In West Africa, hypertension, once rare, has now emerged as a critical health concern and the trajectory is upward and factors are complex. The true magnitude of hypertension in some West African countries, including in-depth knowledge of underlying risk factors is not completely understood. There is also a paucity of research on adequate systems-level approaches designed to mitigate the growing burden of hypertension in the region.In this review, we thematically synthesize available literature pertaining to the prevalence of hypertension in West Africa and discuss factors that influence its diagnosis, treatment and control. We aimed to address the social and structural determinants influencing hypertension in the sub-region including the effects of urbanization, health infrastructure and healthcare workforce.The prevalence of hypertension in West Africa has increased over the past decade and is rising rapidly with an urban-rural gradient that places higher hypertension prevalence on urban settings compared to rural settings. Overall levels of awareness of one’s hypertension status remain consistently low in West African. Structural and economic determinants related to conditions of poverty such as insufficient finances have a direct impact on adherence to prescribed antihypertensive medications. Urbanization contributes to the increasing incidence of hypertension in the sub-region and available evidence indicates that inadequate health infrastructure may act as a barrier to optimal hypertension control in West Africa.Given that optimal hypertension control in West Africa depends on multiple factors that go beyond simply modifying the behaviors of the individuals alone, we conclude by discussing the potential role systems-thinking approaches can play to achieve optimal control in the sub-region. In the context of recent advances in hypertension management including new therapeutic options and innovative solutions to expand health workforce so as to meet the high demand for healthcare, the success of these strategies will rely on a new understanding of the complexity of human behaviors and interactions most aptly framed from a systems-thinking perspective. West Africa comprises 16 countries that are highly diverse both in ethnicity and culture. For example, the region is characterized by numerous cultural and ethnic affiliations that govern the language people speak, how they interact or even what food they eat . The regIn this review, we examine the prevalence of hypertension in West Africa; discuss factors that influence its diagnosis, treatment and control. Furthermore, we; highlight social and structural determinants of hypertension and thus, the importance of systems thinking for interventions aimed at reducing the prevalence of hypertension in West Africa. For the purpose of this review, systems thinking is defined as a ‘paradigm or perspective that considers connections among different components (or systems), plans for the implications of their interactions, and requires an active engagement of those who have a stake in the outcome to govern the course of change ’.Relevant published literature on the prevalence of hypertension in West Africa were identified via searching of the PUBMED, African journals online, and PsycINFO database. The review methodology was adapted from a previous review on cardiovascular risk factor burden in SSA . The sea‘determinants of hypertension in West Africa have not been well defined’[‘the prevalence of hypertension in West Africa was considerably lower than typically observed in industrial countries’[. Currently, estimates from available studies suggest that the prevalence has increased over the past decade and is rising rapidly with an urban-rural gradient that places higher hypertension burden on urban settings compared to rural settings. Available data indicates that the prevalence of hypertension is in line with the degree of urbanization in West Africa, with prevalence highest in Guinea (43.6%), [In 1996, Kaufmann and colleagues noted that the  defined’; and theountries’. Current(43.6%),  Nigeria (43.6%),  and Togo(43.6%), . Althoug(43.6%),  while re(43.6%),  and 35% (43.6%), .The challenge of hypertension in West Africa is even more complex due to low levels of detection/diagnosis, treatment and control. As shown in Table In the WHO seminal work on ‘Equity, Social Determinants and Public Health Programmes,’ Mendis and Banerjee  noted th‘the fact that most patients have to pay out of their own pocket for consultation and medications either fully or in part, is likely to have a negative impact on long-term management of hypertension’[In West Africa, available quantitative analysis indicate that poverty is rife with more than half of its population (60%) living on less than one dollar a day . While trtension’. In a prrtension’. Findingrtension’. Similarrtension’,34,37. Frtension’. In Kumartension’.In 2011, the proportion of West Africa’s population classified as urban reached 44.9% . By 2025Throughout sub-Saharan Africa, available evidence indicates that inadequate health infrastructure is a barrier to optimal hypertension control . In WestIn addition to poor health infrastructure, in many parts of West Africa, and sub-Saharan Africa, the shortage of healthcare workforce has reached a crisis point and it severely limits the ability to effectively reduce hypertension-related morbidity and mortality . AddressEvidence of social and structural determinants of increased rate of hypertension in West Africa highlight the need for systems-level approaches targeted at the reducing the increasing burden of hypertension in the sub-region. Anderson and Johnson  define sCasual loops provide a visual means of articulating our understanding of the relationship/connections between the most salient variables ,53 that In this review, we explored the increasing prevalence of hypertension in West Africa; identified the social and structural determinants influencing the prevalence; and highlighted the potential role of systems-thinking approaches to achieving optimal control in the sub-region. In West Africa, there is ample evidence to suggest that the prevalence of hypertension has increased dramatically over the past decade. Hypertension, once rare in rural parts of West Africa, has now emerged as a critical health concern and the trajectory is upward and factors are complex. For example, recent findings from Ghana report a high prevalence of hypertension among rural agrarian farmers that may not be easily attributed to western diet given their reliance on traditional home-cooked meals . It was The adverse impact of stress, coupled with urbanization and weak health infrastructure provide a good rationale why systems-thinking approaches could be essential for the effective management and optimal hypertension in West Africa. This is particularly important in the context of recent advances in hypertension management including new therapeutic options and innovative solutions to expand health workforce so as to meet the high demand for healthcare. Although these opportunities signal optimism about improved hypertension control, the success of these strategies will rely on a new understanding of the complexity of human behaviors and interactions most aptly framed from a systems-thinking perspective. Indeed, a patient’s ability to effectively manage and control their hypertension is a product of a dynamic process, influenced by multiple social, structural, economic and environmental factors that change and interplay over time. Therefore, simply put, promising advances in therapeutic options or task-shifting to cope with the high demand for care could be futile, if the same vigor is not applied to understanding the complex nature of hypertension control and how effective case-management depends on multiple factors that go beyond simply the behavior of the individual alone or the growing shortage of healthcare workforce.This review has several implications. First, it is important to explore the social determinants of optimal hypertension control in West Africa. As evidenced in the literature reviewed, pragmatic considerations of the root social factors such as poverty, is critical for understanding factors influencing uptake of services and the development of cost-effective approaches to optimal hypertension control. Second, to the extent that future studies and policymaking seek to identify ways to reduce the increasing prevalence of hypertension in the sub-region, knowledge of differential access to healthcare as well as differential exposure to multiple factors ranging from the adverse impact of globalization and urbanization to changes in dietary patterns and constraints with adopting health behaviors are crucial. Third, systems-thinking methods can contribute innovatively to developing an in-depth understanding of the complex factors that influence optimal control of hypertension in West Africa ranging from the role of job stress, to high costs of antihypertensive drugs, coupled with unhealthy dietary habits, and inadequate access to effective blood pressure monitoring devices and primary health practices. The application of systems-thinking modeling like causal loop diagrams illustrates not only the causal factors at play but also leverage points where optimal hypertension control in West Africa can be achieved. More importantly, it enables researchers and policymakers to view the rising prevalence of hypertension in West Africa as a complex health problem composed of different, interacting components and emphasizes the importance of understanding the behaviors of the whole components rather than individual components. Despite these implications, there are some potential limitations with this review as well as challenges or barriers in using systems thinking to findings solutions to optimal hypertension control in West Africa that should also be noted. Differences in study populations, including small numbers of participants in some studies and inconsistencies in the definition of hypertension outcomes limits confidence in conducting a thorough systematic review of available literature. Publication bias is also possible as available studies varied widely in the methodologies used. Partly to deal with the heterogeneous nature of available studies, we used principles of thematic analysis to identify, compare and contrast themes relating to the multiple factors influencing hypertension prevalence in West Africa. Also, with reference to systems thinking approaches, we anticipate that long-entrenched traditions with care-seeking alongside narrow focused and/or regimental attitudes in health service delivery from practitioners may act in various ways to influence optimal control of hypertension in the region. Furthermore, implementation of systems thinking approaches may also be affected by a range of factors that can be barriers or facilitators to optimal management of hypertension. Nevertheless, the rising prevalence of hypertension in the region require solutions that go beyond simply modifying the behavior of the individual patient alone to address the multifactorial nature of the barriers to optimal hypertension control. Simply put, developing interventions to reduce the increasing prevalence may be futile, if attempts are not made to understand, for example, the social, environmental, and health systems contexts in which patients and providers interact for diagnosis, treatment and management of an illness. Taken together, in light of the pressing need to reduce hypertension-related morbidity and mortality rates not only in West Africa, but throughout sub-Saharan Africa, these findings suggest the need to further explore the exact mechanisms through which social determinants influence optimal hypertension control while modeling the potential pathways and entry points where reduction in BP levels can be achieved in West Africa.The author declares that they have no competing interests.JI had the original idea for this paper which was refined by CA and GB. CA and GB were involved throughout in supervising the writing of the paper and in discussing the findings. RC, BT, JPR, and RA provided comments on various drafts and contributed to writing the final manuscript. All authors have read and approved the final manuscript.


The assessment of parenting has been problematic due to theoretical disagreement, concerns over generalisability, and problems with the psychometric properties of current parenting measures. The aim of this study was to develop a comprehensive, psychometrically sound self-report parenting measure for use with parents of preadolescent children, and to use this empirical scale development process to identify the core dimensions of contemporary parenting behaviour. Following item generation and parent review, 846 parents completed an online survey comprising 116 parenting items. Exploratory and confirmatory factor analyses supported a six factor parenting model, comprising Emotional Warmth, Punitive Discipline, Anxious Intrusiveness, Autonomy Support, Permissive Discipline and Democratic Discipline. This measure will allow for the comprehensive and consistent assessment of parenting in future research and practice. It has long been recognised that child development is affected by multiple interacting contextual factors at individual, familial, and societal levels . One facFactors such as evolution, family dynamics, culture, and social and political institutions have influenced parenting beliefs and practices over time . HoweverIn addition, there are several specific social trends that have occurred in recent decades that have had a significant influence on contemporary parenting behaviour. Since the 1970s, the number of women in the workforce has increased without a corresponding decrease in the number of men working, general material prosperity has increased, divorce rates have increased, and there have been significant changes in the structure and composition of the average family . In addiAlthough children appear to be better off in many ways than children were 30 years ago, a number of adjustment and psychological problems, such as childhood depression and anxiety, are increasing in prevalence with the age of onset decreasing . FurtherWhile a substantial amount of theoretical and empirical research over the past six decades has focused on the concept of parenting, there is a lack of agreement regarding the key elements and assessment of this construct. A large proportion of the literature has been based on Baumrind’s –20 parenIt has also been argued that important information may be lost in combining parenting dimensions into styles, and disaggregating these typologies will allow the individual key elements of parenting to be operationally defined, assessed, and combined into meaningful styles or patterns , 25]. R. R25]. RO’Connor  and SkinTherefore, this research aimed to develop an inclusive assessment of parenting through which the key elements of parenting could be identified and operationally defined, and the specific effects on childhood outcomes could be investigated. It was hoped that the comprehensive identification of important parenting elements would allow for clear comparison of parenting behaviour across parent, child, family, and cultural groups, and greater cohesion between the various theoretical conceptualisations of parenting, and provide an indication of the important parenting behaviours to assess in the development of future observational and interview assessment measures.This research was based on a wide range of theoretical parenting conceptualisations, self-report assessments, and qualitative and quantitative input from a sample of parents. A mixed-method approach was employed in order to combine the expertise of parenting researchers with the endorsement of contemporary parents in selecting important and relevant items for inclusion in the final Parenting Behaviours and Dimensions Questionnaire (PBDQ).DeVellis  suggesteThis study was approved by the Curtin University Human Research Ethics Committee. In study 1, participants provided written consent to participate. They were provided with an information and consent form, which they were invited to send back in a separate provided envelope to ensure confidentiality.M = 41.71, SD = 7.48). Number of children per family ranged from one to four, with children’s ages ranging from 3 to 17 years of age; however all parents had at least one child aged between 3 and 12 years.Sixteen parents recruited from advertisements throughout the researcher’s university, community newspapers, and snowballing participated in this study. Participants were all mothers, with ages ranging from 31 to 51 years . Number of children per family ranged from one to five, with children’s ages ranging from 2 to 18 years of age.A further 15 parents of children aged 3 to 12 years of age were recruited for focus groups using community advertisements and snowballing. Participants were all female with ages ranging from 32 to 51 years , 2 (sometimes), 3 , 4 (often), and 5  rather than assessing attitudes or beliefs, as behavioural frequency appears to be more reliably reported by parents in previous research , ,  reflectsEmotional warmth facilitates the development of a sense of competence, agency, and trust in the child, providing the foundation for confidence and competence in social interactions as well as high academic achievement , 84]. W. W84]. WPrevious research suggests that punitive, power assertive, or physical punishment methods are associated with poor outcomes in children , 88]; a; a88]; aThe Anxious Intrusiveness factor was given the same name as the factor in Becker’s  researchr = -.03) in the current study. It is important to note that Cronbach’s alpha for the Anxious Intrusiveness subscale was only minimally acceptable in the combined sample  , ,  Self-repr = -.28), which reflects contingent, responsive parenting behaviour.Permissive or inconsistent discipline has long been associated with externalising problems in children , as wellr = .51) and Autonomy Support (r = .48), and negatively correlated with the noncontingent disciplinary factors of Punitive Discipline (r = -.30) and Permissive Discipline (r = -.29).The final factor to emerge from the EFA was labelled Democratic Discipline, which reflected the parent’s use of reasoning and explanation. One of these items was suggested by parents in the focus groups, while the remaining items were based on items from previous questionnaires , 51], , . DemocraIt appears that the PBDQ dimensions of Emotional Warmth, Autonomy Support, and Democratic Discipline are associated with autonomy supportive parenting behaviour which is administered in a responsive and contingent manner, while Punitive Discipline, Anxious Intrusiveness, and Permissive Discipline describe non-contingent and unresponsive parenting behaviours that can be described as psychologically controlling. These results provide strong support for the importance of assessing autonomy supportive and psychologically controlling behaviours in parents of preadolescent children.Interestingly, most of the dimensions uncovered in this research appear to relate to the conceptualisations proposed by Baumrind –20 and tIn addition, Autonomy Support and Democratic Discipline appear to reflect Hoffman’s , 30], ,  conceptsIndeed, one of the major contributions of the PBDQ is the assessment of parental autonomy support or responsiveness in parents of preadolescent children. This dimension appears to be related to the administration of specific parenting behaviours, such as assistance, behavioural control, and comfort, in a way that takes into account the child’s developmental level, needs, and abilities. Johnston and colleagues  explaineAlthough the original item pool for the PBDQ included items from assessments of parenting styles, homogenous parenting dimensions emerged in the factor analysis. Furthermore, these dimensions had differential relationships with other PBDQ dimensions. For example, Emotional Warmth was moderately correlated with Anxious Intrusiveness, while the related concept of Autonomy Support did not appear to be related to this dimension at all. These results provide support for the assessment of disaggregated parenting dimensions rather than focusing on aggregated parenting styles.The PBDQ can be used to improve comprehensiveness, quality, consistency, and accuracy of parenting assessment in both research and clinical settings. The dimensions identified by the PBDQ can also provide the foundations for the development of alternative and more complex parenting assessment systems, including observational measures, research and clinical interviews, and child-report measures. These can then be used to collect comprehensive and valid multitrait multimethod parenting assessment data that addresses problems such as shared method variance. Grolnick  suggesteThe evaluation of such parenting interventions or clinical studies could also be achieved by administering the PBDQ before and after the intervention is conducted to determine if any meaningful changes in parenting behaviour have occurred. This measure has the additional advantage of being relatively brief and economical, which minimises the burden of participant responses and increases the utility of the measure, particularly for research purposes . As a reA major strength of the PBDQ is the rigorous methodology that was used in developing the scale, combining previous parenting literature and existing parenting assessments with qualitative parent feedback and empirical assessment of the item and overall model performance. The combination of a number of different sources of expertise was particularly important as the content of the questionnaire was not mapped onto domains of interest as a result of the large number of parenting conceptualisations in the literature and the lack of agreement over the core dimensions to assess . In addiOne limitation of the current study was the failure to use random sampling in asking parents to choose a child to answer the parenting items about. This may represent a source of bias in the responses; for example, parents may have chosen the child who they employed the most socially desirable parenting behaviours with. It is also possible that the higher education level attained by the participants in all phases of this research as compared to Australia’s national average as reported by the Australian Bureau of Statistics  may haveAlthough a diverse range of parenting issues and behaviours were considered relevant and important by parents in Phase One of this research, many of these items failed to meet the minimum loading criteria on any factor in the EFA. It is possible that the decision to interpret the suggestions made by parents as indicative of specific parenting behaviours rather than broader parenting constructs may have contributed to this outcome. Indeed, further factors may have emerged in the EFA if more items had been developed to reflect these broader themes, which could be an area of future development of the PBDQ model. In addition, the decision to use a Likert scale anchored by ‘Never’ and ‘Always’ may elicit trait judgments in respondents and it is possible that some of the assessed content may vary over time and situations.The newly developed PBDQ is a brief but comprehensive measure of contemporary parenting behaviour that measures six core dimensions of parenting: Emotional Warmth, Punitive Discipline, Anxious Intrusiveness, Autonomy Support, Permissive Discipline, and Democratic Discipline. These dimensions combined a number of different concepts from previous literature, providing some clarity to the definition of key parenting dimensions as well as highlighting the similarities and differences between a number of parenting concepts that vary in terminology, definition, theoretical basis, and assessment. The measure was developed using rigorous scale development procedures, and the results of this study provide preliminary support for factorial validity and internal consistency.


It may increase the likelihood that smoking occurs during a critical period of development that enhances susceptibility to the adverse effects of cancer causing agents in cigarette smoke, thereby facilitating the initiation of the carcinogenic process. While evidence for the latter hypothesis derives from a variety of sources, definitive proof has proven elusive. Whether or not early age of smoking serves as an independent risk factor for lung carcinogenesis, the consensus of the public health community is that prevention of smoking onset at a young age and early cessation are keys to stemming the current lung cancer pandemic. Population approaches to tobacco prevention and control, such as measures contained in the World Health Organization Framework Convention Tobacco Control Treaty, offer the best opportunity, on the scale needed, to create a smoke-free world and bring an end to the pandemic of tobacco-related disease.A vast array of data suggests that early age of smoking onset enhances the risk for development of lung cancer in adulthood. Initiation of smoking at a young age may influence the development of lung cancer because of its effect on duration of smoking. Early onset of smoking also may serve as an  After controlling for age, sex, and amount of tobacco exposure, men who began to smoke before age 20 had a higher risk of developing lung cancer than men who began smoking at age 20 or older  study  producedng onset . The modng onset .The investigative team also modeled the influence that a smoking-dependent first mutation rate would have on the risk patterns. They found that the ratio of the excess relative hazards was largest for those model smokers who started smoking earlier. The ratio was highest for smokers who started at young ages and who only smoked for short periods of time. That is, for individuals who started smoking 20 cigarettes per day at age 15 years and who smoked for five years, the ratio in excess relative hazard was about 3.5. This heightened risk for lung cancer, given the short duration of exposure, is consistent with the influence of early age smoking, perhaps at a critical period of development, on initiation and clonal expansion that may set in motion the process of life threatening malignancy in adulthood . “Preventing smoking and smokeless tobacco use among young people are critical to ending the tobacco epidemic. Since the first Surgeon General's report on youth in 1994, the basis for concern about smoking during adolescence and young adulthood has expanded beyond the immediate health consequences for the young smoker to a deeper understanding of the implications for health across the life span from early tobacco use.” . Whether or not age of smoking onset is an independent risk factor for lung cancer rates later in life or influences lung cancer risk primarily by contributing to duration of exposure to tobacco smoke, there is overwhelming consensus that the key to preventing lung cancer and stemming the 21st century pandemic lies in preventing smoking onset in young people and helping those who start to quit. The most wide-reaching initiative for stemming tobacco use and smoke exposure in young people on the scale needed to impact worldwide rates of lung cancer and other chronic diseases is the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) . The WHOAs noted by Morello in her recent review of policies to prevent tobacco use and exposure in children,  the WHO To help countries fulfill their WHO FCTC obligations, the WHO introduced the MPOWER package of six evidence-based tobacco control measures that are proven to reduce tobacco use and save lives . The WHOdenormalization of smoking and provide a model of a smoke-free lifestyle for their children [This global approach to tobacco control brings together a widerange of participants. They include world, national, and community leaders, governmental bodies, voluntary agencies, advocates, educators, and health care providers, particularly those that treat and care for young people. With respect to the latter, it is critical that child health care providers address tobacco prevention and control in parents and care takers, as well as in children, adolescents, and young adults. Parents have a major impact on the smoking behavior of children, and when they quit or refrain from smoking, create a smoke-free household, and/or talk with young people about how they can resist pressure to smoke, they contribute to the children .The decline in smoking rates and lung cancer deaths in a number of developed countries  offers fAn editorial by Glynn noted that since 2000, the pace of tobacco control in the United States has accelerated . The Affindependent risk factor for lung cancer and there may be a critical period when lung tissue is particularly susceptible to smoking-induced carcinogenesis. However, definitive proof remains elusive, and there is need for additional research in areas such as the molecular biology and epidemiology of lung cancer. It should be noted that a number of cohort studies  fail failindes (e.g.,  stratifimodest.” .life course epidemiology [independent risk factor for lung cancer later in life. As noted by Weincke et al., [per se on lung cancer. Early onset smokers tend to smoke more cigarettes per day, inhale deeper, and are less likely to quit smoking than those who start smoking later [Like so many other issues in emiology , our und et al.,  the cumung later , 49. Theng later . Hence, ng later , 52. By ng later .Genetic factors also may play a role. Specific chromosome loci associated with enhanced susceptibility to nicotine addiction and lung cancer have been identified . Despite


This review focuses on the process of adapting the original concept of Integrated Pest Management (IPM) to the wider conception of the Integrated Fruit Production (IFP) implemented in Europe. Even though most of the pest management strategies still rely on the use of synthetic pesticides, a wide array of innovative and environmentally friendly tools are now available as possible alternative to the pesticides within the modern apple production system. We also highlight how recent pest management strategies and tools have created an opening for research towards IPM improvement, including the use of biorational pesticides, semiochemicals and biological control. Forecasting models, new tree training systems and innovative spray equipment have also been developed to improve treatment coverage, to mitigate pesticide drift and to reduce chemical residues on fruits. The possible threats that jeopardize the effective implementation of IPM and particularly the risks related to the development of the pesticide resistance and the introduction of new invasive pests are also reviewed. With the directive 128/09, the European legislation recognizes IPM as a strategic approach for the sustainable use of pesticides. Within this context, IPM and related guidelines is called to meet different areas of concern in relation to the worker and bystander safety. Beside the traditional economic criteria of the market-oriented agriculture, sustainable agriculture includes the assessment of the environmental impact of the agronomic practices within the societal context where they take place. As a consequence of the raising consumer concerns about environmental impacts generated by the fruit production, IFP certification over product standards, including process aspects, are frequently required by consumers and supermarket chains. Historically, pest control in fruit orchards was based on broad-spectrum pesticides which were associated with a diversity of problems, traditionally including environmental effects, beneficial organism extinction, and pesticide resistance. More recently, other potential negative effects caused by the use of pesticides in agriculture have drowned the attention of the public and policy makers: the threat toward the pesticide applicators and bystanders’ health and the food safety endangered by pesticide residues. Fears about these issues have increased the interest in the development of alternative means for pest control that causes trivial or no impact on humans, beneficial organisms and sensitive ecosystems ,2. Neveret al. in 1959 . The EIL belongs to the most basic of the decision rules; it is a theoretical value that, if actually attained by a pest population, will result in economic damage ,115. HowNevertheless, a challenge for a wider applicability and application of models and thresholds, if available, under a routine field conditions basis is to use these mathematical descriptions across locations and real environments in an automatic manner . This enDespite apple production system was one of the first implementing the IPM principles, fruit protection still requires one of the highest numbers of spraying operations per year that are generally performed with air assisted spray machine. If the final goal of IPM is minimizing the use of pesticides and their potential adverse effects on human health, wildlife, soil water, and overall environmental quality, we cannot neglect the role played by the sprayer technique in optimizing the average deposit required for acceptable biological efficacy whilst minimizing spray losses and contamination of users, bystanders and the environment. The importance of the performance of spraying equipment for the safety and efficiency of pesticide use is also recognized by the enforcement of the European Union directive on the Sustainable Use of Pesticides , that make necessary to inspect all sprayers employed for professional use in the European Union at least once by 2016 and to establish periodical mandatory inspections schemes in all EU countries .Replacement of the fine or very fine hollow cone hydraulic nozzles operated at moderate to high pressures with air induction cone nozzles, which produce very coarse spray qualities, significantly decrease environmental impact by mitigating the spray drift ,121,122.Over the last 60 years, large apple trees once constituting the extensive orchards, have been replaced by dwarf trees, ideally not higher than 4 meters and planted in rows 3.5 to 4 meters apart. In these modern apple orchards, applications of chemical control are still widely based on axial fan airblast sprayers which produce a large radial spray plume resulting in high spray losses to the ground and as spray drift. A new direction in tree training is what is called “pedestrian fruit wall” that is similarly to modern vine grape plantings. This new multi axis tree training system ,131, witApple production is considered among the most dynamic crop production systems. To date, the International Organization for Biological Control has provided the leadership for developing the philosophy Integrated Production, the general guidelines, and crop specific technical guidelines . AgreeinIOBC Guideline for IFP provided a rigorous foundation for development of sustainable utilization of pesticides legislation in the EU. Integrated Fruit Production in pome fruits has been regularly utilized to launch IFP programs in a number of European rural areas and along with pesticides properties databases can be used for environmental sound decision making ,140. TheIn general the IFP guidelines contain the following sections: definitions; professional trained and environmentally and safety conscious growers; conserving the orchard environment; site, rootstocks, cultivar and planting system for new orchards; soil management and tree nutrition; alleyways and weed-free strip; irrigation; tree training and management; fruit management; integrated plant protection; efficient and safe spray application methods; harvesting, storage and fruit quality; post-harvest chemical treatments; mode of application, controls, certification and labeling ,140. NevHowever, a part of the mentioned official IFP definitions and guidelines, the regulations used by each country or organization vary and they are not always consistent with the IOBC Guidelines. The overall IPM standards, unlike organic production, are not precisely defined or legally specified in an EU or international agreement and the level of guidelines implementation varies considerably among the state members . For exaAmong the possible threats that jeopardize the effective implementation of IPM in the European apple production system, the risks related to the development of pesticide resistance and the introduction of new invasive pests deserve to be discussed.The development of resistance to pesticides by apple pests as a consequence of increasing frequencies of chemical treatments is known since long time . PesticiC. pomonella, is a worldwide pest in apple orchards. For many years, pesticide applications have been the dominant tools used for its control. However, increasing frequencies of chemical treatments led to the acquisition of resistance to many of the recommended pesticides belonging to various chemical groups. In this species, the first case of resistance was the resistance to arsenates reported by Hough in 1928 in the USA. Since then, new cases of resistance have been and are being reported in almost all of the main apple-growing regions worldwide. In Europe, insecticide resistance in the codling moth was firstly detected in the 1990s with the emergence of resistance to diflubenzuron in Italy and southeastern French populations [The codling moth, ulations ,143,144.ulations ,146. Curulations ,150,151 ulations .A. orana, to chlorpyrifos was first detected in England comparing a population regularly treated with the organophosphates and one collected in an orchard that never received the insecticide [. orana nor for other leafroller species infesting the European apple orchards.Unlike the codling moth, in the European apple orchards the cases of insecticide resistance within the leafroller species are only sporadic. A reduction of susceptibility of the summer fruit tortrix moth, ecticide . A largeecticide ,154,155 ecticide . No otheThe implementation of integrated resistance management strategies is of the utmost importance to avoid further spread of the phenomenon. Moreover, rotational use of non-cross-resistant insecticides would benefit fitness costs associated with resistance . This inPanonychus ulmi, the European red mite (ERM), is the main Tetranychidae member that causes major damage in apples and, together with Tetranychus urticae (Koch), it has been reported among the top 10 resistant arthropods [Apart from insects, spider mites have historically demonstrated a propensity for developing resistance particularly in tree and vine crops. thropods . Resistathropods  to paratthropods  and to sthropods  and in oT. urticae and the apple rust mite Aculus schlechtendali . Tetranychus urticae is the most studied mite regarding its resistance to agrochemicals, mainly because it is highly polyphagous and can damage a wide variety of crops. The apple rust mite can also cause damage in apples arriving to affect the yield [Other mites can also cause damage in apple, e.g., he yield . Up to nhe yield .et al., 2008 [P. ulmi, T. urticae and A. schlechtendali and this information has to be used to properly design the management of mites in an apple IPM program.Concerning the management of mites in apple orchards, it is clear that the few compounds that remain effective are consequence of strict resistance management strategies ,166 and l., 2008  and IRACl., 2008  offer a et al. [In the case of plant diseases resistance development may be more harsh and difficult to be managed. Because most IPM strategies for plant diseases have been adapted from insect biology models, with little considerations in biological differences, resistance management may not be as effective as in the case of arthropods. For instance, most fungal plant pathogens are haploid and with faster reproductive rates, compared with mostly diploid arthropods of economic significance, which affects inheritance of pesticide resistance traits. Beckerman et al.  argued tVenturia inaequalis (Cooke) winter, is the main disease of apple and requires numerous fungicide applications, especially where frequent rains and fairly high temperatures occur during the first growth stages. As a result, the impact of fungicide resistance in apple scab has been significant, with fungicide resistance having been identified in all classes of curative fungicides used for the control of scab. The reiterated use of fungicides to control this apple key disease threats their effectiveness and endurance over the time. Among the most recent chemical families of fungicides, activity reduction has been observed for the anilinopyrimidines (AP), the demethylation inhibitors and respiration inhibitors at the Qo site (QoI) [Scab, caused by te (QoI) ,171,172.To minimize potential treatment failures due to resistance events, reliable control of apple scab epidemics can be achieved by the integrated application of all types of countermeasures including the use of scab resistant varieties, biological control agents, and appropriate agronomic and hygienic practices. Contrary to arthropods pesticide resistance management, non-chemical methods of disease control are often weak or not available, so the application of fungicides of different modes of action together with the use of forecasting models, for correctly timing of treatments, is the predominant strategy in order to overcome resistance problems.In recent years, the international trade in fruits and vegetables has been pointed out for a substantial growth in the volume. Europe together with the United States, and Japan are the largest importers of fruits and vegetables. Despite the international cooperation and regulatory systems put in place to inhibit the spread of plant pests, the international trade of fruits and plants is the main responsible for facilitating their spread.Halyomorphahalys (Stål) (Heteroptera: Pentatomidae), is probably the one that deserves the highest attention [Halyomorphahalys, is an herbivorous insect species that was accidentally introduced to the United States with international commerce, i.e., via bulk freight containers from either Japan, Korea, or China [H. halys fruit injuries in apple orchards in the mid-Atlantic states have increased dramatically in recent years and many fruit growers have implemented an aggressive management programs to control this pest resulted in up to an approximately fourfold increase in insecticide use [Among the potentially invasive species endangering European apple orchards, Brown Marmorated Sting Bug (BMSB) ttention . Halyomoor China  where itor China ,176. Loscide use ,177. Inscide use .Halyomorpha halys has been included in the EPPO Alert List for more than 3 years [H. halys has not been reported in Europe so far, damage to apples may be under-reported because it can be confused with cork spot or bitter pit, two physiological disorders caused by calcium deficiencies [Additional invasions have been detected also in Europe, namely in Switzerland, Liechtenstein, Germany, Italy, France, Hungary and Greece  suggesti 3 years . In 2013ciencies . Based ociencies ,177, chepercapita is decreasing at the rate of 2% per year and it accounts now for 15 kg/person per year. The apple production system is also challenged by a loss of competitiveness due to high labor costs in relation to other regions of the world and the political goal to significantly reduce pesticides use. In addition, consumers and the markets that supply them are demanding a large reduction, ideally the elimination, of pesticide residues on fruit.The total apple production in Europe is estimated to be close to 12 million tons in 2014 . While pIn fact, the consumer's attention to the potential risks to health and the environment arising from the use of pesticides in agriculture is growing and despite checks by regulatory authorities attesting to the contrary, many consumers are instead concerned about the safety of fruit which are perceived as “residue carriers”. Supermarket chains have interpreted this concern by imposing limits on pesticide residues on fruit well below those required by the law, introducing a new element of discrimination in the acquisition of the product . These cAlthough Integrated Production does not mean a reduction in number of pesticide residues, alternative systems to pesticide use are recommended and expected by both EU regulation and markets, to improve the quality of agricultural production and environmental safety and to meet consumers’ expectations for safety apples.As an example of how the apple production system has included the pesticide residue issue in its IFP strategies, we report here the cases of the Trentino  and Girona (Spain) regions. In Trentino apple production covers 10.500 ha and produces 500.000 tons/year representing nearly 5% of the European apple production. Guidelines for integrated fruit production are implemented since 1991  with theCydia pomonella, the main pest in this area.In recent years, there has been a steady reduction of insecticide/acaricide residues in so much that in 2011 two thirds of the samples were free of insecticide/acaricide residues, and if the residue was present, 99 times out of 100 it was below 30% of the MRL. This positive results are a consequence of a careful management of pests, based on field scouting and visual controls performed by the consultants, application of tolerance thresholds when available and extensive use of mating disruption for the control of the codling moth A. schlechtendali [htendali .Similarly, in the Girona region, IPM started in the early ’90 and in the Catalonia region there is also an IPM committee formed by researchers, technicians and officers that update the guidelines. This committee is depended on the Government and from the beginning of IPM in the area and progressively, all the available new technologies for pests control has been incorporated at experimental orchards level until a complete program to produce apples with low residues was achieved. When results were strong and reliable regarding both pest control and residues at harvest, it was decided (2009) to implement the program in a wider area, after an agreement with the majority of the growers. In These control methods were chosen in function of its efficacy and also taking into account the environmental protection. The main sprays with chemicals have been concentrated when the fruits are not still present or when they are very small. In case of an outbreak close to harvest, it is recommended to use a chemical that can have an easy and quick degradation in the environment respecting the rules of resistance management. Although this program maximizes all the available tools, there still are some bottle necks; one of them is related with diseases which control are based on fungicides which in some cases can be applied as directed by the predictive models; but, in any case, these sprayings are still highly dependent on weather conditions of each year, demanding more or less sprayings. As a consequence, sometimes it is quite difficult to avoid some fungicide residues at harvest. The second bottle neck regards the new arthropods or diseases that are lately appearing. Some of them are invasive, while some others were already present in the environment and by unknown reasons started to increase their populations and damage. Nevertheless, the results of the program were highly satisfactory because it has permitted to decrease the use of insecticides up to 36.9 % and 24.5% the use of fungicides. Regarding residues level, in the 58% of the orchards in which this system was applied there were no residues and in the 42% remaining the level of residues detected was minor than the 20% of the LMR stated by the EU normative, which is very low.From the initial development and leading implementation of the IPM in years 1950s, many other expectations were placed on this pest control approach beside the original aim of the reduction of the deleterious effects caused by broad-spectrum insecticides used in agriculture. Integrated Pest Management, is a decision-based operation, required the coordinated function of multiple tactics for optimizing the control of whole classes of pests  in an ecologically and economically sound manner. With the development of the concept of the holistic system approach where the orchard is playing the central role of agro-ecosystem, IPM became an indispensable element of the Integrated Fruit Production. The pest control strategies are more and more integrated with the use of natural resources where natural mechanisms are expected to replace potentially polluting inputs. Chemical treatments, accurately selected taking into account the protection of the worker and the consumer’s health as well as the safeguard of the environment, are still essential to control pest and weed but they are integrated with agronomic preventive measures and biological and physical methods.This evolution of the IFP is also referred as sustainable agriculture and involves economic, environmental and social aspects. Beside the traditional economic criteria of the market-oriented agriculture, sustainable agriculture includes the assessment of the environmental impact of agronomic practices like the carbon footprint, life cycle assessment, energy use, biodiversity. Economic and environmental sustainability are strictly interdependent, as it is the entire agricultural production process with societal context where it is held. These environmental impacts generated by the fruit production are raising consumer concerns over product standards which are now not only limited at the quality and safety standards, but they are frequently including process aspects of the production system. As a consequence, consumers and supermarket chains are requiring certification of good farm practices .Europe is well placed to take advantage of sustainability issues due to its long tradition in IPM and its demonstrated ability to evolve this old concept in an innovative approach required by modern society.


Customer complaint has been the important feedback for modern enterprises to improve their product and service quality as well as the customer's loyalty. As one of the commonly used manners in customer complaint, telephone communication carries rich emotional information of speeches, which provides valuable resources for perceiving the customer's satisfaction and studying the complaint handling skills. This paper studies the characteristics of telephone complaint speeches and proposes an analysis method based on affective computing technology, which can recognize the dynamic changes of customer emotions from the conversations between the service staff and the customer. The recognition process includes speaker recognition, emotional feature parameter extraction, and dynamic emotion recognition. Experimental results show that this method is effective and can reach high recognition rates of happy and angry states. It has been successfully applied to the operation quality and service administration in telecom and Internet service company. Customer service has been playing an increasing important role in the competitive market in business administration in recent years. As one of the routines in customer service, the handling of telephone complaints from customers plays a significant role in showing the image of the enterprise, obtaining the feedback from the market, and improving the loyalty of the customers. Therefore, it has attracted high attention from enterprises and researchers. The existing researches on customer complaints mainly focus on the classification of complaints, record analysis, handling operation, information management, and so on –3. HowevAffective computing was proposed by Professor Picard in 1977, attempting to create a way of perception, recognition, and understanding of human emotion, which would make the computer system intelligent and sensitive so as to react friendly to human emotions . It has In this paper, we first study the characteristics of telephone complaint speeches and then conduct a cost-sensitive learning technology  to identThis paper is organized as follows. In The classifications and the descriptions of emotions have been so diverse due to the different understanding of people's psychological experiences in a variety of applications. For a long time, scholars have not reached consensus on the classification of emotion. However, two types of emotion classifications have been widely accepted in psychological studies: one is the classification of basic emotions, and the other is the description of emotion in dimensions .The basic emotion theory claimed that each type of emotions has its basic and disparate characteristics in human experiences, physiological arousal patterns, and the explicit modes. It suggested that all human complex emotions are the different combinations of basic emotions. And Ortony and Turner (1990) summarized the typical classifications of basic emotions proposed by the scholars in this field, which are shown in Different from the basic emotion theory, dimension theory argued that the changes of human's emotions are continuous emotion. It suggests that emotions should be described in a dimensional space, and the similarities and differences between each emotion depend on the dimensions in the space distance. Russell and Peterson proposed the two-dimensional circumplex model for the sentiment classification, which included pleasant-unpleasant dimension and the strength dimension. They thought that affective states can be described by the above two dimensions –15. In aThe commonly used acoustic parameters related to emotions can be divided into three categories , prosodyRecent experiments have shown that the combined parameters from different categories can acquire a more ideal performance , 19. ForShort-time average energy refers to the average energy of the speech signal. It is mainly used for acoustic boundary and the ligatures boundary. Short-time average energy can be expressed as in the following formula:Short-time zero crossing rate refers to signal through the zero frequency in a frame. And it can be expressed as in the following formula:MFCC is derived from a type of cepstral representation of the audio clip. It reflects the characteristics of the short-time amplitude spectrum of speech. Extraction process of MFCC coefficients is shown in k-nearest neighbor method (k-NN), artificial neural network (ANN), hidden Markov model (HMM), Gaussian mixture model (GMM), and support vector machine (SVM). Telephone complaints are continuous speeches in the conversations between the customer and the service staff with background noise. Among the proposed methods, ANN can simulate the complicated relationship between the input and output variables and utilize the hidden knowledge very well by sufficient training samples, while SVM has the advantages of superior stability, good generalization ability, and high efficiency d.Polynomial kernel function: (iii)K = exp(−‖x − y‖2/2σ2).RBF kernel function: (iv)K = tanh(a(x · y) + b).Sigmoid kernel function: When we use the SVM method for emotion recognition, the selection of kernel function is very important. Four kinds of kernel function are often used in SVM, which can be described as follows.The speeches of telephone complaints occur in the conversations between the service staff and the customer. Therefore, the speakers should be identified so that we could find out the customer's speeches and deal with the emotion recognition of his speeches. In order to do well in spell recognition, the speeches in conversations will be first cut into a series of segmentations according to their continuous sound waves. Usually, the speech signals contain possible noises in telephone communication and the speaker's surroundings, so a bandwidth limited filter and the 50 Hz circuit noise elimination had to be adopted in the preprocessing procedure [Our previous study has indicated that intensity, pitch frequency, and spectrum parameter could be used as the prominent feature parameters for distinguishing those emotional states . For exaFrom In order to precisely distinguish the customers' speech from the conversations, we adopted a robust speaker identification algorithm. The algorithm introduced a cost-sensitive learning technology to reweight the probability of the tested affective utterances in the pitch envelope level, which can effectively enhance the robustness in emotion-dependent speaker recognition as shown in Based on previous analysis, we propose a recognition method of customer's emotions in telephone complaints as shown in The recognition process includes preprocessing, feature parameter extraction, and emotion recognition.In order to improve the quality of speech signals, the preprocessing aims to provide successor analysis services for feature extraction and speech emotion recognition, which may include speech unit segmentation, preemphasis, framing and windowing, and detecting endpoint –23.Because the high frequency part of the spectrum is relatively small in telephone voice signals, the preemphasis processing is usually utilized to enhance the high frequency part of the signals' amplitudes. This is frequently dealt with by the first order high pass filter as shown in the following:Previous studies have found that the characteristics and physical characteristic parameters of telephone speeches can remain stable in the period of 10 ms–30 ms and can keep the short-time stationary , 24. TheWindowing is to select the window function after framing, and there are two factors to be considered, namely, the shape and the length. Generally speaking, we use three windows: rectangle window, Hamming window, and Hanning window.The rectangular window is shown as in the following formula:Hamming window (Hamming) is shown as in the following formula:Hanning is shown as in the following formula:The main purpose of endpoint detecting is to use computer technology and digital processing to find the start point and the end point of emotional information contained in a section of speech signal. The basic parameters of the endpoint detecting are short-time energy, short-time average zero crossing rate, and short-time correlation function, and so forth. After detecting endpoints, we will employ the speaker identification algorithm to identify the customer's speeches and put them into the next step for feature parameter extraction.Research findings in the fields of psychology and metrics have pointed out that prosody and voice quality in speeches are the most intuitive indicators to reflect the changes of a speaker's emotions. Statistical analysis shows that if someone is happy, he usually speaks very fast and the volume is high. However, if he is in time of sadness, he tends to speak slowly with relative small intensity. The emotional features which are commonly used in the researches of speech signals include short-time average energy, short-term zero crossing rate, pitch frequency, formant parameters, and Mel Frequency Cepstrum Coefficient (MFCC), as well as a variety of their derived variant forms, such as maximum, minimum, mean, range, and change of the covariance rate , 26. In The calculation of Mel frequency is shown in the following formula:As we discussed above, the telephone complaints of a real case are included in the conversations between the service staff and the customer, so we should firstly identify the speakers. And it is performed by the algorithm based on cost-sensitive learning technology.After detecting the customer's speeches, we adopted the affective computing technology based on BPNN and SVM methods and recognized the dynamic changes of customer's emotions from the extracted feature parameters of his complaints.In the management of customers' telephone complaints, the typical emotions frequently concerned by the service staff are anger, discontent, and calmness. Anger and calmness are not likely to occur simultaneously; then, discontent can be regarded as their intermediate state. Therefore, anger, discontent, and calmness can reflect the customer's possible emotion changing period in a conversation and can be used to evaluate the service effects in telephone complaint management. In speech recognition algorithm, we used BPNN, SVM methods and cost-sensitive learning technology  to optimWe took CASIA Chinese speech emotional database and the records from the customer complaint service center of a telecom and Internet service company as experiment data. CASIA was developed by the National Laboratory of Pattern Recognition and Human-Computer Interaction research group at Chinese Academy of Sciences Institute of Automation . It has The records from the customer complaint service center are 252 real speech samples saved as wav files at the sampling rate of 16 kHz. Each sample contains a whole conversation process between the staff and the customer with 6–12 sentences, which includes the dynamic changes of different emotional states. In order to suppress the noises and highlight the main features of the speeches, framing and windowing are used to preprocess the samples and transfer the speech signals into frames. For example, the framing and Hamming windowing waveform of file “Anger-02.wav” whose frame length is 240 and the shift is 80 is as shown in The intensity represents the strength of voice by the amplitude of speech signals. We considered the typical complaint situations such as the complaints of broadband fault and fee deduction of rubbish short messages. For example, “My home broadband has gone wrong. When would you repair it?” Getting fundamental frequency from this voice file is as shown in The 12-order MFCC parameters extracted from the above sample speech are shown in After passing the test by CASIA database, we apply our method to the 252 real speech samples [From This paper studied the characteristics of customers' telephone complaint speeches and discussed the factors of speaker identification from the conversations as well as the dynamic emotion recognition of customer speeches. In order to recognize the dynamic emotions in customers' complaints, we first employed the cost-sensitive learning technology to identify the speakers and then utilized the BPNN and SVM methods to realize the recognition of customers' dynamic emotions based on the affective computing from extracted feature parameters. Experimental results show that SVM with combined 12-order MFCC and short energy has the highest average recognition rate of 80.08%.In the recognition of speech emotions, six typical emotions, namely, anger, distaste, fear, joy, sadness, and surprise, have been well researched based on the isolated speeches. Nwe et al. obtained the accuracy rate of 78% by HMM method . Bhatti Due to its specificity and complexity, the dynamic emotion analysis of customers' telephone complaints in the real application is expected for further researches. This paper provides a valuable reference on this issue. In the further improvement, the feature parameters which reflect the calm state may be explored and the quantitative evaluation should be made to show the strength and its dynamic changes of emotions. Besides, a knowledge base considering the differences of the customer's gender, age, and other attributes may be introduced to enhance the recognition rate.


Computerized clinical decision support systems (CDSSs) have been shown to improve the efficiency and quality of patient care by connecting healthcare professionals with high quality, evidence-based information at the point-of-care. The mere provision of CDSSs, however, does not guarantee their uptake. Rather, individual and institutional perceptions can foster or inhibit the integration of CDSSs into routine clinical workflow. Current studies exploring health professionals’ perceptions of CDSSs focus primarily on technical and usability issues, overlooking the social or cultural variables as well as broader administrative or organizational roles that may influence CDSS adoption. Moreover, there is a lack of data on the evolution of perceived barriers or facilitators to CDSS uptake across different stages of implementation.We will conduct a qualitative, cross-sectional study in three Italian specialty hospitals involving frontline physicians, nurses, information technology staff, and members of the hospital board of directors. We will use semi-structured interviews following the Grounded Theory framework, progressively recruiting participants until no new information is gained from the interviews.CDSSs are likely to become an integral and diffuse part of clinical practice. Various factors must be considered when planning their introduction in healthcare settings. The findings of this study will guide the development of strategies to facilitate the successful integration of CDSSs into the regular clinical workflow. The evaluation of diverse health professionals across multiple hospital settings in different stages of CDSS uptake will better capture the complexity of roles and contextual factors affecting CDSS uptake. Evidence-Based Medicine (EBM), the integration of individual clinical expertise with evidence from scientific research , is wideCurrent studies shows that CDSSs have the potential to improve the efficiency and quality of patient care by increasing, for instance, the safety of medication prescribing, use of preventative care in hospitalized patients, access to accurate medical records, patient-physician communication, and adherence to guideline-based care –6]. The. The6]. e.g., lack of access to personal computers or hardware devices), as a key facilitator or barrier to the acceptance and use of CDSS ,. Cl. Cle.g., of CDSS .The complexity of introducing new technologies into healthcare settings may play an additional role in CDSS uptake. The integration of a formal tool into an organized context requires negotiating with all involved parties and addressing the particularities of specific workplaces. When a technology is implemented in a workplace, the two shape and transform each other through an iterative process ,19]. Be. Be19]. The introduction of information technologies in clinical settings, even when highly promising, is far from straightforward. Social, cultural and contextual factors, together with clinicians’ perceptions and understandings of information technologies, can influence the outcome of CDSS introduction in healthcare settings. Therefore, CDSS implementation needs to be analyzed with a socio-technical approach  that is e.g., hospital administrators, chiefs, or non-physician staff) that are key to establishing the overall mission and vision of the healthcare institution in addition to shaping the expected behavior and standards of its personnel. Organizational leadership that is supportive of technological innovation, for example, may encourage and reward the use of CDSSs to improve patient care. Third, the studies often addressed contexts in which CDSSs had already been introduced; these studies did not account for the perceived facilitators and barriers existing prior to CDSS introduction, or for the evolution of perceptions throughout the technology’s various stages of uptake. These limitations are especially relevant in countries such as Italy where the majority of healthcare contexts have not yet adopted CDSSs.After reviewing the literature on the perceived facilitators and barriers to CDSS implementation of health professionals, we identified three main limitations to previous studies. First, the studies largely focused on technical and usability issues, while they tended to overlook the social, cultural and contextual factors potentially influencing their implementation ,11],,,25]. Mo. Mo25]. Our study seeks to identify potential barriers and facilitators to the adoption of EBM-focused CDSSs linked to EHRs in specialty hospitals. We address the limitations of previous studies by considering: a) multiple health professionals, including physicians, nurses, and hospital managers, and b) hospitals with different levels of CDSS infrastructure and use as well as experience in implementing EBM.We will conduct a qualitative, cross-sectional study based on semi-structured interviews to examine individual and contextual barriers and facilitators to CDSS uptake. The interview will be designed and analyzed accordingly to the constructivist Grounded Theory (GT) approach, the inductive development of theory from data . InsteadOne of the main elements of the GT method is the collection of data before its analysis. The former is driven by theoretical sampling, the sequential selection of individuals in a study sample according to the state of theory generation . FollowiWe will adopt a purposive sampling strategy and select the first participants using a maximum variability logic . This stTo determine the impact of particular clinical setting characteristics on CDSS uptake, we selected three specialty research hospitals located in northern Italy based on the following criteria: the hospital reported the use of evidence during practice, an EHR, and a level of CDSS implementation and familiarity. Specifically, setting ‘A’ is an oncology hospital that abandoned paper-based clinical documents and fully adopted an EHR beginning in 2008. The hospital’s EHR is linked to a variety of CDSSs, including evidence-based messages on treatment and diagnosis using care management algorithms. All participants from setting ‘A’ will be considered current users of CDSSs and compliant with EBM. Setting ‘B’ is an orthopedic research hospital that has been using an EHR since 2011, but does not have a CDSS. In fact, this hospital’s EHR is not sufficiently developed to link to a CDSS or to be utilized by health professionals who have adopted standard international codes, a prerequisite to the activation of CDSS guide messages. Health professionals in setting ‘B’ may or may not be compliant with EBM depending on their own capacity and willingness. Setting ‘C’ is an orthopedic research hospital that does not have an EHR or a CDSS. This setting will be considered an environment reluctant to innovation and the use of evidence in practice.In order to determine the impact of particular professional or organizational roles and characteristics on CDSS perception, we will interview frontline physicians, nurses, information technology staff, and members of the hospital board of directors. We will use purposive sampling to capture the perspectives of a diverse and representative sample of professionals.The demographics or seniority of participants will not be considered in the selection criteria; nonetheless, this information will be collected during the interview. Table e.g., the use of personal computers, tablets, and smartphones to obtain information relevant to their clinical practice); b) beliefs and experiences with CDSSs, specifically; c) willingness to adopt EBM and clinical guidelines in their routine practice; and d) perceptions regarding the potential of CDSSs to integrate evidence and guidelines in clinical practice. We will ask participants to discuss both their own experiences and those of their colleagues in their workplace.Data will be collected through interviews in hospital consultation rooms. The interview will address the following topics: a) participants’ beliefs and experiences with information technology, in general  and invited to participate in the study. Each interview will be conducted by two individuals: a trained investigator who will conduct the interview, and a medical doctor with competence in the participating hospital’s field of specialty who will support the investigator in clinical topics. The expected duration of the interview is 30 to 90 minutes. The interviews will be taped and transcribed verbatim.e.g., `CDSS is less reliable than colleagues’). Investigators will analyze the interview transcripts line-by-line to detect ‘in vivo’ codes that directly use the participant’s wording. In axial coding, the second analytical step, investigators will reassemble particular sets of data based on central concepts that emerge from the ongoing analysis; in other words, codes will be progressively aggregated into broader categories . This step involves the recurrent identification and comparison of themes both within and across sub-categories and broader categories. In selective coding, the final step of data analysis, investigators will further define, develop and refine discrete concepts and categories. The core categories, pivotal concepts encapsulating the whole phenomenon under investigation will be selected and systematically related to the other categories. The combined categories and their interrelationships will ultimately form a larger storyline surrounding the process of CDSS uptake . In. In28]. S uptake ,[28].The coding process will be conducted by three investigators . The NVivo software (version 10)  will be The study was approved by the Research Ethics Committees of IRCCS Istituto Ortopedico Rizzoli , IRCCS Ospedale San Raffaele , and IRCCS Istituto per la Cura dei Tumori della Romagna . This work is supported by the Italian Ministry of Health (GR-2009-1606736) and by Regione Lombardia (D.R.G. IX/4340 26/10/2012). Funding sources had no role in the writing of this manuscript or the decision to submit it for publication.Before beginning the interview, participants will be given an informed consent form as well as information outlining the purpose of the study and participant rights. Participants will be notified that their involvement is voluntary and can be withdrawn at any time, and that confidentiality is protected through the anonymization of all collected data.e.g., keep alerts simple, straightforward, and specialized to the area of use) [CDSSs are likely to become an integral part of clinical practice in the endeavor for continual improvement in patient care and safety. Well-established clinical workflows and EHRs are important requisites to the successful introduction and uptake of CDSSs in clinical settings. Users should also be provided with sufficient training, education and support. In addition to developing technical suggestions on CDSS design and implementation ( of use) , the undWe propose a dynamic and integrative model for studying CDSSs that considers a wide range of contexts, from healthcare organizations that are unfamiliar with the technology to those in mature stages of its implementation. The inclusion of diverse stakeholders beyond frontline clinicians will capture the complexity of the roles and responsibilities influencing CDSS uptake. This may further foster trust, transparency and cooperativeness in healthcare settings, contributing to the increased acceptance and use of CDSSs. The results of this study will guide the development of strategies and recommendations for the successful introduction and integration of CDSSs into healthcare organizations.A limitation of the study is the collection of data through interviews rather than real-life settings in which health professionals directly engage with CDSSs. The observation of health professionals in their practice would require longer and a more demanding access to the specialty hospital that has adopted CDSSs. Moreover, we believe that observing CDSS use is an insufficient trigger for a detailed investigation of the understandings, beliefs and attitudes on the technology and evidence-based practice. However, to address the limitations of our methodological choice, we created a three-minute video that will be shown to health professionals during the interviews. The video introduces the main functions and features of the CDSS that distinguishes it from other similar technologies. This video is intended to provide basic information to participants who are unfamiliar with the tool, and encourage concrete and practical reflections on the issues related to CDSS use in routine clinical activities.We anticipate several challenges in the running of this trial. Because the study involves multiple sites, an effective communication strategy will be necessary to promote optimal communication between the investigators and researchers. We will schedule regular teleconferences and face-to-face meetings to share updates on the progress of the study at each site. We will use the NVivo software to share data and information for data analysis. We will further develop an instructional manual with clear procedures for the sharing and handling of data in order to ensure its security, integrity and quality.Additionally, there may be difficulties in coordinating interview schedules for busy health professionals while maintaining the consistency and accuracy of the data collection process. We anticipate that the structure, setting or nature of an interview itself may influence participants’ responses. Investigators will attempt to make the interview resemble a natural conversation as much as possible so that participants can freely discuss their experiences and beliefs. We will also verbally inform participants that the purpose of the study is not to evaluate the staff, but to explore their beliefs and experiences with CDSSs and evidence-based practice.Future studies can focus longitudinally on CDSS introduction and uptake in order to determine the long-term effects of the intervention.