To make health services more equitable and accessible for women and children and to achieve a universal coverage, human resources for women and children’s health (WCH) should be evaluated. However, since there is still no consensus on the real situation of Chinese WCH professionals, we aim with this study to compare the actual and required amount of WCH professionals for China.The data of the actual number of WCH professionals and workload of each service type was obtained by a national institution-based sampling survey. We then estimated the time that a WCH professional spends at work , the time norm of each service schedule and the required number of WCH professionals based on workload. We evaluated the situation of Chinese WCH professionals in 2010 by comparing the actual and required WCH professionals and by calculating the ratios of the actual-to-required number of staff.There were 515,778 health professionals providing WCH services in the investigated 5,168 medical/health institutions in 2010. Workloads of most WCH services in east areas were larger than that in the central and the west. For women’s health, the numbers of required WCH professionals were 48510, 43992, 40571 and 133073 for the east, the central, the west areas and the whole nation respectively. For children’s health professionals, the corresponding numbers were 56241, 36818, 40618 and 133677 for the east, the central, the west and the whole nation.The WCH professionals in China were sufficient for workload in 2010, there were still lots of potential capacities to provide better services, especially for women. Strategies should be taken to improve the quality of WCH professionals or their working motivation. Women and children’s health (WCH) is regarded as one of the foundations of public health and is critically important for human development . Six of In China, women and children receive specialized all-round preventive and curative healthcare by health professionals from general hospitals, WCH institutions and community-based healthcare services at province, prefectural, county, township and village level ,9. TheseThe basis of universal health coverage is financial and physical access to necessary good quality health care for all people . In addiThis study is a national institution-based sampling survey with formal administrative approval from the national maternal and child health annual report office. It was also supported by the National Health and Family Planning Commission of the People’s Republic of China  and it had been publicly announced in the Chinese Center for Disease Control and Prevention  and Xi’aIn the 22 provinces and 5 autonomous regions in China Figure , 28 distSince our research focus was the level of WCH resources we excluded all other auxiliary maternal and child health workforce personnel . For our study WCH professionals are health workers with legal medical certificates that provided women and children’s curative and preventive healthcare. All other workers who did not provide WCH services and workers who did not hold legal medical certificates were not counted. In addition to the number of WCH professionals, we also measured the annual WCH service workload of an institution by service types.To estimate the required WCH workforce, we firstly calculated the time that a WCH professional could spend at work annually . Then, the time norm for conducting each maternal or child related health service was set by an expert review of WCH experts from Beijing (25 experts), Tianjin (15 experts) and Gansu (35 experts) using the Delphi method. The time norm was the average time a health professional needed to perform one activity, counting from the start of this activity to the start of a next similar activity. Thirdly, we multiplied the service workload (of 2010) by the time norm of WCH services and got the total required time. Finally, we got the required number of WCH professionals by dividing the total required time by the time devoted by one health professional annually. Note that when estimating the required workforce, we assumed that the WCH professionals are well-trained, skilled, motivated and full-time workers.All the data was calculated and analyzed using SPSS 13.0. In order to get the actual number of WCH professionals and WCH workload of the whole country in 2010, we weighted the workload data based on the proportion of sampled districts/cities from each area before calculation. As a result, the weights were 4 for Beijing and Tianjin, 4.5 for Shanghai, 10 for Chongqing and 11 for every other city . Therefore, each WCH professional devotes a maximum of 92,400 minutes every year in patient related tasks.Time norm for each service was estimated by the Delphi exercise. We conducted face-to face expert interviews with WCH experts and adopted the median of each WCH service time as the time norm for this service/activity Tables  and 3. TWe then multiplied the service workload with the corresponding time norm for calculating the required time for providing these services in 2010. Finally we estimated the number of required WCH professionals in the three Chinese regions by dividing the required time by the total working time one WCH professional could provide per year. For women’s health professionals, the corresponding numbers of health professionals were 133,073, 48,510, 43,992, 40,571 for China, East, Central and West regions respectively  to be granted to each pregnant mother or to each newborn across the whole, this is a limitation of our study. So we consulted WCH experts from different cities and different facilities in order to make the norms’ representativeness better. These norms could also be further used in China as a tool for evaluating WCH service performance at a national level or estimating the required WCH human resources in a different year. Also, for the actual number of WCH professionals, we acquired reliable routine data from each health institution and all these data resources allowed a realistic and objective measure of service utilization. Although it is possible to estimate the workload and then required number of professionals in different services, it is not possible to count the actual number of WCH professionals in each service type, since in the real world, one WCH professional may be occupied in many different services in the same time. Therefore, we could only make comparison between the actual and required number of WCH professionals in large scales, such as at regional and national level.According to the development plan for women and children (2011–2020), the Chinese government put an emphasis on expanding the WCH human resources , howeverThe WCH professionals in China were sufficient for the actual workload in 2010, there were still lots of potential capacities to provide better WCH services, especially for women. On the national level, kinds of strategies should be taken to improve the quality of WCH professionals or their working motivation.


Background. A new group A meningococcal conjugate vaccine was developed to eliminate deadly meningitis epidemics in sub-Saharan Africa.Methods. From the outset of the project, advocacy and communication strategies were developed and adjusted as the project evolved in Europe, Africa, India, and the United States. Communications efforts were evidence-based, and involved partnerships with the media and various stakeholders including African ministries of health, the World Health Organization, UNICEF, Gavi, the Centers for Disease Control and Prevention, and Médecins Sans Frontières.Results. The implementation of an integrated communication strategy ensured the active cooperation of stakeholders while providing an organized and defined format for the dissemination of project-related developmental activities and the successful introduction of the vaccine.Conclusions. Early in the project, a communications strategy that engaged stakeholders and potential supporters was developed. The strategy was implemented and adapted as the project matured. Linked communication proved to be key to the successful wide-scale introduction of the PsA-TT (MenAfriVac) vaccine in Africa. Neisseria meningitidis, the PsA-TT vaccine (MenAfriVac), was developed and provided African health authorities, for the first time, with an affordable, long-term solution that protects against meningitis. Communications activities in support of MVP were essential and had to be strategically adapted to the development and introduction cycles of this long-awaited vaccine. This paper reviews the major strategic communications and advocacy initiatives that contributed to the success of MVP.Meningitis epidemics have plagued sub-Saharan Africa for more than a century, causing immense human suffering for families and communities. In 2001, the Meningitis Vaccine Project (MVP)—a partnership between the World Health Organization (WHO) and PATH, with support from the Bill & Melinda Gates Foundation—was established with the mission of eliminating epidemic meningitis as a public health problem in sub-Saharan Africa through the development, testing, introduction, and widespread use of conjugate meningococcal vaccines. As a result of MVP, a new conjugate vaccine against group A www.meningvax.org) was created; an in-house scientific library was established; and a variety of fact sheets, question-and-answer documents, and brochures were developed in both French and English. Efforts were made to ensure consistent messaging within the WHO-PATH partnership that constituted MVP.Initial steps focused on developing communication materials and a strategy targeting audiences in developing as well as in industrialized countries . The foundation of all activities was communication based on scientific evidence. A communications officer was hired at the project headquarters in Europe; a logo was designed; a website  office in Ouagadougou, Burkina Faso. His role proved to be crucial in promoting and advocating for the vaccine's use while reporting on the project's progress from an African perspective. Over time, the European and African communications officers developed a comprehensive communications plan to complement the MVP operational work in target countries.During decades of meningitis epidemics, African public health officials, families, and communities in the meningitis belt countries had become increasingly frustrated at not being able to better protect their populations against meningitis epidemics. Expectations were high that a new meningococcal vaccine could offer a real prospect of ending group A meningitis epidemics. Nonetheless, when MVP conducted its first field missions in Africa, the vaccine was still a distant and uncertain hope. Hence, promoting a product still in early development was a daunting communications challenge.Setting up MVP's clinical trials in Africa  entailed promoting the project with a series of activities, including country visits, workshops, targeted radio and television broadcasts, articles, regular updating of the MVP website, and production of quarterly electronic newsletters to keep stakeholders updated on the project's progress.To enhance the scientific knowledge of journalists in clinical trial countries, MVP and partners organized a series of national workshops, inviting 20‒30 health communicators and journalists  to each workshop in Mali, The Gambia (both 2006), Senegal (2007), and Ghana (2008). The workshops offered an introductory course on why a meningitis vaccine clinical trial was taking place in their country, meningococcal disease and the epidemiology of meningitis, vaccine development, MVP, and vaccine introduction strategies. Whenever possible, the workshops included a visit to the clinical site so that journalists could tour the facilities and talk to the clinical team. Reporters were not expected to produce stories following the visit, but the tour was a way to foster a relationship between the clinical site and the media. On the final day of the workshop, participants wrote communication plans aimed at facilitating the conduct of the clinical trial in their country. However, as time went on it became apparent that lack of financial resources and qualified staff in media outlets made implementation of the proposed activities difficult.Nevertheless, these workshops encouraged country ownership and the formation of communication networks that later became the foundation of the successful promotion of the vaccine when it was rolled out. All participants in the MVP workshops became part of the “MVP communication network” and received the quarterly newsletters, which regularly apprised them of the latest news on the development of the candidate vaccine, and later, on its rollout.Although these workshops were not repeated for subsequent clinical trials in the same country, all clinical sites had access to “long-distance communication coaching” during the duration of the trials. Both the Europe- and Africa-based communicators provided this assistance, which covered areas such as writing communiqués for local use, developing visual aids for clinical staff and trial participants, and responding to rumors and political events that sometimes threatened the conduct of clinical studies. When needed, communication support was also provided to research partners. For example, when the London School of Hygiene and Tropical Medicine and the Centers for Disease Control and Prevention, Atlanta, initiated meningococcal carriage studies in Africa, communications plans were collaboratively developed to explain research activities that local populations might have considered intrusive . To keep stakeholders informed about the trial and project progress, MVP also made targeted informational visits in each country where a trial was conducted Table .Table 1Historically, reactive mass vaccination campaigns with polysaccharide vaccines that offered only short-term protection had been the norm in the meningitis belt, with these campaigns taking place whenever a meningitis epidemic occurred  The new With the success of the group C vaccine as a starting point, communication efforts concentrated on convincing stakeholders of the added value of using a conjugate vaccine instead of the polysaccharide vaccines that were already in use—namely, that the new vaccine was expected to protect younger children and to confer herd protection. Also, the possibility of someday introducing the vaccine as part of the Expanded Programme on Immunization routine schedule was cited as another major advantage, as well as the low price and the ability to use the vaccine preventively.A significant challenge was how to present the need for the vaccine without making it appear to be an emergency. This was the critical and prime justification for the early media workshops. Attendees served as primary communications targets for the duration of the trials and were key in preventing the spread of misinformation. Similarly, researchers, academics, and local international press correspondents were also targeted. Keeping these stakeholders and players up-to-date from the beginning meant ensuring ownership while including them as key partners who could engender trust, argue for the project, and defend the project should local opposition arise. In the target countries, the media actions focused on basic information, presenting the project, and announcing the coming availability of an effective vaccine against the most fatal form of meningitis in the near future.In 2006, the results of the first clinical studies confirmed the vaccine's major preventive potential, and a new initiative was launched to give maximum visibility to the vaccine and to the project. This effort included the appointment of a prominent African “patron” to lead peer-to-peer advocacy at the highest political levels with 2 aims: (1) to facilitate acceptance and introduction of the new vaccine; and (2) to help mobilize sufficient resources to vaccinate all at-risk populations.The WHO Regional Office for Africa (AFRO) approached the President of Burkina Faso to serve as patron, as Burkina Faso had historically been the country most affected by group A meningitis epidemics. The Director-General of WHO had previously appointed him as an ambassador for the fight against neglected tropical diseases; thus, he had already lent his support to WHO AFRO to mobilize resources to fight epidemics. As chief advocate for the new PsA-TT vaccine, the President could make public declarations and provide high-level support during these crucial stages.As MVP patron, the President held a series of meetings with Dr Luis Gomes Sambo, then Regional Director of WHO AFRO, during visits to Burkina Faso. Each of the meetings was an opportunity to communicate with the Burkina Faso–based national and international media.The first notable achievement of the high-level patronage strategy occurred in September 2008, during the 58th session of the WHO Regional Committee when African ministers of health from meningitis belt countries unanimously adopted the Yaoundé Declaration, committing themselves to introduce “a highly promising candidate meningitis vaccine  …”. This public statement from the leadership of countries where the new vaccine would be introduced—made when the early MVP African clinical trials were still ongoing (PsA-TT-002 and PsA-TT-003), and before the first infant trial had begun PsA-TT-004)—provided early crucial support for the aims of MVP [—providedAnother major step committing African leaders to the introduction of MenAfriVac took place on 24 June 2010, when Dr Sambo announced that the vaccine had been prequalified by WHO. This sent a clear signal to all meningitis belt countries that the vaccine met international standards of quality, safety, and efficacy and that its large-scale introduction in Africa could begin. It was a happy coincidence that Dr Sambo was on an official visit in Burkina Faso when the prequalification news broke; this high-level announcement was made at the end of Dr Sambo's presidential meeting and generated a strong signal of local political will to support MenAfriVac introduction in Africa.Presidential support for the meningitis initiative culminated in the official MenAfriVac launch on 6 December 2010, in Ouagadougou, Burkina Faso's capital. Under the patronage of the President, the launch ceremony was held in the presence of key African political leaders and partners, including high-level representatives from PATH, WHO, Serum Institute of India, Ltd (the manufacturer of the vaccine), the Bill & Melinda Gates Foundation, the United Nations Children's Fund (UNICEF), and Gavi.Communications preparations for the event had started in April, and by December, a package of information materials in French and English had been developed; partners had created special “MVP/MenAfriVac” sections on their organizational websites ; desk-side meetings with science journalists had been held in London and Paris; communications teams from partnering organizations were deployed on the ground; filming crews were on standby to document the launch and the first vaccinations; and correspondents from African, European, and Asian media were on the ground in Burkina Faso to cover the event –8.These activities—the largest deployment of public relations efforts since the creation of the project—were successful in raising global awareness about MenAfriVac and its potential to eliminate epidemic meningitis as a public health problem in Africa. News of the launch was covered over the next several weeks by major news agencies and media  around the globe.MenAfriVac had been the subject of news stories in the past, but coverage of the launch represented a sea change in the way journalists covered the vaccine. For the first time, media reported the new vaccine as a breakthrough—not just in combating meningitis epidemics, but as a new model to develop vaccines and drugs, particularly for developing nations, with MVP acting as a virtual vaccine development company that orchestrated the work of partners around the globe. The successful development and introduction of MenAfriVac in Africa was eventually recognized as one of the top health global success stories in 2010 –11.It is worth noting that the key messages developed for global media outreach at the launch of the vaccine were different from those created by partnering institutions for social mobilization and to advocate for the vaccine's introduction in Africa. Whereas the launch messages emphasized the many “firsts” accomplished by MVP/MenAfriVac , terms like “first/revolutionary/new/cheap” could have aroused suspicions in African populations; the terminology to be used was therefore left to the discretion of African stakeholders who could make that decision based on their own cultural environment.The target age group for the vaccine is 1- to 29-year-olds. From the first campaigns in 2010, it was clear that it was a challenge convincing adolescents and young adults—those between 15 and 29 years of age —to take part in the vaccination campaigns.MVP employed several new strategies, with the support of local and UNICEF specialists in social mobilization, that contributed to success in increasing vaccination rates in this population. These included peer education, vaccination lines for young boys only, targeted social mobilization messages, the participation of celebrities known by young people, and the launch of vaccination campaigns in universities and schools. In other populations, community discussions with the aim of engaging tribal and administrative leaders, or the use of social mobilization through public criers and other techniques, before, after, and especially during the official 10 days of the vaccination campaign, improved outreach to the desired targets. The same approaches and strategies, involving administrative, tribal, and religious leaders, were applied in Nigeria, a country that introduced the vaccine over 4 years. This led to an increase in participation among young people and a demand for additional vaccine doses in 2013 during the subsequent phase of introduction.Following introduction in Burkina Faso, Mali, and Niger, another dozen countries in Africa organized mass campaigns in several phases. In each country, communication workshops were jointly conducted by staff from the UNICEF West and Central Africa regional office in Dakar (WCARO) and WHO IST in Ouagadougou to inform communication and health professionals about MenAfriVac's introduction in the country. When deemed necessary, additional workshops were organized, focusing on the development of country-specific communication plans and messages.Each workshop sought to boost the skills of the journalists to report on public health. Terms such as adverse events following immunization (AEFI) were explained, so that journalists could use them appropriately when communicating with the general public. They were therefore invited to participate in the technical committees set up to support the running of the vaccination campaigns where campaign results were discussed and explained. Finally, it is important to note that in 2012 the communication budget for the campaign was increased significantly, thanks to the financial support of the Gavi Alliance.During the MenAfriVac campaigns, according to information collected in a survey conducted by campaign supervisors in Burkina Faso, information on the vaccine and the campaign in that country came from a variety of sources. Social and media mobilizers accounted for 65% of the information sources, followed by healthcare agents (24%) and religious leaders (11%). If >12 million Burkinabé were vaccinated in 10 days, it was because they were duly informed. Indeed, 95% of respondents in the survey said they were aware of the campaign, and 98% were able to give the name of the disease they were being immunized against. The survey results suggest that communication efforts played a key role in the success of the vaccination campaigns.The communications plan included identification of events that could maintain or renew media interest in the MenAfriVac Project in Africa or globally. Two such events included the symbolic celebration of the 100-millionth vaccination and the first distribution of MenAfriVac in a controlled temperature chain (CTC) , 13.According to data gathered in the first 10 countries to introduce MenAfriVac, some 103 million people had been vaccinated by the end of 2012. This was of particular importance in Africa, and proactive communication raised the visibility of this milestone. The choice of Benin as the country where the celebration would be held was not only practical—the country was organizing a campaign in 2012—but above all, it was a geostrategic and political choice because the Benin President was also President of the African Union. He would be in an excellent position to promote the vaccine to other African heads of state where MenAfriVac was due to be introduced. The 15 November ceremony was broadcast live throughout Africa. The event led to several news stories in African media on the success of the MenAfriVac campaigns. Not only was a symbolic milestone acknowledged, but awareness of the risks of meningitis was raised for countries where knowledge was more limited and introducing the vaccine might be more challenging.As the Africa-based MVP media outreach from Cotonou catered to populations living in meningitis belt countries and African leaders, the European team took advantage of new findings on the stability of the MenAfriVac vaccine to reach out to the international scientific/vaccine community with news that MenAfriVac had become the first vaccine to receive regulatory approval to travel at up to 40° for up to 4 days in Africa in a CTC, thus breaking with the traditional mold of the 2‒8°C cold chain, which requires constant refrigeration. There was a risk that the new method could be viewed as dangerous or as “another vaccine test” conducted on African populations, which is why a strategic choice was made to first establish awareness in the scientific community. The 14 November CTC announcement—deliberately coincident with the Cotonou event—was made from the American Society of Tropical Hygiene and Medicine conference in Atlanta, Georgia , and attMeanwhile, the announcement on the launch of the CTC pilot study in Benin provided an opportunity to follow up in February 2014 with a related paper on the economic benefits of vaccine distribution in CTC , 14. TheThroughout the project's lifespan, training in crisis communications was a key component of the MVP communications strategy. For the clinical trials, this involved drawing up crisis communications plans to include all relevant partners, and a short training exercise to ensure that principal investigators and staff would know how to handle media queries and respond to potential crisis situations that might derail a clinical trial. Needless to say, community acceptance and an awareness of local sensitivities were crucial On a larger scale, crisis communication plans were drawn up and training was provided in preparation for the mass vaccination campaigns. In August 2010, the first crisis communication workshop was held to prepare for vaccine introduction. Jointly organized by PATH, WHO IST/West Africa, and UNICEF WCARO, managers and decision makers from health ministries along with communication officers in Burkina Faso, Niger, and Mali (the early adopters) were trained on the important elements in identifying and managing a crisis. This training included how to identify key technical personnel, interested politicians, and spokespersons and how to prepare a crisis management plan before a crisis occurs. The workshops were repeated for each new introducing country, either as national or multicountry workshops.In December 2010, a crisis developed in Burkina Faso with the death of a child on day 8 of the planned 10-day vaccination campaign. News of the death was published on the front page of a national daily newspaper that linked the child's death to the vaccination (day 1 of the crisis). Following the advice of the crisis management team, consisting of both technical and communications experts, a task force was immediately sent out to investigate and a response prepared. The following day a press conference was held, led by the Minister of Health, surrounded by his staff and key partners (WHO and UNICEF), that described the results of the investigation. The press conference was held sufficiently early in the day to enable declarations from the national healthcare authorities to be written and published the following day (day 3) and report that the death of this child was due to a prior illness and unrelated to the vaccine. This quickly put an end to articles that questioned the quality of the vaccine.Special attention was devoted to the social and cultural management of the child's death. A local mission was assembled, consisting of tribal, administrative, and elected representatives, to offer condolences to the grieving family. Employing these parallel approaches defused the Burkina Faso crisis, which had the potential to derail not only the campaign in Burkina Faso, but also the introduction of MenAfriVac in other countries. The timely and professional handling of the Burkina Faso crisis at local and national levels enabled the continuation of the mass vaccination campaign with no impact on vaccine introduction in other countries.Nothing in the successful management of the Burkina Faso crisis or the smooth introduction of MenAfriVac in 7 countries in 2011‒2012 foreshadowed the crisis that snowballed from Gouro, an isolated settlement in northern Chad, into a wave of anti-MenAfriVac stories worldwide in early 2013. Chad had successfully conducted 3 vaccination rounds with MenAfriVac in other parts of the country in 2011 and 2012 that immunized 7.2 million Chadians with no safety concerns. The Ennedi region, where Gouro is located, was part of the fourth and final vaccination phase in Chad. The campaign, which had started in Gouro on 11 December 2012, was abruptly stopped on December 15 when vaccinated children reportedly fell ill.The incident prompted a Chadian journalist (subsequently identified as a regime opponent) to post a story on December 22 that described 40 children who had become severely ill  in Gouro after being vaccinated with MenAfriVac. Within 24 hours the story was reposted by an online national news channel, and a few days later the information made headlines in Chadian print and online media. The story was subsequently picked up by European and US antivaccination activists, who accused MVP and partners of deliberately committing genocide among Africa's poorest and most fragile populations. The story was published on the website of an international news agency 41 days after the publication of the first blog, but was removed within a couple of hours thanks to the swift intervention of MVP communicators.Chadian authorities invited an international team of clinicians and epidemiologists to investigate the problem. An investigation proceeded; all cases were examined by physicians, who did not find cases of paralysis, and all of the affected individuals recovered without incident. These findings were published in an official report. The episode was determined to be “mass psychogenic illness”—an unusual phenomenon that has been well described, the affected tending to be clusters of young girls with unusual clinical findings that gradually improve , 17. EpiIn the end, the daily visits of expert clinicians to hospitalized children in N'djamena, the accessibility of the authorities to local leaders, and discussions with the ministry of health brought a satisfactory outcome to this crisis. It ultimately created an opportunity to communicate positive messages on the vaccine, recognizing it as safe and of good quality. Bearing the signature of the health minister, 2 communiqués were distributed to break the “radio silence” and get back in touch with the general public, who were asking for official information. These communiqués, one of which reported on the result of the investigation published on 21 January, were used by most of the media, helping to calm the tense social climate , 19. NonThe MenAfriVac mass vaccination campaigns in Africa will go down in history as a stunning success. One year after large-scale vaccine introduction in late 2010, experience from Burkina Faso provided early evidence that mass vaccination was associated with a significantly reduced risk of meningitis in the targeted population, as well as among the unvaccinated age groups, suggesting that MenAfriVac induced “community” protection. Findings were confirmed in a major way in Chad in 2012 where researchers reported a dramatic reduction in transmission and incidence of group A meningococcal disease, a drop of >90% following vaccination [Some lessons are worthy of note for future communication campaigns. Key factors for success included good planning, with suitable strategies and an approach that built to a crescendo, the engagement of stakeholders and potential supporters, and timely allocation of resources. Effectively promoting MVP with well-defined targets and objectives was accomplished by pooling skills and expertise, both within the communications team and with partners holding distinct, but complementary, responsibilities.The training courses proved to be a bonus that will be part of MVP's legacy. Although many countries were doubtful about the need for crisis communication training, the postworkshop feedback clearly indicated that the participants considered them to be valuable. To be most effective, this type of training should be an integral part of vaccine introduction. The “crisis” experiences in Burkina Faso and in Chad raised awareness of the importance of communications, which, if not managed, can have dramatic repercussions.An advocacy and communication strategy that is woven into the fabric of the project and that evolves dynamically with all aspects of the project;A culturally appropriate approach;Boosting of the skills of healthcare teams in community dialogue and other interactive techniques if necessary.In addition, we note 3 important factors that have to be taken into account by all players if communication efforts are to succeed:The implementation of MVP enjoyed a significant advantage: It had an excellent vaccine protecting people against a killer disease. But it is worth remembering that even fear does not always spur action, and often action does not last. One needs correct strategic communication choices to instill lasting trust within communities.


Background. Emergency department (ED) readmissions are considered an indicator of healthcare quality that is particularly relevant in older adults. The primary objective of this study was to identify key factors for predicting patients returning to the ED within 30 days of being discharged. Methods. We analysed patients who attended our ED in June 2014, stratified into four groups based on the Kaiser pyramid. We collected data on more than 100 variables per case including demographic and clinical characteristics and drug treatments. We identified the variables with the highest discriminating power to predict ED readmission and constructed classifiers using machine learning methods to provide predictions. Results. Classifier performance distinguishing between patients who were and were not readmitted (within 30 days), in terms of average accuracy (AC). The variables with the greatest discriminating power were age, comorbidity, reasons for consultation, social factors, and drug treatments. Conclusions. It is possible to predict readmissions in stratified groups with high accuracy and to identify the most important factors influencing the event. Therefore, it will be possible to develop interventions to improve the quality of care provided to ED patients.  Population ageing is one of the most important sociodemographic changes in recent years. It is expected that, in the near future, people over 65 years will be 21.2% of the overall population. This trend will continue having a great impact on the health system, especially in emergency departments (EDs) [Compared to younger patients, older patients have increasingly complex medical conditions in terms of their number of illnesses and the characteristics of, thereof, the number of medications they use, geriatric syndromes, their degree of physical or mental disability, and the interplay of social factors influencing their condition , 4. FurtEDs are designed to care for acutely ill patients with single health problems. The need for triage and rapid intervention makes it difficult to provide proper care to patients with complex characteristics and, on the other hand, such patients slow down the functioning of EDs, sometimes even overloading them . A systeThe population covered by the public health system in the Basque Country (Spain) is stratified according to the level of complexity of diagnosis and treatment, with the objective of ensuring that the specific needs of older adults are met at the different levels of care provision . AccordiIf we are able to identify the most relevant factors for the prediction of readmission in patients in levels 2 and 3, these factors may be taken into account for the design of improved operation of the ED. They can also be considered as indicators of the quality of care provided. Finally, prediction of readmission will allow better planning of the resources for improvement in terms of clinical effectiveness and efficiency.n = 99), and patients with COPD (n = 81), with HF (n = 85), or with DM (n = 126).We analysed patients stratified at levels 2 and 3 who attended the ED of the Araba University Hospital (AUH) during June 2014, divided into four groups: patients identified as requiring case management (CM), these corresponding to individuals in level 3 . The description of the variables measured for each patient is given in the Supplementary Material.The study variables include sociodemographic data, personal medical history, reasons for consultation, and regular medications. The full list of variables is given in the Supplementary Material available online at http://www.csie.ntu.edu.tw/~cjlin/libsvm/) and has been shown to provide the greatest efficiencies. For the sake of complete exploration, we produce classification results with the Weka (http://www.cs.waikato.ac.nz/ml/weka/) and scikit-learn (http://scikit-learn.org/stable/) implementation of LibSVM. Variations in implementation details, that is, random number generator, may produce differences in the classifier performance.In this section, we describe the analysis performed over the data. We have tested the statistical significance of differences between populations, the predictive power of the variables, akin to their importance, and the expected predictive performance that may be achieved using the selected variables. With multivariate analysis, it is possible to analyse many variables at the same time, taking into account their interactions and correlations, both for the classification of a population into groups using classification algorithms and for predicting control variables using regression algorithms. In this study, we used classifiers based on support vector machines (SVM), which have been accepted as standard in bioinformatics research, because they perform very well even when the data are high dimensional and there are scarce data samples to train the classifier . For trak-means clustering on the distance matrix between classifiers, built from their distances between classification output distributions over the training sample, and a combination of dynamic selection and circulation of the selected classifiers. Initially, the process generates a large number of classifiers; that is, it creates and overparameterized system and proceeds to prune and select the best performing combination. The k-means step aims to select cluster representative classifiers, while the second step aims to select classifiers that are maximally diverse, as measured by the interrater agreement and the majority voting error. The dynamic selection uses sequential forward and backward selection. Individual classifiers include decision trees, SVM, and other ensembles such as Adaboost. We have used the implementation available in Weka.Moreover, we try an innovative ensemble classifier building method called LibD3C , which iIt is customary in machine learning applications to estimate the performance of the classifiers for unknown data in terms of accuracy, sensitivity, and specificity through 10-fold cross-validation, which is carried out by dividing the data into 10 subsets and repeating the training and testing of the classifiers using each set in turn for the testing, while the other nine sets are pooled together for the training. The average performance obtained from these repeated training and testing experiments is an unbiased estimate of the performance that we can expect when new cases arrive.We want to make statements about the relevance of variables and their importance for the prediction of the patient reentry. To assess the predictive power of the variables for patient readmission, Breiman's method  consistst-test [To assess whether differences between populations were significant, we used the Welch t-test , which tt-test, the importance of the variables, and the classification validation results for the classifiers introduced above. P values of the t-tests for the most significant variables in each one of the stratification categories. We performed the processes described in the previous section to the data from each group separately: the Welch Figures Prediction of rehospitalization within a short period of time after discharge may reduce at least 10% of its costs . This isThe reasons why these patients attend the ED are diverse and have a role as readmission predictors. Notably, in level 2 groups , patients with illnesses associated with a single organ, exacerbation/worsening or stabilisation of the primary condition plays a role in the risk of readmission, though not a dominant one.Our findings of age and comorbidity as predictive factors for ED readmission in all four stratification groups agree with previous published results . It is wVarious authors have analysed the relationship of ED readmission and hospital admission with multiple medications and its impact on rates of morbidity and mortality . In agreSocial and family factors, such as having a caregiver available or living alone, are not irrelevant to EDs and play a key role in enabling these patients to reach the hospital , 32. OurAn important conclusion of this study is that the care provided in the ED for the four groups of patients studied must go beyond treating the disease, paying attention to appropriate interventions preventing readmissions . To dateIn summary, the results of this study show that population stratification allows predicting ED readmissions with high accuracy, as well as identifying the most important influencing variables, enabling specific interventions to be initiated to improve quality of care for older patients who present a growing burden on emergency services.We plan to extend the study for a longer period of time to obtain larger sample sizes. Other limitations of the study are as follows: (a) the coding of the reasons for ED consultations is based on the main diagnosis; (b) there is lack of information regarding quality of life, level of independence, and severity of the disease; (c) the data collected on patients' functional status are actually limited to their ability to walk and personal history of falls.Supplementary material contains the detail enumeration of the demographic and other variables of the patients which describe their profile. Classification were performed on the basis of these variables and/or the features extracted from them.


Socioeconomic inequalities in mortality are one of the greatest challenges for health policy in all European countries, but the potential for reducing these inequalities is unclear. We therefore quantified the impact of equalizing the distribution of six risk factors for mortality: smoking, overweight, lack of physical exercise, lack of social participation, low income, and economic inactivity.upward levelling scenario in which inequalities in the risk factor were completely eliminated, and a more realistic best practice scenario, in which inequalities in the risk factor were reduced to those seen in the country with the smallest inequalities for that risk factor.We collected and harmonized data on mortality and risk factors by educational level for 21 European populations in the early 2000s. The impact of the risk factors on mortality in each educational group was determined using Population Attributable Fractions. We estimated the impact on inequalities in mortality of two scenarios: a theoretical In general, upward levelling of inequalities in smoking, low income and economic inactivity hold the greatest potential for reducing inequalities in mortality. While the importance of low income is similar across Europe, smoking is more important in the North and East, and overweight in the South. On the basis of best practice scenarios the potential for reducing inequalities in mortality is often smaller, but still substantial in many countries for smoking and physical inactivity.Theoretically, there is a great potential for reducing inequalities in mortality in most European countries, for example by equity-oriented tobacco control policies, income redistribution and employment policies. Although it is necessary to achieve substantial degrees of upward levelling to make a notable difference for inequalities in mortality, the existence of best practice countries with more favourable distributions for some of these risk factors suggests that this is feasible. Inequalities in health between socioeconomic groups are increasingly recognized as one of the main challenges for health policy Explanatory research has identified many factors contributing to inequalities in health. These include behavioural risk factors such as tobacco smoking, excessive alcohol consumption, and physical inactivity, but more ‘upstream’ social and economic risk factors such as social isolation, low income, unemployment, and occupational risks have been shown to contribute as well On the basis of these explanatory findings, policy proposals have been developed, both at the national level We have therefore set out to quantify the potential for reducing inequalities in mortality by tackling each of a number of key determinants. We have done this by estimating the reduction of educational inequalities in mortality that would be obtained, if European populations would succeed in reducing or even eliminating inequalities in important risk factors through effective policy interventions.smoking, overweight, and physical inactivity. These risk factors are relatively easy to measure and have a reasonably well-documented causal effect on mortality The first group of determinants is a set of three ‘downstream’ risk factors: lack of social participation, low income, and economic inactivity. Lack of social participation, low income and economic inactivity (through temporary unemployment or more permanent detachment from the labour market) probably all increase mortality Because an emphasis on behavioural risk factors may distract from the necessary action on ‘upstream’ risk factors The main purpose of this paper is to show to what extent inequalities in mortality can potentially be reduced by tackling each of these determinants, and to provide guidance on priorities for health policy in different European countries. As will be demonstrated, the potential for reducing inequalities in mortality is substantial, but priorities for action should not be the same everywhere.Data on mortality by sex, age, cause of death and education were obtained from mortality registries for all European populations for which good quality data are available. They cover people aged 30–79 in 21 European populations in the period ca. 2000 – ca. 2005 and are mainly based on longitudinal or linked cross-sectional studies representing whole nations. These populations are those of Finland, Sweden, Norway and Denmark in the North; Scotland, England and Wales, Netherlands, Belgium, France, Switzerland, and Austria in the West; Spain  and Italy (Turin and Tuscany) in the South, and Czech Republic, Poland, Hungary, Lithuania and Estonia in the Centre/East. Our main sources of mortality data are presented as supporting information  because data on educational attainment are available for both men and women in all European populations under study. In addition, education is the most stable measure of socioeconomic position because it is normally completed early in adulthood, which avoids reverse causation problems  Risk factor prevalence data by sex, age, and level of education were collected for the early 2000s, mainly from national health surveys. Smoking was measured in three categories , overweight in three , leisure-time physical activity in two (‘active’: less than once a week and ‘sedentary’: once a week or more), social participation in two , income in four , and economic activity in two . Temporary unemployed were classified with the inactive in Norway, Sweden, Switzerland, and Madrid, and with the active in all other populations.Relative risks for the impact of smoking, overweight, physical inactivity and lack of social participation on mortality were collected from large reviews and meta-analyses Written informed consent of the usage of mortality and survey data was given by the relevant administrative units in the respective countries.We quantified educational inequalities in mortality by calculating rate ratios (RR) and rate differences (RD) from age-adjusted mortality rates using high education as a reference category. In this paper we only present scenario changes in RRs and RDs comparing the lowest with the highest educational group. Results for all educational groups can be found elsewhere upward levelling scenario which assumes that the exposure to a risk factor would be reduced to the level currently seen among the highest educated within each country. This will identify a possible upper limit to what can be achieved in each country. In the uncommon case that the lower educated are less frequently exposed to risk factors than the higher educated, which mainly applies to female smokers in the South of Europe, we assume that the potential reduction of inequalities in mortality is zero.The estimates of the potential reduction of inequalities in mortality are based on two different types of counterfactual scenarios. The first is an a best practice scenario, in which we choose the country with the smallest educational inequalities in a risk factor . In the uncommon case that the prevalence of the risk factor was less favourable among high educated in the best practice country than in the country analysed, which mainly applies to smoking, we assume that the potential reduction of inequalities in mortality is zero. After we had identified the best-practice countries for each risk factor, we took the prevalences from both the highest and the lowest educational groups from these countries and applied them to other countries.The second type is We used a specially developed, excel-based tool to quantify the expected changes in mortality that would result from modifying the population distribution of exposure to a risk factor. This tool is based on Population Attributable Fractions (PAF) and estimates the impact of counterfactual distributions of the risk factors on the magnitude of social inequalities in mortality The PAF is defined as the fraction of deaths which would have been avoided if the prevalence of a specific risk factor had been lower, and is measured with the following formula:n =  number of exposure categoriesiP =  proportion of population currently in the ith exposure categoryP′i =  proportion of population in the ith exposure category in the counterfactual  scenarioiRR =  relative mortality risk for the ith exposure categoryFor the low- and mid-educated we first calculated age-specific PAFs in order to estimate new mortality rates and numbers of saved deaths in each age group . In a second step we summed up the age-specific saved deaths for the ages 30–79 years and calculated the overall PAF in each educational group.To account for sampling variability, particularly of the risk factor distributions which were derived from survey data with limited sample sizes, we calculated 95% confidence intervals (CIs) around the PAF values of the lower educated using bootstrapping in R.As indicated by their non-overlapping 95% CIs, the observed differences in PAFs between countries are often unlikely to be due to random error. For example, reducing smoking prevalence to the level of the high educated will prevent a considerably larger fraction of deaths among the low educated in the North, West and Centre/East than in the South. This is due to the fact that inequalities in smoking prevalence are larger in the former than in the latter regions .The results for relative inequalities in mortality sometimes lead to a rather different picture of variation between countries . The maiExcept from being a more realistic scenario, the best practice scenario differs from the upward levelling scenario in that the “best practice group” no longer stems from the same country , but from another country, and that the risk factor exposure among all educational levels is changed, not only that among the lower educated. This explains why best practice scenarios sometimes have larger effects than upward levelling scenarios. It should also be noted that the best practice scenarios sometimes have "negative" effects, in the sense that inequalities in mortality go up instead of down. This is the case when countries have a high average risk factor prevalence, and therefore could not be selected as best practice country, but at the same time have smaller inequalities in risk factor prevalence than the best practice country.When we compare Still, small reductions of absolute inequalities may go together with sizable reductions in relative inequalities when average mortality levels are high, as in the case of Central/Eastern Europe . The rates corresponded well to the national averages. We thus believe that our results on educational differences in disability-free life expectancy are not crucially affected by the use of regional mortality data instead of national data. Furthermore, the comparability of our economic inactivity data was clearly suboptimal because temporary unemployed were classified with the inactive in Norway, Sweden, Switzerland, and Madrid, and with the active in all other populations. This implies that the causal effect of economic activity on mortality will be different between these two groups of countries. However, different RRs were applied for these groups and we could also not find any systematic differences in reduction of mortality inequalities between countries with different classifications of the unemployed  for the association between education and all-cause mortality. Table S3: Relative risks for the impact of risk factors on all-cause mortality. Table S4: Sources of prevalences. Table S5: Prevalences of smoking. Table S6: Prevalences of overweight. Table S7: Prevalences of physical inactivity. Table S8: Prevalences of social participation. Table S9: Prevalences of lower income quartiles. Table S10: Prevalences of economic inactivity. Table S11: Potential reduction (in %) of relative educational inequalities in all-cause mortality between low and high educated, upward levelling scenario, by risk factor, country and sex. Table S12: Potential reduction (in %) of relative educational inequalities in all-cause mortality between low and high educated, best practice scenario, by risk factor, country and sex.(DOCX)Click here for additional data file.


The aim of this paper is to describe the research aims, concepts and methods of the research Consortium Integrated Approach of Overweight (CIAO). CIAO is a concerted action of five Academic Collaborative Centres, local collaborations between academic institutions, regional public health services, local authorities and other relevant sectors in the Netherlands. Prior research revealed lacunas in knowledge of and skills related to five elements of the integrated approach of overweight prevention in children (based upon the French EPODE approach), namely political support, parental education, implementation, social marketing and evaluation. CIAO aims to gain theoretical and practical insight of these elements through five sub-studies and to develop, based on these data, a framework for monitoring and evaluation.For this research program, mixed methods are used in all the five sub-studies. First, problem specification through literature research and consultation of stakeholders, experts, health promotion specialists, parents and policy makers will be carried out. Based on this information, models, theoretical frameworks and practical instruments will be developed, tested and evaluated in the communities that implement the integrated approach to prevent overweight in children. Knowledge obtained from these studies and insights from experts and stakeholders will be combined to create an evaluation framework to evaluate the integrated approach at central, local and individual levels that will be applicable to daily practice.This innovative research program stimulates sub-studies to collaborate with local stakeholders and to share and integrate their knowledge, methodology and results. Therefore, the output of this program  will be matched and form building blocks of a blueprint for a local evidence- and practice-based integrated approach towards prevention of overweight in children. The output will then support various communities to further optimize the implementation and subsequently the effects of this approach. Childhood overweight (and obesity) is one of the most serious public health challenges of the twenty-first century in the world . In the The prevalence rates and the severity of overweight, especially regarding complications associated with obesity, put it high on the political and public health agenda of policy makers and funding agencies in the Netherlands. They are becoming increasingly aware that an integrated approach might be the only sustainable solution to this so-called wicked problem of overweight. A wicked problem is defined as a complex problem that prevails in society, with multiple interwoven determinants and for which evidence for the effectiveness of potential solutions is often lacking . Driven EPODE (or Together Let’s Prevent Childhood Obesity) is a French community-wide comprehensive intervention program. It aims to prevent overweight and obesity in children aged 0–12 years and their families through a multi-activity, multi-setting and multi-stakeholder approach , 15. TheIt is expected that the number of municipalities in the Netherlands that implement an integrated approach will further increase in the coming years since the Minister of Health actively supported the integrated approach by the establishment of the Dutch JOGG central coordination team in 2010. JOGG stands for Youth on Healthy Weight and is a centrally coordinated and locally implemented integrated approach based on the EPODE approach. In fact, the Dutch government has set the target of the number of cities joining the JOGG programs at 75. In addition to the four critical components of EPODE, JOGG formulated a fifth component: the integrated pathways between prevention and care. The five critical components of the JOGG program are part of a logic model which is shown in Figure To optimize the implementation of JOGG, and subsequently its effectiveness, innovative research is needed. Moreover, local health promotion specialists have indicated that they are in need of tools and guidelines to support the implementation and evaluation of this integrated approach targeting overweight and obesity . HoweverAfter the Dutch Ministry of Health had mentioned the integrated approach as a possible solution to tackle overweight , the resAn ACC is a local collaboration between 3 academic institutions, regional public health services, local authorities and other relevant sectors. Each involved ACC aims to promote knowledge exchange between municipalities, regional Public Health Services, academic public health departments and other local stakeholders on specific public health issues , 23. ThiCIAO started with an inventory study of (inter)national interventions proven effective or promising directed at the primary prevention of overweight and obesity in children and adults and their conditions for successful implementation. Literature studies, surveys and workshops were conducted with health promotion professionals and parents in addition to interviews with experts . Also moHow can intersectoral collaboration between policy sectors within municipalities result in integrated policies with an effective, easy-to-implement, well-described plan of action?Based on the inventory study, CIAO will continue to further develop a blueprint for a national framework of evidence-and practice-based integrated approach towards local prevention of overweight and obesity. The research program will consist of five sub-studies, conducted by five research teams integrated in the ACCs, which together will constitute the building blocks of such a blueprint. According to both JOGG and EPODE, political commitment is a critical component and is identified by CIAO as a key-element for a successful implementation of the integrated approach. Since determinants of overweight cannot only be found in the domain of public health, but also in other domains such as safety, spatial planning, economics that may influence the physical and/or social environment (more upstream determinants) , involveHow can current interventions and integrated policies be reinforced by using up-to-date parenting support, and by adaptations increasing the reach in disadvantaged neighbourhoods using social marketing strategies, resulting in effective, easy-to-implement preventive interventions?The reduction of inequalities in health is an important target in public health policies of WHO Europe and the EU. Overweight and obesity are positively correlated to low-income and low education populations, leading to a high prevalence of overweight and obesity in disadvantaged neighbourhoods –33. The How can integrated policies be implemented in disadvantaged neighbourhoods, and how can process and effect indicators be routinely measured and applied in the development and implementation of effective local integrated policies promoting healthy weight in youth?Moreover, it is important to gain insight into factors that influence the implementation processes of the integrated approach and interventions, especially in disadvantaged neighborhoods and into strategies to further optimize the use of these factors. Therefore, a thorough monitoring and evaluation of the implementation process is necessary, and process and effect indicators should be routinely measured. For this purpose, it is important that consensus is reached with respect to the indicators that are used to measure the progress and outcome of the integrated approach. The third study question for CIAO to answer is: Guiding and monitoring the process of political commitment for intersectoral collaboration leading to integrated policy,Influencing reach and effect of community interventions by guiding and monitoring social marketing strategies,Strengthening parenting styles and practices in existing interventions,Guiding the intended adoption and implementation processes in an integrated approach,Developing a theory and practice based evaluation framework.In order to address these questions, CIAO has designed five sub-studies directed at the prevention of overweight and obesity in children:It is essential that in each of the sub-studies several of the participating ACCs collaborate so that the consortium can optimally benefit from the vast experience and expertise available in these centres. Research will be carried out to improve the program design and implementation of JOGG as it is rolled out.All five sub-studies will follow the same research cycle as shown by Figure The results of the five sub-studies will inform a well-rounded answer to the three main research questions. Research methodology, data-collection, data-analyses and outcomes will be matched and coordinated. To increase understanding and readability, the various sub-studies will be presented here separately .In the identification phase, operational criteria of integrated public health policies will be developed by using a literature review and the Behaviour Change Wheel [ge Wheel  as a thein the development phase to obtain insight into the factors that were hampering or facilitating intersectoral collaboration. By comparing these cases, insight into the effects of implementation style on interventions aimed at local governmental officials will be derived.Interview data will be collected in two small-sized Dutch local governments In the testing phase, the conceptual framework will be applied in two relatively large Dutch local governments. The aim is to explore to what extent this conceptual framework might be able to illuminate the process of developing integrated public health policies. Additionally, the definition of integrated public health policies will be used to determine if the policy content of these local governments can be considered 'integrated.’ After that, the conceptual framework will be used to evaluate the effect of a resource that was developed in New South Wales, Australia to assist local governments in developing a specific type of integrated public health policy, i.e., an active living policy. Interviews with general managers, directors of community services, health officials and environment and recreation officials and a document analysis of policies developed in the included municipalities will be used to collect data about the policy process and policy content.In the adaptation and finalization phase, focus groups will be held with actors at the strategic and tactical levels within the three Dutch local governments. The focus will primarily be finding solutions for identified barriers in our previous studies.Research has shown that community involvement may contribute to improved outcome effects as well as more sustainable programs with better reach and impact , 39–41. In the identification phase, public health programs aiming to prevent overweight among children in which social marketing is applied to enhance the outcomes will be explored.In the development phase, a practical tool or format for monitoring social marketing will be designed This format will be based on theory, e.g. the social marketing benchmark criteria as defined by French [y French  and pracIn the testing phase, the developed monitoring tools will be tested while evaluating the application of social marketing in the case-studies using quantitative and qualitative methods.In the adaptation and finalization phase, the lessons learned and insights gained from the testing phase will be used to make the practical format adaptable for practice, possibly for nationwide implementation in the Netherlands.Following the outcomes of the inventory study of CIAO this sub-study aims to strengthen parenting styles and practices in existing interventions to prevent overweight in children. Therefore, a web-based parenting intervention, an E-learning module will be developed and tested for effectiveness. This E-learning could be added to existing interventions to prevent overweight in children and as such be an integral part of the intervention. Furthermore, a pedagogical message for parents will be developed, which can support them in preventing overweight of their child. All local professionals working with children could use this message.In the identification phase, a literature search will be carried out regarding the role of parenting in the prevention of overweight in children and the involvement of parents in existing interventions. Furthermore, data from the Youth Health Care on the attitudes of professionals and parents regarding overweight in children will be analyzed. Subsequently, existing data from a large survey of parents (n=7000) on their perception of overweight and the rules parents set at home regarding healthy eating and physical (in)activity will be analyzed . More insight into and specific examples of difficult daily life situations in which mothers experience problems in promoting healthy eating and physical activity with their child will be compiled by using focus groups comprised of mothers of different ethnic and socio-economic backgrounds. The Medical Review Ethics Committee Region Arnhem-Nijmegen approved this focus group study, reference number 2012145. This study was not liable for WMO. Written informed consent for participation in the study was obtained from participants.In the development phase, the outcomes of the identification phase will be used for the development of a Dutch web-based parenting intervention. Thereafter, a Delphi method will be conducted in which we use the knowledge of different experts, researchers and professionals working with children for the development of a pedagogical message regarding overweight and obesity.In the testing phase, the effectiveness of the web-based parenting intervention will be investigated in a two-armed cluster randomized controlled trial. This trial is in compliance with the Helsinki Declaration. The Medical Review Ethics Committee Region Arnhem-Nijmegen approved the study protocol, reference number 2012495, NL4280309112. This study was not liable for WMO and registered at the Dutch Trial Register NTR3938. A passive informed consent procedure will be followed in which parents (and their children) can refuse study participation. Thereafter, the usability of the textual content of the pedagogical message will be evaluated by means of focus groups with different ethnic and socio-economic backgrounds.In the adaptation and finalization phase, the web-based parenting intervention and the pedagogical message will be adapted and optimized according to the findings of the testing phase, and the final versions will be disseminated.When preventive programs are being implemented the iterative and dynamic interactions that occur often diverges from the process as originally planned. The integrated approach faces even more implementation challenges as it is based on a convoluted program plan and addresses multiple settings and involves many sectors. During the inventory study, it was concluded that there is limited knowledge of (determinants of) the implementation of the integrated approach. This lack of knowledge makes it difficult to formulate sound implementation strategies and value reported effects of the approach. Therefore, this sub-study will explore the implementation of the integrated approach and its determinants at the community level.In the identification phase, experts and local project managers of several municipalities initiating the integrated approach will be consulted to identify local implementation plans and strategies to formulate a status quo. Furthermore, a systematic review will be conducted to elucidate what is already known about the implementation of the integrated approach and what instruments and outcome measures have been used to evaluate the implementation process of this approach.In the development phase, a process evaluation plan will be constructed and several instruments to evaluate the implementation process of the approach will be created or adjusted. This will be guided by the information obtained during the identification phase and by the framework for determinants of innovations as formulated by Fleuren et al. [n et al. . The proIn the testing phase, five municipalities in which a longitudinal study will be performed on the implementation process of the integrated approach will be selected. The methods for the process evaluation will be adjusted iteratively when indicated by data-collection and data-analyses.In the adaptation and finalization phase, the results from the longitudinal study will be combined and compared to create an overview of the level and determinants of the implementation of the integrated approach. Interpretation of data will be based on a framework analysis of qualitative data via Atlas Ti, Qualitative Comparative Analysis, a Social Network Analysis and statistical analysis of quantitative data. Moreover, results of different analyses will be compared to triangulate our data. The process of analysis will lead to a guideline for evaluating the innovation process. Additionally, it will provide implementation indicators that could aid municipalities in formulating implementation strategies for the integrated approach. If needed, the framework of Fleuren et al. [n et al.  will be This study aims to construct an evaluation framework for the integrated community approach of overweight and obesity in children in order to stimulate evaluation of JOGG. This evaluation framework will consist of an evaluation handbook set as an action plan in the planning and implementation of evaluation, supporting health promotion specialists to overcome evaluation barriers and in the meantime, build evaluation capacity. The evaluation framework will also consist of an evaluation planning matrix in which practice and evidence based knowledge from the all CIAO sub-studies will be combined. To increase understanding and readability, the methodology for the evaluation handbook will be presented first (A), followed by the description of the evaluation planning matrix (B).In the identification phase, a literature study and interviews with experts, health promotion specialists and JOGG-program managers will be conducted to determine barriers in program-evaluation. Subsequently, a comprehensive search in electronic databases to identify a suitable evaluation action plan or handbook will be conducted.In the development phase, the identified evaluation handbook will be translated into Dutch. Practice based examples from JOGG communities will be added to this evaluation handbook (version 1.0). Supportive educational training will be developed following the outline of the evaluation handbook. Training will follow essential aspects of the Social Cognitive Theory: modelling, practice, feedback and coaching [coaching .In the testing phase, the evaluation handbook will be delivered to JOGG program managers to support evaluation of the local JOGG program. Educational training will be provided to the program managers and involved epidemiologists. Both the training and the evaluation handbook will be evaluated through four focus groups consisting of JOGG program managers and designated researchers and experts in community-wide intervention approaches and evaluation from research institutes and semi-governmental National Health Promoting Institutes.in the adaptation and finalization phase the handbook will be adapted and finalized.Following the outcomes of the focus groups An evaluation planning matrix is a tool that describes the evaluation questions, the indicators, data-collection instruments and time-line, data-analyses and dissemination per the main goal.In the identification phase, the JOGG model will be determined. Subsequently, main goals and objectives of the JOGG-approach will be discussed and determined with the JOGG-board, JOGG central coordination office, six JOGG pilot municipalities and executive researchers of CIAO sub-studies 1,2,3 and 4. Evaluation questions, indicators and data-collection instruments will be delivered by the CIAO sub-studies 1,2,3 and 4.in the development phase, these elements will be placed in an evaluation planning matrix.In collaboration with the other CIAO researchers, In the testing phase the evaluation planning matrix will be submitted to experts, program managers and the JOGG central coordination office and evaluated on use, usefulness, and feasibility.In the adaptation and finalization phase, the evaluation planning matrix will be adapted in accordance with results from the expert meetings and focus groups and disseminated to the JOGG central coordination office.Both the evaluation handbook and the evaluation planning matrix will be combined in the evaluation framework for the integrated approach on overweight in children. Expert meetings will be held to create consensus and support for the evaluation framework.It is generally accepted that to combat overweight and obesity, an integrated community-wide approach is needed. An inventory study showed that some elements of the integrated approach could be more important than others and that in the Netherlands these elements need further definition and operationalization . The conThe demonstration of the effectiveness of the integrated approach is beyond the scope and the timeframe of the CIAO collaboration. The effectiveness depends largely on the capacity of local program management, involved local stakeholders, local resources, the severity/prevalence of overweight and the surrounding social and physical environment of the target population. CIAO will help to develop a better understanding of the integrated approach and offer an evaluation framework, including strategies on effectiveness, which may support local professionals in monitoring their program, taking the local context in account. An evaluation framework is important because evaluation can improve local program design which improves the likelihood of achieving successful outcomes .There are multiple challenges in this type of research. CIAO researchers have to take the challenges and solutions of this type of research into account. Nastasi and Hitchcock (2009) conclude in their paper on the challenges of multilevel interventions that “even under relatively controlled experimental or quasi-experimental conditions, many factors can interfere with efforts to carry out well-designed evaluation plans” . The firThe second challenge CIAO faces concerns the necessary processes and productive-interactions between the separate research teams. The integrated output of a consortium thrives on the interactions and knowledge exchange between its partners, but these interactions take time. Incentives are provided for individual research publications, but funding is only provided for five four-year research projects, and the additional requirements to establish collaboration between several research teams is not accounted for and so far not acknowledged. Simply stated, the 'glue’ between the separate research teams might be missing. Thus, for CIAO to harvest the success of the five ACCs collaborating, all stakeholders involved  should acknowledge that integrating group processes and competencies are essential.The third challenge CIAO will face is 'inaction’. CIAO tries to unravel the blueprint for the integrated approach to show presumable effective elements of this approach. An important reason for this is to allow policymakers, researchers and professionals to understand the drivers and solutions of the wicked problem of overweight and obesity. However, the more thorough a description becomes, and the more it shows the complexity of the chain of causality, 'inaction’ might be the result as it raises the difficult question of where action should begin within a highly connected complex system .CIAO research is important because it is the first of its sort in the Netherlands to collect solution oriented evidence in the field of overweight prevention. CIAO aims to find out what processes work best at more upstream environmental levels in an integrated community-wide approach to prevent overweight and obesity. This differs from more traditional social and behavioural sciences that try to demonstrate the efficacy of behavioural interventions to modify health outcomes. The output of the CIAO sub-studies  will be matched and form building blocks of a blueprint for a local evidence- and practice-based integrated approach towards prevention of overweight in children. Subsequently, the output will support various communities to further optimize the implementation and subsequently the effects of this approach.


To investigate the magnitude of barriers in access to health services for chronic patients and the socioeconomic and demographic characteristics that affect them.A cross-sectional study was conducted in 1,594 chronic patients suffering from diabetes, hypertension, COPD and Alzheimer. Logistic regression analyses were carried out in order to explore the factors related to economic and geographical barriers in access, as well as the determinants of barriers due to waiting lists.A total of 25% of chronic patients face geographical barriers while 63.5% and 58.5% of them are in front of economic and waiting list barriers, respectively. Unemployed, low-income and low-educated are more likely to face economic barriers in access. Moreover, women, low-income patients, and patients with lower health status are more likely to be in front of geographical barriers. In addition, the probability of waiting lists occurrence is greater for unemployed, employees and low income patients.Barriers in access can be mainly attributed to income decrease and unemployment. In this context, health policy measures are essential for removing barriers in access. Otherwise, inequalities may increase and chronic patients’ health status will be deteriorated. These consequences imply adverse effects on health expenditure. Availability is related to the adequacy of health resources, such as providers and facilities. Accessibility is associated with the location of the provision of healthcare and the location of patients, namely it includes concepts such as travel time and transportation cost. Affordability is related to the relationship between prices demanded by providers and the health insurance, ability to pay and income of patients. Accommodation is relevant to the organization in order the supply resources to be able to accept patients and serve their needs and expectations . The last dimension, acceptability, is associated with some attributes of providers and patients  and the impact of those on their attitude and behavior. Taking these aspects into consideration, the interaction between providers and patients may affect access to healthcare services.The concept of equal and universal access is acknowledged as a core priority for the egalitarian health systems. It is nIn Greece, economic crisis and the implementation of austerity measures have worsened the self-rated health status as well as several health indicators,4. The aAccess to adequate health care is an important aspect especially for patients suffering from chronic diseases, who constitute a group with many needs for healthcare and their number is high and increasing in plethora of developed countries. TherefoBased on these introductory comments, this paper aims to investigate the main characteristics related to economic and geographical barriers in access as well as barriers in access due to waiting lists for chronic patients, using data from the Greek healthcare setting, a system under severe constraints, austerity measures and ongoing consequences of a deep economic crisis.The analysis is based on primary data from a sample consisting of 1,594 chronic patients suffering from Alzheimer, hypertension, diabetes and chronic obstructive pulmonary disease (COPD). These patients were participants in a cross-sectional study that was conducted in March 2013. Patients were approached through their treating physician. In more detail, 160 physicians were randomly selected through the official list of the National Medical Association of Greece, based on specialty and geographical distribution. Primary care physicians comprised 27.5% of the sample of the physicians. The selected physicians were requested to provide the contact details of 10 patients suffering from the aforementioned chronic diseases. Specifically, each physician was provided with a set of 10 random numbers between 1 and 20. According to those numbers, physicians were asked to inform 10 of their patients that visit their practice about the objectives of the study and to provide them with the patient consent form. Ethical approval was obtained from the Hellenic Data Protection Authority (reference number 1139) and from the Bioethics Committee of the National School of Public Health.As a second step, the research team approached the patients and derived the study data via telephone interviews, based on a structured questionnaire. Participants answered a series of closed type questions, including self-rated health status (currently and one year before the interview), income (current and change during the last year), educational level and occupation. The respondents were 394 patients suffering from Alzheimer, 400 patients suffering from hypertension, 400 patients suffering from diabetes type II and 400 patients suffering from chronic obstructive pulmonary disease (COPD). The specific diseases were chosen on grounds of epidemiology/disease burden as well A series of ordinal logistic regression models were constructed, in order to explore the impact of a set of baseline parameters of the population to the dependent variables of interest. In this paper, three different models are presented, each of them focusing on the impact of socioeconomic variables on the economic barriers, the geographical barriers and the barriers due to waiting lists as dependent variables.Income, educational level, occupation, age, health status and gender were used as independent variables of the aforementioned regression models. The choice of these regressors can provide a wide framework of the socioeconomic status and the demographic and health characteristics. The measurement of these variables is analytically presented in Table Self-rated health status of chronic patients was deteriorated between 2012 and 2013 (62.2% in 2012 vs. 58.5% in 2013). This fact is more intense for the patients suffering from Alzheimer (53.9% in 2012 vs. 47.0% in 2013), while the deterioration of self-rated health is the lowest for patients suffering from diabetes (63.6% in 2012 vs. 61.7% in 2013). Moreover, chronic patients mentioned a significant income decrease and an expenditure reduction in many aspects related to their lifestyle. However, the reported drop of the expenditure for health and education is much lower than the corresponding for other needs. It is noteworthy that the reported income decrease is approximately 34.1% (1668.5 in 2012 vs. 1099.2 in 2013), while the private health expenditure is estimated at 10.2% of the total family income. Furthermore, 24.8% of the interviewees face increased difficulties in access to healthcare services due to geographical barriers, while the corresponding percentage for the economic barriers is approximately 62.8%. In addition, 55.1% of the respondents are in front of increased difficulties in access because of the presence of waiting lists.The aforementioned descriptive aspects provide a general framework, or a "big picture" of the access to healthcare services for chronic patients. However, apart from mentioning the problem, it is crucial to search for more specific characteristics. In this context, some ordinal logistic regressions were carried out in order to illustrate the characteristics which lead to increased probability of barriers occurrence. The results are represented in Tables The economic barriers in access depend on income  and educational level . Moreover, unemployment is also an important aspect which causes economic barriers in access to healthcare services . It is noteworthy that both the coefficients of income and educational level have a negative sign. This means that a higher income or educational level leads to lower probability of occurrence of economic barriers. It is noteworthy that gender and health status do not have impact on the difficulties in access due to economic aspects.Another type of barriers in access is related to difficulties due to geographical reasons. Specifically, low-income patients are more likely to face increased difficulties in access to healthcare services for chronic patients . Moreover, women  and patients with lower health status  are more likely to face geographical barriers in access. According to the analysis of this paper, the type of occupation has also impact on the access of chronic patients, through the geographical difficulties that may occur. It is noteworthy that almost all occupational categories demonstrate a statistically significant relationship with geographical barriers occurrence. However, students are more likely to be in front of geographical barriers, compared with other occupational categories. Employees without wage will probably face less geographical barriers than the students, but more than the typical employees, the unemployed, the housewives and the retired chronic patients. Furthermore, the ordinal logistic regression for this case does not conclude that education is a statistically significant regressor.Barriers in access due to waiting lists represent the difficulties that occur because of the cost of time. High-income chronic patients will probably face fewer barriers due to waiting lists . In addition, some specific occupational categories have a statistically significant relationship with the probability of waiting lists barriers occurrence. These are the employees  and the unemployed patients .According to this regression the unemployed patients are more likely to face barriers in access due to waiting lists than the employed ones. Moreover, education, gender and health status do not consist statistically significant determinants of barriers in access due to waiting lists.According to the results of this analysis, income level is a major factor that affects access to healthcare services. High-income patients are able to overcome the barriers in access, as they can afford to pay for the quest of healthcare outside the public healthcare services frame, implying that high income can increase the alternatives, such as private services or, even, informal payments. It is noteworthy that high private spending and high informal payments are both typical characteristics of the Greek health system,17. ThusThe educational level was also an independent variable of the regressions of this study, as it is regarded as a crucial determinant of socioeconomic status. Generally, higher prevalence in chronic diseases is observed in the population group characterized by low education. MoreoveThe type of occupation has also impact on the barriers in access to healthcare services. Specifically, unemployed chronic patients are more likely to face economic barriers in access, mainly because unemployed have very low income. This finding is quite reasonable, given the high unemployment rate in Greece during the recession of the last years. It is noteworthy that unemployment also causes barriers in access due to waiting lists, partly because the low income reduces the alternatives, such as private healthcare. Moreover, geographical barriers are more likely to occur in students, and in self-employed in the family firm.Although barriers in access to healthcare services are identified by many aspects, the main drivers which cause these difficulties are directly related to economic recession and the current restrictive fiscal policy. Specifically, low income and unemployment are the key characteristics affecting difficulties in access.Other studies conclude to similar results, as socioeconomic status  affects chronic diseases prevalence. Specifically, chronic diseases are more prevalent in the lower socioeconomic groups. MoreoveDespite the ongoing burden of chronic diseases and the implications in access of chronic patients, health policies are not oriented toward facing and managing them,25. NowaA first dimension of a health policy plan for chronic diseases is associated to public health and prevention actions, namely that government, health organizations and NGOs should inform the population about the risk factors, . However, although prevention of chronic diseases is a low-cost and effective solution, political will and support towards this direction is limited. The othDespite the importance of lifestyle and risk factors, our analysis indicates that economic and social causes are the main factors affecting barriers in access. Therefore, the aforementioned actions (namely prevention actions and chronic diseases management) should be accompanied with interventions that face the main drivers of barriers in access. In this context, social and health policies are considered as essential actions for the decrease of the adverse impact of unemployment and low income on patients’ access. Such actions are becoming more urgent, in a period of economic crisis. Therefore, a social safety net against the increasing unemployment and the income decrease could improve patients’ access, by reducing the reported barriers. These actions constitute an integral part of the agenda, and thus they should be transformed into specific policy actions for the vulnerable groups of the population.As with any study of this kind, the present one also has some limitations that should be acknowledged. Ideally, the sample would consist of chronic patients throughout the whole chronic diseases spectrum. Unfortunately, this study selected to examine four chronic diseases, due to resource constraints. Moreover, we could not select the interviewees from a survey that is based on the total population, as it was costly and time-consuming. Thus, we chose the aforementioned methodology. In addition, this study focuses on the barriers in access in a period of economic recession and crisis. Although it would be interesting to present the determinants of barriers in access, based on the whole period of an economic cycle, we think that this approach is useful in terms of health policy. This claim is based on the fact that the abovementioned finding could be taken into consideration when governments decide to implement restrictive fiscal policy and austerity measures either by "chance"  or by "choice".Income has significantly fallen since 2010 and supply has been reduced in healthcare sector. In this context, according to this analysis, economic crisis has led to barriers in access to healthcare services for chronic patients, who constitute a vulnerable group of the population with increased needs for healthcare. Income drop and unemployment –both consequences of the economic crisis- constitute the main reasons of the difficulties in access.In this framework, health policy should take into consideration chronic diseases management, in order to reduce the consequences not only in terms of costs (which are high and increasing) but also for the accessible provision of healthcare to chronic patients. Therefore, although health policy is not oriented towards chronic diseases management and their risk factors, a reconsideration of the agenda in Greece would be beneficial in terms of access, public health and potential savings. Moreover, social policy measures -for supporting chronic patients who face difficulties- are essential, during a period in which the adverse effects of the main drivers of barriers in access are increasing.Written informed consent was obtained from the patients for the publication of this report.The authors declare that they have no competing interests.DZ, AS and KM contributed to the conception and the design of the study and the acquisition of the data. IIK, DZ, AS, KM and KA contributed to the analysis and the interpretation of the data. IIK, DZ and KA drafted the manuscript. JK contributed to the critical revision of the manuscript for important intellectual content. All authors read and approved the final manuscript.