Many studies worldwide have demonstrated the negative impact of an unhealthy built environment on citizens. In the case of diabetes, studies have concentrated on the environmental impact and accessibility issues of a place i.e. the home and neighborhood, whereas few studies have addressed the comfort of the type and spatial arrangement of a household and linked it with the prevalence of diabetes. Also, little research has tackled the place’s impact on diabetic patients and their views concerning their environments. This paper demonstrates the outcomes of survey that was carried out on diabetic individuals who usually visit the King Fahd teaching hospital of the University of Dammam, Al-Khober, the Kingdom of Saudi Arabia (KSA). The patients were surveyed and physically examined. The present researchers found significant links between patients’ diabetes symptoms such as reported paresthesia and blurred vision, and medical investigations results such as lipid profile, blood glucose and blood pressure with the environmental conditions of their homes and neighborhoods. The paper shows that the prevalence of the disease is not only caused by an unhealthy lifestyle but also by an unhealthy built environment. Moreover, it illustrates that unhealthy built environment promotes unhealthy life styles. It makes recommendations on how to improve the built environment in the KSA to be healthier for all citizens including the diabetic patients. The provision of a healthy built environment became increasingly under focus nowadays as profound links are found between a healthy built environment and healthy lifestyles. The design of a healthy environment would facilitate social cohesion and offer access to educational, cultural, leisure and retail facilities capable of sustaining urban development . Researcunhealthy lifestyles”, and enable the built environment to contribute to the healthy lifestyles of diabetic patients in the KSA but also sustain the healthy urban development of towns and cities in the KSA. This research investigates the possible indirect built environment and spatial arrangement impacts on the health of diabetic individuals in the KSA. A survey has been carried out on a sample that consists of seventy six patients who usually visit the King Fahd teaching hospital of the University of Dammam, Al-Khober. The patients were surveyed and physically examined. The field study’s results are discussed and linked with previous research studies.The next section below discusses the diabetes symptoms and complications and the occurrence of the disease in developed countries including the KSA. Section three and four demonstrate the adverse impacts of the built environment on people, and section five introduces the characteristics of the healthy built environment. Section six highlights the research methodology and tools. Section seven outlines the survey results, and discusses the statistical links between the physiological conditions of the patients with their homes and neighborhood settings and their perception of the neighborhood’s conditions, thus section eight suggests future research venues.Diabetes mellitus is the most common non-communicable disease worldwide and the fourth to fifth leading cause of death in developed countries. There are – in general- two types of diabetes. In Diabetes type I (T1DM), the person’s own body has destroyed the insulin-producing beta cells in the pancreas. Although type II diabetes mellitus (T2DM) can be caused by genetic factors, an unhealthy lifestyle happens to be the main cause . A persoPrevious surveys from the KSA suggested that diabetes is present in epidemic proportions throughout the country with exceedingly high rates concentrated in urban areas . Al-HazzLittle research though was conducted in the KSA with regard to the effect of the built environment on diabetic patients whereas it is evident that urbanism and poor built environment conditions in the KSA  promote Diabetes affects the number and/or function of sweat glands, so it would decrease the volume and effective evaporation of sweat that is necessary to heat dissipation during a heat wave . This caThis section discusses the characteristics of a home and neighborhood, such as its’ socio-economic status, how it promotes social connections, accessibility, physical activity, and whether it creates positive perception for the residents in their neighborhood.At home level, a US study has looked at many risk factors for diabetes including physical characteristics and personal habits , marital status, education and housing conditions. The study rated the houses on the following basis: cleanliness inside of the building, the physical condition of the building’s interior and exterior, and the condition of the furnishings in the building. The researchers tested the impact of housing conditions and used physical attributes and habits as mediators and they found that housing conditions still influence diabetes risk and contribute to the development of diabetes . For insIt was known the influences of interactions between the level of activity and psychosocial wellbeing and stress in the pathogenesis of T2DM.1 . FurtherStewart et al. (2011) conducted a study in the USA that explored potential county-level associations between diabetes prevalence among adult African Americans and five socioeconomic characteristics: persistent poverty, unemployment, rurality, the number of fast food restaurants per capita, and the number of convenience stores per capita. They found diabetes prevalence rates in South Carolina where African American adults live, are among the highest in the nation, and there is a connection between the socioeconomic measures and diabetes. So, urban areas that have the above socioeconomic characteristics, would highly likely to have higher rates of diabetes prevalence (ibid).Poorer health status in socioeconomically deprived and rural environments may reflect, in part, the inaccessibility of built environmental features such as public pools, recreation centers, physical fitness facilities, parks, sidewalks, and streetlights .Allanah, Ashley and Farley (2010) stated that an ill designed urban setting would enforce people to adopt an unhealthy lifestyle thus contribute to the development of T2DM. In respect of social connections, researchers have linked fewer and weaker social networks with a number of health outcomes, including cardiovascular disease, mental health problems and increased mortality .So, neighborhood design that promote social networks are those which have mixed use and pedestrian oriented, with public spaces, such as parks, that can act as places for socializing .Those living in more “walkable” neighborhoods, characterized by high population density, mixed land use and high levels of connectivity (e.g. good pedestrian and cycling facilities) have been found to be more physically active , evening shopping trips to local malls and shopping arcades or sitting in coffee shops and these activities replace outdoor activities such as children’s playgrounds, and mothers walking children to school . Also, aMany researchers have tackled the potential impact of neighborhood characteristics on people’s health e.g. . The resPerception of problems refers to aspects people say they dislike about their local area when interviewed in general health surveys . Such prStudies have consistently found evidence of a relationship between neighborhood environment (both perceptions and more objective measures) and self-reported health . For exaReported neighborhood problems and perceptions of neighborhood cohesion were both significantly associated with health outcomes after controlling four socio-demographic variables . This waPrevious studies have shown the general level of participation in neighborhoods activities to be important for people’s health and not simply what the individual does him or herself .On the other hand, high self-efficacy, perceptions of good quality facilities in the area and high levels of neighborliness were independently associated with good self-rated health and physical functioning. Perceptions of problems in the area were also predictive of poorer health .A study on the residents of a number of neighborhoods in the Que´bec City region and it had tested the self- reporting of their physical conditions such as poor self-rated health, long-term disability, low feeling of mastery and their perception of neighborhood on health . The study found that after considering individual attributes, the perception of problems and social cohesion varies significantly by neighborhood and/or localities and can be considered as contextual variables. Furthermore, these perceptions of place appear to be significant predictors of people’s health (ibid).The perception of problems in the neighborhood is negatively associated with several health outcomes such and health behaviors . MoreoveSuch perceptions might influence people’s health through various pathways . So, perThe perception of social ties is also important. It is found that the role of shame, trust, social cohesion and more social capital  are key determinants of health inequalities . Health The built environment should be designed to promote healthy lifestyles, facilitate social cohesion and offer access to educational, cultural, leisure and retail facilities capable of sustaining urban development . To promOn a neighborhood, urban or city level, urban planning plays a vital role in encouraging walking, the use of public transport, minimizing the number of vehicles on roads, providing well (cross) ventilated and shaded urban areas in hot climate countries, and exposure to sun for urban areas in cold countries. It also reduces the pollution and noise levels and would provide thermally comfortable urban areas.Considering the valuable contribution of the previous research in regards to the relation between the built environment and health, the aim of this research is to test the effect of the built environment on diabetic individuals within the context of Saudi Arabia.Therefore, the researcher has set a number of objectives and these are:To find out the relation between the disease’s symptoms and resulted medical investigations of patients with the characteristics of their residence;To find out possible links between the disease’s symptoms and medical investigations of patients with their perception of the neighborhoods; andTo make recommendations on how to enhance the Saudi built environment to be healthier.Consent was firstly obtained from the University committee for biological and medical ethics. Thus, the field study was initiated in 2013 on diabetic individuals. The study’s sample constituted of patients who usually visit the diabetic clinic at the King Fahd teaching hospital of the University of Dammam, Al-Khobar. The choice of sample was based on the following criteria: the exclusion of severely ill, and children patients; and the inclusion of T1& 2DM male and female adults, age 15-70 years old and residents in the Eastern province, KSA.Seventy six patients have participated in the study. These patients were handed a questionnaire form to fill in, and physical exams of patients’ health statuses were carried out. The questionnaire includes questions on the characteristics of their home and neighborhood, the patients’ lifestyles and activities since the onset of the disease, their perception of the environmental conditions of the home, work and neighborhood, and self-reported health conditions since the onset of the disease. All patients have filled in the questionnaire and returned it. The patients were physically examined. The exams include; a blood pressure test and Body Mass Index (BMI). The medical test results such as the fasting blood glucose, HBA1C, urine albumin, and lipid profile, were extracted from the patients’ medical files. The data collected from physical exams and the questionnaire survey was analyzed using SPSS.The participants were asked about the distance between their homes and the local amenities. More than half of the respondents said that the public amenities are within walking distance i.e. up to 500 meters whereas 24% said that it is more than 1000 m from where they live. Around a quarter (23%) of the respondents said that the public garden is more 2000 m from their homes. 38% said that the recreation and sport center is more than 2000 m from their homes.The respondents were asked about their daily life activities. More than half of the respondents  said they never or rarely do any recreational activities or morning sport exercises. 41% of the respondents said that they never or rarely do any social activities, 33% said that they never or rarely do any religious activities. Around half of them (48% - 59% respectively) said that rarely or never drink fizzy drinks or eat junk food meals. 86% of the respondents said that they never or rarely smoke. Around quarter of the respondents said that they rarely or never walk for 30 minutes whereas half (48%) of the respondents said they walk for 30 minutes daily. 72% of the respondents said that they often or always watch TV or work in the office. Around two third said that they often or always eat fruits and vegetables.A quarter to one third (i.e. 24% to 34%) of the respondents have sometimes or often respectively, suffered from the following spatial and environmental conditions :The house organization is uncomfortable and it’s size is smallLow level of ventilation in the houseAnnoying flow of air in the houseUnpleasant outside viewsNoise from neighborsTraffic noiseDifficulty of wandering around in the neighborhoodThe most frequent diabetes manifestations that are experienced by the respondents are: extreme fatigue/tiredness, tension/stress, blurred vision, and inability to control their nerves. Whereas the least experienced symptoms are: cardiatric problems, loss of sensation, loneliness and isolation and blood pressure problems.It should be mentioned that the study reports the significant results only (i.e. 0.5> P). The ANOVA results show that the house type  and area is associated with patients’ lifestyles and perception of home and neighborhood conditions. For instance, respondents who live in villas watch TV more frequently than those who live in flats duplexes or other types of dwellings. Respondents who live in flats or duplexes reported that they more frequently suffer from the lack of sunlight entry to their homes, poor air quality, unpleasant outside views, and noise from neighbors, than those who live in villas.The ANOVA results show that the environmental conditions as experienced by the respondents at home are linked with the disease’s symptoms. Respondents, who suffer more frequently from the poor air quality in their houses, said that they experience Paresthesia symptoms more frequently.Respondents, who more frequently experience uncomfortable furniture, said that they more frequently suffer from Paresthesia, blurred vision, tension/stress, or feeling overloaded. Respondents, who more frequently experience a low level of ventilation in their homes, said that they more frequently feel overloaded and an inability to relax.Respondents, who more frequently experience an annoying flow of air in their homes, said that they more frequently suffer from a poor memory, and an inability to concentrate and relax. The uncomfortable temperature also causes a problem, as it constantly enforces the patient to sleep. Respondents who reported a poor finishing of their homes or said the organization of their houses is uncomfortable, said that they more frequently and constantly have blood pressure problems.The study discovered an association between the actual measurement of medical test results and the home’s conditions. For instance, respondents who suffer more frequently from low level of ventilation in their homes, have higher lipid LDL (i.e. Low-Density Lipoproteins) and TG (i.e. triglyceride) levels. It is also found the lower/poorer lipid HDL (i.e. High-Density Lipoproteins) or unhealthy levels of lipid; are associated with uncomfortable internal furnishings.On a neighborhood level, the study found an association between socio-economic conditions of the neighborhood and the individual diabetic’s lifestyle. Respondents who live in rich and upper middle areas tend to watch TV or work more in the office. On the other hand, respondents who live in poor areas suffer more from the following environmental conditions: poor air quality in the house, unpleasant outside views, noise from neighbors, polluted environment, and difficulty of wandering around in the neighborhood.Respondents who reported poor condition of the neighborhood such as horrible odors and pollution said that they more frequently suffer from paresthesia, Blurred vision, and stress. The study found a relation between the onset of the disease and the location of the recreation and sport centers. Respondents, who had diabetes earlier, said that the recreation and sport centers are farther from their homes than those who had diabetes later.Many previous researches have pointed out to a number of links between the built environment and health. It proved that the place’s characteristics and people’s perceptions of the environmental and social conditions of their neighborhoods affected their health’s status through a number of pathways such as; psychosocial, physiological and behavioral pathways . This isIn this paper the researchers examine the negative impact of the built environment on health of specific population that is the diabetic individuals in the KSA. The study shows that the progress of the disease is not only caused by an unhealthy lifestyle but also by an unhealthy built environment . This unThe survey found that such irregular settings of urban services would promote unhealthy lifestyles as around half of the respondents never or rarely do any recreational activities, morning sport exercises or participate in social activities whereas one third do religious activities  are linked with the individual diabetic’s lifestyle. The rich/high class environment encourages some bad habits such as watching TV or working longer hours at the office. On the other hand, respondents who live in poor areas suffer more from the poor environmental conditions at home and in their neighborhoods and subsequently they suffer more from a number of diabetes manifestations such as: Paresthesia, Blurred vision, and stress (also see So, in conclusion, control and prevention of Diabetes mellitus will require radical changes in the Saudi built environment to promote physical activity, improve psychological and physiological conditions of diabetic individuals. However, as diabetes is a lifelong disease, it would be affected by lifelong and ongoing changes in the life of individuals and the built environment. In the context of KSA, these would include the followings:As highlighted above, Saudi cities have unique planning, social, cultural, environmental and economic characteristics that should be considered. The fabric of the cities is rapidly changing due to the urban sprawl on macro level, changes on a neighborhood, and ongoing changes on macro level. The latter are undertaken by Saudi citizens on their dwellings;the Islamic lifestyle and lifelong practices and the Saudi culture as highlighted above, thus the ongoing impact of these issues on the built environment should be appreciated;the onging negative changes in the environment due to the increased levels of desertification, pollution etc. in the KSA and Gulf countries and climate change at regional and global level.The consideration of these potential ongoing factors would enable researchers to develop better understanding to the eternal relation between the prevalence of diabetes and the built environment in the KSA.


The aim of the study was to investigate workplace incivility as a social process, examining its components and relationships to both instigated incivility and negative outcomes in the form of well-being, job satisfaction, turnover intentions, and sleeping problems. The different components of incivility that were examined were experienced and witnessed incivility from coworkers as well as supervisors. In addition, the organizational factors, social support, control, and job demands, were included in the models. A total of 2871 (2058 women and 813 men) employees who were connected to the Swedish Hotel and Restaurant Workers Union completed an online questionnaire. Overall, the results from structural equation modelling indicate that whereas instigated incivility to a large extent was explained by witnessing coworker incivility, negative outcomes were to a high degree explained by experienced supervisor incivility via mediation through perceived low social support, low control, and high job demands. Unexpectedly, the relationships between incivility  and instigated incivility were moderated by perceived high control and high social support. The results highlight the importance of including different components of workplace incivility and organizational factors in future studies of the area. The aim of the present study was to explore workplace incivility as a social process, including experienced as well as witnessed incivility from coworkers and supervisors and its relationships to instigated incivility and negative outcomes in the form of well-being, job satisfaction, turnover intentions, and sleeping problems. The goal was to create comprehensive models including direct relationships between workplace incivility and its outcomes, as well as mediation and moderation of organizational factors. This adds to the current literature through including different components of workplace incivility as well as organizational factors in the same models to explain instigated incivility and negative outcomes. Workplace incivility has been defined as “… low-intensity deviant behavior with ambiguous intent to harm the target, in violation of workplace norms for mutual respect. Uncivil behaviors are characteristically rude and discourteous, displaying a lack of regard for others” . IncivilBeyond experienced incivility, research has also been requested on perspectives focusing on the bystanders and perpetrators as well as the organizational context as components of the incivility process .Studies have approached the social process of incivility, exploring it as a group-level phenomenon , 5. AndeWhen investigating the escalation of workplace aggression, Taylor and Kluemper  reported experienced and witnessed workplace incivility, from coworker or supervisor, is directly related to instigated incivility.In the field of workplace incivility, more research on possible mediators has been requested , all CI of the single indirect effects excluded zero, and the direct effect was 0.00). To summarize, participants' reported negative outcomes was directly related to their reported experienced incivility from coworker and witnessed incivility from supervisor. Experienced incivility from supervisor had the strongest relation to negative outcomes, but there were no direct effects when the indirect effects through the mediating organizational variables were included in the model.Hypothesis 5 concerned the possible mediation of organizational variables on the relationships between incivility and negative outcomes. Possible mediation effects were only tested for experienced incivility from supervisor. This was the only incivility variable correlating with the organizational variables that also correlated with negative outcomes. The total effect from experienced incivility from superiors to negative outcomes was  was slightly lower than the direct path (β = .245) between control and instigated incivility.In relation to our models we report total, direct, mediation, and moderation effects but since the present work is cross-sectional there is no possibility to know if the directions are causal. The high correlations between the latent variables may have revealed one suppressed relationship in the model. This can explain that the total effect (Moreover, the low response rate could to some extent have limited the study. The low response rate could maybe be due to e-mail administration through the union. As the study was conducted among members of the Hotel and Restaurant Workers Union, largely representing unionized parties of the hospitality industry, the sample is not representative of a general population of the labour market.The use of the WHO-Five scale in order to measure levels of well-being needs to be considered. More intense testing of the Swedish version of the scale is warranted. However, previous studies have shown that using the WHO-Five rather than other instruments may reduce the risk of ceiling effects . This faBased on the findings of this study, future research should consider workplace incivility as a social phenomenon. More research is needed concerning the different components of workplace incivility, and their relationships to instigated incivility and negative outcomes. Special attention should be paid to mediating and moderating effects of organizational variables. The results found in the present study support potential indirect paths via organizational variables, but these paths need to be more thoroughly investigated in future research. In addition, testing the moderation effects of organizational factors should be particularly considered in other samples, as the moderating role of a socially supportive environment is a counter-intuitive finding and may even be reversed in other sectors. Longitudinal studies are needed to complement the cross-sectional nature of this studyand address the issue of causality in research on workplace incivility.The present research effort shows that workplace incivility was connected to both instigated incivility and negative outcomes in the form of reduced well-being, job satisfaction, turnover intentions, and sleeping problems. Witnessing coworker incivility was the most important dimension to explain instigated incivility. In addition, experienced incivility from coworker and supervisor, as well as witnessed incivility from supervisor, were unexpectedly related to instigated incivility via moderations of perceived high control and high social support.Negative outcomes were to a high degree explained by experienced supervisor incivility via mediation through perceived low social support, low control, and high job demands. The results emphasize the significance of studying workplace incivility as a social process, considering both experienced and witnessed workplace incivility from coworkers and supervisors in the same model. The results also indicate the importance of including organizational factors as key components in future studies of the research area.


Primary out-of-hours care is developing throughout Europe. High-quality databases with linked data from primary health services can help to improve research and future health services.www.icaredata.eu) for primary and interdisciplinary health care at the University of Antwerp, linking data from General Practice Cooperatives, Emergency Departments and Pharmacies during out-of-hours care. Medical data are pseudonymised using the services of a Trusted Third Party, which encodes private information about patients and physicians before data is sent to iCAREdata.In 2014, a central clinical research database infrastructure was established (iCAREdata: Improving Care And Research Electronic Data Trust Antwerp, iCAREdata provides many new research opportunities in the fields of clinical epidemiology, health care management and quality of care. A key aspect will be to ensure the quality of data registration by all health care providers.This article describes the establishment of a research database and the possibilities of linking data from different primary out-of-hours care providers, with the potential to help to improve research and the quality of health care services. The growing need to improve accessibility, quality, efficiency, sustainability and safety of primary care has changed the landscape of out-of-hours (OOH) care in many European countries , 2. The Belgian health care is characterised by unlimited access to primary, secondary and tertiary care facilities. Originally, Belgian GPs were continuously available to their patients, and a system of call time rotation was later implemented. During OOH, GPs on duty worked from their own practices, without any professional or administrative support . In 2003Preliminary figures from our own studies in Flanders show that the introduction of a GPC results in small effects on the workload of GPs and hospitals, but longitudinal data are needed to show any quality changes , 6.During OOH, patients can choose between GP services and Hospital Emergency Department (ED) without former contact or referral. At the ED there is no direct payment as compared to the GP services, where a direct fee for service applies. Medical care is largely reimbursed by medical insurance, which is obligatory in Belgium. Out of pocket payment accounts for approximately 25 % of health expenses. Patients can purchase over the counter medication at pharmacies on call .Research is needed to support the optimisation of patients’ health seeking behaviour as well as the improvement of the organisation and quality of primary OOH care. In surrounding countries, high- quality databases with linked data from primary health services are already successfully used for different research purposes , 8. Fromwww.icaredata.eu) for primary and interdisciplinary health care at the University of Antwerp . Currently, this research infrastructure is being developed as a unique, interactive and central clinical research database based on weekly-collected clinical data registered in different OOH primary care settings. To support interdisciplinary collaboration, iCAREdata will collect, link and integrate data from different individual databases unlinked thus far. The aim is to connect and integrate data from all GPCs, EDs of general and academic hospitals and pharmacies involved in OOH primary care in Antwerp (inner city and suburban area). Once established, iCAREdata will provide unprecedented opportunities for OOH primary care research, serve as a state-of-the-art example of clinical data storage and linkage and improve the quality of OOH primary care. Further it will enable follow-up of patients throughout the health care system.In 2014, a central clinical research database infrastructure was established  is coordinated by the Department of Primary and Interdisciplinary Care (ELIZA)—Centre for General Practice (CHA) of the University of Antwerp . The construction and overall safety of the database as well as the coordination of the project is entrusted to a postdoctoral researcher (supervisor—safety and database coordinator). He supervises the quality manager, whose task is to perform the quality control, feedback and research on the database and collaborate with the information and technology (IT) specialist, who is developing the required software tools or searching and adapting existing ones. For the daily management, they collaborate closely with a team of CHA (www.huisartsgeneeskunde.be) researchers dedicated to iCAREdata.iCAREdata  . The sciThe steering committee is composed of the supervisor—safety and database coordinator and the senior academic representatives of the research group. Representatives of partners involved are invited on a voluntary basis. The steering committee meets monthly, and oversees the construction, operating and further elaboration of the research infrastructure and resolves management issues.Routine clinical data and patient characteristics are collected from the GPCs, EDs and pharmacists electronic records completed during OOH-care on a weekly basis. Unique, individual patient data such as year of birth, gender, postal code, insurability and social security identification code (INSZ code) are registered. For each unique patient contact, the following data are collected during OOH: date and time of arrival, method of contact , consultation or home-visit, urgency level, identification code of the treating physician ), any referrals or sick leave. Reasons for encounter and diagnosis are registered by the physician using a thesaurus term, and this is mapped to the matching International Classification of Primary Care (ICPC)-2 code. Subjective complaints and clinical examination are captured in free text fields. Finally, drug prescription and matching CNK code  are collected. This ‘national code’ is mapped to the international Anatomical Therapeutic Chemical (ATC) classification system .At the pharmacy level, the delivered medication, the matching CNK code, the identification code of the prescribing physician (NIHDI code), as well as the date and time of purchase of the medication are collected as ‘medical data’.In addition to the medical and patient information, iCAREdata will provide valuable information about health care costs. Because of fixed tarrifs used in the Belgium health care system, treatment costs can be derived from the produced data within the OOH care services. This relates to consultations, home visits, medication, diagnostic tests, etc. Thus costs can be calculated indirectly by researchers using the database.Medical and demographic data: this data gets encrypted at the source level . We use the asymmetric encryption services of eHealth  . The encPersonal data (INSZ number patient and NIHDI physician code): the TTP encodes this data .To secure the privacy of information about individual patients, a permission for the data collection at the GPCs was obtained from the Committee of Health of the Commission for the Protection of Privacy .(5) A separate application for the data-linkage was approved on July 28th, 2015 (N° 14/194 n133).Because of its complexity and the knowledge required to query the database, and especially because the database information is still vulnerable even after thorough encryption, each potential investigator has to make an official request to the scientific advisory board and can only apply when permission of a licensed ethical committee has already been acquired. The scientific advisory board reviews the final purpose and scientific goal of each research request. In general, this procedure is necessary for all research questions and feedback to the applicant should not take more than 3 weeks. If no objections are formulated, the request is handed over to the safety and database coordinator to perform the appropriate queries. Direct interaction between the requester and the database coordinator is recommended at this stage.Publication of research results making use of iCAREdata is encouraged whatever the findings, without interference from the original data owners. However, publications should always cite the iCAREdata and the original databases involved.The supervisor—safety and database coordinator and the quality controller have direct access to the iCAREdata server. They have to report their activities regarding iCAREdata to the scientific advisory board. For this purpose, a provenance tool monitors and visualizes all actions with the database.UA, CHA is expected to be the prime, but not the only, user of iCAREdata. Research projects of UA, CHA have to follow the general procedure as described below.GPC managers and managers of other databases  involved in the project have the possibility to consult their own data after pseudonymisation according the directives of eHealth and the Commission for the Protection of Privacy. They can perform their own queries on their own data without interference from other partners. When they wish to study data from other providers, they have to make an official request to the scientific advisory board.industry and companies) not involved in the project have to apply for access to the scientific advisory board if they have research questions needing one or more of the databases included in iCAREdata. Because of privacy issues relating to individual patients or so called “small cells”, only the data manager coordinator has access to data at the individual patient level. When access is needed on individual patient level, permission from the Committee of Health of the Privacy Commission has to be obtained by the requesting party.Other researchers  and diagnosis. Participating GPCs are offered feedback reports on their data quality. This intervention should lead to quality improvement in data registration . Also ofIn addition to improving quality of registration, the data can also be used for clinical epidemiological research, e.g. on the diagnosis and management of a number of conditions. The initial focus would be on infectious diseases (e.g. respiratory and urinary infections). Further, the impact of interventions to improve the management of these conditions can be assessed as we did in former research –16. FinaiCAREdata information has multiple purposes, including feedback reports for individual GPCs or EDs, benchmarking, and advising different stakeholders such as the Ministry of Health. Feedback on numerous items can be provided to health care professionals and their management and can serve as a way of benchmarking their performance . Annual reports, required by the government, can be easily produced. The database also facilitates easy access to aggregated data, benchmarking and surveillance. It will be possible to measure the quality of care provided by GPs using indicators that quantify quality of care . For insData will also allow documentation of the whole chain of care because it can provide an overview on: the characteristics of the population contacting the GPC, the ED and/or pharmacist on call, the incidence of the reasons for encounter and diagnoses, the work burden for all personnel , the influence of new services on patient choices, patient preferences in OOH care, the effect of co-payment and out-of-pocket payment on patient behaviour, and the influence of triage systems on patient flows. This offers the opportunity to optimise the quality, safety, and the organisation of OOH care.Until now, individual patient data from different services were not linked, nor could groups of patients be followed throughout the health care system. iCAREdata will allow us to study the quality of care more profoundly with a special focus on health benefits.In the EurOOHnet network, we collaborate with EU partners on data sharing . The useThis project is the first of its kind in Belgium to securely link and integrate data from OOH care from GPCs, EDs and pharmacies, thereby allowing exploration of a broad range of research questions about the health care system. Our research group has broad experience with data linkage, for example as an active partner in the TRANSFoRm project .www.intego.be) to provide information on incidence and prevalence of diseases, laboratory tests and treatments in Flanders (Belgium). Although very valuable data on primary care are gathered in that project, the clinical data registered by Intego do not capture OOH primary care, do not allow linkage, lack information on the reason for encounter and contain data from less than 100 GPs [iCAREdata complements a project, started in 1990 by the Department of General Practice of the Katholieke Universiteit Leuven, on an integrated computerized network (Intego; By using an automated procedure of data transfer, there is no extra burden for participating GPs in iCAREdata. Since computerisation gives inexpensive and easy access to large volumes of data, researchers will be able to retrospectively analyse a large amount of valid data, adhering the most recent ethical and privacy rules. In addition, the implementation of quality enhancing projects in OOH care can be analysed with iCAREdata. Another potential added value is providing GPCs with information that can act as catalyst for behaviour change during office hours. Linking OOH data with data from during office hours is the logical next and future step.Quality of data depends on practitioners’ registration performance. There is an enormous variability in the quality of data extracted from GPs’ electronic medical records . The eleAnother issues is that practitioners on call base codes on a correct diagnosis or assessment. Criteria based diagnoses are more accurate than symptom based diagnoses, but experience with registration is lacking among Belgian physicians . CapturiRoutinely collected primary care computer data aggregated into large databases can be used for auditing, quality improvement, health service planning and clinical epidemiological research . By inte


Under the modern network environment, ubiquitous learning has been a popular way for people to study knowledge, exchange ideas, and share skills in the cyberspace. Existing research findings indicate that the learners' initiative and community cohesion play vital roles in the social communities of ubiquitous learning, and therefore how to stimulate the learners' interest and participation willingness so as to improve their enjoyable experiences in the learning process should be the primary consideration on this issue. This paper aims to explore an effective method to monitor the learners' psychological reactions based on their behavioral features in cyberspace and therefore provide useful references for adjusting the strategies in the learning process. In doing so, this paper firstly analyzes the psychological assessment of the learners' situations as well as their typical behavioral patterns and then discusses the relationship between the learners' psychological reactions and their observable features in cyberspace. Finally, this paper puts forward a CyberPsychological computation method to estimate the learners' psychological states online. Considering the diversity of learners' habitual behaviors in the reactions to their psychological changes, a BP-GA neural network is proposed for the computation based on their personalized behavioral patterns. In today's society, ubiquitous learning (U-learning) has been bringing about magical changes to traditional education –3. UnderIn that circumstance, the participants of ubiquitous learning have formed an ecological social community which displays many new features and is sustained by the common motivation and goal, favorable atmosphere, and emotional communication, as well as enjoyable experiences , 9. ManyIn the past century, learning theory has made great progress. Constructivism, situated cognition, and informal learning theories offer the guidance for ubiquitous learning by focusing on the individual's self-construction of knowledge and aim to provide new online intelligent, virtual interactive, and seamless learning patterns for learners on the basis of such situational characteristics as location, time, and environment , 8. ReseHowever, the environment and patterns of ubiquitous learning in a social community differ from those in classroom completely. Different social media and interactive activities between the participants have all major impacts on the cognition, emotion, and attitude in the learning process , 16–18. Therefore, considering the new features and special environment in cyberspace, a further study of ubiquitous learning theory is required to provide comprehensive and systemic guidance for improving the organizational mode, learning behaviors, and teaching skills, which involves the interdisciplinary areas of pedagogy, psychology, sociology, organizational behavior, neuroscience, and information technology. Scholars have paid attention to the above issue in the 1990s. CyberPsychology, coined by Dr. John Suler in his hypertext book “The Psychology of Cyberspace” with the first version appearing in January of 1996, launched the original conceptual framework for understanding how people react to and behave within cyberspace . The proBy affective computing  on the lThis paper aims to explore an effective method to monitor and analyze the learners' psychological reactions based on their observable behaviors in cyberspace and therefore help to conduct the smart education in ubiquitous learning. This paper is organized as follows. Social community of ubiquitous learning is affected by a lot of factors associated with social, psychological, organizational, managerial, and technological aspects. Since the 1990s, a lot of scholars such as Webster and Hackley , Hill anti) represents the vector of psychological assessment at different times ti   given by the learners and A(ti), I(ti), E(ti), and S(ti) represent the scores of attention, interest, emotion, and satisfaction, respectively, at time ti.Recent experimental observations showed that a desirable learning atmosphere, good visual effects, pleasant voices, suitable topics and materials, and positive evaluation feedbacks were the most important factors that aroused the learners' interest in ubiquitous learning and contributed to the pleasant emotional experiences . In ordeThe calibration for scoring records is shown as in In ubiquitous learning, the learner's behaviors can be divided into three categories from simple to complex: operational behaviors, information exchanging behaviors, and problem-solving behaviors . Howeverpa) represents the behavioral pattern related to psychological reaction pa, A(j)   represents a series of basic actions in a certain period T under the psychological reaction pa, and P(j)   is the parameters of A(j).The pattern of each learner's habitual behaviors can be expressed as formula The action's data are mainly acquired from the server's log files or by some online tracking tools. The switching frequency and retention time of webpages, the locations and movements of the mouse, and the keyboard operations are all the important parameters as the features to reflect the learners' psychological reactions. For example, if the learner has strong interest in something and is in a fairly good mood, he/she tends to stay on the interesting webpage longer, use his/her mouse and keyboard with higher frequency, answer the asked questions more quickly, and be more willing to make positive comments. On the contrary, if he/she is anxious and fretful, he/she will switch from one webpage to another frequently, move the mouse in a wide range quickly, and be more likely to give negative feedback . ProfessThe psychological reactions of the learners are the results of a series of neural activities dominated by the brain mechanism , which wHowever, in the ubiquitous learning environment, the possible information we can obtain from the learners is their observable actions as well as the voice and video signals produced by their online activities under some circumstances. Considering the protection of the learners' privacy, CyberPsychological computation cannot be based on the content analysis and semantic detection of the above information. Fortunately, technologies of psychological computation from voice and video signals have developed quickly in recent years. For example, progress has been made on the voice signal based on its acoustic features parameters such as speech speed, voice intensity, pitch frequency, LPCC (Linear Prediction Cepstrum Coefficient), and MFCC (Mel Frequency Cepstrum Coefficient) , 37, 38.L1, L2, and L3) to almost the same psychological reaction PA{9.3,9.2,2.5,9.1} (within the relative errors of 10%) in a period of 10 minutes.In our research, we mainly consider the learners' behavioral features from their observable actions in cyberspace. The relationship between the learners' psychological reactions and their observable features is related to the habitual patterns of the learners' behaviors, which is dependent on a statistical study in the real cases. From In order to monitor the learners' psychological reactions in the learning process, we put forward a CyberPsychological computation method as shown in In the learning system, online activities such as answering questions, retrieving information, discussing problems, chatting with each other, and submitting assignments are all assigned in different functional areas on the webpage. So the layout structure and its related information of the webpage are extracted to assist in identifying the learners' action.Every change of the elements on the webpage, such as moving, clicking, and scrolling of the mouse or the operation of the keyboard, will trigger the corresponding JavaScript function. In order to meet the requirements of real-time data collection, we adopted the PHP language to program the above JavaScript function and process the mouse and keyboard data acquisition, which can be realized by the intelligent multiagent technology .As we discussed before in this paper, the learners' psychological reactions are exhibited in their diverse habitual behaviors and the CyberPsychological computation should be based on their personalized behavioral patterns. Therefore, we consider the learner's ID and his/her historical behavior patterns in our method. The computation on the learners' psychological reactions based on their behavioral features in the learning process can be regarded as a dynamic and nonlinear estimation problem by machine learning. So the subjective psychological assessment of learners' situations should be given by them in the sample training.Nonlinear Regression, Kalman Filter, Artificial Neural Network (ANN), and SVR (Support Vector Regression) have been reported as successful technologies for solving the above estimating problem , 19. HowBP (back propagation) neural network is a nonlinear function to establish the uncertain and continuous relations between input and output variables based on trained samples by machine learning. It can continuously modify the network weights and thresholds through the error back propagation algorithm  and reach the target of minimizing the mean square error. However, the traditional BP neural network easily causes the nonconvergence problem or falls into a local extremum. Those defects can be overcome by combining with a genetic algorithm (GA) , 40.The input layer has 12 nodes which are composed of the data of course information, learner's ID, mouse actions, and keyboard actions. The output layer has four nodes which correspond to the scores of the learner's psychological reactions in formula  with different activities arranged in each period. The learners are 16 social participants with more than 60 learning hours in a normal and stable environment of ubiquitous learning community. They are required to complete this course in 40 days. However, they can arrange the learning time freely in a ubiquitous learning environment. In this experiment, we assigned different activities in each period of a lecture and asked the learners to make a psychological assessment of their general situations in the final 1 minute of each period.In the end of our experiment, 11 participants successfully finished this course and provided completed subjective assessments of their psychological reactions in the learning process. We extracted randomly the records of 16 lectures as the training samples for BP-GA neural network and took the rest of the 4 lectures for the test of computation results. The above process was carried out 3 times. By analyzing learners' psychological reactions and their varying characteristics in the learning process, we can explore the statistical distribution and the changing rhythms of the learning community in different periods and scenarios and find the learners' ROI (Region of Interest). This has significant implications on the design of learning strategies such as the education scheme and teaching plans which are on-demand and more appealing and enjoyable to learners in order to provide state-of-the-art teaching models, skills, and technologies for smart education in a ubiquitous learning environment .With the development of modern information network and mobile communication technology, personalized learning in a ubiquitous learning environment has been made possible in web space accessible by a variety of multimedia terminals anytime and anywhere. It has brought about new changes to the theories, means, and patterns of traditional education. In the U-learning environment, learners' psychological reactions and learning experiences have significant impacts on stimulating their learning interest and improving the teaching efficiency.This paper aims to explore an effective method to monitor the learners' psychological reactions based on their behavioral features in cyberspace and therefore provide useful references for adjusting the strategies in the learning process. As the comprehensive result of our research, a CyberPsychological computation method based on BP-GA neural network was proposed for estimating the learners' psychological states online. The experimental result shows that it can achieve accuracy near 78%.Future researches should consider the dynamic psychological reactions of the learners through the studies of their physiological signals such as EEG, ECG, EDR, respiration, and skin temperature by a wearable device system and assist in obtaining a more precise psychological assessment of the learners' situations. Besides, the influence factors of different lecture's contents and the statistical distribution of the learning community as well as its varying characteristics in the learning process are all worthy of further explorations based on more cases and samples.


Home-based asthma environmental education for parents of asthmatic children is needed since many health professionals lack the time to offer it. However, developing targeted and tailored education is important in order to address the individual needs of participants. This nonrandomized longitudinal study examined knowledge on asthma with an Asthma and Healthy Homes educational intervention training offered to parents of children from low income families who reside in the Rio Grande Valley of Texas. Eighty-nine parents received the training and pre- and posttest surveys were used to measure knowledge outcomes. A standardized assessment on asthma triggers was used to identify the different triggers each child was exposed to, and a follow-up survey was conducted 6 months after the educational intervention to identify how many parents reported household and behavior changes as a result of the training. Results showed significant changes in behavior by participants as a result of the training received. This study suggests that these behavioral changes are attributed to the dual “targeted” and “tailored” educational interventions delivered to parents which resulted in a greater understanding of how to manage asthma by eliminating asthma triggers in their respective homes. Asthma is a leading cause of illness and hospitalizations among children with a significant impact on their health and quality of life. More than 10 million US children under age of 18 (14%) have been diagnosed with asthma; 6.8 million children still have asthma (9%), and boys (16%) were more likely than girls (12%) to have ever been diagnosed with asthma [In 2012, the National Center for Health Statistics reported the prevalence of asthma in children in the United States to be 9.3% and 11.4%, in Texas, respectively [ colonias that exist in the Texas-Mexico border region are located in this county [ Colonias are unincorporated, impoverished settlements along the Texas-Mexico border, which in many cases lack some of the most basic living necessities such as plumbing and electricity [Hidalgo County is located along the Texas-Mexico border within the state's Public Health Region (HSR) 11. The HSR 11 has an asthma age-adjusted hospitalization rate of 13.4% (12.5–14.3) and 14.4% (14.2–14.7) per 10,000 at the state level for children in the ages 0–17 and a large uninsured (41% in 2007) Hispanic population. Hidalgo County is the poorest county in Texas, and it is estimated that 42% of the 2,294From a public health perspective, the implications of these poverty conditions translate into a disproportionate risk factors burden . In the  colonias based upon income and location. Research shows that there is a link between health status and the home environment. These studies agree that successful asthma management involves case management and environmental adjustments [These issues represent well-documented asthma risk factors , 10, witustments , 12. It ustments . Home-baustments , 15. Howustments  and thisustments . It is wustments . intended to reach one specific person, based on characteristics that are unique to that person, related to the outcome of interest, and have been derived from an individual assessment” [Tailored and targeted health communications have been used in promoting pediatric injury prevention and childhood immunizations , 20, in essment” . targeted educational intervention based on an Asthma and Healthy Homes curriculum, (b) to identify asthma triggers in the residences of participants and provide them with tailored educational interventions, and (c) to assess behavioral changes made by parents based on both targeted and tailored education that were provided.The purpose of this study was threefold: (a) to improve the knowledge of parents of children diagnosed with asthma through a promotoras  to the parents of program participants in order to identify asthma triggers within their respective homes. This instrument included the collection of information relevant to the characteristics of each household which was used to tailor educational interventions at an individual level. A follow-up survey was conducted 6 months later to evaluate the degree to which participants made changes (self-reported) to their household environment based on acquired knowledge. The study was conducted in Hidalgo County, which is located in the Texas Lower Rio Grande Valley, between September 2012 and August 2014.This study was longitudinal and nonrandomized and targeted eighty-nine parents of children, 1–17 years of age, with a diagnosis of asthma. Pre- and posttest surveys were utilized to measure knowledge-based outcomes at baseline. Additionally, a standardized assessment on asthma triggers was applied by the colonias located in Hidalgo County. The study, which was approved by the Texas A&M University Institutional Review Board (IRB), had five attritions at various times for such reasons as moving out of the city, lack of interest, the fact that the child was feeling better, and so forth. The initial asthma education was delivered as a targeted educational intervention and consisted of one 60-minute session in Spanish provided by bilingual and bicultural health professional promotoras. The promotoras were trained to obtain consent from participants, and once received they administered the Asthma and Healthy Homes survey through face-to-face interviews in English or Spanish, based on the preference of the participant, and followed up with each family six months later. Promotoras were also directly involved with each household and focused on the triggers and concerns identified by participants and reflected in the assessment. The data collected from these surveys was utilized to further “tailor” the educational interventions on an individual basis.The eligibility criteria were a household with a child, 1–17 years of age, diagnosed with asthma and willing to participate in the two-year study. A snow-ball technique was used to identify potential study participants living inThis study used a combination of target and tailor strategies. First the “target” population, parents of asthmatic children, was identified and all individuals in this population received the same educational intervention. Afterwards, each parent was administered a standardized assessment to obtain information on their specific home environment and unique circumstances related to such. Based on the outcome of these assessments, specific tailored recommendations on how to mitigate asthma triggers within the home were provided to participants. The rationale for the latter is that an individual who perceives that the education or message they are receiving responds to their particular circumstances is more likely to make a recommended behavior change. Additionally, studies have shown that exposure to tailored messages has been associated with changes in a variety of health-related behaviors .The targeted educational tool used by the promotoras was the “Asthma and Healthy Homes” curriculum, which has been certified by the Texas Department of State Health Services and used in previous studies with excellent results –26. The  promotoras on a face-to-face basis 6 months after the training was completed. The purpose of the follow-up survey was to identify behavioral changes parents made as a result of the education received.In order to test the knowledge acquired, a pretest assessment to measure knowledge changes among participants was applied before the one 60-minute training session. The posttest was applied three months after the education intervention was done. An asthma trigger standardized assessment was used to identify both the different triggers in each household and the physical living characteristics of participants. A follow-up survey was administered to participants byPre- and Posttest. The pretest was comprised of six questions related to the participant's background and demographics and 12 true-false questions that related to asthma triggers, household chemicals, and pests. The pretest was conducted during a face-to-face interview with the parent prior to receiving the training to develop a baseline of knowledge. The posttest covered the same questions as the pretest and was applied three months after the educational intervention was completed.The asthma trigger standardized assessment was developed by the researchers as a checklist to identify home-based asthma triggers and preventative strategies including the following: housing structure and materials, presence of mold or water leaks, home cleaning and maintenance habits, exposure to indoor and outdoor pollution, presence of pets in the home, use of chemical irritants, smoking inside the house or car, and insect droppings. This standardized assessment was the basis for identifying and providing tailored educational interventions to individual parents based on the unique environmental circumstances in their home environments. promotoras to reinforce the “tailored” educational concepts needed in order to address the specific needs for each family based on the information previously gathered.A follow-up survey was conducted six months after the first encounter with the parents to assess any behavioral changes made as a result of the Asthma and Healthy Homes' training. The follow-up survey included 33 questions regarding specific household changes and ten questions concerning changes in the home as a result of topics covered in the training, for example, water and mold, cleaning, air quality, trash, safety, hazards, paint, and lead, as well as the health of the participant's asthmatic child. This encounter was also used by thet-test. Additionally, changes in numbers and percentages of pre- and posttests were compared for each individual question, and statistical significance of the difference between two frequencies was determined by the McNemar tests. Descriptive statistics were also used to summarize demographic characteristics of the respondents and frequencies of asthma triggers and follow-up surveys. Data collected at 6-month follow-up were analyzed by calculating the frequencies of the responses in different areas of household change after the training, while asthma trigger questionnaires were also examined to understand various environmental triggers at each household and physical living characteristics of participants. All analyses were conducted using SPSS version 22, and missing values were excluded from the analysis.To estimate the impact of healthy home trainings, overall mean scores for both pre- and posttests were obtained by summing the number of correct answers for all fourteen questions (maximum score = 14), and differences in the proportion of correct answers between pre- and posttests were assessed using a paired Among the 94 families that enrolled in the study, 89 completed the program, for a retention rate of 95%. Given the longitudinal nature of the program, this retention rate is outstanding and demonstrates the promotora's skill in engaging families for a sustained period of time. Nearly all of the 89 families who completed the program reported household incomes that were less than $30,000 a year and 89% of families reported a decrease in the frequency of asthma attacks.p < 0.001). For each knowledge-based change question, percentages of correct answers before and after the healthy home training were also compared. In the pretest, the percentage of respondents who answered the questions correctly ranged between 77% and 100%, while they ranged from 87% to 100% for the posttest. In the posttest, 12 out of fourteen questions were answered correctly by more than 90% of the respondents.Overall changes in knowledge mean score, obtained by summing all correctly answered questions, before and after the healthy home training were presented in We found that, out of 14 questions, six responses showed significant difference between pre- and posttest and thus are presented in When asked about types of asthma triggers that are problematic for their children, the proportion of parents identified cigarette smoke, smoke from a campfire or wood-burning stove, strong smells, and pollen. Since it is unlikely that children's actual asthma triggers changed, these findings seem to indicate a growing awareness on the part of parents and caregivers.Regarding asthma triggers, we found that more than half of study participants indicated that their asthma was worse around dust (83%) and that they primarily live in a dusty neighborhood (52%). The most common material for flooring in the region where the study took place is tile or vinyl due to the hot temperatures throughout the year. 82% of participants responded that they have tile or vinyl as flooring which makes cleaning it easier. However, a large percentage (81%) responded that their households have curtains or drapes which accumulate great amounts of dust. Almost half of participants have a history of allergies and 61% reported an air conditioning window unit which, in many cases, is not functioning properly and contribute to outdoor air coming inside the house. There was evidence of cockroach droppings (frass) in the households of participants and some water leakages; 44% of participants reported that their asthma is worse when aerosols or sprays are used near them and 62% when chemicals with strong odors are used in close proximity.Families and children with low socioeconomic status, minorities, and those who have either no insurance or Medicaid are at higher risk for hospitalizations and emergency department visits for asthma . ChildreIdentification of asthma triggers in each home, through the use of the standardized assessment, was needed in order to educate parents both on the environmental asthma triggers present in their home and more importantly on what to do to mitigate those triggers using the educational tools they received through the Asthma and Healthy Homes curriculum. Changes in behavior by parents of the asthmatic children who participated in the study were evident. Among nine families whose house had evidence of water damage, based on the asthma triggers checklist completed during the first home visit, five reported that they repaired the water leaks. Of four families that reported using gas stoves for heating, two indicated that they were no longer doing this during their follow-up survey. These behavioral changes are attributed to the dual “targeted” and “tailored” educational interventions delivered to parents which resulted in a greater understanding of how to manage asthma by eliminating asthma triggers in their respective homes. The education received empowered parents to better control the home environment resulting in improved health for their asthmatic child. These findings are corroborated by the literature which reports that there are improvements in asthmatic conditions when asthma triggers at home and schools are under control, since children spend most of their indoor time inside those places , 30. promotoras trained on how to apply and fill them out, which, at some point, reduces the bias that could occur if the forms were completed by each participant. There was difficulty in reaching some parents due to disconnection of their cell phones, moving from the house, or not wanting to continue the study; this resulted in an attrition of eight parents. However, since the attrition rate was relatively low, one strength of the study was the high retention rate of participants until its completion (two years).The surveys applied in this study are not validated and they were conducted byAsthma and Healthy Homes education was an important factor in improving the well-being of participants. As a result of the targeted educational intervention, study participants increased their knowledge related to asthma symptoms, case management, and how to identify triggers and exacerbating factors. In addition, due to the tailored interventions, they learned to control the symptoms of their asthmatic children by decreasing and/or eliminating their exposure to asthma triggers in their homes and thereby reduced asthma exacerbations. promotoras played a crucial role in this study and their work was key to the successful outcomes resulting from visits they made to each participant's home, the numerous follow-up phone calls they made, and the attention they provided to each participant. Their work resulted in an attrition rate of 5% of participants due to different reasons .In treating and preventing asthma, it is important that there is a clear understanding that, for many patients, more often than not, there may be multiple asthma triggers affecting their condition, not just one. The promotoras use the information gained from the surveys to tailor the dialogue with the family in order to correspond directly to the needs of the family and demonstrate that their responses are being used in a way that is meaningful to them.This study shows that visiting households and engaging directly with parents produce an important reduction in behavioral changes regarding asthma triggers. This tailored or personal customization was well received by program participants as evidenced by changes they adopted in their respective homes. It is vital that


A COS represents an agreed minimum set of outcomes that should be measured and reported in all trials of a specific condition. The COMET  initiative aims to collate and stimulate the development and application of COS, by including data on relevant studies within a publically available internet-based resource. In recent years, there has been an interest in increasing the development of COS. Therefore, this study aimed to provide an update of a previous review, and examine the quality of development of COS. A further aim was to understand the reasons why individuals are searching the COMET database.A multi-faceted search strategy was followed, in order to identify studies that sought to determine which outcomes/domains to measure in clinical trials of a specific condition. Additionally, a pop up survey was added to the COMET website, to ascertain why people were searching the COMET database.Thirty-two reports relating to 29 studies were eligible for inclusion in the review. There has been an improvement in the description of the scope of a COS and an increase in the proportion of studies using literature/systematic reviews and the Delphi technique. Clinical experts continue to be the most common group involved in developing COS, however patient and public involvement has increased. The pop-up survey revealed the most common reasons for visiting the COMET website to be thinking about developing a COS and planning a clinical trial.This update demonstrates that recent studies appear to have adopted a more structured approach towards COS development and public representation has increased. However, there remains a need for developers to adequately describe details about the scope of COS, and for greater public engagement. The COMET database appears to be a useful resource for both COS developers and users of COS. When designing clinical trials, it is important to measure appropriate outcomes, so that the results can be compared with other trials and will be as useful as possible to decision makers. At present, many studies which explore the effects of the same intervention on a specific health condition measure and report different outcomes, making it difficult to compare, contrast or combine their findings. This causes problems for people trying to use healthcare research. Inconsistency in outcome measurement and outcome reporting bias have led to avoidable waste in the production and reporting of research ,2. HowevThe COMET  initiative aims to collate and stimulate the development, application and promotion of COS, by including data on relevant individual studies within a publically available internet-based resource. The COMET database is a unique inventory that includes published accounts of COS development, as well as planned and ongoing work. Initially, the database included studies that had been identified by ad hoc means and a systematic review which addressed outcome selection in clinical trials in children . In ordeAwareness of the need for COS and knowledge of the COMET Initiative has continued to grow, reflected in website and database usage figures . More thTo update the original systematic review , in ordeThe methods used in this updated review followed the same approach used in the original review .As described in detail previously . BroadlyAs previously , studiesIn January 2015, we searched MEDLINE via Ovid and SCOPUS (including EMBASE) without language restrictions. The search identified studies that had been published from January 2013 onwards (MEDLINE) and August 2013 onwards (SCOPUS). The multifaceted search strategy developed in the original review using a combination of text words and index terms  was usedRecords from each database were combined and duplicates were removed. Titles and abstracts were read to assess eligibility of studies for inclusion in the review (stage 1). Full texts of potentially relevant articles were obtained to assess for inclusion (stage 2). Two of three reviewers  independently checked the title and abstract of each citation. One reviewer (SG) assessed the title and abstract of all citations. A second reviewer (JW) assessed the title and abstract of the first half of the citations and a third reviewer (BG) assessed the title and abstract of the second half of the citations. Citations were retained for further checking if agreement could not be reached. One reviewer (SG) assessed each full paper for inclusion in the review and another reviewer (BG) assessed half of the full papers. Reasons for exclusion at this stage were documented for articles judged to be ineligible.During each stage of the review process, agreement between reviewers was assessed. Prior to independently assessing records, the three reviewers  independently checked batches of abstracts and full papers for agreement.Of the records that had been excluded on the basis of the title and abstract, full text papers were obtained for a 1% sample and a fourth reviewer (EG) assessed correct exclusion. If any studies were identified as being incorrectly excluded, further checking was performed within the other excluded records. Of the records that had been excluded after reading their full text papers, 5% were assessed for correct exclusion at that stage.As described in detail previously , data weAs described previously , the resDuring May-June 2015, a pop up survey consisting of one question was added to the COMET website search page, with the intention of finding out why people were searching in the COMET database. At the beginning of each search, the survey would appear, to ask people to select a response as to their reason for searching in the COMET database. The survey was designed so that it was just one question with a set of multiple-choice answers, which was fully contained within the pop-window. This meant that people could answer the question and close the window with a single click. People were asked only once to do this although they could have run a number of searches.Following the removal of duplicates, 4980 citations were identified in the initial database search. A total of 4551 records were excluded during the title and abstract stage, and a further 400 were excluded following the assessment of full text papers . S1 TablThe figure displaying the year of first publication of each COS that was included in the original review has been updated to include the 29 new studies identified in this updated review . The figThere has been an improvement in the description of the scope of a COS. In the original review, only 25% (49/198) of studies were found to clearly define the population characteristics, as compared to 55% (n = 16/29) of studies in the updated review. The majority, 58% (n = 115/198), of studies in the original review neglected to report intervention characteristics, compared to 17% (n = 5/29) in the update.COS have been developed using a variety of methods . The incThe stakeholder groups regarded as key to developing a COS will vary between clinical areas. Clinical experts continue to be involved in almost all studies see , but theDuring the four-week period of the survey, 396 different people searched the database. The survey achieved a 52% (206/396) response rate. As in the original review, studies identified in this update covered various areas of health, with cancer and rheumatology being the most common. In addition to identifying the areas where COS are continuing to be developed, the review identified that COS had been developed for the first time in the areas of rehabilitation and eyes & vision. Regular review updates will allow us to identify the areas where there is an ongoing absence of COS, which may highlight future opportunities for COS developers.It is apparent that many studies still do not report important characteristics pertaining to the scope of the COS. The development and implementation of a reporting guideline, may facilitate improved reporting of COS, a project currently underway .http://www.comet-initiative.org/resources/PlainLanguageSummary, and a research agenda around methods for patient engagement has been set.A variety of methods continue to be used to develop COS. However, there has been an increase in the proportion of studies using literature/systematic reviews and the Delphi technique. As in the original review, the updated review found clinical experts to be the most common group involved in developing COS. However, the proportion of studies that reported patient and public involvement in the process has increased. Since the systematic search was completed in January 2015, we are aware of a further six COS studies that have been published, and of these six studies, 100% have included patient and public representatives. In addition, patient and public representatives are also involved in 89% (64/72) of the planned and ongoing studies registered in the COMET database. It is important that clinical trials include outcomes that are considered to be important to patients and other users of health and social care. It appears that the issue of patient and public involvement is no longer about whether to involve, but rather how. In response to this need, COMET has set up the PoPPIE  Working Group to develop resources in this area. As an example, plain language summaries are being developed in partnership with patients, The studies identified in this updated review have been added to the COMET database; a freely accessible, publically available, searchable online resource that shows what work has been done in relation to outcomes to measure in effectiveness trials. This update has ensured that the database stores the most current research, and provides readily available information about existing COS, which will assist researchers, practitioners and other stakeholders, including the public, when designing new clinical trials, systematic reviews and clinical guidelines. Moreover, it will also help to avoid unnecessary duplication of efforts in COS development.The results of the pop up survey demonstrate that people thinking about developing a COS are checking the COMET database to see whether a COS exists in their area of interest to avoid such duplication, hence emphasising the importance of keeping the database current. The pop-up survey also shows that the COMET database is being used for a variety of reasons by people besides COS developers, including clinical trialists, systematic reviewers, auditors, COS funders, and people who have been asked to participate in the development of COS. Interestingly, nearly one sixth of respondents were searching for reasons not anticipated, and further research is needed to understand those. Although 48% of visitors to the website did not respond to the survey, closing down the pop-up box immediately, this may reflect a typical response rate for such surveys.There are a number of limitations of this review that should be noted. First, although two well-established, large bibliographic databases were searched to identify studies meeting the inclusion criteria, we may have missed some relevant studies within these databases, either because the reports of these studies are not indexed in these databases or because the information in the indexed record is insufficient to show that the report is eligible. It would be beneficial for bibliographic databases to introduce an indexing term to facilitate easier identification of COS. As shown by both our original review  and thisA second limitation of the review is that the lack of an assessment tool means that there has been no formal quality assessment of the included studies. Determining the quality of a COS is not straightforward. A high quality COS would be one that leads to improved health outcomes but this would be difficult to measure. A tool is needed to assess how the COS developers minimised biases which would otherwise undermine the ability of the COS to have a positive impact on patient care and outcomes.We have provided an updated review of studies that have addressed the development of COS for measurement and reporting in clinical trials. The updated review has demonstrated that COS are continuing to be developed across a range of health areas. Recent studies appear to have adopted  a more structured approach towards COS development, and public representation has increased. However, although general reporting quality has increased, there remains a need for developers to adequately describe details about the scope of COS, and for greater public engagement. The COMET database is likely to be a useful resource for both COS developers and users of COS including clinical trialists and systematic reviewers.S1 PRISMA Checklist(DOC)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.


The full economic and societal value of vaccination is complex to assess. Although direct protection is the immediate goal of vaccination programmes, it is rare that 100% uptake is attained. An important facet of vaccines value comes from the indirect (or herd) protection they provide. The evolving dynamics of our society, including the increase in the proportion of older individuals enhances the value of indirect protection in reducing disease transmission within the family setting and the society as a whole. For example, grandparents are increasingly involved in childcare, putting them at risk of disease transmission if they or the children are not vaccinated. Preventing disease in children can also reduce absenteeism for parents who otherwise would take days off work to care for their sick children, leading to a substantial societal burden. Preventing disease in working adults reduces absenteeism and presenteeism, enhancing productivity and contributing in turn to economic growth. Quality of life is essential at all ages. It is fundamental in children for their life chances, educational achievements, and healthy wellbeing. Additionally, preventing common diseases in adults and the elderly also contributes to their quality of life and helps to assure healthy ageing for growing ageing populations. These wider economic and societal values, although difficult to measure, should be taken into consideration in assessments of the economic value and cost-effectiveness of vaccination programmes. Vaccination is often regarded as an individual intervention with a wider public health impact. By vaccinating one person, protection can be conferred to a wider group of people through the phenomenon of ‘herd effect’ that provides indirect protection. In today's highly globalised world, the demographic changes occurring and the increasing cross-border population movements and migration between countries and continents have important implications for global health. Controlling the spread of diseases, and related transmission dynamics, is a key challenge in global health, and the role and value of vaccination in this area are obvious. Vaccines have an important role for both preventing disease and reducing societal burden through the prevention of indirect costs of disease, such as absenteeism from work, productivity losses, and working days lost for parents and caregivers. In this article, we will present some examples of vaccination's indirect protection and its associated benefits within the family and the broader society, as well as examples of vaccination's impact on absenteeism, productivity and quality of life, which are of critical importance in the growing elderly populations.One of the unique properties of vaccination – and sometimes even potentially one of the main goals – is its ability to confer indirect protection through a herd effect to unvaccinated individuals and groups . VaccinaThe conjugate pneumococcal vaccine provides an example of the economic benefits of indirect protection. In Germany, the results from a cost-effectiveness study showed that the total costs from pneumoccal disease for the entire German birth cohort were €808.3 million without vaccination and €928.1 million with vaccination, when the benefits from herd effects were not considered . ExcludiVaccination protects and influences circumstances in whole families. Indirect protection is key if the impact that infectious diseases in children can have on families’ dynamics and caregivers’ absenteeism is considered. For example, a child with varicella may be excluded from school for up to 2 weeks, which corresponds to the disease's incubation period. When the child recovers and returns to school, infected siblings may exhibit symptomatic disease and be off school for another 2 weeks, prolonging parental or caregivers’ absenteeism. The importance of the role of grandparents is also highlighted by policies implemented in some European countries. In Germany, parents are entitled to take leave for up to 3 years after their child is born, 12 months of which can be deferred until the child is eight. Working grandparents may also take 10 days leave in an emergency to care for their grandchildren or to take unpaid leave of up to 6 months . In the The role of indirect protection is also pertinent for wider protection across society, extending protection benefits to population groups that are not, cannot be or will only be reluctantly vaccinated . This protection may be crucial in public places, such as public transports, schools, and workplaces. The dynamic nature of mixing and contact patterns within a given population is a strong argument in favour of vaccination to provide both aggregate direct, and subsequent indirect protection to reduce disease transmission within the society as a whole. Even if some of the broader benefits of indirect protection may be difficult to quantify in monetary terms and, thus, challenging to include in economic evaluations , public It is increasingly acknowledged that the costs of disease not only fall on the individual patient but also on caregivers including family, friends, communities, and the wider society. It is from this perspective that vaccination against preventable infectious diseases warrants a broader societal value. As mentioned previously, varicella disease in children incurs considerable indirect costs as a result of parental absenteeism and loss of productivity , 9. For Another study conducted in seven European Union (EU) countries estimated the percentage of rotavirus gastroenteritis (RVGE) cases that required at least one parent or another person to be absent from work was up to 91% for hospitalised children, between 4 and 64% for those attending emergency departments and between 20 and 64% for those seen in primary care . SimilarAbsenteeism can have a profound economical impact by undermining productivity in the workplace. For example, in the UK, each absent employee cost their employer an average of £975 in 2012, while absenteeism direct costs alone amounted to more than £14 billion a year across the economy . Loss ofAs an adjacent issue, vaccination of healthcare workers can help to improve the productivity of healthcare systems, where the level of absenteeism is becoming increasingly problematic, affecting the quality of care and resource management. This is especially pertinent in the case of influenza vaccination. Research suggests that even a 1% decrease in absenteeism of healthcare workers could lead to savings of around £34.2 million for the National Health Service in the UK . AdditioAs populations grow older and the retirement age is increased to cope with the financial pressure of retirement funds of social security organisations, avoiding preventable disease in the working population and the ‘young’ elderly becomes more important. For example, herpes zoster (HZ) and post-herpetic neuralgia (PHN) have a negative impact on the productive work life of individuals. In a Canadian study, 64% of the employed participants reported missing work and 76% reported decreased effectiveness at work  due to HZ and PHN, for a mean number of 43 and 46 h, respectively . VaccinaA central role of public health policy is to protect lives by reducing the burden of infectious diseases and preventing premature deaths. Vaccination has successfully contributed to these key goals. In addition, public health policy also aims to improve the quality of life and promote healthy ageing for all citizens.European governments have recognised the importance of healthy ageing as part of the inevitable demographic changes occurring in many countries , 23. As Also, in this context, vaccinations against influenza, pneumococcal disease, and HZ can be considered as quality-of-life enhancing interventions. A recent UK study that investigated the clinical presentation and quality-of-life burden of HZ and PHN from individual, clinical, and societal perspectives found that the pervasive nature of PHN pain and associated symptoms placed significant strains on individual and healthcare resources –26. The The principle of equity and equal access to maximise populations’ health is a keystone of modern healthcare systems. Absence of equity and equal access can result in significant missed opportunities, inflating social security and healthcare expenses with the well-known societal consequences that invariably occur. This, in turn, strengthens the adagium ‘prevention is better than cure’ as a general value proposition also as a means of reducing health inequalities. For example, a recent study in the UK showed that hospital admissions for all-cause gastroenteritis in children increased with a lower level of socio-economic status . The stuVaccination leads to lifelong individual and societal benefits, helping to reduce indirect costs, such as productivity losses and absenteeism from work, and improve quality of life. These key aspects of value contribute to equity and, in turn, avoid unequal access and health differences related to socio-economic status. Evaluations of vaccines should, therefore, consider these wider dimensions of value, particularly in the context of indirect protection. The societal benefits resulting from vaccination, although difficult to ascertain, should not be underestimated; they are fundamental to the true value proposition of vaccination. Wider social value, in addition to economic value, should be captured as part of routine assessment of the economic interest and cost-effectiveness of vaccination programmes.