Several models suggest how the qualities of a product or service influence user satisfaction. Models such as the Customer Satisfaction Index (CSI), Technology Acceptance Model (TAM), and Delone and McLean Information Systems Success demonstrate those relations and have been used in the context of health information systems.This study aimed to investigate which qualities foster greater satisfaction among patient and professional users. In addition, we are interested in knowing to what extent improvement in those qualities can explain user satisfaction and whether this makes user satisfaction a proxy indicator of those qualities.The Unified eValuation using ONtology (UVON) method was used to construct an ontology of the required qualities for 7 electronic health  apps being developed in the Future Internet Social and Technological Alignment Research (FI-STAR) project, a European Union (EU) project in electronic health . The eHealth apps were deployed across 7 EU countries. The ontology included and unified the required qualities of those systems together with the aspects suggested by the Model for ASsessment of Telemedicine apps (MAST) evaluation framework. Moreover, 2 similar questionnaires for 87 patient users and 31 health professional users were elicited from the ontology. In the questionnaires, the user was asked if the system has improved the specified qualities and if the user was satisfied with the system. The results were analyzed using Kendall correlation coefficients matrices, incorporating the quality and satisfaction aspects. For the next step, 2 partial least squares structural equation modeling (PLS-SEM) path models were developed using the quality and satisfaction measure variables and the latent construct variables that were suggested by the UVON method.Most of the quality aspects grouped by the UVON method are highly correlated. Strong correlations in each group suggest that the grouped qualities can be measures that reflect a latent quality construct. The PLS-SEM path analysis for the patients reveals that the effectiveness, safety, and efficiency of treatment provided by the system are the most influential qualities in achieving and predicting user satisfaction. For the professional users, effectiveness and affordability are the most influential. The parameters of the PLS-SEM that are calculated allow for the measurement of a user satisfaction index similar to CSI for similar health information systems.For both patients and professionals, the effectiveness of systems highly contributes to their satisfaction. Patients care about improvements in safety and efficiency, whereas professionals care about improvements in the affordability of treatments with health information systems. User satisfaction is reflected more in the users’ evaluation of system output and fulfillment of expectations but slightly less in how far the system is from ideal. Investigating satisfaction scores can be a simple and fast way to infer if the system has improved the abovementioned qualities in treatment and care. Each sfaction ,7, how tsfaction ,9, or hosfaction . Below tsfaction ,10, accesfaction -13 are csfaction . There asfaction -17.satisfaction construct at the core of their path structures. There, the satisfaction construct is affected by leading indicators such as perceived quality. At the same time, it impacts lagging indicators such as user loyalty. There are at least three versions of CSI widely being used. The original CSI model was introduced in Sweden [customer term, and the inclusion of some constructs, such as loyalty, suggest that measuring user satisfaction at the micro level, that is, the product level, was not their main target. However, the manifestation of the satisfaction concept in the CSI models through its 3 manifest variables [The Customer Satisfaction Index (CSI) model family places the n Sweden . The Amen Sweden , and then Sweden . The ECSn Sweden , which aariables  is versaariables  that shanet benefits and intention to use, that are in a bidirectional impact relationship with user satisfaction [The Delone and McLean Information Systems Success (D&M IS) model, a prevalent model for analyzing the success of information systems, sets out the relationship between user satisfaction and quality dimensions ,20. In tsfaction . In addisfaction . The D&Msfaction . Furthersfaction , but thesfaction  or priorsfaction  more speacceptance of a system or technology at the core of relationships. These models have been applied in health information system studies, although they have reported the significance of some of relationships differently [acceptance, that is, the behavioral intention to use in TAM, an equivalent for satisfaction [intention to use is a different construct from satisfaction in a well-studied model such as D&M IS.Technology acceptance models, such as Technology Acceptance Model (TAM) as well as the Unified Theory of Acceptance and Use of Technology, which are supported by a great many of studies ,9, placeferently . The usesfaction , but thefit [belief elicitation [Contextualizing TAM by adding variables has been a common practice ,28,29. Ifit . Howevercitation , when inFor the CSI, D&M IS, and TAM, the set of relationships between their proposed constructs have been already examined in various contexts ,14,13. NIn addition, finding a systematic approach to define manifests for construct variables, as mentioned before, is another direction for extending a model . Many ofIn the forthcoming sections, we put forth a list of qualities that create and predict user satisfaction with health information systems. The qualities are embedded within a path model that demonstrates their relationships with user satisfaction. This study’s methods and materials are discussed in the Methods section. The qualities elicited from the Future Internet Social and Technological Alignment Research (FI-STAR) project by applying the Unified eValuation using ONtology (UVON) method are reported in the Results section, an exploratory result is demonstrated in the Correlation Patterns section, and an estimated model is presented in the Partial Least Squares Structural Equation Modeling Path Models section. The European Union (EU)–wide empirical data collected through the FI-STAR project, detailed in the Methods section and The empirical data for this study have been collected from the FI-STAR project, an EU electronic health  project with 7 subprojects across the EU . A conveWe applied the UVON method  to the FIn 2 steps, we arrived at a model based on the empirical data from the answers to the questionnaires. The calculations were done using the R language, version 3.4.0 . The booIn the first step, a matrix of Kendall correlation coefficients tau (τ) for each of the patient and professional questionnaires was formed. The results are presented in matrixpls library in R, version 1.0 [In the second step, we created a PLS-SEM path model. For each set of the qualities that have already been grouped by the UVON method and show a high degree of correlation, a latent construct variable was considered. These latent variables are not directly measurable but manifest themselves through quality and satisfaction variables. If a quality corresponds only with one question in the questionnaire, one latent proxy variable was considered. Consequently, it would be possible to add more measure variables to the same latent variable in future studies. The PLS-SEM analysis was performed using the sion 1.0 . The samsion 1.0 .The result of PLS-SEM should be interpreted in the context of the questionnaire. Accordingly, as discussed in the Partial Least Squares Structural Equation Modeling Path Models section, negative coefficients were considered noninformative and were excluded from the final results. The validity of the result was demonstrated through a toolbox of significance, discrimination analysis, internal consistency reliability, and convergence validity. The calculation of significance indicators was performed applying the bootstrapping approach using SmartPLS software . WheneveThe result of applying the UVON method on the FI-STAR project was a tree-style ontology of qualities , of whicDescriptive statistics of the variables in the patient and professional questionnaires, including mean, SD, and median, are shown in Corrgram diagrams [P>.05). The results of the Cronbach alpha (α) test can be found in As can be seen in diagrams  for the The 2 PLS-SEM models and their loadings and coefficient values are depicted in The most contributing and predictive qualities regarding satisfaction are reported in user satisfaction index and can be found in The relationship of each measure variable in the path model with its construct is associated with weights. The standardized weights for the satisfaction construct measure variables are required for calculating the P value results of calculating the significance of quality to success relationships using the bootstrapping approach are shown in P values below .05 are marked with footnotes. Regarding discriminant analysis, the results of the Heterotrait-Monotrait (HTMT) ratio are demonstrated in The For internal consistency reliability, composite reliability (CR) values, and for convergence validity, average variance extracted (AVE) values were calculated for each construct, as depicted in satisfaction index. The outcomes of the study exhibit the effectiveness of the UVON method in proposing quality constructs that can be applied to a path analysis. Conclusions from the results are achieved in 2 steps. First, the correlations give better insight about the groupings of the qualities as manifest variables of the latent constructs. Second, the path model justifies and quantifies the relationship between those grouped qualities, their latent construct variables, and the satisfaction construct.This study advances and prioritizes the qualities in health information systems that determine and predict user satisfaction, both for patients and health professionals. As a secondary outcome, it also suggests weightings for calculating the In the exploratory step, as shown in The above correlations suggest that the members of a quality or satisfaction group can be combined. Alternatively, in other words, they manifest a common latent variable. It is worth mentioning that the Kendall correlation tau (τ) is less generous than Spearman rank correlation rho (ρ) in confirming the correlations . Hence, Besides the possible existence of latent variables, there are 2 other corollaries to the correlations. First, the high degree of correlation between a family of qualities results in the multicollinearity problem. Multicollinearity makes ordinary regression techniques inefficient and the interpretation of the regression coefficients challenging . OverallSecond, the correlation between qualities and satisfaction aspects suggests a causality relationship between quality and user satisfaction. Similarly, there are models, such as the CSI family of models -13 as weA summary of the above discussion is that we can group the qualities within a family as manifests of a latent variable, consider a causal relationship from those quality latent variables to a satisfaction latent variable, and present these groupings and relationships through a PLS-SEM model.The PLS-SEM path model has traditionally been used to represent causalities for the CSI series ,12,47, tsystem quality, information quality, and service quality. The model presented in this study is inclined to be more domain-specific by focusing on the health information system domain. The model is also more concerned with the qualities improved in the whole treatment setting by using the health information system rather than the qualities of the system. Finally, in comparison with the previously mentioned mainstream models, the model in this study is more specific about the type of qualities and how they compare in determining and predicting user satisfaction.The 2 PLS-SEM path models in this study comply with the general pattern in CSI, D&M IS, and TAM series models in which a central construct—be it called system success, user satisfaction, customer satisfaction, or user acceptance—is influenced by system qualities. Besides the use of different constructs, each model captures a distinct level of detail for the same or similar concepts. The CSI and TAM models are more concerned about the general perception of quality, whereas D&M IS examines further details about the qualities by considering 3 separate constructs: Before discussing the qualities with the most influence on satisfaction, model validity and the right way of interpreting the results need to be investigated.Regarding internal consistency reliability, CR indicators need to be higher than 0.7 , which ieffectiveness and satisfaction pair for professionals. However, this unfulfilled criterion might be justified considering that, in the domain, one should segregate satisfaction and effectiveness, while effectiveness highly contributes to satisfaction. The relatively high HTMT ratio for the pair of empowerment and effectiveness can indicate that the users’ empowerment to reach effectiveness is not very distinctive from the improved effectiveness.From the discriminatory validation perspective, both patient and professional models show indications of correctly assigning the measure to construct variables. The HTMT ratio demonstrates if the assignment of measuring variables to a specific construct is better, that is, more relevant, than other alternatives. All the HTMT results in both models, except one as shown in The interpretation of the negative coefficients that appeared in the models must be discussed. The wording in the FI-STAR questionnaires captures only the user perspective on positive relationships but not the negative ones. The information gathered from the questions is unidirectional. Therefore, one cannot interpret the negative coefficients as an indication that some qualities are inversely related to satisfaction.For example, if it is asked whether the app has increased the effectiveness of a treatment by decreasing the number of mistakes, a responder might answer “disagree.” This answer can mean whether the user does not believe that the app has decreased the number of mistakes in the treatment or the user might think that the app has decreased the number of mistakes but does not contribute to the system’s effectiveness. On the other hand, it is still a possible interpretation that the app has caused more mistakes; however, we cannot separate this interpretation from the other previously mentioned valid interpretations. Therefore, we can only confirm the positive part of relationships, where quality contributes to user satisfaction.As shown in effectiveness is considerably predictive in creating satisfaction. Both patients and professionals care considerably whether an app has increased the effectiveness of treatment and care. This result highlights the nonintuitive contrast between the effectiveness of other qualities, such as the efficiency for patients, in affecting their satisfaction. Nevertheless, there can be alternative interpretations. For example, if the apps in the FI-STAR project could significantly improve efficiency for patients, efficiency might have shown an impact as the effectiveness on satisfaction.Within the list of qualities in This result confirms the studies that consider effectiveness the major contributor or even equivalent to user satisfaction, generally, in information systems ,51,52. Meffectiveness of the treatment are not articulated identically in all those studies. For comparison, one needs to consider this discrepancy [performance [It should be noted that improvements in the crepancy . Some stformance , a term formance .affordability has a high degree of impact on satisfaction for professionals, similar to effectiveness. The affordability to satisfaction relationship for the patients was not statistically significant in this study, whereas its magnitude was also negligible compared with other relations. An explanation might be that, in the FI-STAR setting, patients did not have to be concerned about the costs and affordability of solutions, whereas professionals might have a more holistic perspective. In a different setting, where patients are more concerned about treatment costs, their satisfaction might be more influenced by the improvements in affordability, showing higher significance and magnitude in the coefficient that relates affordability to satisfaction constructs.According to our results, perceived usefulness [Although studies report increased affordability and cost reduction in treatment can improve the satisfaction and acceptance of health information systems ,59, onlyefulness ,61,62. Tefulness ,63 or suefulness .efficiency or safety. It is important to note that health information systems, as a side effect, can degrade the status of efficiency or safety in a health care setting [Patients showed some degree of improved satisfaction when there was an improvement in  setting . Hence, perceived usefulness [perceived usefulness [Considering most of the apps in the FI-STAR project could be categorized as telemedicine apps see , it coulefulness ; therefoefulness ,66,67. Rprovider performance [perceived usefulness [outcome [information satisfaction [Looking at the safety questions for the patients in formance , perceivefulness , outcome[outcome , or infosfaction .safety concept might have divergent embodiments in various studies. Two of the manifest variables in our models, pa.safety.2 and pr.safety.3, refer to providing correct information, which is also mentioned in distinct studies, mostly as a manifest variable for the information quality construct [To the best of our knowledge, there are few studies that investigate the impact of safety brought by health information systems on the satisfaction or acceptance of the users of those systems. However, one should pay attention to this caveat that the onstruct ,58,69. Ionstruct ,71.satisfaction index, both for patients and professionals. Using this index can be a makeshift way of assessing qualities inside health information systems.Each of the satisfaction constructs in the PLS-SEM models is operationalized by 3 measure variables, embodied as 3 questions. The relationship of each of these measure variables with the latent satisfaction construct is characterized by loading and weighting values. The weighting values make it possible to calculate a weighted The standardized weightings for the scores of the 3 measure questions of satisfaction are determined by the overall balance in the model as it is implemented by the PLS-SEM algorithm. The weightings, along with the scores of those 3 questions, make it possible to calculate the user satisfaction that is engendered by the improvement of qualities. Without the weightings, the satisfaction score represents the evaluation of a kind of unidentified trait that is relevant but not necessarily the same as a quality engendered satisfaction. A larger and more diverse sample population of respondents and apps might be needed to stabilize the weightings for a larger scope.Collecting satisfaction scores is a common practice in health-related studies. However, to the best of our knowledge, the studies on health information systems that suggest a kind of satisfaction index with adjusted weights regarding other qualities are limited. Conversely, the studies that have calculated the parameters of TAM or D&M IS models in their contexts or have used a path model that includes user satisfaction alongside other impacted qualities, such as studies by Jo et al, Schaper et al, and Pai et al ,56,69, i2R=.43 for patient satisfaction and 2R=.88 for professional satisfaction (as depicted in The qualities investigated in this study can explain different amounts of satisfaction variations with effectiveness is largely similar to performance or performance expectancy in the studies that are based on the TAM family, and consider the performance expectancy definition as “the degree to which an individual believes that using the system will help him or her to attain gains in job performance” [performance expectancy as a form of efficiency [efficiency in our study is more or less similar to effort expectancy or perceived usefulness in the TAM series. Some other studies have used productivity or even performance instead of what we called efficiency [perceived usefulness [The list of most influential qualities should be read with the precaution of how the similar or even the same qualities have been articulated differently in studies . Studiesormance” . It is sficiency . In addificiency , and othefulness ,55,66,67Another caveat when comparing the results is that the qualities specified in our study are the qualities of the treatment or care that using FI-STAR systems might have improved, which are different from the intrinsic qualities of those systems. Accordingly, for example, a higher speed system might increase the affordability of treatment and care in some way. What we have focused on was the affordability of care but not the speed of the system. Therefore, reports on the intrinsic system qualities that have increased user satisfaction or acceptance cannot be compared directly with our study, unless those qualities get translated to their final impact on treatment and care.software to data paradigm [All the eHealth apps, being developed in the FI-STAR project, were supposed to support the required general technical specifications, which includes using the FIWARE infrastructure and being based on paradigm . These rThe predictive power of qualities in projecting user satisfaction can support design decision making for health information systems. When trade-offs are necessary, designers can prioritize features if they can compare their user satisfaction yield. Knowing the quality profile of each feature, one can combine that with the table of quality to satisfaction magnitudes, such as in Another extension to the model of this study is to consider the qualities or system usage ramifications that impact satisfaction negatively. This needs articulation of questions to capture negative attitudes—not noninformative ones—about the impacts of systems. That kind of wording permits elicitation of constructs that are negatively related to other constructs or new manifest variables for the current constructs that reflect the construct negatively.A possible future extension to our PLS-SEM model is to consider relationships between quality latent variables. In the model presented in this study, no relationship has been proposed between the quality constructs, but one might try, for example, to investigate if a system that improves adherence also changes user attitudes about its contribution to effectiveness. However, considering that only recursive relationships can be used in the PLS-SEM models, we cannot investigate the circular impact between qualities and satisfaction with this technique ,78.The satisfaction of health information system users is highly influenced by certain qualities that are improved by those systems. Both patient and professional users consider improvements to the effectiveness of health care a highly important quality that makes them satisfied with the system. For patient users, safety and efficiency qualities come after effectiveness in creating satisfaction. For health professionals, better health care affordability brought by health information systems is important, much like effectiveness, in creating their satisfaction.satisfaction index for health information systems. The satisfaction index can be used to compare and monitor health information systems from user satisfaction and quality improvement perspectives.The PLS-SEM model presented in this study can demonstrate the above ranking of qualities in the creation of user satisfaction. Furthermore, the model suggests weightings to calculate the


Background and objectives: Urinary incontinence is defined as the involuntary leakage of urine. Studies have reported that the severity of urinary incontinence symptoms can cause decreased quality of life and female sexual dysfunction in women, but the association between the duration of the incontinence and the aforementioned disturbances has not been evaluated. The objective of this study was to evaluate the differences in the occurrence of decreased quality of life and female sexual dysfunction in Croatian women with urinary incontinence, with regard to the duration and subtype of urinary incontinence. Materials and Methods: We conducted a cross-sectional study from March 2017 to July 2018 at our neurourology and urodynamics outpatient clinic, among 120 women with urinary incontinence symptoms. Based on medical history, physical exam and urodynamic assessment, participants were divided into groups with stress-, urgency- and mixed urinary incontinence. Several quality of life and female sexual dysfunction questionnaires were used for evaluation. The differences between the three UI groups were tested by the Kruskal–Wallis test. All p values were two-sided. The level of significance was set to Alpha = 0.05. Results: The mixed urinary incontinence group had a significantly inferior quality of life (p = 0.003) and lower scores on the female sexual dysfunction questionnaires (p = 0.02). The longer the duration of incontinence King’s Health Questionnaire total score was worse (p = 0.003) and Female Sexual Function Index total score was worse (p < 0.001). Conclusions: Our results showed that there was a statistically significant difference in the occurrence of decreased quality of life and female sexual dysfunction considering the duration and subtype of incontinence in Croatian women. Urinary incontinence (UI) is a common and significant health problem in women, with considerable social, physical, mental and economic impacts on individuals and society, which can cause decreased quality of life (QOL) and female sexual dysfunction (FSD) ,2. The rThe prevalence of UI in women in developed Western countries ranges between 8% and 55%, and the incidence ranges between 10% and 58%, depending on the age and the will of women to talk about UI ,4. ThereThe 2010 International Continence Society (ICS) and International Urogynecological Association (IUGA) joint report defined UI as the complaint of any involuntary leakage of urine . ICS claThe academic and scientific community recommend the World Health Organisation  definition of QOL . Many scAs far as sexual function (SF) disturbance is concerned, the 2010 ICS and IUGA joint report defined “symptoms of FSD” as a departure from normal sensation and/or function experienced by a woman during sexual activity . FSD is To our knowledge, no studies have been carried out to determine the effect of the duration of each subtype of UI on FSD and QOL, which could be influential for the enhancement of future larger and higher quality studies on similar topics. The objective of this study was to evaluate the differences in the occurrence and severity of decreased QOL and FSD in Croatian women with UI, with regard to the duration and subtype of UI.We conducted a cross-sectional study of the occurrence and severity of decreased QOL and FSD among women with UI in Osijek, Croatia. The study was carried out at the neurourology and urodynamics outpatient clinic of the Urology Department at University Hospital Center Osijek. The study was in compliance with the World Medical Association Declaration of Helsinki. The ethics committee of the University Hospital Center Osijek accepted the survey protocol and approved this study . Women who visited our outpatient clinic because of their UI symptoms were asked to participate in the study. The patients were enrolled in the research after reading and signing informed consent. The inclusion criteria for our research were women with one of the aforementioned three subtypes of UI, age above 18 years and interest in participating in the research. The exclusion criteria were women aged under 18 years and those who either had active urinary infection, urolithiasis, urothelial cancer or gynecological cancer. We managed to collect the required sample of the three UI subtype groups  in the period from March 2017 to July 2018. There were 14 women with UI examined in the aforementioned period who were unwilling or unable to participate in our survey.To determine the type of UI, all women were assessed by neurourological physical exam, medical history and urodynamic techniques and measurements in accordance to the ICS standards. The assessment also included several QOL and FSD questionnaires, which have been used in similar previous original scientific studies. To evaluate QOL, FSD and the presence, severity and intensity of UI symptoms in a good manner, all women filled out the questionnaires alone in a safe and friendly environment in a separate, isolated room, after the physical examination and urodynamics. It was necessary to allocate approximately 30 min of time to complete the questionnaires. All the questions were formulated in a simple and understandable way, and women answered sincerely about QOL and SF.Patients who agreed to participate in the study received the following questionnaires during their examination in order to collect the necessary data for research: sociodemographic questionnaire, 3-day bladder diary, International Consultation on Incontinence Questionnaire—short form (ICIQ-UI-SF) , WHO QOLWe used a standardized sociodemographic questionnaire which included data about age, duration of UI symptoms, sexual orientation, place of residence, living conditions, marital status, employment status, use of medications, cigarettes and alcohol, and number of births.The frequency of micturition, the volume of single voided volume, urgency, the situation in which the UI episode occurred, the number of urine “leakage” episodes, and the volume of urine that involuntarily “leaked” were estimated through a 3-day bladder diary.QOL was measured using three questionnaires: ICIQ-UI-SF, WHOQOL-BREF and KHQ. ICIQ-UI-SF provided us with insight into the frequency and volume of involuntary urine leakage, UI severity and impact on QOL, and information on situations in which incontinence occurred. We have divided the ICIQ-UI-SF score into four severity levels . We firsFSD was measured using two questionnaires: PISQ-IR, in which we had a special insight into the SF problems of sexually inactive and sexually active women, and FSFI, with the help of which we gained insight into FSD considering the normal sexual response cycle in women. FSFI was used to assess different aspects of SF in the period over the last 4 weeks before the women answered the questionnaire in our outpatient clinic. Each domain had components that were specifically scored and then multiplied by a certain coefficient, and a total score that was ≤26.55 was classified as FSD, as stated in the FSFI scoring instructions.To discern the mean effect of the numeric variables of the three independent groups, with the significance level of 0.05, power 0.8, and the effect size 0.29, the minimum sample size required was 111 subjects (37 subjects per group)  . RegardiThe overall analyzed sample was 120 women with UI, divided into three groups of 40 participants, according to the three most common subtypes of UI: SUI, UUI and MUI groups. Regarding sexual orientation, all women declared themselves heterosexual. The duration of UI in the overall analyzed sample measured in years ranged from 1 to 30 years, with a median of 5 years interquartile range (IQR) from 3 to 9 years, and this was not significantly different among the observed UI groups. The sociodemographic characteristics of participants are presented in Results obtained from the 3-day bladder diary are presented in The ICIQ-UI-SF results of situations in which UI occurred are presented in The WHOQOL-BREF results are presented in The KHQ grade scale was from 0 (full satisfaction with QOL) to 1127 points . The participants with MUI had a worse overall KHQ result in comparison with SUI or UUI participants, and a lower result in the KHQ incontinence impact domain and KHQ physical limitations domain compared to the other two UI groups .The longer the symptoms of UI were present, the participants had a considerably lower overall perception of health. Also, we have established that the greater the incontinence impact, the poorer the QOL, and this showed the strongest correlation with the duration of UI. The total KHQ score, the scores of general health perception, incontinence impact domain, role limitations, physical limitations and emotions were lower with a longer duration of UI .PISQ-IR gave us insight into the FSD in sexually inactive and active women. Of the total number of participants, 69 were sexually active (only 15 participants in the MUI group). Of the total number of participants, 87 had a sexual partner, without significant differences between the UI groups. Of those 87 participants who had a sexual partner, there were 69 sexually active women and 18 sexually inactive women . DistribSpearman’s coefficient of correlation was used to evaluate the correlation between FSD and the duration of UI in sexually inactive participants. In all sexually inactive subjects, there was a significant positive correlation between the duration of UI and partner-related SF domain .Also, Spearman’s rank correlation coefficient was used to evaluate the correlation between SF and the duration of UI in sexually active participants. There was a significant negative correlation between the duration of UI and the excitement/orgasm domain, and between the duration of UI and partner-related domain .FSFI gave us an insight into the SF of participants during the last 4 weeks before answering the questionnaire, through six domains. The score of FSFI was significantly lower in participants with MUI. The participants with SUI and UUI had similar FSFI scores. The desire domain was better scored in the group with UUI. The satisfaction domain was better scored in the group with SUI. There were no significant differences regarding the orgasm, lubrication and pain domains in all three UI groups, although the scores were lower. The Kruskal–Wallis test results of the six FSFI domains and total FSFI score of all three UI groups with regard to sexual activity are presented in The longer the duration of UI, the participants rated their QOL significantly worse. Total KHQ score and the general perception of health had lower results. UI had a greater general impact on QOL, daily and physical limitations and emotional status. The participants with MUI were significantly more dissatisfied with QOL, they had significantly lower total KHQ scores due to general impact of UI on QOL, and more physical limitations compared to the other two groups. Other studies also showed that women with MUI had lower QOL than women with SUI and UUI . ParticiThe FSFI score was lower in women with MUI and higher in the SUI and UUI groups. The results for the SUI group were very similar to previous scientific studies, maybe because SUI is more predictable, therefore, women may have used coping strategies more often  ,30. We wWe have noticed that a longer duration of UI is associated with a lower overall FSFI score. This result may be related to the genital complaints of women. Chronic involuntary urine leakage can cause skin and mucosa inflammation of the vulva and vagina, which can lead to genito-pelvic pain/penetration disorder and other female sexual disorders .FSFI domains of sexual desire and pain during intercourse had the lowest scores among all participants. Participants reported decreased sexual pleasure, which over time could decrease arousal and lubrication and cause pain, which could further decrease pleasure and desire, regarding the current state of research in the field of FSD.Given the obtained results and the objective of our study, we have shown that there is a difference in the occurrence and severity of decreased QOL and FSD with regard to the duration and subtype of UI. There were some clinical implications and confounding factors regarding the results of the FSD questionnaires in the sexually active and sexually inactive women. All sexually inactive women with a longer duration of involuntary urine leakage episodes had higher partner-related domain scores according to PISQ-IR, which indicated a greater impact of the duration of UI on their SF associated with avoiding any kind of sexual activity with a sexual partner, or avoiding finding a sexual partner. In our study we did not want to focus on the methods of treating UI and FSD. We wanted to emphasize that if physicians could openly communicate with women about their sexual inactivity related to their UI symptoms and use specialized FSD questionnaires, maybe they could encourage them to become sexually active again, find a sexual partner, use behavioral treatment for sexual problems, permission, limited information, specific suggestions, and intensive therapy (PLISSIT) model, or advise them to consult a certified specialist in sexual medicine . In all Since we do not have data on the number of women with UI in Osijek and in Croatia, our sample was probably inadequately represented and therefore maybe this was also a source of selection bias. The participants with MUI had similarities regarding the fact that they had both UUI and SUI symptoms, so this was a potential source of sampling bias. Regarding non-response bias, there were 14 women with UI examined in the aforementioned period that were unwilling or unable to participate in our survey.Women are generally reluctant to talk about problems related to involuntary urine leakage because they are ashamed, uninformed of treatment options and convinced that UI is a natural, inevitable and integral part of ageing. It was difficult to gather the required sample for our research because in Croatia incontinence and sexuality are still controversial themes and women were at first reluctant to participate in our research. As far as other sources of potential bias were concerned, we did not take into account or investigate the influence of other aspects on the onset of FSD, for instance estrogen status in women, the health of their sexual partner and frequent or habitual partner change among participants.The issues associated with UI are very challenging and they require a very detailed analysis, which can be facilitated with the help of various specialized questionnaires. The identification, prevalence, incidence and relationship between UI, QOL and FSD described in previous scientific studies were dependent on whether women with UI sought medical attention and whether they agreed to participate in the research. So, there is relatively small number of original scientific studies about this topic and a small number of respondents in those studies, which makes it difficult to assess the state of the problem of the overall population.There are different interpretations about what is the normal and abnormal degree of involuntary leakage of urine within different cultural, social, age and sex groups, and its degree of influence on the QOL of the individual. Depending on social circumstances and subjective expectations, an individual’s reaction to involuntary urine leakage can change from one situation to another, which can lead to a deterioration in the QOL to a greater or lesser extent. Very mild leakage of urine can have a major and devastating impact on one individual, and on the other hand, somebody with more severe leakage may manage it with less significance.Because UI is usually a chronic problem, a longer duration of UI can have a major impact on QOL and FSD. Women with UI worry about urine odor and the loss of urine during coitus, so they often avoid sexual contact and consequently the frequency of sexual intercourse can decrease which can cause FSD. FSD can cause problems within marriages and sexual partner-related problems, which can have strong influence on the occurrence of decreased QOL. Decreased QOL is one of the psychosocial consequences in women with UI, despite the increasing availability of safe and effective types of treatment for UI.It is necessary to raise awareness in women about the benefits of prompt recognition and discussion about UI issues and related FSD with a physician, in order to improve QOL. It is also necessary to inform physicians about the possibility of using questionnaires during the evaluation, not only of UI but of other LUTS. Future studies should take into account the duration, severity and subtype of UI, assess other risk factors that can lead to the onset of FSD, include more participants over a longer period of time in different outpatient clinics, and describe the results achieved by using multiple QOL and FSD screening questionnaires. Also, it is important to include in the future studies questions about involuntary urine leakage with regard to penetration and female sexual response cycle models. This could lead to an early recognition of the aforementioned disturbances associated with UI in women, minimize possible complications and negative consequences, because of the prompt treatment based on the individual approach.


Endoscopic diagnosis is an important means for gastric polyp detection. In this paper, a panoramic image of gastroscopy is developed, which can display the inner surface of the stomach intuitively and comprehensively. Moreover, the proposed automatic detection solution can help doctors locate the polyps automatically and reduce missed diagnosis. The main contributions of this paper are firstly, a gastroscopic panorama reconstruction method is developed. The reconstruction does not require additional hardware devices and can solve the problem of texture dislocation and illumination imbalance properly; secondly, an end-to-end multiobject detection for gastroscopic panorama is trained based on a deep learning framework. Compared with traditional solutions, the automatic polyp detection system can locate all polyps in the inner wall of the stomach in real time and assist doctors to find the lesions. Thirdly, the system was evaluated in the Affiliated Hospital of Zhejiang University. The results show that the average error of the panorama is less than 2 mm, the accuracy of the polyp detection is 95%, and the recall rate is 99%. In addition, the research roadmap of this paper has guiding significance for endoscopy-assisted detection of other human soft cavities. Gastroscopy plays a major clinical role in the diagnosis of gastric diseases. The detection and diagnosis for gastric polyps by gastroscopic intervention is the most routine solution . HoweverMany literatures have been proposed to assist gastroenterologists to detect gastric polyp and reduce the rate of misdiagnosis with modern science and technology . For insBased on the above research studies, this paper proposes an automatic diagnosis system for gastric polyps on basis of the panorama image of the gastric inner wall. Specifically, the main innovative work of this paper shows the following aspects: firstly, we build a panorama model for the gastric inner wall. Compared with the previous work, we do not rely on hardware to estimate camera position, so it is more available for operation. Furthermore, we optimize the method by means of optical consistency and solve problems as registration error, blur, and others caused by image stitching. Secondly, we develop an end-to-end panoramic multitarget detection network for gastroscopic procedure. Compared to the conventional deep learning target detection framework, this paper uses the panorama image as network input, supports the multitarget detection of polyps, and avoids distortion caused by stitching, which may mislead the doctors' diagnosis. Thirdly, we conduct clinical trials on entire system in Affiliated Hospital of Zhejiang University. The experimental result shows the model's error of our system is less than 2 mm and recalling rate of polyp detection is close to 100%. Our developed system can assist doctors in diagnosis, and it helps reduce the rate of misdiagnosis, improve the efficiency of diagnosis, and relieve the storage pressure of server data. Finally, the research method of this paper has a certain guiding significance for auxiliary diagnosis for other human soft organs, theoretically. In , a promiThe algorithm flow chart is shown in Relative to conventional computer vision problems, there are lots of challenges to reconstruct the panorama image of the gastric inner wall in the human soft cavity. These challenges can be summarized as the following aspects: first, it is hard to extract and match features, and endoscope is usually a fisheye lens, so the images captured are always seriously distorted see . FurtherIn previous work, researchers used a electromagnetic tracking device to estimate real-time coordinates of endoscope in the stomach to solve the matching problem . HoweverFirst of all, we give an overview of HPFT. HPFT uses some patch feature transform to detect initial feature points, such as SIFT. If local image blocks of image registration satisfy the homographic principle of computer vision asm′ and m represent image local feature point pair to be determined. H represents homographic relationship that can be shown as 3 ∗ 3 matrix. ρ represents scaling scale. On basis of the homographic principle, it divides image sub-blocks for initial matching feature points. By means of KL similarity, it verifies the similarity of image sub-blocks. It iteratively subdivides from the center of the image sub-block, until the subdivided image sub-blocks satisfy the homographic hypothesis, for the sub-blocks that do not satisfy the homographic hypothesis.In the formula , m′ and Our experimental result shows we get a better-distributed matching feature points by adopting HPFT, compared to patch feature transform of computer vision as SIFT, FAST, and so on see .The other problem during image registration is to exclude the mismatching image feature point pairs. Conventional method adopts external polar line constraints and other methods to filter the matching results of image feature points. However, the accuracy of external polar line highly relies on camera viewing. So the filtering result is not satisfactory. In this paper, we regard the entire process from the gastroscope entering into the stomach to leaving as a closed chain process of image registration, and use closed chain optimization to filter and exclude the mismatching points of the image registration.After the image registration, the major problem in building panorama image is how to deal with stitching problem between the borders of the stitched image blocks after directly using the result of image registration. The stitching problem is generally caused by the two following reasons: first, in the result of registration obtained by HPFT and closed chain optimization, there exists mismatching point pairs inevitably, which lead to the error of transformation matrix between images calculated, and finally reflect on the seaming results; second, there are lots of mucosa on the gastric inner wall. The images captured from different viewings will have different degrees of glisten or even direct reflection. Eventhough the images reflect a same physiological location, there may be large difference in the pixel value.Based on the above facts, we develop an optimized method of texture characterization on basis of optical consistency. This method directly regards pixel difference of minimizing stitched seam as optimized target, so as to obtain panorama image structure of the gastric inner wall of smoothing process. This method will be elaborated below.In={I1, I2, I3,…}. Stitching relationship obtained by image registration can be represented by Ti−1,i asAssume the sequence of images to be matched is x, y) of the image Ii−1 converts to  by T transformation. The seam pixel difference after spliced isRandom coordinate , r1 and r2 represent rotating information. t1 and t2 represent moving information. On basis of the above assumption, formula (T is fixed, the formula (We use an iterative method to optimize the formula . Firstly formula  can be s formula  is equivFor texture projection model, we adopt the double cube projection model to project and expend the texture , 18. RelAfter building the panorama image of the gastric inner wall, we develop an automatic detection technology for polyps to assist doctors in diagnosis. In the field of computer vision, this type of issues belongs to object detection. Currently, the mainstream object detection technology adopts a deep learning frame to recur and fit the target region labeled by images, such as faster RCNN  and SSD First of all, we need to develop the network model for gastroscopic panorama image detection. In the literatures of deep learning, the classic idea of object detection technology is like this: it firstly predicts potential local bounding box on the image, and then determines the category prediction confidence of the bounding box in the thought of image classification. Finally, via a series of post processing optimization, the final results are finetuned. The representative technology of this method is RCNN and Faster RCNN , which iDuring the panorama data processing, because the polyps are relatively small in the panorama image, after SSD prediction most of bounding boxes are negative samples. Compared to predicting directly the original images, a large amount of negative samples will lead to the unbalance of training sample sets and be hard to converge in training. For these issues, we propose an optimized SSD called selective SSD. In selective SSD, we sort negative samples detected in the process of iteration on SSD original loss function, and only select the negative samples with high confidence for training, directly filtering the low ones. This method solves the network convolution problem and improves the accuracy of convergence to a certain degree see .In addition to the network model, to get the training data of the panorama image is also a key in polyps' detection. In this paper, based on gastroscopic examination system of Zhejiang University Affiliated Hospital, we recruit clinical experts to mark the polyps in original gastric images. Then, we use the proposed panorama technology to construct the panorama image, and the global truth is marked by clinical experts. Multiple-check solution is adopted. Only the polyps that are found by two more experts can be considered as true positive samples. During the data training, apart from clinical experts' marking, we adopt data enhancement technology to obtain more training samples. The enhancement method is like this for any panorama image originally captured, and we take advantage of Gaussian function for local smoothing with different scales.∗ 480. All the volunteers recruited have a history of moderate or severe gastrointestinal diseases, 43 cases in total. Patients provided written informed consent. The clinical data collected can be used for evolution and follow-up visits. During the experiment, there is not any adverse event. Volunteer information is described in So as to verify the accuracy of polyps detection method based on the panorama image that we proposed in this paper, we embed the developed system into a gastroscopy system of the gastroenterology in Zhejiang University Affiliated Hospital. The endoscope device is GIF-QX-420 from Olympus, Japan. The frame rate of the images collected by this endoscope is 30 frame per second. And the image resolution is 560 Gastroenterologists can construct the panorama image without extra interoperations. During the examination, this system extracts HPFT feature descriptors in real time, on basis of gastric inner wall texture information collected by doctors. Then, it estimates real-time position of the camera. The panorama image is gradually constructed and unfolded, as well as the polyps in the panorama image are detected in real time, shown in First we evaluate the performance of the panoramic result. Accordingly, our method is easier compared with the ones that construct a gastroscopic panorama image based on a electromagnetic guided tracking device . This paTo evaluate the accuracy of the polyp detection, we compare the results marked by clinical doctors to the ones of automatic detection for polyps see . We consFinally, the comparing results show in the case of a recalling rate close to 100%, the accuracy is 95%, which meets the requirements of clinical auxiliary diagnosis.Furthermore, we develop the selective SSD object detection framework for dealing with panoramic images; as a result, we also evaluate the performance of the selective SSD and other object detection method.In Gastroscopy is one of the most routine solutions in the current gastric diseases. It is of importance to improve the efficiency of diagnosis and reduce the risk of misdiagnosis clinically. Compared with published papers, we first put forward an end-to-end full-view automatic detection technology. Specifically, we researched a method to assist doctors in understanding the whole picture of the human stomach by means of panorama obtained without extra device. Then, on the basis of the panorama image, we propose a polyp auxiliary diagnosis method based on the deep learning framework, which can improve the efficiency of doctors' diagnosis. The method is a good reference for endoscope intervention diagnosis in other human soft organs theoretically.


Public medical service facilities are among the most basic needs of the public and are directly related to residents’ health. The balanced development of medical service facilities is of great significance. Public medical service facilities can be divided into different levels according to their medical equipment, service catchment, and medical quality, which is very important but has been ignored for a long time in accessibility evaluations. In this research, based on the hospital and population datasets of Shenzhen, we propose a hierarchical two-step floating catchment area (H2SFCA) method to evaluate the spatial accessibility of public medical resources considering the factors at different levels of medical resources. In the proposed method, the spatial accessibility of each level of public medical service facilities are evaluated using different distance attenuation functions according to the medical service’s scope. In addition, a measurement is proposed to evaluate the equity of medical service facilities based on accessibility and population density distributions. To synthesize the general spatial accessibility and the distribution balance of public medical service facilities, we standardize the spatial accessibility of public medical service facilities at each level and then calculate the weighted sums of the accessibility of each level. The general spatial equity of public medical service facilities is also evaluated. The results show that the accessibility and distribution balance of medical resources performs dissimilarly at the three levels and can be discriminated within different regions of the city. The accessibility of citywide medical facilities in Shenzhen decreases from the city center to the suburban area in a radial pattern and the accessibility and distribution balance in the suburban areas needs improvement. Rapid economic and social development has led to a transition period in China in recent years, and the equalization of basic public services has received unprecedented attention. Equalization of basic public services refers to the government’s efforts to provide the basic public supplies and services needed to meet the fundamental requirements of daily life for residents. Equalization of public services also reflects the principles of fairness and justice, which directly influence the basic conditions of residents’ survival and development. Public service facilities are among the most important components in the normal operation of society and include social infrastructure such as education, medical care, and sports; these services are provided throughout the city to serve its residents . RationaIn this research, the accessibility of medical facilities mainly refers to the convenience with which people who need to reach medical facilities can access to medical care from a given location through a certain means of transport, i.e., the cost of access to medical services. Spatial accessibility provides a summary measure of two important and related components of access; first, the volume of services provided relative to the population’s size, and second, the proximity of services provided relative to the location of the population . The accPublic service facility accessibility has been a long-term concern for researchers that can be dated back to the 1950s . A similAs for the methods applied, multiple approaches have been proposed to estimate spatial access to medical services. The models used in the measurement of spatial accessibility of medical services include provider-to-population ratios, distance to the nearest provider, the gravitational model, and the two-step floating catchment area method. The provider-to-population ratio is also considered the supply ratio; it is the most popular spatial accessibility measurement because it requires easy-to-access data and does not require GIS analysis ,15,16. TPrevious research on the accessibility of medical service facilities has led to remarkable progress in methods, yet there remain issues in urban planning related to balanced medical service facility accessibility for residents. Public medical services can be divided into different levels according to its medical technology, medical equipment, serving scale, and medical quality, the last two of which should be addressed but which have been ignored for a long time in accessibility evaluations. Although it has been suggested that the accessibility of medical service facilities differs at different levels ,36, therWe chose one of the metropolises in China, Shenzhen, as our study area because its ongoing economic development and large population result in a major transportation burden. Shenzhen is located in southern Guangdong Province in South China and is situated immediately north of Hong Kong. After the institution of the reform and opening-up policy in China in 1979, Shenzhen became the first special economic zone in China and started booming: it grew from a tiny fishing village into a massive modern city. The data from Shenzhen utilized in this research were collected in 2015. By the end of 2015, the population in Shenzhen had reached approximately 20 million, and the per capita income in Shenzhen was 4951 yuan, ranking fourth among cities in China.Originally, Shenzhen City was considered to consist of two parts: the SEZ (Shenzhen economic zone) and the part outside the SEZ. While a clear separation between the SEZ and the area outside the SEZ no longer exists, the influence of the previous partition remains in multiple aspects, although economic development has maintained an extremely high pace.Influenced by historical and objective factors, the equitable development of medical facilities in Shenzhen is lagging behind that of other Chinese super metropolises, and numerous problems exist, such as inadequate resources and an unbalanced distribution of facilities. Since the establishment of the SEZ in 1980, economic development has been booming under the guidance of the principle of “taking economic construction as the center” and has produced remarkable results. However, the rapid development of the economy has attracted an enormous population, and basic public service facilities, including public medical facilities, bear certain issues, such as resource shortages and uneven distribution. Moreover, administrators realize that the development of public service facilities is obviously lagging behind economic development and urban construction in Shenzhen. Having experienced nearly 40 years of rapid economic development, Shenzhen has built a solid economic foundation, and its social development is now in the transition stage: simple economic development has gradually shifted to coordinated economic and social development. At this particular moment, an important issue for basic public service facilities is the equal development of public medical facilities, which has long been a public concern. It is crucial to evaluate the accessibility of medical services in Shenzhen to understand the supply and demand status of public medical facilities precisely and comprehensively and to effectively improve the convenience of public access to health care.In Shenzhen City, a major proportion of medical facilities consist of public medical facilities, and thus, in this research, public medical service facilities are the main focus. Generally, the medical service facilities in Shenzhen compose a comprehensive medical care system covering most kinds of medical departments and sections. From a hierarchical perspective, the medical facilities in Shenzhen can be categorized into three levels—namely, municipal hospitals, town-level hospitals and community-level hospitals—according to their different service scopes. The levels of medical resources have a great impact on residents’ medical treatments and serve as a strategy to balance the medical needs of residents; the higher-level medical facilities cover larger areas than the lower-level medical facilities, and the different levels serve different needs. For example, community hospitals mainly treat slight illnesses, whereas municipal hospitals treat vital diseases. The medical facility data used in this research are provided by the Urban Planning, Land and Resources of Shenzhen Municipality. This includes geographic locations, level categories, doctor numbers, nurse numbers, hospital bed numbers and address of all public hospitals in Shenzhen City. The distribution of three level hospitals are shown in Another set of data utilized in this research is the population data of Shenzhen City, which was used to indicate the demand for medical facilities and was provided by Urban Planning, Land and Resources of Shenzhen Municipality. As shown in The minimum spatial unit used in this research is the community scale. The community is the smallest area with completed functional facilities for residents’ basic needs in daily life and is also a population statistical unit recognized by the administration.This study aims to assess public medical service facility accessibility in a hierarchical perspective. The primary process is to categorize the medical service facilities in the city. The medical service data we obtained contains classifications of the hospitals and health care facilities in Shenzhen. In this study, we reorganize those classifications into three levels according the health care demands of the residents in the city into municipal hospitals, town-level hospitals and community-level hospitals. Community-level hospitals are defined as the preferential choice of medical service facility for patients who have minor illness with little cost for transportation, referring to community health care centers in this article particularly. Town-level hospitals are defined as healthcare facilities with advanced medical services that community-level facilities could not offer, referring to first-level or second-level hospitals. Municipal hospitals are the medical service facilities that are able to treat extremely severe diseases, referring to the third-level general hospital.As introduced in the previous section, accessibility measurements of public service facilities have been thoroughly discussed in previous studies. The methods based on 2SFCA are the methods most commonly applied, and have been verified to be efficient and accurate for measuring the accessibility of public service facilities ,36. For j, search all demand locations (k) that are within a threshold travel distance from location j, compute the supply-to-demand ratio jR within the catchment area, and consider the distance attenuation to convert [jS is the capacity of supply at location j, the number of doctors in this study; kP is the demand at location k, the real population of the community in this study; kjd is the distance between k and j; and f (d) is the distance attenuation function.First, for each supply location  convert :(1)Rj=Sji, search all supply locations j that are within the threshold distance from location i and sum up the supply-to-demand ratios jR that are converted to the distance attenuation at those locations to obtain the accessibility iA at demand location i:ijd is the distance between i and j and iA is the medical accessibility of the demand location i; a larger value of iA indicates better accessibility at a location.Next, for each demand location In this study, we assume that for different medical service facility levels, the radiation levels for the service should differ. Thus, the accessibility evaluation of medical service facilities should be calculated to determine the service level. In general, the distance attenuation function is defined as follows:According to the previous research, the coefficient α is chosen based on travel distance, which is passively correlated with the travel distance. In previous research, α is sometimes valued as 0.6 for larger impact ranges, and 1–2 for minor ranges of influence ,38. The The government requires that community-level medical services are distributed within 15 to 20 min of access for residents . Since tx is the current sample value; μ is the average of the samples; σ is the standard deviation of the samples. As the treatment scopes of the three levels of medical services are different, the z-scores for each level of medical service accessibility are multiplied by a weight value according to the proportion of the total treatments for the corresponding medical service level. The general accessibility synthesized three levels of medical service facility accessibilities is therefore formalized as:mw is the weight of municipal hospital; m,iz is the z-score of the municipal hospital accessibility for unit i; tw is the weight of town-level hospital; t,iz is the z-score of the town-level hospital accessibility for unit i; cw is the weight of community-level hospital accessibility; c,iz is the z-score of the community-level hospital accessibility for unit i. Since residents demand different medical services from different levels of hospitals and since the attraction of the three hospital levels differs, resulting in different distance decay coefficients, the accessibility measurements of the three levels of hospitals are not quantitatively comparable. Despite the fact that the capacities and treatment scopes of different medical service levels differ from one another, each individual’s requirement for medical service is one package, including treatment from all three levels. Therefore, a synthesis of all public medical service accessibilities in general in the city is a crucial issue for supply and demand analyses of public medical services. For calculating medical service facility accessibility in general, first public medical service facility accessibilities at each level are normalized respectively using z-score normalization:The measurement of accessibility of medical service facilities is usually considered a valid method for evaluating medical service distribution in urban regions. Nevertheless, the accessibility measurement reflects merely a synthesis of the capacity and demand for a medical service, which is not sufficient to indicate the spatial equity of the medical service facility. As previous research insisted, public facilities can be considered equally distributed when the accessibility level in the city matches the population distribution level, meaning high accessibility should serve high population density regions and vice versa ,42. ThisThe methodology described in The results of the municipal hospital accessibility analysis show a clear outward decentering of the center-level structure; the accessibility is better within the SEZ than it is outside the SEZ, where it is relatively poor . There eThe town-level hospital accessibility distribution seems better than the municipal hospital accessibility distribution, especially in the area inside the SEZ and in the northeast area, while in large areas of the western region, medical accessibility is not as common . This isCommunity-level hospital accessibility is generally well distributed, and outside the SEZ, there is even a slight advantage. This is because grassroots community health services in Shenzhen City have received more attention than in other areas; each neighborhood has established a community health service center, leading to more balanced community health accessibility. The distribution of community health service centers in Shenzhen is relatively uniform, and this convenience allows residents to go to community hospitals for medical services for minor illnesses .An integrated view of public health service accessibility in the whole city is synthesized by the three-level hospital accessibilities along with their weights . It is cIn particular, Futian District and Luohu District, which are located inside the SEZ, have achieved a remarkable mark of public health service accessibility. Especially in Futian District, high accessibility regions overlap all regions with high density populations. This phenomenon might be caused by the rapid economic growth of those two districts, and thus, medical services at all levels are concentrated in the region. On the other hand, the regions outside the SEZ suffer from low accessibility to public health services on average because the population distribution and the medical service distribution do not match, leading to a severely competitive situation for residents who to go to the hospitals. There are exceptions, such as the part of Longgang District close to the SEZ and Longhua New District. In those areas near the SEZ, the influence of good economic conditions and well-designed facilities has extended accessibility to a certain degree.As illustrated in the results, analyses that consider population distribution are indispensable. Therefore, it is essential to further discuss the relationship between population distribution and the accessibility and balance of public service distribution.As discussed in the results of the accessibility evaluation for the three medical service levels, the population density distribution has a close connection with the distribution of accessibility. The balance of the accessibility distribution of medical service facilities is not indicated by the distribution of accessibility, as demonstrated in the previous subsection.By utilizing the measurement of distribution balance, which combines normalized accessibility and population density, the results of the balance evaluation of the medical service accessibility are evaluated as follows.The correlation between population density and the accessibility of municipal hospitals is shown in Overall, municipal hospital accessibility inside the SEZ is sufficient and even extends beyond demand in some areas. In total, 70% of the residents in Shenzhen are enjoying balanced accessibility. The rest of the residents in Shenzhen mostly live outside the SEZ and suffer from insufficient municipal medical facilities, especially in regions with large population densities.The results of the balance evaluation between population density and accessibility of town-level hospitals are shown in Generally speaking, 55.4% of residents in Shenzhen have appropriate accessibility to town-level hospitals; these are residents who mainly live inside the SEZ or who are dispersed in low population areas. The distribution of population and town-level hospitals is relatively balanced for over half of the population in Shenzhen. The rest of the residents are living in areas suffering from an unbalanced distribution of population and town-level hospitals; these areas have either redundant or insufficient facilities.The results of the balance evaluation between population density and the accessibility of community-level hospitals are shown in The results indicate that even though the distribution of community hospital accessibility alone seems balanced in Shenzhen , over haAdditionally, a synthesis of all three levels of medical service accessibility is obtained from the population data in Shenzhen to evaluate the distribution balance of medical service facilities in an integrated way. From the results shown in Public medical services are designed and built for diverse treatment purposes, which can be categorized into multiple levels. Although abundant researches have focused on public medical service accessibilities, the medical service level issue is often neglected. In this research, considering that different levels of medical service facilities in the city have different service scopes, we focused on constructing a framework for the measurement of the accessibility of three levels of public medical service facilities from a hierarchical perspective, along with a hierarchical evaluation of medical service facility distribution equity. Two major contributions were achieved in this study. First, considering that the treatment scope of public medical services varies with the medical service facility level, we proposed a hierarchical measurement of accessibility, H2SFCA, with several distance attenuation functions corresponding to the service scopes of the three levels of medical service facilities, in order to obtain a more accurate and comprehensive medical accessibility measurement.Thus, a fresh view of hierarchy was brought to the facility accessibility assessment issue, ameliorating the accessibility measuring methods. Second, an evaluation method for medical service facility distribution balance was proposed by comparing the accessibility level and population density level in the city. This contributes to the evaluation of public facility distribution equilibrium in general.The metropolis of Shenzhen was chosen as the study area, and real datasets from Shenzhen City were applied to evaluate the accessibility of medical service facilities and the balance of medical service distribution. According to the results and discussions from this empirical study, which utilizes Shenzhen medical service facility data and population data, several issues with medical service distribution balancing are revealed. First, the distribution of medical service facilities varies with different levels of medical service. For example, in Shenzhen, even though the SEZ regions generally have better medical accessibility than areas outside the SEZ regions, high accessibility to municipal hospitals is concentrated inside the SEZ, while lower-level hospitals have fewer accessibility distribution differences. The proposed H2SFCA method has proved its advantages as a comprehensive medical service accessibility measurement at different medical service levels. Second, the equity of medical service facility accessibility does not necessarily depend on accessibility distribution alone. Population distribution should also be taken into account when discussing the balance of service facility distribution. We located certain regions suffering from an unbalanced distribution of medical service facilities in Shenzhen, where residents could not obtain convenient health care services. Overall, we found that Shenzhen is currently suffering from a critical issue in medical service facility distribution and that more than 30% of residents cannot benefit from the medical service distribution balance. City planners should focus more on the high-density districts outside the SEZ and improve medical service conditions by increasing the number of medical service facilities, especially municipal hospitals, in those areas.Future work will focus on combining large datasets to validate and apply the multilevel hospital accessibility framework to multiple cities proposed in this research. The availability of mass spatial temporal data offers a major opportunity to evaluate the characteristics of public facilities, including medical services ,44. Furt


The COME-ON study was a cluster-controlled trial of a complex intervention that consisted of a blended training program, local interdisciplinary meetings, and interdisciplinary case conferences in Belgian nursing homes. The intervention was associated with significant improvements in the appropriateness of prescribing. The aims of this study were to describe the implementation of the intervention and to explore the experiences of participants, for the purpose of identifying factors associated with implementation and perceived impact and to draw lessons for future implementation.We performed a mixed-method process evaluation. Questionnaires and reports were used to collect quantitative data on implementation and experiences from the 24 NHs and participating healthcare professionals  in the intervention group. Multidisciplinary focus groups focusing on factors associated with implementation and perceived impact were conducted in 11 NHs.Overall, the rate of implementation and the satisfaction of participants were good, despite some variability between NHs and HCPs. Although perceived impact on nursing home residents varied, most participants perceived a positive impact for themselves. Factors associated with implementation and perceived impact were identified at different levels: intervention, healthcare professionals, organization, and external context. The interdisciplinary and face-to-face approaches were recognized as key elements for the success of the intervention, despite organizational constraints. The attitude of general practitioners was identified both as a barrier to and a facilitator for implementation and its success. The professional role and competency of the pharmacist influenced perceived impact. The pre-existing relationships between HCPs and the presence of a leader facilitated implementation and perceived impact. Remuneration was deemed necessary for the study and for future implementation.Overall, the intervention, and more specifically its interdisciplinary aspect, was well implemented and appreciated by HCPs. This probably contributed to the positive effect on the appropriateness of prescribing. Future implementation must take into account the various factors found to affect implementation and perceived impact, in order to maximize effect and sustainability.Trial registrationhttps://www.isrctn.com/ISRCTN66138978Current Controlled Trials ISRCTN66138978; registered 18 November 2015, retrospectively registered,  For many years, concerns have been raised about the high prevalence of polypharmacy and potentially inappropriate prescribing (PIP) among nursing home residents (NHRs) –3. The pProcess evaluation is an essential part of designing and testing complex interventions , 20. BesThe COME-ON (Collaborative approach to Optimize MEdication use for Older people in Nursing homes) study was a cluster-controlled trial in 54 Belgian NHs to evaluate the impact of a complex intervention on the appropriateness of prescribing . The corp = 0.021]; number needed to treat 19). Analysis of PIMs at a criterion level showed slightly better results for the intervention group for some criteria . Underuse of vitamin D substantially decreased in the intervention group [The primary outcome measure related to the appropriateness of prescribing at resident level and was considered successful when at least one potentially inappropriate medication (PIM) or potential prescribing omission (PPO) present at baseline had been solved at the end of study and when there were no new PIMs or PPOs at the end of study compared with baseline. Explicit tools were used and incorporated in an algorithm to detect PIMs and PPOs. Using a three-level mixed-effects model accounting for data clustering, a significant effect in favor of the intervention was observed  did not significantly differ between groups. Data on clinical outcomes must however be interpreted with great caution for different reasons, and these are discussed in detail elsewhere .The aim of the present paper is to describe the process evaluation of the COME-ON study. Specifically, the objectives were to understand how the intervention was implemented and to explore the experiences of participants, for the purpose of identifying factors associated with implementation and perceived impact and to draw lessons for future implementation.Each Belgian NH is legally bound to have a coordinating physician—a GP with specific additional training—who is, among other things, responsible for promoting rational medication use within the NH through the development of a therapeutic formulary. NHRs have the right to choose their GPs and the number of visiting GPs is unrestricted. The role of pharmacists is mainly limited to the delivery of medications. Standardized medication reviews are not recommended or funded as in Australia or the United States (U.S.A.).We followed the Medical Research Council guidance on process evaluation of complex interventions . The thrData were collected using a mixed-methods approach combining quantitative and qualitative data. The data collection methods and main aspects evaluated are summarized in Table Quantitative data were collected from the 24 intervention NHs.For the training component, participation in an e-learning course was registered automatically through an e-learning platform and participation in the interdisciplinary workshops was registered using attendance forms. An online satisfaction survey was sent by email to healthcare professionals (HCPs) who took part in the training 3 months after the start of the training period. Two reminders were sent. In designing the survey, we focused on the first two levels of the Kirkpatrick model: reaction (to what degree participants react favorably to the training) and learning  . We formFor LIMs, implementation data were collected through reports filled in by the coordinating physician and/or head nurse after each meeting and sent by email to the research team. Data collected included general information , level of consensus reached, and conclusions.For ICCs, implementation data were collected during or straight after each ICC. The HCPs recorded the following information via a dedicated web application: participants, duration, preparation, drug-related problems identified, action taken, and follow-up.Two months after the end of the study, qualitative data were collected using multidisciplinary focus groups (FGs) in a sample of intervention NHs. Purposive sampling was used to ensure variation in NH characteristics , the number of included NHRs per GP, previous experience with any form of ICCs, and the research team’s perception of implementation and success, based on regular contact between the research team and NHs. Twelve of the 24 intervention NHs were invited to participate. One contact person per NH was asked to invite eight to ten participants in total and at least one participant in each profession. One NH refused to participate due to lack of time.Our aim was to collect information about how participants experienced the COME-ON study. In particular, the objectives were to understand in-depth how the intervention was implemented and how it produced changes and to identify barriers and facilitators affecting implementation and perceived impact. The results on the primary outcome were not available when the FGs met. Therefore, FG participants were invited to reflect on their perception of the determinants of the intervention’s success or failure. A semi-structured interview guide was developed and addressed each component of the intervention and each domain of the process evaluation. Participants were also asked to make recommendations for consideration if the intervention were to be scaled up across NHs in Belgium. The guide was tested during the first FG. Only minor modifications were made subsequently and, therefore, the first FG was retained in the final set for analysis. Each FG took place in a quiet room in the NH. One researcher moderated the discussion and a second was present as an observer and took field notes. The discussions were conducted in Dutch for the five NHs in Flanders and in French for the six NHs in Wallonia. Additional focus groups were not conducted because of the saturation of data. The mean duration was 106 minutes and on average eight HCPs were present. The coordinating physician, the pharmacist, and at least one nurse attended all FGs. For three FGs, no GP was present.Quantitative data were summarized using descriptive statistics using R software .All FGs were audio-recorded and transcribed verbatim in the original language. Participants were pseudo-anonymized by the assignment of an ID code. NVivo 10 was used to assist with the analysis. Researchers were experienced in qualitative analysis and their background (pharmacists and psychologist) differed so as to enable richer data interpretation.A thematic analysis was performed using the pre-defined categories based on the themes in the interview guide. The first focus group was coded separately by three researchers ; MVG’s native language was Dutch but she had sufficient command of French to participate in the coding exercise for the first FG (held in French). Agreements were reached on the development of the coding tree after discussion among the three researchers and other members of the research team. Then, two researchers  coded all transcripts for the focus groups held in their native languages. Consistency of coding was ensured through the use of a common coding book and through frequent meetings among researchers to discuss coding and, when needed, to edit the coding instructions. Afterward, the main barriers and facilitators that influenced the implementation and/or perceived impact of the intervention were classified using the four-level framework defined by Lau et al. . The fouThe study was approved by the Ethics Committee  and by the Belgian Privacy Commission (SCSZ/14/084/174). All NHRs or residents’ representatives provided written informed consent. FG participants provided oral consent for audio-recording.http://www.isrctn.com/ .This study has been registered at In total, 71% 268/378) of all HCPs in the intervention group participated in the training. Participation rates varied according to profession, with GPs having the lowest participation rate. Full implementation data are presented in Table 78 of allOne hundred and twenty-nine HCPs answered the satisfaction survey . Overall, the blended training was highly appreciated. With regard to the e-learning, 90% of respondents found that the content met their personal needs and 80% found its level of difficulty reasonable. Ninety-four percent self-reported an improvement in knowledge about appropriate medication use in older people and 98% in knowledge about conducting an interdisciplinary medication review. Ninety-four percent saw the content of the interdisciplinary workshops as relevant to COME-ON activities. In general, participants felt comfortable about discussing cases with colleagues, but fewer nurses (78%) and pharmacists (70%) than physicians (95%) felt comfortable about discussing the appropriate use of medicines with other professions. The interdisciplinary aspect was highly appreciated: 92% of respondents agreed that the workshop had stimulated collaboration with other HCPs within their NH. Furthermore, most respondents indicated an improvement in their confidence in actively participating in ICCs (84%) and in the skills required for performing a medication review (88%). The combination of the e-learning platform and the interdisciplinary workshops was considered “complementary” by 91% of respondents. Detailed results of the satisfaction survey are presented in Additional file Overall, data from the FGs confirmed the results of the satisfaction survey. Although the flexibility of the e-learning was appreciated by some HCPs, others—mainly nurses—found it difficult to find time to do it during working hours and showed reluctance to do it at home. The interdisciplinary workshop was preferred by some HCPs because of its interactivity and its planned/scheduled aspect, as well as by those lacking computer skills.The majority of the NHs (22/24) carried out two LIMs. Two NHs organized only one meeting because of planning difficulties, even when the first meeting was appreciated, or unwillingness, because no benefit had been perceived after the first LIM. Participation rate per profession varied from 57% for GPs to 100% for coordinating physicians. An interdisciplinary team  was present at most meetings 83%, 38/46). In two NHs, no GP attended either LIMs. In one of these, the coordinating physician did not dare to invite GPs because he considered that the workload due to the study was too high. On the other hand, he believed the notions discussed during the LIM should already be familiar to the other GP. Full implementation data are presented in Table %, 38/46.A large majority of NHs reported having achieved a partial or complete consensus on the use of both medication classes for which support material was provided, i.e., antidepressants  and lipid-lowering drugs . However, data from the FGs show that opinions were divided on the level of consensus and the perceived impact of the LIM. Consequently, perception of the value of scaling up LIM meetings in Belgian NHs differed.Some participants stated that the meetings did not have an impact because no real consensus was reached due to the lack of constructive discussion and/or the low level of GPs’ attendance. Even when a consensus was reached, some HCPs did not perceive an impact and/or were not sure that it led to changes in prescribing habits. The reasons cited included GPs were not convinced by the principle of selecting one or two first-choice drug(s), GPs clearly stated that they were attached to their therapeutic freedom, and the goal of the study was not always understood . Other reasons included the feeling that no improvement was needed and the observation that the LIM was too late in the study to have an impact on the ICC. Participants in some NHs, however, perceived a positive impact: discussion of a specific medication class made it possible to bear the latest evidence in mind and made it easy to apply what they had agreed to the participating NHRs during the ICCs and also more broadly to all NHRs.In spite of these mixed feelings on perceived impact, the LIMs seem to have been generally appreciated, especially the training aspect and the exchange of experiences. Nurses, in particular, but also some GPs, recognized that they learned something about the medication classes discussed. Moreover, with this extra knowledge, nurses reported feeling more confident about asking GPs questions about medications for individual NHRs.The main barriers and facilitators that influenced the implementation and perceived impact of the LIM are presented in Table 25-P75, 2–3; range, 1–4). The proportion of NHRs with at least three ICCs varied greatly between NHs, from 0% to 100% . Full implementation data are presented in Tables A total of 1675 ICCs were registered for 681 NHRs. The median number of ICCs per NHR was 3  recorded per NHR was 4.8, but varied from 0 to 8 in different NHs. The median number of DRPs per NHR was 2 for the first ICC and 1 for the second and third ICCs , the implementation may be lower. This is in line with the findings on medication use data, which show a significant decrease in the use of lipid-lowering drugs, but no major modification in the use of antidepressants. Given the positive experiences reported with LIMs in other countries such as Switzerland , the lowThe interdisciplinary and face-to-face approaches of ICCs were identified as facilitators for the success of the intervention, but also as barriers to implementation due to organizational constraints. The face-to-face approach has been acknowledged to contribute to effective teamwork because it fosters the establishment of a trusting relationship , 33. TheConsistently with the literature, the presence of the GP during ICCs was regarded as essential . HoweverIn contrast to studies in other countries such as the U.S.A. and Australia , activelThere were also factors in NHs as organizations that had a positive influence on the implementation and impact of the intervention, such as preexisting relations between HCPs , the preFunding was provided for ICCs and certainly contributed to the good implementation rates. It seems obvious that future implementation of ICCs must be remunerated. The clinical trial context also positively influenced implementation. Particular attention should be paid to real-world implementation data, if any component of our intervention is to be adopted in routine practice.This study is one of the first studies to have conducted an in-depth pre-planned process evaluation of an intervention implemented in NHs that aimed to improve the quality of prescribing , 19. A nHowever, this study has some limitations. We used FGs to collect qualitative data. Participatory observation supplemented by individual interviews could have provided an even fuller picture of how different factors influenced implementation and impact, but this was not possible due to time constraints. Due to the multidisciplinary nature of FGs, participants may have been reluctant to mention barriers relative to interprofessional collaboration in front of other HCPs. The FGs were moderated by members of the COME-ON study team, some of whom had regular contact with participating NHs, so some participants may have felt uncomfortable about voicing their views. Moreover, FG participants may also have been more enthusiastic HCPs. However, we observed variations in opinions and experiences between FGs. Therefore, we can reasonably assume that the process evaluation made it possible to identify the main enablers and barriers. We did not explore the views of NHRs or relatives. Finally, we did not quantify associations between the present process data  and the primary outcome measure. Those should be studied in future research.The process evaluation of the COME-ON study shows that the intervention was, overall, well implemented, including with regard to its interprofessional aspect, and was appreciated by HCPs under certain conditions. Careful development and piloting of the intervention likely contributed to good implementation and satisfaction data, and these in turn probably contributed to the positive effect seen on the appropriateness of prescribing. The current process evaluation data also suggest that a larger effect could be reached with several adaptations such as reinforcing the role and competency of the pharmacist, strengthening interprofessional relationships, and improving medical governance and GP’s accountability. Future implementation must take into account the various factors—at the intervention, professional, organizational, and external context levels—that were found to affect implementation or impact, in order to maximize effect and sustainability.Contributions to the literatureStudies of complex interventions to improve appropriateness of prescribing in nursing homes have produced mixed results.In this controlled trial with a favorable effect on appropriateness of prescribing, implementation of the intervention was generally good. We identified elements at various levels—the intervention, professionals, organization, and external context—that may explain variations in implementation and impact. These elements are consistent with or complement the existing literature.These findings contribute to recognized gaps in the literature on the optimization of prescribing in nursing homes, including describing the level of implementation, identifying mechanisms of impact and contextual influences.Additional file 1. Blended training: satisfaction survey - Results.Additional file 2. Quantitative data on the implementation of ICCs.Additional file 3. Examples of final recommendations made to Belgian stakeholders, derived from the process evaluation data.