While insecticide-treated nets (ITNs) are a recognized effective method for preventing malaria, there has been an extensive debate in recent years about the best large-scale implementation strategy. Implementation costs and cost-effectiveness are important elements to consider when planning ITN programmes, but so far little information on these aspects is available from national programmes.This study uses a standardized methodology, as part of a larger comparative study, to collect cost data and cost-effectiveness estimates from a large programme providing ITNs at the community level and ante-natal care facilities in Eritrea. This is a unique model of ITN implementation fully integrated into the public health system.Base case analysis results indicated that the average annual cost of ITN delivery (2005 USD 3.98) was very attractive when compared with past ITN delivery studies at different scales. Financing was largely from donor sources though the Eritrean government and net users also contributed funding. The intervention's cost-effectiveness was in a highly attractive range for sub-Saharan Africa. The cost per DALY averted was USD 13 – 44. The cost per death averted was USD 438–1449. Distribution of nets coincided with significant increases in coverage and usage of nets nationwide, approaching or exceeding international targets in some areas.ITNs can be cost-effectively delivered at a large scale in sub-Saharan Africa through a distribution system that is highly integrated into the health system. Operating and sustaining such a system still requires strong donor funding and support as well as a functional and extensive system of health facilities and community health workers already in place. Vector control generally and insecticide-treated nets (ITNs) specifically have been identified as effective and cost effective methods for the prevention of malaria related mortality and morbidity in sub-Saharan Africa (SSA) . DespiteEritrea is divided into three zones of malaria risk based on epidemiology and geography. In the western lowlands, where the malaria burden is most severe, transmission is highly seasonal and most intense along water bodies or irrigation projects. The transmission season lasts from September until November. In the highlands there is generally little risk of malaria transmission, but due to the low immunity of the population there is a risk of epidemic malaria. Finally, in the coastal plains along the Red Sea, highly seasonal malaria transmission occurs which peaks between January and March, though transmission in this zone is generally low due to low levels of precipitation. A recent study estimated that two-thirds of the Eritrean population are considered at risk of malaria, either epidemic or endemic , and theThe Eritrean ITN programme is part of a broader malaria control programme which includes environmental modification, larviciding, IRS and the provision of prompt and effective treatment. The mix of interventions used varies depending on the area of the country, with IRS being used more extensively in the highest burden areas and environmental management and larviciding used in all malarious regions, but most extensively in moderate to low burden areas -12. The ITN distribution began in 1995 as a pilot project in Gash-Barka, in the western lowlands. ITNs were delivered through health facilities and local administrations, with assistance from CHAs. The programme was gradually scaled up from a few villages to cover all malarious areas of the country. Families were charged 30 Nakfa (USD 2–3) per ITN before the 2003 distribution. Local administrations could make exceptions for those families deemed too poor to pay. In 2001, free distribution to women at ANC and maternal and child health (MCH) clinics began, and from 2003, nets were also given freely to the general population living in malarious areas. Since 2001, over 900,000 ITNs have been delivered and two million re-treatments have been conducted through community campaigns and health facilities -21.Re-impregnation campaigns are conducted once a year, one to two months prior to the malaria transmission season, at health facilities and community re-treatment points. Supervision is ensured by health facility staff with the support of CHAs and with the collaboration of community members.Administratively the country is divided into six regions, called Zobas, and further into sub-Zobas (districts) and Kebabis (agglomerations of ~3–10 villages). Four of the Zobas are considered to be at significant malaria risk, with the highest risk Zobas being Debub and Gash Barka and the lowest risk in the Northern Red Sea Zoba . OperatiThe ITN distribution system in Eritrea was highly successful in raising the level of coverage to Abuja target levels and survey evidence that the country had met the 60% coverage targets set under that agreement within specific regions became available in 2003 , the World Bank-funded HAMSET project, and the Global Fund to Fight AIDS, TB and Malaria (GFATM). Cost and activity information collection occurred during two periods, from May to June 2005 and from May to June 2006. Costs were collected by examining agencies' financial records, including budgets, expenditure records, reports, receipts and invoices. In addition, cost and activity information were collected through stakeholder interviews and direct observation where costs were not reflected in the financial records.Where possible, the ingredients approach was used, meaning that unit activities were first determined and then a unit cost was determined for these activities, allowing for the establishment of a total cost. Where this approach was not possible, either because the information was deemed too sensitive or was not available in adequate detail, aggregated expenditure was generally used.Resource use was valued at three levels: centrally (within the MOH and the NMCP), at the Zoba level, and peripherally including health workers, health facilities, and CHAs. Direct costs to Kebabi administrators have not been included since they are believed to be small and no reliable information about these activities could be acquired within the framework of this study.Resources were valued based on the reported expenditures or budgets, and in the case of shared personnel, on salary plus any fringe benefits. Capital goods were valued based on their procurement costs or alternatively, in the case of building rents, on an average market value of similar properties as reported by the Eritrean government.capital and recurrent costs based mainly on the lifetime of the goods being purchased. As stated above, it was not possible to collect start-up costs. Because of the long and gradual build-up to a full national scale programme, the start-up costs were likely to be large but also difficult to define as they were spread over a long time period and involved pilot programmes which would not be replicated if the strategy were used elsewhere. Due to the long development period, these costs would have little effect on the current running costs of the programme, but failure to capture them reduces the stated costs. Capital costs have been discounted in the economic analysis using lifetimes and discount rates determined through stakeholder interviews, expert information, and past literature. Varying discount rates and lifetimes were examined in the sensitivity analysis. Both financial and economic analyses were conducted, in order to show (1) what the actual expenses of running a programme would be, as well as (2) the level of all resources used. In the financial analysis, taxes on nets and insecticide have been included, while in the economic analysis, they have been treated as transfer payments and have therefore been excluded. In the financial analysis, capital costs have not been discounted and are instead incurred in full at the time of the purchase.Costs have been divided into Costs were collected in either Eritrean Nakfa or United States Dollars (USD). Costs collected in Nakfa were converted to USD based on official yearly average exchange rates for the period during which the costs were incurred, and all costs were adjusted for inflation to 2005 prices using the US Gross Domestic Product deflator produced by the US Bureau for Economic Analysis .number of nets delivered and (2) number of re-treatments performed. Both figures were reported by the NMCP annually, and reflect nets and re-treatments delivered at the primary health care facility level or community level. In the years 2001 and 2002, care was taken to disaggregate nets delivered via ANC clinics and community mechanisms, as nets delivered through community mechanisms involved a user fee, while nets delivered through ANC clinics did not. The number of re-treatments performed during annual re-treatment campaigns were reported by the Eritrea NMCP [Generally, two main output measures were used: (1) rea NMCP -21.treated net years (TNY), which blends the results of both outputs by assuming that either a re-treatment or a new ITN provides one year of full protection for any individual using that net. This combined indicator is useful because it allows the inclusion of re-treatments of existing nets as part of the outcome measure, while the calculation of the cost per ITN delivered does not. Though some nets in the year 2005 were LLINs, all nets have been treated as conventional nets for the calculation of outputs in the base scenario of this analysis. The number of TNYs delivered through an LLIN will be higher – approximately 3–5 years per net. In the sensitivity analysis, outputs were also calculated using the assumption that all nets delivered were LLINs.The two output indicators above were used to calculate a third combined output measure: cost per child death averted and (1) cost per disability-adjusted life year (DALY) averted. Each of these ratios has been calculated using both the cost and effects of ITNs delivered and TNYs achieved. Only the effects of ITN use and possession by children were included in either calculation, thus ignoring potential benefits to older individuals. While this calculation underestimates the morbidity burden averted by ITN use, it would be difficult to include other effects, which are not well quantified at present [Two separate cost-effectiveness ratios were measured: (1)  present . It is a present . The effCost results were coupled with standard health impact indicators derived from (1) the Cochrane review on ITNs , and (2)In this analysis, the base case scenario relies on the following set of assumptions. A discount rate of 3% has been applied to both DALYs (see below) and to economic capital costs. Shared costs have been attributed to the interventions based on the actual value of the indicator chosen to allocate them. Nets have been assumed to last for 3 years and, as noted above, treated nets and re-treatments are set to provide 1 year of protection each. Fifty percent of the nets delivered were assumed to be used by children and only one child was assumed to sleep under each of these nets. The cost of nets was based on the commodity, insurance and freight (c.i.f.) price of the nets; for the portion of nets delivered with user fees through community mechanisms the user fee was included for the purpose of calculating sources of funding (the proportion of nets delivered this way was assumed to be 50% in the early years of the programme). Clearly, these are conservative estimates, mainly chosen in order to make a cross-country comparison easier and more meaningful .The Eritrean national ITN programme delivered over 900,000 ITNs and over two million re-treatments during the period 2001–2005, at a total economic cost of USD 3.7 million, or a financial cost of just under USD 4.4 million USD , user charges were collected for nets delivered through community mechanisms. Unfortunately, it was not possible to determine the specific number of nets for which user charges were applied. As these charges were used to fund the programme, an assumption that 50% of nets delivered before 2003 included user fees when estimating the contribution to the program from each sector was used. In this scenario, donors contributed 69% of funding, users contributed 14% and the MoH contributed 17%. As the practice of charging user fees was discontinued after 2002, the programme relied much more heavily on donor and governmental financing from 2003 onward. Investment from the government of Eritrea was largely in terms of salaries, building space, and vehicles.When the costs were disaggregated by year Table , severaldata not shown).Evidence of the increasing returns to scale is more apparent in these results due to the large increases in TNYs delivered as compared to the ITNs delivered. However, some of this effect was mitigated after 2003 by rising costs for net procurement. If, however, the analysis took into account the fact that some of the nets delivered in 2005 were LLINs and thus provide more than one TNY, the costs per TNY would have fallen despite the real increase in the cost per ITN delivered . The parameters have been varied to the extremes of their potential ranges, as determined by reviews of the literature or expert opinion.Sensitivity analysis was also applied to the main assumptions about the connection between the cost output ratios and the cost-effectiveness calculations. Parameters examined included the usage rates of the nets delivered, the percentage of nets used by children, the length of time during which a net or re-treatment offers protection, including the extended protection offered by LLINs, and the cost-to-output parameters which affect the overall cost of delivering a net or re-treatment.The LLIN scenarios were calculated by assuming a nominal price and lifetime for types of LLINs: USD 5.00 and 3 years of protection or USD 7.00 and 5 years of protection. These scenarios were expected to bracket the cost-effectiveness ratios which would have been generated by assuming that some protection was offered by untreated conventional nets, an effect which was ignored in our base scenario. Table The overall range of results for the cost per ITN delivered is quite wide, ranging from USD 3.29 to 10.30, indicating that there are significant uncertainties in the cost measurements. However, there are several reasons to believe that the actual variance is less than that suggested by the extremes of the sensitivity analysis. The upper values only exceed approximately USD 5.00 in the case of two variables: the cost of the nets and the allocation of shared costs. In terms of the cost of nets, USD 7 per net is an unlikely figure since the Eritrean programme was able to procure LLINs in 2005 for an average cost of USD 4.85. The other variable which gives rise to the most extreme value in the sensitivity analysis is the allocation of shared costs. In most cases, the personnel involved in the Eritrean ITN programme are involved with ITN activities for only a portion of the year, and even during that time, they are typically not fully dedicated to the programme. Most allocation measures, which were based on either the days of per diem paid to employees, or the amount of space used in offices and buildings, indicated that less than one-third of a given shared resource was being used for ITNs.For the calculation of deaths averted and DALYs averted, the assumptions regarding (1) the length of protection provided by an ITN or re-treatment, and (2) assumptions concerning the usage of these nets among children had a dramatic impact on the results. While published information suggests that usage rates for children in net-owning households were high , the link between the actual number of nets delivered by the programme and usage is less certain . As a maWhen the scenarios using different LLIN assumptions were calculated, the cost-effectiveness ratios in all cases approached the result obtained by delivering inexpensive conventional nets and large numbers of re-treatments through campaigns. As it was not possible to disaggregate all re-treatment campaign costs from the analysis, it would be expected that the true LLIN cost-effectiveness ratios would improve slightly compared to those shown here.Under the base case scenario the cost per DALY averted was as low as 13 USD. Considering that this is a conservative scenario, the result is clearly within the acceptable range for interventions in low-income countries as defined in previous WHO publications . The resThe Eritrean National ITN programme has increased ITN coverage dramatically to the point that it has essentially met the Abuja targets for ITN coverage in vulnerable groups within at least some areas of the country ,14. The Similarly to the four other ITN programmes reviewed in a larger comparative study , the EriMZ and TG are employed by the NMCP of Eritrea. All other authors declare that they have no competing interests.JY assisted in the design of the research and the data collection, and he conducted the data analysis and drafted the manuscript. MZ and TG collected data as well as critically reviewed the manuscript. FTassisted in the conception, design, data analysis and in the drafting and review of the manuscript. CL conceived and designed the research and he assisted in the drafting and review of the manuscript.


The Sri Lankan twin registry is one of the first to be established in a developing country, and its design has ensured sampling from a wide range of environmental conditions. It thus has great potential to examine environmental and genetic influences on diverse phenotypes, including psychiatric disorders, in the context of a diversity of environmental exposures, which may not have been fully explored in previous twin studies in developed countries. This paper presents the rationale for the study, describes its context, and the methods for twin ascertainment and data collection.A population-based twin register was established in the Colombo district of Sri Lanka using infrastructure designed to periodically update the electoral register. We invited a subsample from this register to participate in the project on common mental disorders, using random ascertainment. A separate non-twin sample was randomly selected from the geographical areas where twins were found. Home interviewers collected diagnostic information on common mental disorders, as well as environmental exposures including life events, socio-economic conditions, and the impact of the civil war and the Tsunami of 2004.We identified 19,302 individuals in the creation of the population based twin register. We randomly selected a subsample, of whom 4,387 were eligible to participate and 4,024 agreed to be interviewed . Those who refused consent had a similar mean age and sex ratio to those who were interviewed. We invited 2,485 singletons to participate and 2,019 were interviewed.Initial exploration of the data suggests the samples are very representative of the Colombo district of Sri Lanka, so we have created a unique resource for understanding the influences on mental disorders in developing countries, and to compare to the influences found in developed countries. Twin studies can provide insights into the heritability of psychiatric disorders, and the extent to which within-population variation in psychiatric disorders is influenced by the environment. They can further describe genetic and environmental contributions to overlap between disorders, and provide information on likely gene environment interactions. Previous twin studies have found that 30–70% of liability to major depression is influenced by genetics ,2, as isHeritability is an estimate of the causes of variability of a phenotype within a given population. However, a high heritability does not rule out important environmental exposures if these do not vary within the population. For example, if there are important environmental influences on a phenotype, but these exposures do not vary within the specific population, then the phenotype would have a high estimated heritability. Examining populations in diverse environmental settings may increase our understanding of causal influences that are not detectable in populations that are environmentally more homogeneous. For example, the wider range of standards of living experienced in Sri Lanka compared to the West may lead to a greater magnitude of environmental influence on mental disorders. The Sri Lankan environmental context will also allow testing of measurement invariance, for phenotypes that have previously been measured in developed countries.Past twin studies may not have taken full account of the distribution of environmental risk factors. Most have been confined to developed Western countries, which do not encompass the full range and potency/severity of environmental exposures seen throughout the world ,6. Some The twin study we describe aims to overcome these shortcomings. Firstly, it is based in Sri Lanka, a developing country with a per capita gross national income of approximately $1,160, and wide disparities of wealth and environmental exposures. Secondly, we aimed to identify all twins within a defined population, and invite a random sample to participate in the study. Thirdly, we directly measured a range of environmental exposures, both those comparable to populations in developed countries, and exposures specific to this population. Finally, we identified and sampled non-twins in a similar manner, in order to examine how representative exposures and outcomes reported by twins are to the general population.Sri Lanka has a high life expectancy (74 years), low infant mortality rate (12/1000/year) and high literacy rates (91%) despite its status as a developing country , and a hth December 2004 with approximately 40,000 deaths. These deaths were predominantly in the South and East of the island, but the Colombo district was affected with the loss of 56 lives. 3,397 homes were damaged to the extent that they could not be used, and partial damage of a further 2,948 homes [The country has been affected by a prolonged civil war with hostilities in the North and East between the government and Tamil separatist forces. Whilst the Colombo district has been relatively spared from this unrest, a proportion of the residents will have had direct experience. Sri Lanka was also affected by the Tsunami of 2648 homes .The aim of the present paper is to describe the methods we used to conduct this study, and to provide baseline results on the nature of the samples identified.The twin register is based in Colombo, one of the 25 districts of Sri Lanka. Colombo District includes the capital city, its suburbs and surrounding rural areas. The population of this district is 2.23 m according to the 2001 census . There aWe attempted to identify twins from birth records and key informants. Whilst this method was successful for young twins, it was not efficient to identify older ones . InsteadDuring the course of the twin study, we also identified all households in Colombo in which no twins were residing. This household data was organised into GNDs. Having performed the twin sampling, we identified the GND from which each selected twin came. The non-twins were sampled from the lists specific to each GND in a ratio of 1:1 . Households were selected using random numbers such that each household in the GND had an equal chance of selection. Letters were sent to the selected households explaining about the study and the twin registry field workers visited the house to determine how many individuals over 15 years were residing there. One research participant from each selected household was selected at random from this list. The consequence of this approach is that the non-twin sample was selected from the same geographical area as the twin sample, but no other socio-economic variables have been used to match the two groups.A group of 10 individuals  were extensively trained in the Composite International Diagnostic Interview by NG, a CIDI approved trainer . These iWe sent the measures to a total of 13 bilingual twins (contacted from the registry) and other Sri Lankans fluent in English and Sinhala. Each measure (or in some cases subcomponent of measures) was translated at least twice independently. The translations were then reviewed in group meetings consisting of 7 professionals  over a period of 4 months. A scholar in Sinhala also checked the translation. The adaptation was not a direct, literal translation, but aimed to find forms of words in Sinhala that best described the concepts of interest and where the questions when translated seemed cumbersome, they might be broken down into two component items for clarity . Some meAll twins were sent information about the registry and the present study. Participants who were randomly selected were then sent a more detailed letter providing information and explaining their freedom to refuse consent if they did not want to participate. They were informed that interviews could take place in their own home or at the research centre. Twins residing in more rural GNDs were again sent a letter with a stamped addressed envelope for them to provide information about how researchers could reach their home. A date was then set for an interview by phoning or a visit. A full information sheet was given and the participants were encouraged to read it carefully and if necessary, time was given to discuss with close ones before consent was given. Another appointment was made after a week to obtain written informed consent with separate consent for a buccal smear for zygosity testing on same sex twins. Field workers completed the interview  and offered a payment of 300 Rupees (approximately £1.50) in compensation for their time, at the end of the interview. Compensatory payment was not mentioned in the information provided prior to the interview. A substantial percentage of the participants refused the payment and instead requested it to be donated back to the research project.The subjects were interviewed using the WHO-Composite International Diagnostic Interview , for curSymptomatic fatigue was measured on the Chalder Fatigue Scale , a 13 itSubjects were also questioned on their exposure to potential environmental stressors. We used the Childhood Experience of Care and Abuse Questionnaire (CECA-Q), but excluded questions on sexual abuse as this was thought to be culturally inappropriate in this setting of an epidemiological survey. Life events were ascertained using an 11 item questionnaire (derived from ). We conPoverty related variables were derived from a recent census and adapted from other studies in South Asia. We performed a focus group of life events considered important in the local context. These were covered largely by a generic life events measure . We idenData were collected in paper format, and were entered into a database using SPSS . We usedThis research was funded by the Wellcome Trust (UK), and was executed as a collaboration between the Institute of Psychiatry, King's College London (IoP), the World Health Organisation's Human Genetics Programme, and the Sri Lankan Twin Registry. The initial pilot work was approved by the IoP Research Ethics Committee and the Research Ethics Committee of the Faculty of Medicine, Colombo. The main research received the necessary approvals from the Research Ethics Committees of the Institute of Psychiatry, World Health Organisation (Geneva) and Sri Jayewardenepura University of Sri Lanka. This research led to the establishment of ethical guidelines appropriate to twin research in developing countries.We assessed zygosity using a questionnaire scored out of 10, asked to both twins in a pair . This quStatistical analysis shown here were conducted in STATA  and StatA previous paper  describeThe population of twins identified in Colombo numbered 19,302. Of these 5,621 were excluded from the sampling frame because they were under 15 years. Of 13,681 left, 6,600 were randomly selected to participate, excluding 145 who were discarded due to data base errors, and 679 who we were unable to trace. On performing household visits, it was apparent that 1389 were not eligible to participate , 785 all female pairs  and 534 mixed gender pairs. Among the 3980 twin individuals, the mean age was 34.0 years and over three quarters were under 45 years .Alongside the twins, 2,485 non-twins were randomly selected for interview. Of these 174 were excluded because they have gone abroad or were working far away or could not speak Sinhala, or the interview was of poor quality. Of those selected, 292 (12.6%) refused to participate. A total of 2,019 interviews were completed. The mean age was 43.5 years and 45.6% were male.The ascertainment of twins for the population based register was thorough and should have included the vast majority of twins actually residing in the area, due to the redundancy of reporting (many reports of twins were duplicates). However, the ascertainment appears to be slightly less thorough in the regions where the election department officers rather than Grama Nildharis administered the questionnaire inquiring about twins .There appear to be no important gender or age differences between the interviewed twin sample and the twins refusing to participate, suggesting the final twin sample is not biased according to selective participation. The mean age of the twins sampled is slightly younger than the mean age for all people 15 years or older in Colombo district. This is likely due to twins in older pairs being more likely to have died or moved far away from one another . SimilarThis study has contributed to capacity building by translation of psychiatric instruments, including the CIDI, into Sinhalese. A cohort of research workers have been trained in interviewing and general survey research methods, which will enable future epidemiological research. A laboratory will be established for zygosity testing, which will develop the capacity to perform techniques underlying many molecular genetic approaches.The Colombo twin register is one of the first population-based twin registers in the developing world. A rigorous ascertainment system has produced a sample capable of exploring the genetic and environmental influences on the variation in many human conditions in this developing country. It could uncover environmental effects that operate in developed countries but have so far been missed due to the narrower range of environments seen in these countries. It will also assess the impact of measured environmental exposures. The focus will initially be on common mental disorders, somatization and substance abuse, but the sample can readily be used to assess other phenotypes.The authors declare that they have no competing interests.SS, HB and MH wrote the paper. SS assisted in the design of the study and was the main study coordinator. He trained and managed the field workers, and was responsible for data collection and quality control; HB cleaned and analysed the data; SNH assisted in coordinating the study, training and managing field workers, and data collection; NG was responsible for training Sri Lankan investigators in the use of the CIDI; YK cleaned and analysed data; DARK was responsible for the molecular and clinical genetics for the study in Sri Lanka, and contributed to the study design; AS is the Principal Investigator in Sri Lanka, and contributed to the establishment of the twin registry, study design, and management of the study; PMcG contributed to the design of the study; MH is Principal Investigator in the UK, with responsibility for the design of the study. With AS he secured funding for the study, coordinated the wider study group, and supervised the local team in practical issues related to study design and data collection. All authors commented on drafts of the paper.The pre-publication history for this paper can be accessed here:


Inactivated polio vaccine was offered, and the index case-patient and household contacts were quarantined. Australia, along with 36 other countries in the Western Pacific Region, was declared free of poliomyelitis by the World Health Organization in October 2000. Yet, the persistence of wild poliovirus in the 4 remaining polio-endemic countries—Afghanistan, India, Nigeria, and Pakistan—poses a risk for its importation into all countries declared polio free. We describe the public health response and outcomes resulting from the importation of a wild poliovirus infection in Melbourne, Australia, in July 2007. This response, based on an assessment of the risk for transmission, included offering vaccination with inactivated polio vaccine to the contacts and placing the index patient in isolation and the household contacts in quarantine until consecutive fecal specimens were negative for poliovirus by culture. The experience gained from the polio importation event in Australia may assist other polio-free countries to prepare for, and respond to, a similar event. No secondary clinical cases resulted from this importation. Since 2006, wild poliovirus has been endemic in only 4 countries: Afghanistan, India, Nigeria, and Pakistan. Although many countries have not reported a case of poliomyelitis caused by wild poliovirus for some years, they remain at risk for importation of the disease. Australia and the other countries of the Western Pacific Region were declared polio free in October 2000  Global Polio Eradication Initiative recommends clinical surveillance for cases of acute flaccid paralysis in children <15 years of age and suspected paralytic polio in a person of any age as the most sensitive means of detecting a case of imported poliomyelitis in countries declared polio free  in place of the Sabin oral polio vaccine on November 1, 2005. In Victoria in 2007, the proportion of children who received at least 3 doses of polio vaccine was 92.8% at 12 months of age and 95.9% at 2 years of age. Coverage with at least 4 doses of polio vaccine was 91.4% at 6 years of age. No reliable data exist on vaccination coverage with polio vaccine in the adult population.We describe the public health response to an importation of wild poliovirus infection that occurred in Melbourne, Australia, in July 2007; the last reported case of polio in Australia was in 1977  in Victoria, Australia, was notified of a suspected case of imported poliomyelitis in a 22-year-old man (a university student). The patient, who was studying in Melbourne, had returned home to Pakistan on March 13, 2007, and in early June, he visited Islamabad and the North-West Frontier Province. On June 22, 2007, fever, nausea, and pain in the lower back and legs developed and progressed to lower limb weakness. The symptoms appeared to resolve, and he returned to Melbourne, arriving on a flight from Bangkok, Thailand, on July 2, 2007. However, he remained at home with back pain and lower limb weakness and consulted a general practitioner on July 6, 2007. He was advised to go to a hospital, where the emergency department admitted him for further investigation. The patient reported receiving at least 3 doses of oral poliomyelitis vaccine as a child.A case report describing the clinical features and treatment of the patient and the initial laboratory investigation was published by Stewardson et al. , which came into effect in June 2007 and require member countries to notify WHO of poliomyelitis cases .Household contacts were judged to be at highest risk. Anyone who used the same toilet as the index patient before it had been cleaned was regarded as being at lesser risk, especially because the patient had not used a toilet to have a bowel movement either on the plane, at the general practitioner’s clinic, or at the hospital emergency department. In virtually all instances, the vaccination history of contacts was uncertain. Although the likelihood of transmission was deemed to be low, a cautious approach to the situation led to a comprehensive public health response.Household contacts of the index patient were identified as his 5 housemates, 1 visitor who had stayed overnight after the index patient’s return from overseas, and a housekeeper who cleaned the index-patient’s premises, but did not reside there. The household contacts were placed under a public health order following the state’s health laws to remain in home quarantine until released by DHS. The 5 housemates were quarantined at their principal place of residence, together with the visitor who joined them. The housekeeper was quarantined in her own house. The contacts were provided with information on poliomyelitis and given booster doses of IPV. Doses of IPV were administered subcutaneously, according to the Australian immunization guidelines .The index patient reported that he had used the toilet on the flight from Bangkok to Melbourne, although only to urinate. Although the risk to the fellow passengers was deemed to be low, contact tracing was instituted for the passengers on the flight. Two hundred thirty-five passengers terminated their journey in Melbourne , and their incoming passenger cards were obtained by DHS through the Department of Health and Ageing. Upon laboratory confirmation of the diagnosis of the traveler’s poliomyelitis, a media bulletin was released by DHS on July 14, advising the public of the case and asking passengers from the flight to contact a national public health telephone line to obtain further information and to receive a booster polio vaccination. Media interviews were conducted by DHS staff, and a health alert was issued for hospitals in Victoria.DHS also contacted the airplane passengers directly by telephone, letter, or email to provide information on poliomyelitis and offer a single booster dose of IPV, regardless of previous poliomyelitis vaccination history. The results of the airplane contact tracing are shown in On July 6, 2007, the index patient consulted a general practitioner about the symptoms that recurred after his arrival in Melbourne on July 2. He later informed DHS that he had used a toilet at the clinic to pass urine only and so the same risk assessment criteria were used as for the airplane contacts. Nine healthcare staff, 24 patients, and 6 of their friends or relatives were administered IPV.We identified persons who may have used a toilet at the hospital Emergency Department and on the ward where the index patient stayed before isolation procedures were instituted, and we recommended that they receive IPV . In totaHCWs who possibly had contact with the index patient were regarded as at risk, and a total of 83 hospital staff members each received 1 dose of IPV. Australian-born HCWs were judged likely to have been fully immunized and therefore less likely to be at risk. Nine overseas-born hospital staff members who could not provide evidence of vaccination or a booster dose within the last 10 years, per the Australian immunization guidelines  of the 235 passengers could not be contacted. For the 96 passengers who chose to see their own doctor for vaccination and the 29 passengers who were contacted by letter or email, outcome is not known.In large part, the laboratory investigation of the index patient and household contacts followed the procedures recommended by WHO for routine acute flaccid paralysis surveillance with collection of 2 fecal specimens obtained 24–48 hours apart, due to intermittent virus shedding, for virus culture (Household contacts of case-patients are at high risk of infection (The time taken to determine a negative result by cell culture leads to an inevitable delay in finalizing patient tests, which, in the circumstances described in this report, had implications for when the index patient and household contacts could be released from hospital isolation and home quarantine, respectively: 34 days for the index patient and 16 days for the household contacts. It should be noted that household quarantine of the contacts required substantial logistical support by DHS staff in terms of food and entertainment. This also has implications for large-scale quarantine as would be required in an influenza pandemic.No published evidence is available on the role of polio vaccine as postexposure prophylaxis against paralytic disease. However, in persons with some preexisting immunity, which would include most of the Australian population, boosting the immune response with a single dose of oral polio vaccine or IPV is likely to reduce both pharyngeal and intestinal excretion of poliovirus in those who have been infected (Until this imported case, poliomyelitis caused by wild poliovirus had not been reported in Australia for 30 years. The case necessitated a rapid and extensive public health response. The age and vaccination history of the index patient highlight the need for public health officials worldwide to prepare for imported cases of suspected polio in persons of any age and with prior vaccination. The experience gained from the public health response to the importation in 2007, particularly in relation to tracing of contacts, isolation of cases, and quarantine of close contacts, has been incorporated into the national outbreak response plan for the investigation of cases of acute flaccid paralysis and suspected polio, published by the Australian government’s Department of Health and Ageing (


This paper draws together contributions to a scientific table discussion on obesity at the European Science Open Forum 2008 which took place in Barcelona, Spain. Socioeconomic dimensions of global obesity, including those factors promoting it, those surrounding the social perceptions of obesity and those related to integral public health solutions, are discussed. It argues that although scientific accounts of obesity point to large-scale changes in dietary and physical environments, media representations of obesity, which context public policy, pre-eminently follow individualistic models of explanation. While the debate at the forum brought together a diversity of views, all the contributors agreed that this was a global issue requiring an equally global response. Furthermore, an integrated ecological model of obesity proposes that to be effective, policy will need to address not only human health but also planetary health, and that therefore, public health and environmental policies coincide. The pro century .http://www.euroscience.org. This short paper by the contributors to ESOF discussions presents their summary views on the socioeconomic dimensions of this important public health topic, including new holistic approaches to tackle this health issue.Obesity presents a particular challenge for public health policy because treatment is expensive, with poor results and a marginal impact on population trends, suggesting that the emphasis must be placed on prevention ,8; but pObesity occurs when a person's Body Mass Index (BMI), calculated as the weight (kgs) divided by the square height (cm), exceeds 30. For children, issues of measurement are more complex; nor is BMI an always reliable measure given diversity of body shape. Obesity is also a cultural matter . While sPopulation weight gain is increasing despite the best efforts of the health authorities to inculcate healthy eating habits or the ubiquity of commercial weight-loss and low-fat food products. This suggests that an analysis of obesity requires more than an understanding of individual dietary patterns but needs to engage with a more complex explanation incorporating the recognition of the paradox that while society may discourage fatness discursively, it might also encourage it in practice.Obesity has been classified by the World Health Organization (WHO) as a non-communicable disease  . WHO's eWeight gain does not affect everybody in the same way. Not everyone who is overweight is ill because of it and not everyone who is overweight has a poor diet. The way in which people consume food and manage their health varies according to many factors ranging from socioeconomic status, gender, age and ethnic origin as well as the interaction between micro- and macro-structural factors that change from one society to another .Across the European continent, obesity has been growing in prevalence, with particular concern focused on children . The annIn Spain, the location of the ESOF meeting, variables such as age, social class, sex, and region of habitation, for example, all appear to be related to obesity prevalence . OverallAmong the Spanish children (2 to 17 years old) the numbers are also of growing concern  linked to the economic and cultural identity of society is given less prominence. Structural types of explanation for obesity focus on long-term economic and social policy trends - some of which take a global form  and the One approach for explanation begins by analysing changes within the food supply chain and the reshaping of the way in which food is produced, formulated, priced, marketed and consumed. Following the lead of the USA, farming legislation has resulted in ever-cheaper basic ingredients available to food manufacturers and retailers, boosting portion sizes as well as consumption of high fat, energy dense foods . Since tA second type of policy analysis aims at encompassing these economic and business realities, public policy and cultural factors, implying the need for scientific collaboration across different research disciplines (as well as co-ordination and collection of different types of knowledge) together with detailed understanding of the interplay of local, regional, national and global factors -44. A thIf these perspectives add to our knowledge of structural factors, there remains open the need to construct an integrated and holistic perspective which can draw upon not only the biological and physiological aspects of obesity and its social, economic and environmental determinants, but which also examines the feedback between the conditions which are shown to influence health to those which affect the natural environment. In part, the formulation of this new approach has already begun. An ecological perspective has already been established within the prestigious US Institute of Medicine , while aObesity has been dramatised as one of the leading public health challenges of our age, but it is equally a conceptual and public policy challenge as well. What emerged from the ESOF scientific table is that solutions presented at the level of the individual, whether they be health education or medical interventions, are unlikely to be successful while newer ecological approaches have yet to capture the attention of policy makers. As the societal consequences of obesity fully emerge, pressure will be placed upon supply chains, economic actors and upon public and private behaviour to make wholesale changes.The authors declare that they have no competing interests.MG, LY, JRM and EL have written the summarised ideas of their contribution to the ESOF conference. GR has written the summarised ideas of his contribution to the ESOF conference and helped in the writing of the paper bringing all the ideas together. MGRF organised the conference and led the writing of the paper. All authors have read and approved the final manuscript.


Arthritis is one of the most prevalent chronic conditions in Canada and a leading cause of long-term disability, pain, and increased health care utilization. It is also a far more prevalent condition among women than men. Information was obtained primarily from the 1998–99 National Population Health Survey and the Canadian Joint Replacement Registry.In 1998, the overall prevalence of self-reported arthritis or rheumatism in Canadian women was 20.0%. This rate increased to 55.6% among women over 75 years of age. Compared to women with chronic conditions, women with arthritis were more likely to experience long-term disability; report worse health; experience more pain; be dependent upon others and consult general practitioners, specialists, and physiotherapists more frequently. While men and women with arthritis under-utilize total joint replacement surgery, the degree of under-use was over three times greater for women.There is a lack of detailed information on the use of health care services by women with arthritis. There are also no systematic data available on the prescribing of medications, access to services such as assistive devices or exercise programs, or use of community support, self-management strategies, or rehabilitation services. The burden of arthritis both on women and on society is expected to increase as the population ages. A comprehensive health strategy to reduce the impact of arthritis is required to ensure that health and support services are available in a timely manner and provided in such a way to meet the needs of Canadian women. Arthritis is currently one of the most prevalent chronic conditions in Canada and is a leading cause of long-term disability, pain, and increased health care utilization,2 The teArthritis is a far more prevalent condition among women than among men -10. FindThis chapter presents information on the status and impact of arthritis and rheumatism on women in Canada. The impact of the disease will be measured in terms of ill health, pain, long-term disability and health care utilization. In order to set the data on arthritis in women in a broader population health context, we also present data on men with arthritis and various subgroups of women, including those with chronic conditions other than arthritis and those who report no chronic conditions. The information presented in this report has been obtained primarily from analysis of data from the 1998–1999 National Population Health Survey (NPHS) as well as from the Canadian Joint Replacement Registry.The analyses in this chapter are based on the cross-sectional household data from the third cycle (1998–1999) of the NPHS (see Appendix A). Data from the health file for the 14,682 selected respondents who were over the age of 15 were weighted – taking into account the sample design, adjustments for non-response and post-stratification – to represent about 23.8 million Canadians.Arthritis was identified in the NPHS by asking respondents whether they had arthritis or rheumatism as a long-term chronic condition . Individuals were also asked early in the survey to report their sex ; answers to all subsequent questions could thus be linked to each individual's response.The Canadian Joint Replacement Registry (CJRR) is a fairly new, national registry (launched in June 2000) that collects information on total hip and total knee replacement surgeries performed in Canada and follows joint replacement recipients over time to monitor outcomes. The CJRR is a joint effort between the Canadian Institute for Health Information (CIHI) and the orthopaedic surgeons of Canada.According to data from the 1998–1999 NPHS, almost 4 million individuals over the age of 15 reported having arthritis that had been diagnosed by a health professional, two thirds of these individuals (approximately 2.4 million) being women. This represents a disease prevalence among women of 20%, which was almost double the percentage of men who reported the condition (12%).The rates of arthritis increased with age among both men and women Figures  and 2, rFew studies have reported international comparisons of arthritis prevalence, and those that have been carried out have mainly reported on rheumatoid arthritis  and not osteoarthritis. Figure Socio-economic status is a concept that is generally measured by income and by education and/or employment variables. Arthritis is a disease that affects individuals from all socio-economic classes. However, a higher percentage of women who reported low or middle income and fewer years of education reported arthritis than did women from higher socio-economic classes Figure . For exaIn terms of marital status, 40% of women who were widowed or divorced reported the presence of arthritis, whereas less than 6% of single women did so. This is likely a function of the age distribution of women with arthritis. A substantial proportion (44%) of working-age women (between 16 and 64 years of age) with arthritis and 33% of men with arthritis reported not currently being in the labour force, as compared with the 21% of women who reported chronic conditions other than arthritis and 18% of women who reported no chronic conditions.Arthritis has a major impact in terms of long-term disability, which is measured in the 1998–1999 NPHS as long-term activity restriction at home, at work, at school or in leisure-time activities. Approximately 50% of men and women with arthritis reported long-term disability, as compared with about 20% of women with other chronic conditions and less than 5% of women with no chronic conditions Figures . While mApproximately 45% of women with arthritis reported pain that prevented at least some activities, and 21% reported that pain prevented them from participating in all or most activities. Rates among women and men with arthritis were quite similar in terms of the experience of pain. Women who reported chronic conditions other than arthritis or who reported no chronic conditions were far less likely to experience pain – 87% and 96% respectively reporting that no activities were limited as a result of pain.When individuals were asked whether, because of any condition or health problems, they required assistance to accomplish a variety of tasks , 43% of women with arthritis reported that they were dependent upon others to assist them with one or more of these activities. Only 30% of men with arthritis, less than 13% of women with other chronic conditions and 3% of women with no chronic conditions reported a need for assistance.A slightly higher percentage of women with arthritis 67%) than men with arthritis (62%) reported that they had consulted a general practitioner (GP) three or more times in the previous 12 months , whereas women reported using diet and exercise more frequently than men. The 1998–1999 NPHS also asked about the use of some specific types of medications. Women with arthritis were more likely than men with arthritis and women with other chronic conditions to report the use of pain medications (80% versus 73% and 74% respectively) and antidepressants (11% versus 5% and 7% respectively) but equally likely as men with arthritis to report the use of medications containing codeine (9% for both).Total joint replacement (TJR) surgery is a cost-effective means of treating primarily osteoarthritis. TJR can provide significant pain relief and improvement in an arthritis sufferer's functional status and quality of life. AccordiWomen in Canada report arthritis more frequently than men. According to the NPHS, compared with women with other chronic conditions, women with arthritis were older, had lower incomes and fewer years of education and were more likely to be widowed and out of the labour force. Consequently, it appears that the women who are experiencing arthritis may be the women with the fewest resources to deal with the impact of the condition on their daily lives. In terms of the health impacts of arthritis, women with the disease were far more likely to experience long-term disability than women with other chronic conditions. They also reported poorer health, experienced more pain that restricted activity, and consulted with GPs, specialists and physiotherapists more frequently.The prevalence of arthritis increases so dramatically with age that many older people consider the disease to be a normal aspect of aging until it becomes sufficiently painful and/or debilitating to prompt medical care. HoweverDespite the well-documented benefits of the various available treatments for arthritis, surveys have repeatedly shown that between 40% and 60% of individuals with self-reported joint symptoms or signs of arthritis or rheumatism are not receiving treatment. The reason behind the relatively low percentage of individuals with arthritis or rheumatism who see a health professional is unknown, but rates of health care utilization have been shown to be affected by a wide variety of factors, including sex, age and socio-economic status.It is difficult to make comparisons between men and women about the use of health care services for arthritis because basic sex differences in prevalence rates and/or disease severity must be taken into account. For example, despite the slightly higher rate of TJR among women, a recent Canadian study found that although there is under-use of TJR in both sexes, once disease prevalence and need are accounted for, the degree of under-use is more than three times as great in women as in men.The issue of health care utilization by those with arthritis is of particular importance since recent research done in the United States has suggested that individuals with arthritis who receive appropriate care (such as care from a rheumatologist) experience lower rates of long-term disability than those who receive care on a more irregular basis. If the The burden of arthritis in women also has considerable societal costs. A high proportion of women with arthritis reported not being in the labour force. This finding has been reported in other studies as well, many of which have also noted that simple and non-costly adaptations, such as flexible work schedules, may enable many people to remain in, or return to, the workplace -31. As wA number of gaps exist in the arthritis and gender data that are currently available. A major gap is the lack of detailed data on the use of health care services by women with arthritis. Most of the care for arthritis, including specialist care, is delivered in ambulatory settings on which there are currently no systematic data available, although, in principle, such data could be captured by a provincial database of physician billing claims. Data are available on surgery and hospitalization, but only a minority of women with arthritis undergo these interventions. There are no systematic data available on the prescribing of medications, the use of rehabilitation services, such as physical and occupational therapy, or access to other services, such as assistive devices, therapeutic exercise programs, community support and self-management. The need for data on the use of prescription medication is of increasing importance in light of current advances in the development of stomach-sparing anti-inflammatory drugs (e.g. COX-2 inhibitors) and effective, but expensive, drugs for the treatment of rheumatoid arthritis. People with arthritis are also major users of alternative health care services and herbal medications. This is a further area in which there is a deficit of reliable information about efficacy and use.Our only sources of comprehensive population-based data are national and provincial health surveys. These surveys rely on self-reported information regarding socio-demographic characteristics, medical conditions and health status, although there are questions surrounding the validity of this method. Another issue with these surveys is that they do not enable us to differentiate between the many types of arthritis, such as osteoarthritis and rheumatoid arthritis. This is important, since patients with rheumatoid arthritis tend to report more frequent and intense pain than patients with osteoarthritis, and the proportion of individuals with rheumatoid arthritis who are women is higher than the proportion with osteoarthritis. Also, dInformation about the impact of arthritis on women and their associated use of health care services is vital to underpin a strategy aimed at reducing the impact of this disease. Such a strategy would require that health and support services be available in a timely manner and provided in such a way as to meet the needs of women. Any such strategy would need to address access to primary care physicians and specialist services. There are perceived deficiencies in the primary care management of arthritis, and areas of concern include timely referral to specialists, advice to patients about exercise and other non-pharmacological interventions, and the examination of joints -36. We lThe disability associated with arthritis often leads to reduced independence, to lower participation in employment, social and leisure activities, and to loss of income and the incurring of extra expenses. Rehabilitation therapy and community support services need to be in place to help individuals deal with the disabilities and associated costs arising from arthritis. These services represent a vast but largely uncharted territory. There are few data about them and, in the case of community services, very little documentation about what services are available and how they are used. There is evidence that the use of education and self-management strategies can lead to significant decreases in pain, disability and medical consultation as well as increases in self-efficacy -39. As wThe burden of arthritis both on women and on society is expected to increase with the aging of the population. Because of the current age structure of the Canadian population and the aging of the "baby boomer" generation (those born between 1946 and 1960), a large increase is expected in the number of people over the age of 65 and a subsequent increase of approximately 1 million per decade over the next 30 years in the number of people with arthritis or rheumatism. Sixty per cent of this increase in prevalence will occur among women. These statistics alone point to the need for a comprehensive health strategy to reduce the impact of arthritis. Major efforts are also needed to find ways of capturing information on the use of ambulatory care, specialists, medications, rehabilitation and other services by both women and men with arthritis.Arthritis is one of the most frequent chronic conditions in women in Canada, and the health care and support systems aimed at dealing with the impact of arthritis need to be geared to the provision of care over a longer period of time, the ultimate goal of care being to improve the situation of women with arthritis and their families. It is hoped that this report will contribute to putting arthritis on the agenda of women's health.


There are indications of a high prevalence of psychological distress among students in higher education and also that distress increases over the course of study. However, not all studies on student distress controlled for sociodemographic differences and few followed development of distress over an extended period through professional establishment. We investigated if there is an independent effect of time in education and the first two years in the profession on depressive symptoms and mapped change over the period in a national cohort of students.Data came from LANE, a nation-wide longitudinal panel survey of Swedish nursing students (N = 1700) who responded to annual questionnaires over five years from 2002 to 2007. Depressive symptoms were measured by the Major Depression Inventory and change over time analysed in a linear mixed effects model for repeated measures.There was a significant change in level of depressive symptoms over time: an increase from the first to later years in education and a decrease to levels similar to baseline after graduation and a year in the profession. The change in symptoms remained significant after adjustment for sociodemographic factors (p < 0.01). Symptom levels differed due to age, gender, household composition and prior nurse assistant training but change over time was similar in all groups. The correlation among the repeated measures, representing within individual correlation over time, varied between 0.44-0.60.The findings indicate an independent but transitional effect of time in education and professional establishment on depressive symptoms. We think heightened distress over education abates as the graduate accommodates to the profession. Nevertheless, within education, the differences in depressive symptoms associated to demographic factors can help identify student groups more vulnerable to distress. Also, as individual differences in distress seem to persist over time, perhaps students highly distressed in the beginning of education can be helped by awareness among educators of the elevated levels of distress in late education. Research on mental health in university students has shown that they are subject to high levels of psychological distress and depression, with reports of 10-50% clinically afflicted -9. TheseHowever, many studies were performed in samples that did not allow control for demographic factors and different methods were applied to measure psychological distress or depression. When self-report instruments validated to measure a DSM-IV based definition of depression in random samples of students large enough to take age and gender differences into account, results of depression prevalence were similar to those from a general population -13. ThisIn nursing students, results from studies that stratified for stage in education appear similar to other student samples in that they show an increase of distress and/or decrease in adaptive coping skills by year in education -17. In nWe used data from LANE, a longitudinal study of a nation-wide sample of Swedish nursing students, to investigate 1) if there is an effect of time in higher education and establishment in the profession on depressive symptoms, independent of sociodemographic factors and 2) to map the pattern of change in depressive symptoms over the period. The longitudinal design with follow up of the same individuals allowed us to control effects on the individual level on overall change and also to investigate change in individuals compared with overall change. The extended follow-up over the transition from education to professional establishment gave us an uncommon opportunity to connect mental health development during education with mental health in the occupation.LANE is conducted by a research group at Karolinska Institutet to monitor health development among nursing students and newly qualified nurses . In autuAt baseline there was no difference in mean age between participants and non-responders (28.42 versus 28.36 years), but women were more likely than men to partake . The participation rate ranged from 46.3% to 85.9% between universities. Due to technical mistakes three students were excluded from the baseline dataset, yielding a response rate of 1697 year one. These respondents were included from year two .Information on depressive symptoms was gathered each year and measured by the Major Depression Inventory (MDI) ,28 contaTo test the hypothesis of an independent effect of time in higher education and professional establishment on depressive symptoms we adjusted for confounding by age, gender, prior higher education, former training as assistant nurse at high school level, work experience, university (collected at baseline), household composition , and stratified for completion of the nursing degree (collected years four and five). We chose to not to adjust for any self reported evaluations of education and work in the argument they may be indicators of distress themselves.Baseline age was categorised as 20-24, 25-29, 30-34, and 35 years and above. For prior higher education respondents were divided into no experience, less than, and more than a year's experience. Prior work experience was defined as at least six months' continuous employment within or outside health care. In analysis we divided between those with no experience, experience from either within or outside health care, and from both within and outside health care. Household composition was classified in five groups: living with parents, single, single with children, cohabitant/married and cohabitant/married with children.We investigated response profiles over time using a linear mixed effects model for repeated measures. The analyses were run on a) all cohort members, and b) the subset of students who in year four remained in the study and reported that they had graduated . The respondents were clustered within universities and we added a random effect for university to investigate variance induced at this level each point in time. As this was small  compared with variance at the individual level (23.24 - 28.1), university was instead modelled as a fixed effect to test for differences between schools.First, we fitted a series of bivariable models containing the main effect of a factor plus time. Secondly, we included the interaction between the factor and time. Thirdly, the bivariable models were adjusted for the main effect of 1) age, 2) gender, 3) household composition, 4) prior nurse assistant, 5) prior work experience and 5) university, to discern the effect on the crude models (data not shown). Finally, to test that change in depressive symptoms over time remained after adding the effect of all investigated factors, we fitted multivariable models: a) a model of the main effects of all factors plus time, b) a series of models containing the main effects of all factors plus time, and the interaction of a specific factor and time and c) a model containing the main effect of all factors plus time, and the interactions between all factors and time. As we found an interaction between university and time, we tried to identify the source by recategorising the university variable into groups of large or small class size (> or < 70 students), type of school (university or university college) and university setting . In addition we stratified for years in education  and years from graduation  to separate time in education from transition and establishment in the profession.Due to positive skewness in the response variable, all analyses were rerun after log transformation of depressive symptoms, but as results were similar they are presented on the original scale. We chose not to impose any constraints on the covariance structure for the repeated measures at the individual level and used an unstructured matrix . For uniThe age range at baseline was 20-52  with a similar gender distribution across all age groups. More than half of the students were married or cohabited with a partner and 40% were parents. Many had prior experience of work and higher education or were trained as nurse assistants before entering nursing education . Bivariable models confirmed a difference in level of symptoms for subgroups of age, gender, household composition, prior nurse assistant training and prior work experience but also that there was no significant difference in change over time except for subgroups of age  over the first four professional years as nurses than in nursing students at any point in education . In diffOverall, the findings seem to agree with prior research in students and new graduates and in addition, due to the extended follow-up of the former students after education, we were able to join results from education and professional establishment. We then saw a transitional pattern of elevated distress in the latter part of education that decreased once the graduate had had time to accommodate to the occupation. However, beneficial development during professional establishment may also depend on other factors such as employment prospects and job security after graduation . The newThe differences found in symptom levels reflect results on depression from population based American and European surveys: a higher prevalence among young adults compared with middle aged adults, in women compared with men, and among singles compared with married/cohabiters -40. In aThus, we found similar associations between the investigated demographic factors and depressive symptoms in students as has been found for depression in the general population. That, despite differences in level of symptoms, these factors had little impact on change in depressive symptoms over time, supports the hypothesis of an independent effect of time in higher education and professional establishment on distress.The correlation between the repeated measures suggests that individual differences in symptom level between responders persist. This is in line with longitudinal data from both general student samples, where students who reported distress at baseline had an increased risk for depression two years later  and mediBy investigating symptom degree rather than depressive disorder, we could follow change over time but not the proportion of students afflicted by clinical levels of depression. To assess the clinical relevance of the findings we calculated a DSM-IV based measure of presence versus absence of depression from the MDI-scale. This showed an estimated proportion of 10.1% depressed the first year of education and a pattern of change over time similar to that found for levels of symptoms . Despite this, the standard deviations of 4.92-5.39 over time display that even if we found a consistent and significant change in mean levels of symptoms, it is modest compared with variation on the individual level each point in time. We think the results we present have implications on an aggregate level and that they do indicate an effect of education and professional establishment on depressive symptoms, but that for individuals there are other and more important factors that affect depression.The nation-wide design and the demographic make-up of the student group in this study enabled analysis of differences in distress development between nursing programmes and control for differences due to age, living conditions and prior experience. The analysis was restricted to a single profession which limits inference to other professions, but studies performed in other student groups in professional training seem to indicate similar development over time. As for students who do not pursue organised programs they may have different goals with less defined outcomes in terms of a future career, which perhaps affect distress both over education and after graduation differently.The response rate of 73% at baseline was comparable or higher than other studies on mental health in students we know of, and attrition from the defined cohort over time was modest although there were some differences between groups over time. As for change over education and professional establishment the respondents were already in their second term at first measurement and a year into work life at the last, consequently we may have missed initial distress both in beginner students and new graduates. We located a difference in distress development for university setting; but there are other plausible causes we were unable investigate. This said, our impression after inspecting descriptive graphs of development for individual schools, is that the pattern of increase between year one and two and decrease after examination and a year in the profession holds true over a majority of schools (see additional files In LANE, 95.3% of the remaining respondents had graduated by year five, but national registers show that only 83% of those who initiated nursing education in 2001/2002 graduated within five years . This meThe fact that change in depressive symptoms over time was similar across groups indicates an independent effect of time in higher education and professional establishment on psychological distress. We think heightened distress over education is a transitional phenomenon and that in the majority of former students it abates once they have had time to establish themselves in the profession.These findings have implications for how to interpret psychological distress in student samples. Students in higher education are under constant evaluation and after graduation, as they enter occupational life, they have to prove themselves capable in their chosen profession. Heightened distress in late education may be anticipatory worry as well as a response to the immediate educational environment. This can be true of all students in higher education, but is perhaps easier to identify in professional education programs where a successfully accomplished degree defines the skills a graduate is expected to master.Despite the transitional nature; within education, the differences observed for depressive symptoms in association to demographic factors can help identify student groups more vulnerable to distress. And as individual differences in distress seem to persist, perhaps students highly distressed in the beginning of education can be helped by awareness among educators and counsellors of the elevated levels of distress in late education.OECD: Organisation for Economic Co-operation and Development; DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; ICD-10: International Classification of Diseases and Related Health Problems, 10th Revision.The authors declare that they have no competing interests.AC participated in the questionnaire development, co-ordinated three of the data collections, designed the study, performed the statistical analyses and drafted the manuscript. BR was the guarantor of the study, supervised the first author and helped draft the manuscript. PD supervised, participated in and helped interpret results from the statistical analyses. MV supervised the first author and helped draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/343/prepubDepressive symptoms by year and university. Descriptive graph of the observed levels of depressive symptoms by year and universityClick here for fileDepressive symptoms by year and university stratified for class size, type of school and university setting. Descriptive graphs of the observed levels of depressive symptoms by year and university stratified for class size, type of school and university settingClick here for file


In quality improvement collaboratives (QICs) teams of practitioners from different health care organizations are brought together to systematically improve an aspect of patient care. Teams take part in a series of meetings to learn about relevant best practices, quality methods and change ideas, and share experiences in making changes in their own local setting. The purpose of this study was to develop an instrument for measuring team organization, external change agent support and support from the team's home institution in a Dutch national improvement and dissemination programme for hospitals based on several QICs.The exploratory methodological design included two phases: a) content development and assessment, resulting in an instrument with 15 items, and b) field testing (N = 165). Internal consistency reliability was tested via Cronbach's alpha coefficient. Principal component analyses were used to identify underlying constructs. Tests of scaling assumptions according to the multi trait/multi-item matrix, were used to confirm the component structure.Three components were revealed, explaining 65% of the variability. The components were labelled 'organizational support', 'team organization' and 'external change agent support'. One item not meeting item-scale criteria was removed. This resulted in a 14 item instrument. Scale reliability ranged from 0.77 to 0.91. Internal item consistency and divergent validity were satisfactory.On the whole, the instrument appears to be a promising tool for assessing team organization and internal and external support during QIC implementation. The psychometric properties were good and warrant application of the instrument for the evaluation of the national programme and similar improvement programmes. In the past fifteen years enormous progress has been made in monitoring quality of care in the United States and several European countries. Monitoring may serve several purposes. It is often considered a prerequisite for organizational learning and a driver for ongoing development. The Continuous Quality Improvement (CQI) techniques that were introduced into health care in the 1980s, for instance, fit within this line of reasoning, as does the 'Breakthrough Series', launched in 1995 by the Institute for Healthcare Improvement (IHI) . Both CQet al. urged for more research into the different types of QICs and their effectiveness, as well as linking QIC-practices explicitly to organizational and change management theory. Indeed, further study of processes and outcomes of QICs is desirable. QICs are complex, time consuming interventions and hard evidence on their effectiveness is limited [Breakthrough is an example of a quality improvement collaborative (QIC). It is a means to stimulate improvement and an intentional spread strategy. A QIC brings together groups of practitioners from different healthcare organizations to work in a structured way to improve one aspect of the quality of their service. It involves them in a series of meetings to learn about best practice in the area chosen, about quality methods and change ideas, and to share their experiences of making changes in their own local setting . Given t limited -6. The cThe study is part of an independent evaluation of a national improvement and dissemination programme for hospitals in the Netherlands. Objectives of the programme are to enhance patient safety and logistics in 24 hospitals. Three groups of eight hospitals receive programme support for two years. In the first year multidisciplinary teams implement projects that are to be disseminated throughout their hospitals in later years ,8. The pBesides the scientific goal, this study serves a more practical purpose. Knowledge on team organization and supportive conditions is of considerable value for parties involved in QIC-efforts. Hospital managers, project teams, change agents and public stakeholders may benefit from gathering tangible information for real-time adjustments. Furthermore, anticipating on future events, it is important to guarantee the applicability of the instrument for evaluation purposes in other collaborative programmes. This requires measuring the instrument's basic psychometric properties, such as reliability and validity, by testing it in a representative sample of project leaders of the multidisciplinary hospital teams.The measuring instrument in the current study is based on team organization and internal and external support. Before going deeper into the methods we will elaborate some more on the nature of the three dimensions.Team organization affects the teams joining a QIC. Cohen and Bailey defined a team as 'a collection of individuals who are interdependent in their tasks, who share responsibility for outcomes, who see themselves and who are seen by others as an intact social entity embedded in one or more larger social systems , and who manage their relationships across organizational boundaries' (p. 241).[(p. 241). There is(p. 241). To incre(p. 241). The noti(p. 241). is in li(p. 241).et al. even state that the topic should be of strategic importance to the organization.[et al. i.e. foster vision, create alignment, develop relationships, live values and establish process.[Other imperatives for team success are strong organizational support and integration with the organization's key values. Within Qnization. Besides nization. many of nization.,18 They nization. Tasks su process.The involvement of external change agents, arranging group meetings for teams of different organizations, is a typical QIC feature. Team training is a success factor for team based implementation. Team traThe study goal is to design an efficient instrument to gather information on the three dimensions. The instrument is designed to be filled out by the project leader of the multidisciplinary team joining the QIC in the middle or at the end of the project. The project leader is most likely to be confronted with internal and external support aspects. Furthermore, the project leader is acquainted with the functioning of the multidisciplinary team running the project.Item content is based on the three dimensions and their characteristics. To enhance content validity, nine experts in human resource management, organizational psychology, patient safety, logistics and operations management, social medicine and health care management reviewed the first draft of the instrument. They were asked to judge the questions for appropriateness, clarity, completeness, question sequence, completion time and overall appearance. Questions with potential overlap in construct, others that were vague, ambiguous and redundant and some, which appeared irrelevant to the objectives of the study, were removed, resulting in a 15 item instrument. Questions are displayed in table Items were designed based on a 7-point Likert scale in which 1 corresponds to 'strongly disagree', 2 to 'disagree', 3 to 'slightly disagree', 4 to 'neutral', 5 to 'slightly agree', 6 to 'agree' and 7 to 'strongly agree'. The choice for a 7-point scale is based on the notion that this scale offers maximum information, discriminates well between respondent perceptions and is easy to interpret.After the draft version was tested by five researchers it showed that the instrument was simple and straightforward to complete and not time consuming (approximately 10 minutes). The instrument also contains a standard set of socio demographic and job related questions addressing age, sex, education, position, date of birth. Extra background information was added in the form of two questions, addressing the number of team members and meetings since the start of the project.To investigate the suitability of the instrument in a QIC in Dutch hospital care, all the project leaders of the teams participating in the improvement programme were included as participants in the study. The testing fields were 24 hospitals spread all over the country. The central change agency granted permission to approach the project leaders in the programme hospitals. The project leaders of one hospital decided not to participate in the study because of the expected time burden.All questionnaires were assigned a unique code to distinguish between organizations, project types and respondents. In the first group, comprised of eight hospitals, the study was conducted between July and September 2005, 77 questionnaires were sent by mail to the project leaders. In the second group, consisting of seven hospitals, the study was conducted between December 2006 and February 2007 and this time 71 questionnaires were sent by mail to the project leaders. The third group filled out the questionnaire between September 2007 and December 2007 89 questionnaires. The overall response rate was 71%, (168 out of 237 questionnaires). Instructions were provided via an accompanying letter describing the purpose of the study and stating that the participation was anonymous.The sample was analyzed as a whole. Descriptive statistics and the response distribution for each item were calculated, in order to examine central tendency, variability and symmetry. Reliability and validity were investigated as main psychometric properties. Reliability i.e. how well items reflecting the same construct yield similar results, was tested via Cronbach's alpha coefficient. This is the most frequently used estimate of internal consistency. The higher the score, the more reliable the generated scale is. A minimum score of 0.70 is preferred.et al.[Content validity was addressed in the development stage to enlarge confidence that the instrument measures the aspects it was designed for. To support construct validity, principal component analysis was used to determine the underlying constructs, which explain significant portions of the variance. The factor loadings, i.e. the correlation coefficients between the items and the factors, were examined in order to explain the meaning of each construct. Tests of scaling assumptions, according to the multi trait/multi-item matrix , were uset al. Low itemet al. All analNearly half of the respondents (48%) consisted of medical professionals . Two other dominant function groups in the sample are: managers, department heads or team leaders 29%) and a third group of advisors, policy makers and administrative and quality personnel (23%). The majority was female (60%) and the mean age was 43 years. The projects are divided into pressure ulcers 17% (n = 28), medication safety 23% (n = 38), postoperative wound infections 7.9% (n = 16), operation theatre productivity 7.9% (n = 16), process redesign 21.2% (n = 35) and waiting lists 19.4% (n = 32). Response information is provided in table 9% and a Valid responses are high for all items, providing evidence that items and response choices are clear and unambiguous. Three respondents had filled in less than half of the total number of items and were excluded from further analyses. When a respondent had given more than one option, this item was marked "missing". There were no items with 80% of the answers falling in one category. No items were excluded based on the percentage of missing responses.2 = 1211.8; df = 105; P < 0.001). The correlation matrix is thus not an identity matrix, which would indicate that the factor model is inappropriate because variables only correlate with themselves and all other correlation coefficients are close to zero.[The suitability of the data for component analysis was tested via the Kaiser-Meyer-Olkin measure of sampling adequacy, which tests the partial correlations among the items. Its value should be higher than 0.5 for a satisfactory analysis to proceed . The KMO to zero. PrincipaA decision to be made is the number of linear components or factors. A typical approach is the Kaiser-Guttman rule which states that an eigenvalue (i.e. the variance accounted for by each underlying factor) must be greater than one. However this approach usually produces many factors along with the inherent difficulty of properly interpreting them. Another eigenvalue-based approach is to examine Cattell's scree plot; a two dimensional graph with factors on the x-axis and eigenvalues on the y-axis. Based on the scree plot in figure Rotation maximizes the loading of each variable on one of the extracted components whilst minimizing the loading on all other components. The exact choice of rotation depends on the answer to the question whether or not underlying factors are related. When on theoretical grounds the components should be independent an orthogonal rotation like varimax is recommended. However, if theory suggests that factors might be correlated, then an oblique rotation is to be selected. DeVellis provides specific guidance for when an orthogonal rotation should be used. He suggests that when the correlations among the factors are less than .15, the orthogonal approach is best, but otherwise the oblique rotation is a better option. Since weOblique rotation generates a pattern matrix with factor loadings and a structure matrix with correlations between items and components in a structure matrix. Table team is properly trained" was dropped based on this criterion. It was not necessary to apply a second criterion; none of the remaining items loaded higher than 0.4 on more than one factor.[A cut-off point of 0.50 for factor loadings was adopted, i.e. only those items scoring higher than this threshold were retained for further analyses . Item 6 e factor.In table The 14 items were used to create the multi trait/multi-item matrix shown in table Before going deeper into the interpretation and implication of the components found, the steps taken so far will be summarized. The theoretical framework of this study is built on literature about QICs, team based implementation and the dissemination of innovations within health service organizations. Appropriateness, clarity and completeness of the items in a draft version of the instrument was revised by experts who also judged the appearance, question sequence and completion time. This step was an important exercise for supporting content validity and resulted in a 15 item questionnaire that was administered by project leaders of a national hospital care improvement programme, 165 of the returned questionnaires (70%) were included in the study. Principal component analysis was performed and three components were extracted, accounting for 65% of the variance of the items. Item-scale criterion was not satisfied in the case of one item, which was eventually excluded from the instrument. Construct validity was supported by the overall success of the convergent and discriminant validity tests of item-scale correlations, according to the multi trait/multi-item correlation matrix approach. Reliability of the three components was addressed using Cronbach's alpha coefficient, which was well above the recommended minimum value for each individual construct.The first factor contains five organizational support items. The second factor also consists of five items, now affecting the organization of the project team. The four items of the third factor relate to the support given by external change agents. The factor structure found in the data is almost identical to the three subcategories in table et al. samples between 100 and 200 can be good enough provided that communalities are higher than .5 and there are relatively few factors each with only a small number of indicator variables.[A few remarks must be made with regards to the sample size. In the literature different standards are applied for the number of items-number of cases ratio for a factor or principal component analysis. Kass and Tinsley recommend five to ten cases for each item. Nunnallyariables. The loweariables.A limitation of this study is that we could not assess Test-Retest Reliability due to an agreement made between the funding organization, hospitals, programme makers that the questionnaire burden for hospital staff was to be minimized. Another possible limitation is that the instrument was tested for its overall psychometric properties using the combined sample of project leaders. The respondents differ in position, type of project, hospital organization and time period – the first year of the first group, took place a year before the first year of the second group and two year before the first year of the third group. Despite these differences, it is likely that the instrument is suitable for the evaluation of other collaborative health care improvement programmes. The instrument was tested for its overall psychometric properties using the combined sample of project leaders. Notwithstanding functional and other differences the study results show that the respondents could very well make a distinction between the three dimensions. The three components form a basic measuring instrument and a promising step towards a better understanding of QIC-implementation. Combined with the qualitative methods that are indispensable for a programme evaluation, the quantitative data gathered using the instrument can potentially add more detailed information on the relations between the components and narrative data collected by interviews or observations.This study reported on the development and psychometric testing of a measuring instrument. A short term benefit from measuring the conditions during the implementation is that it may be helpful in identifying those project teams with deficiencies in the areas measured by the instrument, in order to provide them with additional resources and support. Yet, more fundamental questions may be answered using data from this questionnaire. Insight into team organization and support during the implementation may help in understanding how process features affect the actual or perceived amount of success. There is, nonetheless, something to gain by adding supplementary questions, i.e. on the complexity, relative advantage and the nature of the specific interventions that are implemented by the teams, as well as the indicators used to monitor the project targets. Other relevant questions affect scales measuring the learning climate within the implementation area, activities taken on behalf of sustaining new working methods, the quantitative spread of the projects throughout the organization and so on. Extensions like these can be rewarding in an a priori fashion, since they potentially illuminate the complexity and advantage brought by a project in relation to the types of interventions and the measuring efforts that are part of applying rapid cycle improvement. At this moment knowledge on these matters is limited but very welcome.This study resulted in the development of a measuring instrument for team organization and supportive conditions for the implementation of QIC projects. After psychometric testing it demonstrated acceptable levels of internal consistency reliability and content and construct validity. This evidence warrants application of the instrument for the evaluation in the hospital improvement programme and similar QICs in health care. Linking outcome data on performance indicators to the state of the conditions during the implementation may be helpful in explaining, perhaps even predicting, the amount of success.The authors declare that they have no competing interests.MLAD was responsible for designing the study, conducting the literature review, developing the questionnaire, acquiring, analyzing and interpreting the data and drafting the manuscript. As research manager of the independent evaluation study of the hospital improvement programme CW was responsible for designing the study and developing the questionnaire. CW and PPG assisted in interpreting the results and revising the manuscript for intellectual content. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here: