Access to healthy food is often seen as a potentially important contributor to diet. Policy documents in many countries suggest that variations in access contribute to inequalities in diet and in health. Some studies, mostly in the USA, have found that proximity to food stores is associated with dietary patterns, body weight and socio-economic differences in diet and obesity, whilst others have found no such relationships. We aim to investigate whether proximity to food retail stores is associated with dietary patterns or Body Mass Index in Glasgow, a large city in the UK.We mapped data from a 'Health and Well-Being Survey' (n = 991), and a list of food stores (n = 741) in Glasgow City, using ArcGIS, and undertook network analysis to find the distance from respondents' home addresses to the nearest fruit and vegetable store, small general store, and supermarket.We found few statistically significant associations between proximity to food retail outlets and diet or obesity, for unadjusted or adjusted models, or when stratifying by gender, car ownership or employment.The findings suggest that in urban settings in the UK the distribution of retail food stores may not be a major influence on diet and weight, possibly because most urban residents have reasonable access to food stores. Access to healthy food is often seen as a potentially important contributor to a healthy diet. Policy documents in many countries suggest that lack of such access in certain areas is one explanation for inequalities in diet and in health ,2. A groEvidence from outside the USA about associations between neighbourhood environments and diet or obesity is also mixed. A New Zealand study found no association between fruit and vegetable intakes and better access to food stores, but living near a convenience store was negatively associated with vegetable intake , while aGiven this observed variation across studies, there is a need for further investigation of the associations between retail food environments and both diet and body weight . This isWe capitalised on two existing datasets relating to Glasgow City, Scotland: a 'Health and Well-Being Survey' , conducted in 2002 by the Greater Glasgow Health Board (GGHB), and a list of food retailers in 2007 held as part of the Glasgow City Council Public Register of Food Premises.'On average, how many portions of fruit do you eat each day?', and 'On average how many portions of vegetables or salad (not counting potatoes) do you eat each day?'). The high-fat snack consumption variable was based on responses to the question 'How often PER DAY do you usually eat items such as cakes, pastries, chocolate, biscuits and crisps?', which we grouped into none or one versus at least two . The former categorisation (none or one versus at least two) was used by the GGHB within the HWB report [The HWB sample was stratified proportionately by local authority and deprivation category (DEPCAT), with addresses selected randomly. Over two thirds (67%) of individuals contacted took part in the study which led to 1802 face-to-face interviews with adults in the GGHB in 2002. Data were gathered on individuals' socio-demographic characteristics, health and health behaviours. Data were weighted to ensure that they were representative of the adult population in this area . In thisB report . BMI wasThe list of food retailers n = 741) was held by the Council for licensing, inspection and planning purposes, and included all premises that fall under the 1995 Food Safety and Hygiene guidelines [ was heldWe obtained street maps (including point addresses) from the UK Ordnance Survey , and useNetwork distance to the nearest general store was dichotomised with a threshold of 500 metres, while network distance to the nearest fruit and vegetable store and nearest supermarket was dichotomised by 1000 metres. We chose 500 metres for the nearest general store to ensure the stores were local to the respondents, and because initial inspection of the data showed that application of a larger threshold for this variable resulted in too little variability . The 1000 metre threshold for the other stores represented an approximately 15 minute walk for adults in an urban area and this has been demonstrated as an appropriate distance in previous literature ,43-47. TLogistic regression was used to explore associations between snack intake and distance to the nearest general store or supermarket; and between fruit and vegetable consumption and distance to the nearest fruit and vegetable store or supermarket. Multinomial regression was used to examine whether proximity to food retailers was associated with BMI category . In addition we used GLM to explore whether proximity (as a continuous variable) was associated with diet and BMI as continuous outcome variables. We examined, firstly, unadjusted odds ratios for diet and BMI; secondly odds ratios adjusted for age, gender, and socio-economic position; and thirdly odds ratios adjusted for age, gender, socio-economic position, car ownership and employment status. We also formally explored various interactions within the models . We then conducted a stratified analysis by gender (controlling for age and socio-economic position), household car access , and employment status . Within the HWB survey 991 respondents had no missing values for any of the variables to be included in the analysis (see table Almost three quarters (73%) of the HWB sample lived within 500 metres (m) of a general store, 32% within 1000 m of a fruit and vegetable store, and 46% within 1000 m of a supermarket.We found few statistically significant associations between proximity to food outlets and diet or BMI. There was little difference in fruit and vegetable consumption by proximity to fruit and vegetable stores, and although the odds of obesity appeared lower in those living within 1000 m of a fruit and vegetable store this difference was not statistically significant. Odds of eating more than one high-fat snack daily, eating less than five portions of fruit and vegetables daily, and obesity were higher among those within 1000 m of a supermarket but again these results were non-significant. The only association statistically significant at the 5% level was that between obesity and proximity to general stores after adjustment for age, gender and socio-economic position  or households with a car(s), non-employed or employed). We did find an association between proximity to a supermarket and not eating fruit and vegetables which is puzzling, given that we controlled for age, gender and socio-economic positions, all of which may be associated with fruit and vegetable consumption. It is possible that proximity to a supermarket is a marker of proximity to a range of destinations selling energy dense foods. Contrary to expectations, associations were stronger among men, car owners and those in employment, a finding which is also puzzling since most hypotheses are that females, those out of the labour market and those without access to a car are more likely to be sensitive to exposures in their immediate residential environment.Methodological limitations include the use of self-reported height and weight to calculate BMI, which may underestimate the true prevalence of overweight and obesity. For example, the proportions of respondents overweight and obese in the Health and Well-being survey (31.3% and 12.3% respectively) are considerably lower than the proportions in the Glasgow area obtained by direct measurements in the Scottish Health Survey 2003 (37.0% and 23.4%) . HoweverThe list of food stores was for 2007, five years after the HWB data collection. However a recent comparison of Council held list of stores available in 1997 and 2007 showed considerable consistency  , and verification on the ground in 2007 showed 88% of the 2007 list to be present and trading under the same name .We recognise that residential proximity may not be the most important factor influencing food purchasing; however we did not have access to information on where people shop . A Canadian study highlighted the importance of investigating environmental influences outwith the local home neighbourhood; travel survey data and retail food store locations were used to create a measure of the types of stores to which participants were exposed while carrying out their daily activities . It was In this paper we did not cover accessibility, affordability, or quality of healthy food items within local shops, which might be more important for diet than proximity to a food store. A survey of all food shops within 9 Scottish areas found that healthy food accessibility was determined by the types of stores in an area and by the stores' stocking policy . There wOur results differed to those of the majority of USA studies; we did not observe that living closer to a supermarket was associated with increased fruit and vegetable intake, or with reduced levels of overweight/obesity, and did not find a link between proximity to a fruit and vegetable store and healthier BMI ,11-16). -16. 11-1Despite its limitations we believe this study has contributed to the limited UK literature on the potential effect of local food retail upon diet and levels of overweight/obesity, and has extended existing studies by looking at various food types and food stores. Our overall finding of a lack of consistent associations highlights the importance of national context, i.e. that findings should not be extrapolated from, for example, urban USA to other countries with different patterns of urban dwelling and retail markets ,53. Our Directions for further research might include exploring the healthiness and quality of what food retail outlets actually stock and promote in particular areas. It would also be useful to have access to actual consumer shopping behaviour, to ascertain what food people purchase, what shops and other food sources they use, and to understand the factors which influence food shopping. More sensitive comprehensive indicators of environmental exposures, such as 'foodscapes' or 'activity spaces' , would aThe authors declare that they have no competing interests.LM did the mapping, data analysis and the literature review. AE, KB and SM contributed to the conception of the paper and discussion of the analysis. All authors contributed to successive drafts of the paper. All authors read and approved the final draft. LM is guarantor.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/464/prepub


Introduction. General practitioners (GP) answer calls to the Danish out-of-hours primary care service (OOH) in Denmark, and this is a subject of discussions about quality and cost-effectiveness. The aim of this study was to estimate changes in fee costs if nurses substituted the GPs. Methods. We applied experiences from The Netherlands on nurse performance in the OOH triage concerning the number of calls per hour. Using the 2011 number of calls in one region, we examined three hypothetical scenarios with nurse triage and calculated the differences in fee costs. Results. A new organisation with 97 employed nurses would be needed. Fewer telephone consultations may result in an increase of face-to-face contacts, resulting in an increase of 23.6% in costs fees. Under optimal circumstances  the costs could be reduced by 26.2% though excluding administrative costs of a new organisation. Conclusion. Substituting GPs with nurses in OOH primary care may increase the cost in fees compared to a model with only GPs. Further research is needed involving more influencing factors, such as costs due to nurse training and running the organisation.  Many of the European out-of-hours (OOH) services are to some degree primary care based , 2, as tFollowing the Danish reform in 1992, OOH primary care in, for example, The Netherlands and the United Kingdom was reformed into large-scale GP cooperatives inspired by the Danish solution , 6. DaniIn recent years, the organisation of the OOH with all tasks being managed by the GPs has been a political issue in Denmark. In particular, substitution of the GPs with fully trained nurses in the telephone triage has been discussed. It is expected to result in a cut-down of expenses, as nurse fees are lower than fees of GPs. However, as there have been no studies on this we need better knowledge on this specific argument.We aimed to examine whether introducing nurse-based triage in the Danish OOH primary care would carry a decrease in costs based on the Dutch experiences.We constructed three scenarios of nurse substitution in Danish OOH primary care taking into account various factors influencing the patient flows and the effects on costs . As the As a basis for comparing the hypothetical scenarios with the existing situation we used information on the number of patient contacts and distribution of type of contacts in 2011 in the existing OOH primary care organisation in the Central Denmark Region. This information was based on data from the Health Insurance Registry . This reTwo estimates were crucial for the calculations: the proportion of terminated telephone consultations and the number of managed calls per hour. The percentage of contacts ended by telephone in case of nurse-based triage was based on the performance of Dutch triage nurses in OOH primary care. According to the annual benchmark of the Dutch association of general practitioners cooperatives (the VHN) the triage nurses terminate 41% of calls on the phone . A DutchFor the simulation, we set up three scenarios.The number of calls to the Danish OOH primary care was unchanged from the existing model. Nurses could terminate 18 percent less of the calls compared with the GPs (41% versus 59%), thus implying a rise of the number of consultations and home visits .The introduction of nurse triage would result in fewer calls to OOH primary care , based on the theory that parts of the calls were related to the direct telephone access to a GP and not to an acute need for help.Like The costs of the present organisation were based on data from the Health Insurance Registry  on GP reFor calculating the fees for nurses in the simulated models, we used the fees for the nurses doing telephone triage at the emergency department (ED), as the characteristics of these tasks are quite similar. We used the fees and pay supplements of the official agreement for nurse salaries including the agreed pension and holiday payment, that is, fixed salaries per hour and not fee-for-service as for the GPs, as fee-for-service for nurses is not a realistic option. Danish nurses are entitled to additional days off due to working after hours, according to the official agreement. This was added in the simulation . Moreover, we estimated absence due to days off work, holidays, illness, and so forth to eight weeks per nurse per year.The number of nurses needed was calculated as follows: in 2011, the mean number of calls per eight-hour shift to the OOH primary care in the Central Denmark Region was 755 . Considering the estimated number of calls manageable by nurses, a mean number of 16 nurses would be needed per hour. As the number of working hours per shift is eight hours, this resulted in a need for a total number of 105,830 nurse working hours annually. Furthermore, the days off due to OOH work and the estimated absence resulted in a total of 97 nurses to cover one year. In simulations 2 and 3, we decreased the number of calls to OOH care, resulting in a number of nurses needed to be 76.Moreover, we followed the Dutch organisation with a GP supervisor for the triage nurses for a fixed salary. Therefore, we counted the number of shifts in the study period and applied one GP for each shift in the scenarios. As GPs currently do not receive fixed salaries in OOH care, we based the estimation of these costs on the centrally agreed fees per hour for doctors acting as consultants. The calculated costs comprised the fees of GPs and nurses only and did not include additional costs due to organisation, transportation, or administration of the nurse schemes, training, maternity leave, and continuous education. We used the exchange rate of 13.4 Euros per 100 DKK (February 2013).In 2011, 634,978 patient calls to the OOH primary care were registered in Central Denmark Region. We found that, in a scenario with nurses substituting GPs in the OOH primary care telephone triage with the same number of contacts to the OOH primary care service and an 18 percent decrease in contacts terminated on the phone, the costs would increase by 23.6% (approximately three mill Euros) compared with the existing situation. Sensitivity analyses, using a number of assumptions, showed that the most optimistic scenario  would result in a 26.2% costs reduction. In our cost calculations, we have been conservative as unknown factors, such as costs due to training the nurses, running the organisation, and specific calculations of the number of supervising GPs, were not included and may add considerably to the final costs.Setting up simulated scenarios like the ones presented here implies incorporating assumptions and risking simplification of things. Additional simulated models with varying patient flows, numbers of nurses needed, and nurse fees could have been integrated in the comparison.The presented scenarios are based on existing data from a large OOH primary care service and on knowledge of the performance of triage nurses in Dutch OOH primary care, which in many ways is comparable to Denmark. Study results on patients' reasons for calling the OOH primary care are sparse. An international study comparing reasons for encounter in the OOH primary care in a range of European countries found that Denmark and The Netherlands were quite comparable in this respect . DenmarkThe number of nurses needed may be over- or underestimated. We could have chosen to use the performance of Danish ED-triage nurses as a basis for comparison instead of using Dutch OOH triage staff. However, as patient calls to the ED-nurses are likely to differ significantly from the calls to OOH primary care we considered this as a less suitable option. As the number of calls per 1,000 Danish citizens is twice as big as the number of calls in The Netherlands , the amoThe fees used in the simulated scenario calculation are based on the minimum level of fees for nurses doing triage to the ED. In reality, many of the nurses can be expected to have additional specialist courses and longer working hours, which will prompt demands for higher fees. Furthermore, we have not included extra costs due to training of nurses, license of a computerised support system, and administration/management of a new organisation, including a head of the department. Such costs will be additionally compared with the existing situation, as these organisational tasks currently are paid for by all GPs in the region at an amount of 269 Euros per year and managed by an OOH board of GPs. As the GPs are paid a fee for service in the existing model, no extra costs are related to sickness or holidays of GPs because if absent another GP takes over with no additional costs involved. GP transportation costs for home visits are not included in the simulated models. If, as assumed, the number of home visits increases this will add to the total costs.The Danish OOH primary care organisations are remarkably larger than the Dutch, covering a much larger service area. In the scenarios, we included the fees for only one supervising GP. However, as the number of nurses needed in the call centre can be expected to be much higher than in the Dutch GP cooperatives, one supervising GP is probably not enough in periods of high call demands. This is the case in which the fees for supervising GPs can be expected to increase from the present 781,000 Euros in the scenarios.We have not been able to simulate possible effects on service and health induced by these different scenarios. However, it is possible that citizens might experience changes in service and medical advice and that there will be a changed demand for, for example, emergency calls.Nurses answer calls and perform triage in general practice in daytime. However, there is a fundamental difference, as patients calling during daytime are listed with the practice, meaning that the staff has access to the patient records. It is likely that decision support systems equivalent to those known from other countries will make the nurses more qualified to perform the triage –21. Yet,This study suggests that the cost-economic consequences of substituting GPs with nurses in the Danish OOH service are dependent on a range of factors. Under certain optimal circumstances  nurse triage may result in a decrease in costs. However, nurse triage can be expected to lead more face-to-face contacts resulting in higher GP fees. Additionally, taking costs to build and run a new organisation into consideration should be included in future calculations of the total expenses of changing the organisation to introduce nurse triage.


The importance of foodborne viral infections is increasingly recognized. Food handlers can transmit infection during preparation or serving; fruit and vegetables may be contaminated by fecally contaminated water used for growing or washing. And modern practices of the food industry mean that a contaminated food item is not limited to national distribution. International outbreaks do occur, but little data are available about the incidence of such events and the food items associated with the highest risks. We developed a combined research and surveillance program for enteric viruses involving 12 laboratories in 9 European countries. This project aims to gain insight into the epidemiology of enteric viruses in Europe and the role of food in transmission by harmonizing  and enhancing epidemiologic surveillance. We describe the setup and preliminary results of our system, which uses a Web-accessible central database to track viruses and provides the foundation for an early warning system of foodborne and other common-source outbreaks. Norovirus (NV) , because those are likely to be detected by routine outbreak investigation, with or without molecular typing. Linking NV outbreaks to common-source introductions nationally or internationally may be more difficult because of the high secondary attack rate that results from rapid person-to-person transmission. Thus, an initial seeding event will rapidly be masked by the occurrence of new cases or outbreaks, suggesting that person-to-person transmission is the primary mode of spread. The likelihood of detecting such seeding events relies on effective surveillance, which combines epidemiologic assessment of the outbreak and molecular typing to discover and track potential links between outbreaks. Such molecular tracing, however, requires knowledge on diversity of “resident viruses” in the region under study to be able to recognize unusual increases. Therefore, we established a combined research and surveillance network for foodborne viruses that was granted by the European Commission. This project group combines complementary expertise from the fields of diagnostic virology, molecular virology, epidemiology, and food microbiology to study modes of transmission of NV across Europe. Mapping these pathways allows better founded estimates of the proportion of illness that may be attributed to foodborne transmission and identification of high-risk foods, processing methods, or import and transport routes, which subsequently can be a focus of prevention programs. The data are important for assessing the risks associated with consumption of certain food items. Essential to the success of this project is the establishment of a common, central database, which is now used by all partners to compare data across Europe as soon as they are available. We describe this project and results from its first 18 months of operation.The network is a collaboration among 12 laboratories in 9 countries in Europe to allow more rapid and internationally harmonized assessment of the spread of foodborne viral pathogens. The project is coordinated by the National Institute of Public Health and the Environment in Bilthoven, the Netherlands. Participants are virologists and epidemiologists with active research programs in (foodborne) enteric viruses from Spain , Italy (Rome), France , Germany (Berlin), the Netherlands (Bilthoven), the United Kingdom (London), Denmark (Copenhagen), Sweden (Solna), and Finland (Helsinki). In addition, groups from Slovenia and Hungary participate.The overall objectives for the complete study are as follows: 1) to develop novel, standardized, rapid methods for detection and typing of enteric viruses, particularly NV, to be used in all participating laboratories; 2) to establish the framework for a rapid, prepublication exchange of epidemiologic, virologic, and molecular diagnostic data; 3) to study the importance of enteric viruses as causes of illness across Europe, with a special focus on multinational outbreaks of infection with NV and hepatitis A virus; 4) to provide better estimates for the proportion of NV infections that can be attributed to foodborne infection; 5) to determine high-risk foods and transmission routes of foodborne viral infections in the different countries and between countries; 6) to describe the pattern of diversity of NV within and between countries and identify potential pandemic strains at the onset; and 7) to investigate the mechanisms of emergence of these strains, including the possibility of spillover from animal reservoirsThe central research goal is to better understand the mechanisms of emergence of variant NV strains. We hypothesized that the observed epidemic shifts might be caused by displacement of endemic variants attributable to a large seeding event with a variant that subsequently spread through the population by secondary and tertiary waves of transmission, or possibly by a smaller seeding event of a highly transmissible new variant, generated by genetic mutation or recombination. To address these questions, we built a European surveillance structure for outbreaks of viral gastroenteritis, including food- or waterborne outbreaks. The first phase of the project, described in this report, was designed to review existing surveillance systems for viral gastroenteritis, to design and agree on a minimum dataset for collection during the second phase of the project; to review and evaluate currently used methods for detection and genotyping of NV with the aim of standardizing methods for virus detection in gastroenteritis outbreaks; and to build a database of combined epidemiologic and virologic data for use by all participants. The overriding aim was to facilitate the early detection of potentially emerging variant strains. Upon completion of this phase, we will begin “ enhanced surveillance”, i.e., standardized surveillance for viral gastroenteritis outbreaks to study objectives 4–7.From the outset, it was recognized that the best approach in developing an international surveillance scheme for foodborne viruses would not be the standardization of practice, but rather the harmonization of existing practices. To achieve this, a number of surveys were undertaken to determine diagnostic capabilities, genotyping techniques, and the status of surveillance of viral gastroenteritis outbreaks among project participants. The results of these surveys are highlighted below.The scale of diagnostic capability in laboratories varies widely, and a range of diagnostic tests  and characterization methods are used  or negative (9 samples) for NV. Samples provided by four laboratories were included, as well as a samples representing the currently known diversity of NV genotypes. Full details of this study have been published , or 2) diarrhea  vomiting as defined in 1) and diarrhea as defined in 2). An outbreak was defined as follows: 1) Patients living in more than one private residence or resident or working in an institution at the time of exposure; 2) cases linked by time and place; 3) vomiting in >50% of total cases  might be possible. Without harmonization of data collection, the comparative analysis would clearly be limited. The historic database, however, also served as a pilot phase because the definitive format of the database is used in the enhanced surveillance program. Participants who had historic collections of sequences were asked to submit these, along with additional epidemiologic information, as described in Since September 2001, participants have been able to access the database directly through a password-controlled Internet connection. At present, the database contains >2,500 entries, mostly on NV, but including some hepatitis A virus, astrovirus, and Sapovirus  and 3. UThe different PCR primers used among the European group all target a highly conserved region within the viral polymerase gene. Sequences of the amplicons from the various diagnostic PCRs overlap and therefore, can be compared to gain inferences on the molecular epidemiology and the spread of NV variants (www.eufoodborneviruses.net). Using Web-based Active Server Pages (ASP) technology, investigators have full access to the secure outbreak database  implicating food or water as a mode of transmission. Pop-up windows are used to define these criteria, since a range of public health scientists use the system. Other features of the ASP technology, including drop-down menus, are used to standardize the data collected. Descriptive information from outbreaks  is collected when possible, to allow comparisons of the clinical characteristics of different NV genotypes. Preliminary data suggest that such differences exist.One of our main scientific objectives is to explain the mechanism behind the emergence of new variant strains. Essential for the early detection of such emerging variants is a rapid reporting network. The initial suspicion of “something strange” may be from clinicians who investigate outbreaks , or from one of the laboratories . The central database is used to facilitate both types of reports. The real power in this format of data exchange is that immediately after entry or update of information, the data are in the database and can be accessed by other collaborators. The database can be searched for common virologic (sequence) or epidemiologic  characteristics that would trigger further investigation of links between outbreaks.This model has proved successful in recognizing a number of internationally linked events. Clusters of cases in Denmark, Finland, and the Netherlands were all linked to oysters imported from France. Another foodborne outbreak traced in part through the network followed the concluding dinner of an international conference in Finland. Symptoms began the day after the conference, when many attendees had returned to their home countries. Approximately 40 persons were affected, and the same NV variant (Melksham) was detected from cases in Finland, Sweden, and the Netherlands. A dessert item was implicated by cohort study. Importations of hepatitis A from Peru into Spain and from Ibiza, Spain, to Germany have also been recognized through the network. Full details of these outbreaks will be published elsewhere.Microbial food safety is considered an important public heath issue but historically has focused on control of bacterial contamination. Several recent publications, however, show that outbreaks of foodborne infection attributable to viruses are common and may in fact be an important public health concern for several reasons: most clinical laboratories involved in outbreak investigations do not have access to routine diagnostic methods for detecting NV, user-friendly methods for use in these laboratories are only now becoming available and need to be validated, foodborne transmission of NV is quite common, and food microbial quality control largely relies on indicators for the presence of fecal bacteria, which may not correlate with the presence of enteric viruses , which is building an infrastructure for reporting of outbreaks of food-related illness attributable to enteric viruses . In Europe, no central institute yet exists with the authority to do this, so the best efforts to date are the voluntary disease-specific surveillance networks, such as Enternet , and the European Influenza Surveillance Scheme (designed to monitor influenza virus activity across Europe) . Both the epidemiologic data and laboratory data (mostly sequences) can be searched easily. Thus, participants can be alerted to similarities in disease profiles  or in sequences. Either signal can lead to contacts between participants to discuss possible indications for a joint investigation. Crucial in this discussion was the issue of confidentiality, both for patient and product information, and for data from investigations. The present modus operandi is that each participant signs a confidentiality agreement, which states that data submitted to the database are owned by the person submitting them ; specific patient and product information is not entered into the database. If necessary for outbreak investigations, the groups involved will decide on a case-by-case basis what information may or may not be used by the consortium. Participants can obtain the complete information from the database for their own analysis, or choose to use it as a search tool and rely on the analysis done by a scientist employed on this aspect of the database, who is stationed in Bilthoven, the Netherlands. So far, five international outbreaks have been detected because of the network.The food distribution chain in Europe is complex, and therefore the transmission of viruses across borders can occur by means of contaminated food. The surveillance network described here allows early detection of international common-source outbreaks of foodborne viruses. Most of the work to date has involved harmonization of methods for investigating outbreaks and detecting the viruses causing these outbreaks, as well as the development of a database system that facilitates the exchange of information between laboratories and institutes involved in viral gastroenteritis research and surveillance. The system’s strength is that it combines basic epidemiologic and laboratory data into a searchable repository. This network has demonstrated its potential to recognize transnational outbreaks. However, the network is inherently limited by the quality of data available at the national level, which is a reflection of the priority given to foodborne viruses. At present, we are undertaking a 2-year enhanced surveillance project to study the frequency and modes of transmission of viral gastroenteritis outbreaks across Europe.


Preventative strategies that focus on addressing the social determinants of health to improve healthy eating and physical activity have become an important strategy in British Columbia and Ontario for combating chronic diseases. What has not yet been examined is the extent to which healthy living initiatives implemented under these new policy frameworks successfully engage with and change the social determinants of health.Initiatives active between January 1, 2006 and September 1, 2011 were found using provincial policy documents, web searches, health organization and government websites, and databases of initiatives that attempted to influence to nutrition and physical activity in order to prevent chronic diseases or improve overall health. Initiatives were reviewed, analyzed and grouped using the descriptive codes: lifestyle-based, environment-based or structure-based. Initiatives were also classified according to the mechanism by which they were administered: as direct programs (e.g. directly delivered), blueprints (or frameworks to tailor developed programs), and building blocks (resources to develop programs).60 initiatives were identified in Ontario and 61 were identified in British Columbia. In British Columbia, 11.5% of initiatives were structure-based. In Ontario, of 60 provincial initiatives identified, 15% were structure-based. Ontario had a higher proportion of direct interventions than British Columbia for all intervention types. However, in both provinces, as the intervention became more upstream and attempted to target the social determinants of health more directly, the level of direct support for the intervention lessened.The paucity of initiatives in British Columbia and Ontario that address healthy eating and active living through action on the social determinants of health is problematic. In the context of Canada's increasingly neoliberal political and economic policy, the public health sector may face significant barriers to addressing upstream determinants in a meaningful way. If public health cannot directly affect broader societal conditions, interventions should be focused around advocacy and education about the social determinants of health. It is necessary that health be seen for what it is: a political matter. As such, the health sector needs to take a more political approach in finding solutions for health inequities. Preventative strategies focusing on healthy eating and physical activity, collectively known as healthy living, have become an important strategy in Canada for combating chronic diseases. Chronic diseases are rising to epidemic proportions in the Canadian population and costs associated with treating them pose a serious threat to the sustainability of the health care system . Addresssocial determinants of health.Within a Canadian context, some examples of social determinants of health that have been identified are: income and income distribution, education, unemployment and job security, employment and working conditions, early childhood development, food insecurity, housing, social exclusion, social safety net, health services, aboriginal status, gender, race and disability . The socThe Social Determinants of Health: The Canadian Facts, and includes policies that offer a higher minimum wage, higher assistance levels for those unable to work, a more progressive taxation structure that redistributes income more fairly, increased unionization, better funding of public education, government regulation of post-secondary institution tuition, stronger legislation on anti-discrimination policies and equal opportunity hiring, a national childcare strategy, strategies to increase the affordability of nutritious food, increased spending on a housing strategy, policies that reduce barriers for refugees and immigrants to practice their professions, and recognizing Aboriginal government authority over a wider range of Aboriginal affairs .In order to effectively address the social determinants of health, ON and BC have committed to multi-sectoral action that targets the population on a variety of levels. Both BC and ON have stressed the importance of partnerships in the public health model to achieve prevention goals with other levels and sectors of government, NGOs, private industry, service providers, researchers, and communities to name a few ,28,30-32These strategies suggest a socio-ecological approach to healthy eating and active living, a model of health that recognizes the interaction between individuals and their greater environment and its impact on health. In a socio-ecological model, the health behaviours that individuals engage in are impacted by individual factors , as well as interpersonal, community, organizational and society-level factors ,34. InteBased on the priorities that are listed above for healthy eating and active living in ON and BC, it would be expected that initiatives in both provinces target the population in diverse settings and at multiple levels, with a majority of initiatives focusing on improving population health through a social determinants of health framework. However, what has not yet been examined is the extent to which healthy living initiatives implemented under these new policy frameworks successfully engage with and change the social determinants of health.This study seeks to evaluate healthy living initiatives in BC and ON that focus on healthy eating and physical activity based on their approach to the social determinants of health and health inequities. The authors draw on a political economy of health perspective in order to evaluate the initiatives within their broader social, political and economic context . This imPublically-available provincial policy documents written between 2005 and 2011 in BC and ON that focused on chronic disease prevention were used as a starting point to identify relevant initiatives. The focus was on chronic diseases that are most affected by nutrition and physical activity - namely cardiovascular diseases, some cancers, diabetes, hypertension, stroke and chronic respiratory disease. Once initiatives were identified, a web-based search was conducted to obtain a detailed description of the program as well as its timeline and current status  etc. Provincial organizations that had the potential to conduct initiatives were also researched online to find initiatives that may not have been mentioned in the original policy documents and database. The search was not restricted to initiatives led by provincial ministries related to health; they could be initiatives of other ministries, arms-length government agencies or independent non-profit organizations that worked to improve healthy eating and physical activity. In order to ensure the list of healthy living initiatives was comprehensive, it was compared against recent documents and public databases that provide listings of healthy living initiatives at municipal, regional and provincial levels in BC and ON ,37,38. La) Initiatives focused on healthy eating and physical activity as a preventative strategy to reduce chronic diseases or improve general health. The initiatives were not limited to government interventions - the initiatives could be funded and developed by various organizations including actors in the government, non-profit and private sectors.b) Initiatives were implemented in BC and ON between January 1, 2006 and September 1, 2011.c) Initiatives were provincial rather than regionally or nationally-based. Initiatives that focused on select sites in the province were also permitted provided they weren't restricted to a particular region or area. For example, an intervention targeting remote communities in ON would be acceptable for analysis, whereas an intervention led by a particular health authority and applied only to that health authority's region would not be included.The findings are limited to the provincial scope of initiatives selected. It is difficult to determine if analysis of regional, municipal or community level initiatives would reveal convergent findings, and represents an area for future study.Each of the identified initiatives was reviewed, analyzed and grouped using descriptive labels. Codes were developed directly from the data by asking the following questions of each initiative:a) What section of the population does the initiative target? b) What factor is the initiative trying to change that will lead to healthy eating and active living? c) Does the initiative directly acknowledge and attempt to act on the social determinants of health? If so, in what way? d) What is the mechanism that the initiative uses to promote healthy living? The predominant themes that emerged from questions b. and c. reflected three types of initiatives: lifestyle-based, environment-based, and structure-based, which were defined for this paper in the following ways:: These initiatives aim to improve healthy living through lifestyle change of individuals. Examples include raising awareness of the issues (e.g. obesity) in the general population, increasing knowledge around nutrition and physical activity, changing attitudes towards healthy living by appealing to social norms  or directly encouraging the adoption of new behaviours through programs . The target audience could be the general public or specific groups • Lifestyle-based: These initiatives are meant to improve healthy living by influencing the immediate environment in which people spend their time, such as schools, workplaces and community spaces. Examples of these initiatives range from encouraging employers to initiate healthy workplace programs to banning the sale of unhealthy foods in schools or working towards a built environment that encourages physical activity. These initiatives were frequently settings-based and address the role that immediate environmental factors play in health.• Environment-based• Structure-based: These initiatives directly acknowledge the impact of various structures  that create inequities leading to chronic diseases and attempt to address the social determinants of health directly in order to improve healthy eating and active living. These types of interventions are most frequently centered around education and advocacy on the social determinants of health and worked specifically to correct health inequities caused by these structural conditions. Examples include a survey tool that assesses the cost of basic healthy eating in different geographic areas in order to monitor accessibility and affordability of a nutritious diet, the creation of community forums to discuss the social determinants of health and explore structural barriers to healthy living, or consultation services that provide gender equity audits to sport and recreation organizations. Of the three categories, this one is the only one that directly acts on the social determinants of health.For each initiative type, it was also found using questions a. and d. that there was a broad variety of mechanisms by which the initiative was supported and delivered. Consequently, in each category, initiatives were classified according to the mechanism by which they were administered. Mechanisms were categorized as direct programs, blueprints, and building blocks, and were defined as the following:: Initiatives that are developed and implemented to directly influence the health of the population. Initiatives could be implemented through organization staff, contracting of other staff, working with community partners, or enforcing mandatory policy. Examples include direct services from health professionals such as phone lines staffed by dieticians and specialists in physical activity, bills to prohibit certain foods, and programs that provide healthy snacks to schoolchildren. This category also applies to programs that reward organizations  for programs they have already implemented.• Direct program• Blueprint: Initiatives that are developed but require implementation and tailoring by a third party such as a school, public health unit, or community organization. These initiatives are categorized as blueprints because while they offer a "plan" for a healthy eating and active living intervention (HEAL), they do not directly act on the population and their implementation is optional. Examples include toolkits for healthy school policies, materials for teachers to encourage student physical activity, and frameworks for how to build healthy communities. These initiatives require more action at the local level than direct programs because although the initiative is planned, local actors are needed to carry it through.• Building Blocks: Initiatives that are meant to act as resources for third parties to develop their own projects, within certain guidelines. Examples include grants for communities to build their own HEAL project, consultation and training services on program planning, and directories of HEAL initiatives to act as a resource for ideas in developing an initiative. These initiatives require the most action at the local level; their planning and implementation fall to local actors and they provide the least support from the organization that is offering the initiative.From the systematic scan of the policy documents, database and website search, 60 initiatives were identified in ON and 61 were identified in BC. . Structure-based interventions were those that received the least direct support: only one was enacted through direct programming, one used the blueprint format, and six were building blocks-type initiatives.ON yielded similar results in terms of distribution - the preponderance of initiatives were lifestyle-based, followed by environment-based, with very few aimed at structural change. Of 60 provincial initiatives identified, 36 were lifestyle-based, 26 were environment-based and nine were structure-based. Six interventions had multiple components that targeted a combination of lifestyle, environmental and structural factors, and so were classified into more than one category. Most lifestyle-based interventions were direct (23), while 11 were blueprint initiatives and four were building blocks. Environment-based initiatives were also more likely to be direct (13) while nine were blueprints and four were building blocks. Of initiatives that acted at a structural level, two acted through direct mechanisms, three were blueprints and four were building blocks.In summary, BC and ON had similar distributions of intervention types, with the majority falling into lifestyle-based initiatives, followed by environment-based initiatives, and a small proportion falling into the structure-based category. While many initiatives focused on changing lifestyle and the immediate environment to improve healthy eating and physical activity, very few were directed towards changing more upstream social determinants of health, such as the economic and social conditions that create inequities between genders, income groups and ethnic groups. Only 11.5% of initiatives in BC and 15.0% of initiatives in ON had structural components that directly spoke to the social determinants of health.In terms of the mechanism by which the intervention was implemented, ON had a higher proportion of direct interventions than BC for all intervention types . However, the same trend can be observed for both provinces: as the intervention becomes more upstream and attempts to target the social determinants of health more directly, the level of direct support for the intervention lessens. In BC direct programming drops from 47.4% for lifestyle-based initiatives to 37.1% for environment-based initiatives to 0% for structure-based initiatives. In ON direct programming drops from 63.9% for lifestyle-based initiatives to 50.0% for environment-based initiatives to 22.2% for structure-based initiatives. For a visual representation of this trend, please see Figure The dominance of lifestyle-based and environment-based initiatives is troubling considering that initiatives were expected (and directed) to focus on the social determinants of health. Although individual behaviour change theories were popular early in the health promotion movement, the field of public health has matured to embrace a more multi-level approach. This change of focus was in recognition of the fact that individual behaviour change strategies are not enough for lasting health improvements, given structural conditions which predispose people to illness -41. TheyEnvironment-based interventions, while more sensitive to the context in which people live and work, still do not tackle the structural determinants which create these conditions in the first place. Programs aiming to increase access to nutritious food and physical activity in particular settings such as schools, workplaces, government buildings and communities do not alter the factors which create inequities and unfavourable living conditions . EnvironWhat is needed are structural interventions that are inherently redistributive in nature; interventions that broaden the distribution of power, income, goods and services across the population. Research has demonstrated limited effectiveness of downstream interventions (such as programs that focus on behaviour change) when structural barriers are not addressed -50. ThisAs can be seen from the paucity of structural interventions, this approach to healthy living is lacking in ON and BC despite provincial policy direction. Another discouraging trend found in the data is the decrease in direct initiatives (direct programs) and increase in more indirect ones (at the blueprint and building blocks levels) as the initiatives become more upstream. The amount of indirect initiatives could be interpreted as a move towards increasing community capacity, inclusion, local responsiveness and decision-making in healthy living initiatives. However, the more upstream and broad-scale an intervention is (i.e. an environment or structure-based program), the more it would benefit from coordinated action at a higher, more structural level . InitiatHealth equity interventions can also require more direct action from government - for example, an initiative that would help to balance the distribution of wealth in Canada is a more progressive taxation structure or an increase in minimum wage to account for inflation and provide a higher standard of living. These are initiatives which cannot be undertaken by individuals and communities. As the word 'structural' implies, they need to be acting directly on the structures  which create and maintain health inequities. Instead, communities that do not have that capacity are more likely to receive this responsibility - in the form of grants, training workshops for program planning, or resource directories. These initiatives are framed as supporting communities in building their own initiative that addresses the social determinants of health. However, the pressure that it places on communities is enormous, and allows the public health system to abdicate its responsibility to address the social determinants of health directly and in a concrete manner. Instead it can point to these initiatives and claim that they are focussing on the social determinants of health - this is essentially the provinces of ON and BC "passing the buck".Given the fact that policy documents on chronic disease prevention and healthy living at the provincial level in both BC and ON acknowledge the importance of the social determinants of health, why is the health sector not acting on them? An explanation can be found in the context of Canada's political and economic policy over the past several decades. A neoliberal approach to the economy that favours freedom of the market has resulted in the retraction of government intervention in the areas that are crucial to the health and well-being of Canadians. Research has found that Canadians are experiencing increasing levels of poverty and income inequality, as absolute levels of poverty increase and the gap between the poorest 10% and richest 10% widens . ResearcOther determinants of health have also been affected by government policy. The public education system has suffered cutbacks and labour conflicts that reduce its ability to provide quality education . StricteThe effects are felt as a result of inadequate policy and public expenditures on social programs, which are key characteristics of the neoliberal model. Public spending on family-related benefits has been scaled back since the 1980s, and taxation policy between 1990 and 2005 has increased the tax burden on the bottom 10% of income earners and relieved it from the top 1% . MinimumWithin the context of a national and provincial neoliberal climate, it is not surprising that the health sectors of BC and ON have not attempted to implement widespread structural change to improve healthy living -64. EvenWe would argue that the ultimate goal of healthy living programs should be to improve the social determinants of health and eliminate health inequities. It is recognized that it is out of the scope of the health care sector to effect those changes on its own, and it faces barriers in partnering with sectors for collaborative, cross-sectoral action. However, public health should be constantly attempting to move towards those goals. It should not settle for programs that bring about changes in lifestyle and the immediate environment while only addressing the social determinants model at a conceptual level.If programs cannot directly affect lasting, broader societal conditions, interventions should be focused around advocacy and education about the social determinants of health - advocacy at the level of the population, service providers, health organizations, and government in order to build political will to address them. The structural interventions listed in Additional file One barrier for public health professionals to address the social determinants of health is a lack of understanding of how to do so; although there is a wealth of theoretical understanding of how these determinants affect health, there have been few examples to date that illustrate how to effectively change them ,65. In aEven in a conservative political climate, it is clear that there are improvements that can be made within public health to foster a greater understanding of how to focus programming on the social determinants of health. The WHO Commission on the Social Determinants of Health notes that a comprehensive health equity surveillance system would capture the most upstream structural drivers of health inequities  as well as more intermediate ones that encompass the daily conditions in which people live and work. Such a system could monitor health equity by stratifying morbidity and mortality data by indicators such as income, occupation, gender, region, ethnicity and immigration status . Some suIndigenous Cultural Competency Online Training Program[It is equally important that health organizations and professionals know how to use evidence on inequities and the social determinants of health to create meaningful initiatives. To do this, there must be a comprehensive understanding among the healthcare force of the social determinants of health and how they affect populations. This includes awareness of the social, political and historical context of how these inequities are generated and continue to be maintained. The provincial health services authority in BC has a program modeling this principle called the g Program. This prEvidence and Practice-based Planning Framework: with a focus on health inequities. In the first two steps of program planning , planners are encouraged to consider the following: community health needs, the OPHS mandate on the social determinants of health, and the association between health status and the determinants of health. Further, they are asked to engage stakeholder perspectives [With solid evidence and a comprehensive understanding of inequities, there are many ways that public health can begin to address the social determinants of health in programming. One possibility is using public health planning models that integrate the social determinants of health into the planning process. The Region of Waterloo Public Health in ON developed a planning model that does this, based on the Ontario Public Health Standards (OPHS) . The modpectives . Anotherpectives . This frpectives . When coNutritious Food Basket, described in Table Nutritious Food Basket is a program mandated by Ontario Public Health Standards (OPHS) for boards of health to implement in municipalities across the province. Boards of health are required to survey local supermarkets and grocery stores in order to calculate the cost of basic healthy eating for individuals and families. This program is ideal for a number of reasons. It links what is normally considered a behaviour  to greater structural determinants such as income and regional differences in food accessibility. Because the survey is taken annually, it can keep pace with larger economic trends such as inflation and food cost patterns, and because it is performed systematically using a detailed protocol it presents reliable data. The data, as mentioned in the Nutritious Food Basket Protocol, can be used for program planning, policy decisions, and advocating for accessible, affordable foods. The Nutritious Food Basket can be used as powerful evidence for the necessity of income redistribution policies ensuring that families make enough money to maintain a healthy diet [Information and programs generated within the public health sector can be used to advocate for structural change to improve healthy living. An exemplary initiative in Ontario is the thy diet . Certainthy diet -74.A current leader in championing health inequities is the Sudbury & District Health Unit, whose team has launched public awareness campaigns linking the social determinants to health outcomes, created health planning and mapping tools that focus on equity, established in conjunction with the City of Sudbury a Food Charter that recognizes food as a basic human right, and developed a primer for municipal leaders explaining the connections of social determinants to public health and how they could address them effectively . AlthougExternal evidence from other countries can also be used as leverage - for example healthy living and chronic disease policy in Northern European countries such as Sweden and Norway. Sweden initiated a public health policy in 2000 which stressed improving employment conditions and decreasing poverty as primary goals for improving health . Sweden This study is not without limitations. For example, the focus on provincial-level initiatives excluded initiatives happening at regional, municipal and community levels. This selection was strategic in that it attempted to maximize the likelihood of finding initiatives which addressed the social determinants of health - conditions that require multi-sector, systemic change. It was assumed that this type of change more likely to happen at the provincial level as opposed to in a city or region, but it is possible that initiatives that address the social determinants of health at a more local level were overlooked. Secondly, our search strategy was limited to initiatives that focused explicitly on healthy eating and active living and did not seek to identify social programs in other sectors (for example housing) that may address the social determinants of health and impact healthy eating and active living indirectly. We would like to emphasize, however, that our focus was on what is occurring within public health at a provincial level to improve healthy eating and active living. The presence of social programs in other sectors does not reduce public health's obligation or commitment to addressing the social determinants of health. Finally, our analysis did not attempt to document whether desired outcomes related to the social determinants of health were achieved by the searched initiatives; such outcomes require many years to manifest themselves.Addressing the social determinants of health necessarily means moving away from depoliticized frameworks that emphasize biomedical factors in disease. Attention to the social determinants and inequities has been growing, as health promotion movements evolve - movements that were initially led by Canada. However it is necessary that health be seen for what it is: a political matter. As such, the health sector needs to diversify to a more political approach in finding solutions for health inequities. Until this occurs, it is debatable how much progress can occur on improving the social determinants of health.The authors declare that they have no competing interests.DG conceived of the study, lead the analysis and drafted the manuscript. AK participated in refining the study's design, acted as a critical discussant of analytical findings and helped to draft the manuscript. Both DG and AK read and approved the final manuscript.BC Healthy eating and active living initiatives analyzed (61).Click here for fileON Healthy eating and active living initiatives analyzed (60).Click here for file


Systematic planning could improve the generally moderate effectiveness of interventions to enhance adherence to clinical practice guidelines. The aim of our study was to demonstrate how the process of Intervention Mapping was used to develop an intervention to address the lack of adherence to the national CPG for low back pain by Dutch physical therapists.We systematically developed a program to improve adherence to the Dutch physical therapy guidelines for low back pain. Based on multi-method formative research, we formulated program and change objectives. Selected theory-based methods of change and practical applications were combined into an intervention program. Implementation and evaluation plans were developed.Formative research revealed influential determinants for physical therapists and practice quality managers. Self-regulation was appropriate because both the physical therapists and the practice managers needed to monitor current practice and make and implement plans for change. The program stimulated interaction between practice levels by emphasizing collective goal setting. It combined practical applications, such as knowledge transfer and discussion-and-feedback, based on theory-based methods, such as consciousness raising and active learning. The implementation plan incorporated the wider environment. The evaluation plan included an effect and process evaluation.Intervention Mapping is a useful framework for formative data in program planning in the field of clinical guideline implementation. However, a decision aid to select determinants of guideline adherence identified in the formative research to analyse the problem may increase the efficiency of the application of the Intervention Mapping process. Adherence to clinical practice guidelines (CPGs) is limited, and interventions to enhance uptake have been only moderately effective ,2. This Non-specific low back pain constitutes a serious public health problem associated with significant socioeconomic burden, and physical therapy is expected to contribute to the reduction or elimination of this burden . AlthougThe aim of our study was to demonstrate how the process of Intervention Mapping can be usThe three core project team members, a doctoral candidate, faculty member and project coordinator, performed the formative research and initial program development. Advisory group members, including the leader of the Dutch physical therapy guidelines program, a member from the Royal Dutch Association for Physical Therapy responsible for quality policy, practicing physical therapists, and a representative of an interest group on patient and healthcare provider communication, began working on the project early in the intervention development phase.Based on the specific recommendations in the CPGs for low back pain, we first developed a set of indicators to operationalize guideline adherence . Then, wWe used the results of our multi method formative work to develop a synthesis of most important determinants. Subsequently, we organized our findings into a logic model of the problem of lack of guideline adherence highlighting the central roles of therapists and the practice quality managers  on physical therapist adherence; the 12 quality indicators that reflect guideline adherence; formative findings regarding the importance of clinical reasoning  and a guiding theory of individual and organizational learning self-regulation  ,20.Performance objectives are listed in Table We combined performance objectives with determinants to create matrices of change objectives, the specific targets for the intervention. Excerpts of the matrices are included in Table Based on the change objectives, we used the next 3–4 months to match theory-informed intervention methods to the change objectives for therapists and managers and to formulate practical applications. An intervention method  is a thAn overview of methods and applications with reference to the theories from which they are derived is presented in Table The project team proposed a series of interactive workshops, away from the worksite, as the primary intervention component to encourage peer education and for interaction between physical therapists and quality managers. Also, by participating in the workshops, the physical therapists and quality managers would break with their daily context and routines, a disruption which was expected to help them change habitual behaviour.During the next 4 months, the project team worked with two experienced physical therapy trainers with expertise in quality improvement projects. The team provided the trainers with program, performance, and change objectives, the theory-informed behaviour change methods and practical applications, and four case descriptions of patients with low back pain. The trainers integrated these elements into a coherent and feasible program with review from the project team.The program comprised six meetings: four 3-hour sessions for physical therapists and quality managers together and two 3-hour sessions for quality managers. We expected the extensive opportunity for therapist and manager interaction to enhance the quality improvement process. During the sessions, physical therapists assessed personal adherence to the guidelines by comparing a patient record with the recommendations in the guidelines. Subsequently, they chose and considered an implementation strategy for three specific, measurable, acceptable and realistic objectives for personal improvement. Trainers challenged the therapists to implement one of their objectives and to evaluate what changed in their process of care. Finally, therapists thought about how to maintain their changes. Results of these activities were a Personal Development Plan that contained pointers for individual quality improvement, goals achieved, goals still to be achieved, intended strategies, and a sustainability plan. Additionally, the physical therapists chose three collective goals with colleagues and the quality managers from their practices.During two sessions, trainers taught the quality managers how to use a management scan to assess issues related to improvement of five organizational domains: leadership, strategy, management of means, people management, and process management . TrainerFinally, the program made use of the most current draft revision of the Dutch physical therapy CPG on low back pain (unpublished manuscript). To explicitly support clinical reasoning, this revised guideline links recommendations to findings from evaluation steps in the process of care. The workshop also provided a patient information leaflet on guideline adherent care to support physical therapists’ as they managed patient’s treatment expectations.From the beginning of the planning process, we paid attention to capacity for the program’s adoption, implementation and sustainability, including its practical acceptability and feasibility throughout development. The plan components to facilitate adoption, implementation and sustainability were directed at policy of the professional association to bring a focus on quality improvement; information for the patient to discourage seeking hands-on treatment and to increase awareness of the importance of psychosocial factors in low back pain; revision of the guidelines to increase support for clinical reasoning and for dealing with psychosocial factors; regular inclusion of our program in nationwide training programmes.The evaluation plan concerned the pilot test of the quality improvement program. Aims of the evaluation were to assess the potential effectiveness of the program as well as to evaluate the fidelity, acceptability and feasibility of the program’s implementation in an accompanying process evaluation.For the effect evaluation, we planned a one-group pre-test/post-test study . We measured adherence to the CPGs on low back pain with clinical vignettes that addressed the previously mentioned 12 indicators reflecting the guidelines’ main recommendations. These vignettes were based on validated vignettes from a previous study, which showed to have acceptable validity (Spearman’s rs = .31) to measure PTs’ guideline adherence -39. ClinThe process evaluation was an observational study of fidelity, acceptability and feasibility. Concerning fidelity, evaluation addressed whether the implementation addressed the planned behaviours, methods and practical applications, performance objectives and change objectives, program components and activities previously specified. We also assessed the extent to which physical therapists and quality managers participated in activities. Regarding acceptability we asked the participants’ to evaluate the intervention and materials used. Feasibility questions addressed potential barriers, such as time and financial limitations.This study demonstrates how the framework of Intervention Mapping can be used to develop interventions that aim to improve guideline adherence based on formative research. Findings from multi-method formative research provided the foundation for a logic model of the problem of physical therapists’ low adherence to clinical guidelines for low back pain. This logic model enabled the planners to first decide “who” and “what” should change as a result of the intervention. From the formative work, we decided that the intervention should influence both therapists and managers at the practice level and that these participants should actively plan and implement practice change through a process of self-regulation with therapists monitoring and analysing personal adherence, setting goals for improvement, implementing plans and evaluating outcomes. Quality managers were taught to plan and implement change at the practice level.Based on the findings from the formative work regarding the behaviours necessary to implement clinical guidelines and the influences on behaviour at both the therapist and practice levels, we produced matrices of change objectives, the guiding documents for program development. The change objectives pointed to the selection of theory-informed behaviour change methods and practical applications and, finally, to the creation and delivery of a coherent program.To systematically develop a multilevel intervention using the Intervention Mapping framework presented some challenges. We were surprised at the analysis needed and the lack of clear guidance for how to sort through the formative findings to select the most important performance objectives and behaviours for both the therapist and the practice levels. The formative data, including literature review, did not  provide clear evidence of causation - either about what people should do to reach the behaviour change targeted by the intervention, nor why they would engage in the performance when specified. For example, from the survey we found that almost 80% of the participating physical therapists were inclined to follow the patient’s preferences. This suggested to us that motivation to comply may be a salient determinant of guideline adherence, but the relation certainly could not be depicted as causal. Nevertheless, this partial evidence is generally the state of the knowledge, in terms of developing interventions and adapting evidence-based interventions to new settings. We would argue that an imperfect systematic process of selecting and using information about behaviours and determinants is much better than simply avoiding the evidence altogether. Several selection procedures have been described by other researchers -43, but A second challenge was related to the selection of theory-based behaviour change methods and practical applications. Although many theories postulate how change in behaviour may occur, the evidence for the underlying assumptions is still under development ,21. A reA third issue arised while developing the intervention program. Preferably, this program would adequately address all selected determinants for optimal change ,21. ThisFinally, the foregoing issues raised, indicate that thoroughly going through each step of Intervention Mapping may be a time consuming, and therefore costly process. It is indeed our opinion that familiarity and experience with the Intervention Mapping procedure may be a great advantage in this respect. The process may further benefit from sound planning based on anticipation on the subsequent steps. This can reduce the likelihood of unforeseen developments and too much backtracking, and consequently of the required time investment.A positive, but challenging aspect of guidance provided by Intervention Mapping is that interventions be focused on various levels of the ecological model. In our case, this meant targeting both individual behaviour and practice level elements. We developed an intervention for guideline adherence of physical therapists, a factor that can be considered to be an environmental influence for patient behaviour and health outcomes. We also addressed quality managers, a group in the practice environment of the therapists. Our formative studies revealed several factors related to inadequate practice quality management that negatively influenced physical therapists’ guideline adherence. Although targeting these multilevel influences on low back pain care complicated our selection of behaviours, determinants, change methods and ultimately program components, our formative work provided us with a sound rationale for the development of our program.We conclude that, despite the difficulties we encountered, applying the framework of Intervention Mapping provided the required sound rationale for the development, implementation and evaluation of an intervention for the Dutch physical therapy CPG on low back pain based on multi method formative research. We expect that the stepwise approach of Intervention Mapping can be a valuable framework for future intervention development designed to improve guideline implementation. However, a decision aid to select determinants of guideline adherence identified in the formative research to analyse the problem may increase the efficiency of the application of the Intervention Mapping process.The study was approved by the Committee on Medical Research Involving Human Subjects (CMO) Arnhem-Nijmegen (Filenr. CMO 2007/172).GR: Geert M Rutten; JH: Janneke Harting; AS: Angelique Schlief; LKB: L Kay Bartholomew; RABO: Rob AB Oostendorp; NKV: Nanne K de Vries.The authors declare that they have no competing interests.GR and JH conceived the study. Together with GR and JH, AS contributed to the formative research and the logistics of the study. LKB, RABO and NKV also contributed to the conceptual idea of the formative research and the intervention. All authors were involved in the development process of the intervention. GR drafted the manuscript, all other authors contributed to manuscript review and revision and read and approved the final manuscript.Data sources and findings of the formative research.Click here for file


In research, diagrams are most commonly used in the analysis of data and visual presentation of results. However there has been a substantial growth in the use of diagrams in earlier stages of the research process to collect data. Despite this growth, guidance on this technique is often isolated within disciplines.A multidisciplinary systematic review was performed, which included 13 traditional healthcare and non-health-focused indexes, non-indexed searches and contacting experts in the field. English-language articles that used diagrams as a data collection tool and reflected on the process were included in the review, with no restriction on publication date.The search identified 2690 documents, of which 80 were included in the final analysis. The choice to use diagrams for data collection is often determined by requirements of the research topic, such as the need to understand research subjects' knowledge or cognitive structure, to overcome cultural and linguistic differences, or to understand highly complex subject matter. How diagrams were used for data collection varied by the degrees of instruction for, and freedom in, diagram creation, the number of diagrams created or edited and the use of diagrams in conjunction with other data collection methods. Depending on how data collection is structured, a variety of options for qualitative and quantitative analysis are available to the researcher. The review identified a number of benefits to using diagrams in data collection, including the ease with which the method can be adapted to complement other data collection methods and its ability to focus discussion. However it is clear that the benefits and challenges of diagramming depend on the nature of its application and the type of diagrams used.The results of this multidisciplinary systematic review examine the application of diagrams in data collection and the methods for analyzing the unique datasets elicited. Three recommendations are presented. Firstly, the diagrammatic approach should be chosen based on the type of data needed. Secondly, appropriate instructions will depend on the approach chosen. And thirdly, the final results should present examples of original or recreated diagrams. This review also highlighted the need for a standardized terminology of the method and a supporting theoretical framework. Diagrams are graphic representations used to explain the relationships and connections between the parts it illustrates. There are many subcategories of the broader term 'diagram', which are distinguished by the elements they incorporate or their overall topic. Two dominant subcategories include 'concept maps' and 'mind maps'. DiagramThe use of diagrams in earlier stages of the research process (i.e. to collect data) is a relatively new method and is not a common data collection approach at present. However, their use is developing in multiple disciplines, including healthcare research. Diagrams have been used to collect data from research subjects by asking them to either draw a diagram themselves or modify a prototypic diagram supplied by the researcher. The use of diagrams in data collection has been viewed favorably in helping to gather rich data on healthcare topics. These research topics are widely varied and include collecting information to improve patient safety with medication, understDespite the increasing use of diagrams in data collection, there lacks a strong "supportive structure" (pg. 343) for researchers choosing this method. The useBy conducting a multidisciplinary systematic review, as defined in the PRISMA statement, we hope(1) What drives the selection of a diagramming approach for data collection?(2) What are the different approaches to diagramming for data collection?(3) What are the different approaches to analyzing data collected with diagramming?(4) What are the benefits and challenges of using diagramming for data collection?Diagramming techniques used for data collection in the research process is a challenging area to review, given the variable terminology across, and even within, fields. A preliminary survey of the literature helped identify some key terminology used in different disciplines (e.g. "graphic elicitation" or "participatory diagramming"). The terms used in the titles and abstracts of the preliminary articles identified, as well as the keywords used to index them in databases, formed the basis of our multidisciplinary search strategy. We combined these specific terms with general 'diagram' terms and with general 'data collection' and/or 'analysis' terms.In December 2009, we electronically searched 13 indexed sources, including traditional health care related indexes and non-health focused indexes . To ensure that all appropriate references were identified and to limit publication bias, non-indexed sources were also searched via general search tools (i.e. Google Scholar and Google Books) to uncover any additional publications. To supplement the search, 35 experts, identified by our searches, were contacted and asked to identify additional relevant articles and grey literature.Reference Manager 11 was used to support the review. Following the removal of duplicates, articles were screened based on their title and abstract. The full-text was then screened for articles not excluded based on their title/abstract. Articles were excluded if they were not written in English, did not use diagramming techniques in the data collection process (i.e. research subjects did not create or edit diagrams) or were not evaluative or reflective about the data collection process and/or analysis of data collected from diagramming methods. No publication date or publication type restrictions were imposed; research studies, theoretical articles, method articles and opinion pieces were included if they met the above criteria.The screening was undertaken by two authors . Double screening was done at regular intervals to ensure inter-rater reliability. Further, the two researchers met weekly during the screening and data extraction phases to discuss the nuances of the articles and to resolve differences by deliberation until consensus was reached.A total of 2690 references were identified, after the removal of duplicates. Given our search had no publication date restrictions and included dissertations, full-text articles were sometimes difficult to retrieve. Authors were contacted when the article could not be found online or through the University of Toronto's library system. While 4 articles were retrieved in this manner, 27 full-text articles still could not be found and were ultimately excluded. In total, 233 full-text articles were screened and a total of 80 articles were included in the study's review. Figure Of the 80 articles included in our review, 53 were published studies-15,19-58The most common discipline, determined by the lead author's affiliation and/or publication title, was from the education field. Other disciplines included healthcare, engineering, environmental science, geography, industrial design, psychology, and social science. The majority of articles clearly specified the study sample size, which averaged 36 research subjects, with a range of 2 to 243. Diagramming methods were used with a wide variety of research subjects, including students (elementary to graduate school), farmers, nurses, physicians, engineers, administrators and graphic designers.The majority of articles specified at least one explicit reason why a form of diagramming was selected for data collection. These reasons fall into two broad categories: requirements or challenges of the research topic and the unique dataset that results from using diagrams.The specific research topic examined was the most common reason for researchers choosing a diagramming technique for data collection. For some research topics, past studies have validated diagramming data collection techniques as a useful way to collect data. For example, research has established the usefulness of diagrams in collecting data about research subjects' knowledge or cognitive structures-22,59,80Secondly, researchers sought out diagramming data collection methods because of the benefits previous studies found regarding the quality and uniqueness of the collected dataset. When research subjects drew diagrams without prompts, previous studies concluded that it minimized the influence of the researcher on the participant and their responses,62,81,82A range of applications were identified, which varied widely based on the degree of instruction, degree of freedom in diagram creation, the number of diagrams created or edited and the use of diagram in conjunction with other data collection methods.Half of the studies did not report the details of the instructions provided to the research subjects, except for describing the basic request to create a diagram. One study explicitly observed that specific instructions are needed to ensure the research participants create a diagram and not another form of written material, such asWhen the researcher sought highly structured diagrams, the degree of instruction provided to the research subjects ranged from the preferred method of giving specific and detailed instructions on what elements should be included  to showing an example of the type of diagram the researcher would like the participant to create. For example, in comparison to other diagramming techniques, concept maps have a fairly rigid definition and a very specific set of elements that the end diagram should contain. Such diagrams may require more detailed instructions. One study had associate nursing degree students draw their own concept maps after a 20-minute introductory tutorial, presentation of a sample diagram, discussion and question period, and instructions listing all elements to be included . In someIt was most common for research subjects to create an original diagram on their own, in groups or a combination of both. Alternatively, some studies had the participant edit either a designated diagram provided by the researcher,14,15,42Half of the studies used diagrams at multiple times within the data collection process as a means of comparison. A subset used a pre-/post- (or time series) approach to data collection, allowing researchers to track changes before, after, and sometimes during an intervention. This was found primarily within the discipline of education. For example, Rios asked a sample of teachers to create concept maps at multiple time intervals in order to identify their conceptual models and examine the impact of student interactions on the teachers' subject matter structure or vice versa.Some researchers explicitly expressed the idea that diagrams alone would not capture complete perspectives from the research subjects,77, suggThe majority of the articles reported details about the analysis of diagram data. The use of only quantitative or qualitative analysis, or a mixture of both types of analysis was fairly equally distributed among the articles. Within each of these three categories of analysis, there were a variety of different techniques used that are briefly outlined below.The majority of studies comparing diagrams across time or across research subjects chose either quantitative techniques only or a mix of qualitative and quantitative techniques for their analysis. Quantitative analysis techniques included counting  and scoring. The two most common scoring methods were structural scoring and relational scoring. StructuStudies which had diagrams completed or edited in the presence of the researcher, included additional data collection methods, and/or studies using less structured diagrams to collect data were likely to use either qualitative techniques only or a mix of qualitative and quantitative techniques for their analysis. For example, Haidet et al. gave medical school research subjects less structure and encouraged creativity in their diagramming exercise within interviews. The diaIn some studies that used mixed-methods, the collected diagrams were the primary source of data and guided the analysis of additional data sources, for example, by providing the core themes for transcript analysis. In other cases the additional data sources played the dominant role in analysis and the diagrams were used almost as verification or visual representation to illustrate conclusions.Some of the benefits to using diagrams for data collection have already been discussed in the section on why researchers chose diagramming data collection approaches. In addition to these, diagramming approaches that were seen as complementary to other data collection approaches were commonly used in interviews and focus groups,73. TheyOver half of the articles discussed at least one challenge of using a diagramming method for data collection. Interestingly, these challenges were often contradicted by other articles. All studies completed their data collection with diagrams, with some reporting that the diagramming allowed research subjects to overcome challenges of verbal communication-29,75,79This systematic review represents the first overview of diagrams being used as a data collection approach in multiple disciplines. In 2006, Nesbit & Adesope conducteGiven our broad definition of a diagram, we have reviewed approaches for collecting data through a wide spectrum of diagrams, from highly structured concept maps to less defined diagrams. We have provided an overview of the instruction options for research subjects, the creation and analysis of diagramming as a data collection approach, as well as highlighted some of the benefits and challenges. While there is variation regarding the guidance in instructions and approaches to the construction of different diagrams, use of diagrams as a data collection tool as a whole is clearly increasing in healthcare and in other disciplines. This systematic review is the first step in consolidating this information to assist in the refinement of this approach. For those considering using diagramming as a data collection approach, we offer three recommendations. Firstly, the diagrammatic approach should be chosen based on the type of data needed to answer the research question(s). Secondly, based on the diagrammatic approach chosen, it is important to select the appropriate instructions needed. Finally, presentation of final results should include examples of the original or recreated diagrams.The most important considerations for choosing the diagramming approach is the type of data needed to answer the research question  and the type of analysis preferred by the researcher. For example, highly structured diagrams allowed for valid quantitative analysis, such as counting and ranking, which could be compared across research subjects. It should be noted that there is some controversy whether items should even be counted and that both an over- or under-reliance may be dangerous to the final research conclusions. In compThe appropriateness of different approaches to instructions to guide diagram creation is an important consideration in ensuring the validity of data. It is clear from our review that the initial instructions given to research subjects varied in structure but had a great impact on the resulting diagrams and their potential for different analysis techniques. If researchers require highly structured diagrams it may be useful to give research subjects more detailed instructions and the opportunity for practice and feedback,64.The last recommendation is that studies using diagramming data collection approaches should include visual presentations of the findings in their results sections. The use of diagrams often results in the collection of unique and unsolicited data through a visual component, which can then be displayed along with the final analysis. Just as diagrams can provide data not easily obtained through verbal data collection techniques, visual presentation of the collected diagrams may provide insights not as easily grasped through verbal communication of study results. While providing a scanned image of the original diagram can be difficult at times, it is also possible to present a photograph of the original diagram or a computer-generated recreation of the diagram. This is especially important given the variation in terminology between disciplines, as it relays to the reader the type and structure of diagrams created or used.In addition to the recommendations for researchers considering the use of diagramming data collection approaches, this multidisciplinary review also identifies areas where future research is needed. This review required a substantial amount of preliminary work to understand the terminology used to describe diagrams and this data collection approach across different disciplines and fields. The intent was to devise a sensitive search, so as to cast a wide net in order to capture articles in a range of disciplines where the terminology is not standardized. Cole et al. illustrate this issue by identifying over a dozen different terms that are used to describe concept maps. Thus faA limitation of our review is that the database search strategy did not capture general articles on visual data collection methods, which may include specific information on diagramming data collection approaches. However the non-indexed searches and articles identified by experts did pick up some of these articles. While efforts were made to contact authors to retrieve articles from our search, twenty-seven full-text articles were irretrievable. Ten of these were dissertations and five were books. This may have contributed to an incomplete representation of what the literature has to offer about diagramming data collection approaches.There has been a growing interest in the use of diagrams for data collection in the research process over recent years, as shown by the increase in publications and the wide range of approaches developed for diagramming data collection and diagram data analysis. As noted earlier, diagrams have been used to collect rich data on a variety of healthcare topics and it is expected that the use of this method will continue to grow. The results of this multidisciplinary systematic review provide an overview of the application of diagrams in research data collection and the methods for analyzing the unique datasets elicited. Recommendations are presented to assist researchers considering the use of diagrams in their data collection process. This review also highlighted the need for a standardized terminology of the method and a supporting theoretical framework.The authors declare that they have no competing interests.MJU, MJD, HEDB participated in the conception and design of the study. Data collection, abstraction and analysis was carried out by MJU and PT. MJU and PT prepared the original draft of the manuscript, and all authors reviewed and critically revised the original and subsequent manuscript drafts and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2288/11/11/prepub