patients responded (a 48% response rate). In 1999, the study was extended to primary healthcare centres located in the catchment area of Tampere University Hospital. There were 65 health centres in this area, serving a total population of 1.2 million.n = 97 468) who had visited a doctor during the survey weeks were then analysed.Data were collected during week 39, in September. Reception staff distributed the questionnaire to patients visiting physicians and nurses due to illness from Monday to Friday between 8am and 4pm. Patients placed the anonymously filled questionnaires in a box in the waiting room after their consultation. During the data-collection periods, 363 464 patients visited the practices, and 157 549 responded. The response rate varied yearly from 39% to 53%. The answers of patients ;visits prior to the present one;which healthcare provider the patient had met;evaluation of the consultation; andopinion of the visit.Patients were asked for their background information, including:From 2005, the question ‘Do you have a particular doctor appointed for you at the health centre?’ was added to the questionnaire. Responses in the affirmative signified that patients were allocated to a specific doctor by health organisations based on where they lived, without them having the freedom to choose which doctor they would see. From 2009 another question was added: ‘In the last 12 months, how many times have you visited the health centre prior to this visit?’.The longitudinal, personal, continuity of care was assessed with the question: ‘When visiting the health centre, do you usually see the same doctor?’; possible responses were ‘yes’ and ‘no’. The responders graded the quality of service using a scale that is traditional in the Finnish school system and familiar to all patients; grades range from 4 (‘very poor’) to 10 (‘excellent’). The highest score, 10, was considered the best and, therefore, represented the best possible quality. The frequency of this top score was determined for each domain compared with other scores (4–9).2 test. Binary logistic regression analyses were used on patient characteristics, and on patients’ evaluation of consultation with their family doctor. To study how the various factors were connected to the continuity of care (dependent variable), both univariate and multivariate regression analyses were used. Patient-related factors and quality factors were dichotomised.SPSS (version 20.0) was used for statistical analysis. The statistical significance of differences in frequencies between the groups was tested by χThe number of responders varied between questions and study years. All the responders did not answer all questions. The replies of those patients who visited a doctor during the study week for all study years were analysed. The total number of patients was 97 468 .Of patients who had seen a doctor, 64% were female, 45% were aged ≥60 years, 57% needed urgent or less urgent treatment, and 70% had visited the health centre at least once in the preceding 12 months. Of the responders, 66% reported having a specific appointed doctor at the health centre.P<0.001) in all quality aspects  for visit, and previous visits to the health centre (within the preceding 12 months) were linked to continuity of care .In the univariate analysis, patients’ experiences of how the doctor had listened and was willing to give answers were related to the continuity of care. In addition, the doctor’s behaviour during the consultation, the information given regarding medication and tests, confidentiality, the sense of receiving help with their problem, and receiving adequate instructions on further care contributed to the correlation . In the Personal continuity of care decreased by 15 percentage points (from 66% to 51%) from 1998 to 2013 . At mostSeveral patient characteristics and features of their consultation experiences proved to be connected to continuity of care. The most clearly determining factor was having a specific doctor appointed by the health centre. Also notable was patients’ experience of the confidentiality of their consultation and how the doctor listened and was willing to give answers. Older patients, in particular, seemed to value having a specific doctor appointed to them, who was able to listen, understand, and care.During the study years, 1998–2013, the continuity of Finnish primary care did not improve.This study constitutes the first longitudinal, systematic inquiry into continuity of primary health care in Finland. During the 15-year study period, it was possible to gather an extensive sample of patient opinions on personal continuity of care of health centre doctors. In this study area of 1.2 million inhabitants, there are both small, rural health centres and large health centres in the conurbations. However, the patients who chose to answer the questionnaire were likely to be those who had an opinion and wanted to express it. The responders’ views cannot be taken as representative of the whole population, therefore, but are likely to be representative of the main population using primary health care services in Finland.The number of responders varied greatly during the study years. One of the reasons for this could be organisational and structural changes within, and between, the municipalities arranging primary healthcare services. This may also have been the result of the strengthening of occupational health services. Furthermore, some of the health centres suffered from a lack of professional healthcare staff. Although there were fewer responders, the number of patients visiting health centres also declined. Patients with relatively simple healthcare problems have gradually moved from health centres to occupational health services, while patients with long-term conditions and multimorbidity seem to remain under the responsibility of health centres. These patients also tend to need more services and longer appointments. At the same time it has become harder for people to access primary healthcare centres as resources are stretched.Attempts have been made to find out reasons for non-response. Some examples are patients having left spectacles at home or being in a hurry; however, patients may not have completed the questionnaire because they had no desire or inclination to do so.The researchers were aware of the challenges of studies using a questionnaire survey.38The results of this study show that patients were less satisfied with the continuity of care at the end of the study, in 2013, than they were at the outset. A number of factors are associated with continuity of care,40Patients in primary care appreciate continuity;Good communication, proper instructions, and confidentiality during the consultation have been shown to increase satisfaction and enhance the continuity of care.40There has been some discussion both internationally and also in Finland about whether personal list systems with patients being allocated to a specific named doctor are desirable, and feasible, in a primary care setting. A specific named doctor seems to lead to fewer critical and uninformed patients.The declined continuity of care in Finland is far from desirable and it would seem that the number of patients who could most profit from having a specific appointed doctor, that is, from being able to see the same physician, has increased. It is disconcerting that continuity of care has not improved in line with this. Patients who would particularly benefit from having an appointed doctor include those who are fragile, such as older patients with long-term conditions and multimorbidity, and patients who need, or use, the care most, such as drug and alcohol misusers, those who are mentally ill, and young people and families with social problems. These patients could profit from having a care manager, who, together with a team of professionals, would not only integrate and coordinate their care, but also empower patients to take an interest in their own care. The possibility of choosing their own doctor would be ideal for these patients but having a specific family doctor assigned to them would, at least, ensure the continuity of their care.This study underlines the importance of the patient in assessing primary care services. It also confirms the significance of having a doctor personally assigned and how aspects of care that indicate good quality care can also promote continuity. The findings also indicate that new means of coordinating and developing care in Finland are still necessary to improve the continuity of primary health care. The authors suggest that, at least, those patients who need care most should be able to consult with a specific family doctor to enhance the continuity and quality of their care.


Genome Biology’s questions on ways to approach neglected tropical diseases in the genomics era, including re-evaluating the impact of new drugs and mass drug administration.Simon Croft answers  The concept of neglected tropical diseases (NTDs) was first proposed in the 1970s by the late Ken Warren. He brought attention to a large proportion of the human population who were poor, who suffered from chronic, disabling but rarely fatal diseases, and who were often stigmatized and unemployed. An excellent overview of Ken Warren’s insight and contribution has recently been published [The World Health Organization (WHO) provides a list of 17 diseases : protozoOther than the label, the NTDs have little in common. They range from those with regional to those with worldwide distribution, from the potentially fatal to the disfiguring, from those that affect childhood growth to those that cause adult disease, from those that only effect people in poverty to those that also impact the affluent . For some NTDs, tools for treatment and control are available; for example, there are vaccines for rabies and drugs for soil-transmitted helminths (STHs) and trachoma. For other NTDs, for example the trypanosomiases and leishmaniases, appropriate tools for treatment and control are still lacking.The NTD label has had major success in raising the profile of this group of diseases over the past 15 years through a combination of advocacy and scientific and public health programs. This has ensured that NTDs are on the agenda of major international organizations, including the WHO, the UK's Department for International Development (DfID), and the Bill and Melinda Gates Foundation, all of which have dedicated NTD programs. In addition, organizations dedicated to NTDs, for example the Drugs for Neglected Diseases Initiative , have been established. In the mid-2000s, a time when there were but 13 NTDs listed, publications described the potential for disease control and the economic benefits of mobilizing resources for combined efforts around, for example, mass drug administration for the control of STHs and schistosomiasis . A sustPlasmodium falciparum mutants, importantly those altered in the K13 propeller gene linked to artemisinin resistance, have provided a tool for chemogenomic profiling and the ability to map drug structures to targets [The genomes of most of the pathogens and some of the vectors responsible for NTDs have been described over the past 15 years, and this research has now become an integral part of most of our work on the target-based development of drugs, vaccines and diagnostics. The potential for genomics in drug discovery and development, well described over 14 years ago , has bec targets . Vaccine targets  and re-d targets  have alsPlasmodium falciparum and Mycobacterium tuberculosis [P. falciparum populations [One area that deserves further exploration to ensure that we design and use drugs and vaccines for NTDs effectively is pathogen diversity, exemplified in recent genomic studies on the pathogens rculosis , 16. Stuulations . In a siulations . To ensuulations .At the same time as host-directed drug therapy is gaining importance in anti-infective discovery , 20, advTrypanosoma and Leishmania parasites [For all infectious diseases, drug development is a complex process rather than the linear process often portrayed . The rolarasites .Wikipedia)? This has been a major concern for the WHO who, through mechanisms such as the Working Group on Research and Development: Finance and Coordination, have been discussing new 'global instruments' for research funding for the past decade. For the diseases of poverty , the Global Fund  invests in endemic countries to mobilize and support the cost of purchasing of many drugs. This also helps the companies producing the drugs and vaccines, for whom the concept of market is essential as it helps to predict demand and scale of manufacture. An expansion of the Global Fund remit to include NTDs could have a major impact. This has been done elsewhere; the European & Developing Countries Clinical Trials Partnership (EDCTP), which supported clinical studies on ‘the big three’, expanded its remit in 2014 to include NTDs. There are also other vehicles to encourage engagement with this market, ranging from tax credits to voucher schemes, the latter are already in action [http://h3d.co.za). Although this might seem a long way from genomics, a clearer understanding of what tools are needed and how they will be used should help to engage basic scientists in the process, for example through engagement with target product profiles [So how does all this relate to market failure  is used on whole populations, irrespective of individuals' disease status, to control, prevent or eliminate common or widespread disease. It has been widely used for infectious diseases in the past, for example for malaria in the 1950s , and conMDA does raise important issues for consideration. First, as drugs are being administered to a whole population, which includes infants and women of child-bearing age who do not have the target disease, safety becomes a major consideration. The need for effective pharmacovigilance  is being adopted by many countries. In relation to NTDs, the WHO Collaborating Centre for International Drug Monitoring, Uppsala, established in 2009 the WHO Collaborating Centre for Advocacy and Training in Pharmacovigilance, Accra, Ghana , with a Second, although the number of pills or doses donated to MDA campaigns for NTDs is in the millions, there are critical issues around both the ability of health systems to deliver the drugs to target populations and the compliance/adherence of populations in taking the drugs appropriately . The impThird, there is also a need to ensure the political and economic will to sustain MDA campaigns, especially when the number of cases decreases. A crucial decision is to know when 'enough is enough' and when the elimination or eradication goals have been achieved, and whether the target numbers are valid in relation to the prevention of disease transmission . The detFourth, there is concern about MDA leading to drug and insecticide resistance, which is frequently raised and based on long experience in the veterinary field. The importance of genomics in identifying drug and insecticide targets is an established part of research in this area. Research on specific insecticide and anti-parasitic target genes of agents used in control programs highlights the importance of this approach , 51. NevSchistosoma [There are other considerations. In relation to STH, Vercruysse et al.  concludeistosoma , 54 willStaphylococcus aureus in vivo in a mouse skin colonization model [Some of the areas where genomic analysis can contribute to drug development are referred to above. There are other areas where understanding of genomes and molecular biology could lead to new therapies. The recently much-vaunted CRISPR technology has been used to investigate the biology of bacteria and protozoa. The CRISPR-Cas systems have already been considered as a route to new antimicrobials , with CRon model . Antisenon model , but theon model  for a reLeishmania involved [One of the most neglected diseases is cutaneous leishmaniasis (CL), a parasitic disease that rarely kills but can have a devastating impact on individuals, causing disfigurement and stigmatization. For CL, treatment is limited because the drugs that are used have known toxicity, they normally require injection and have variable efficacy depending on the species of involved . Recent involved . For CL,involved , 62.