The report found no evidence that the proportion of treated people in the developing world had increased since 1990. There is now a debate among mental health professionals in low-income countries over how best to improve patient care. In this article, three psychiatrists give their different viewpoints on the current status of treatment efforts for schizophrenia in the developing world and the measures that can be taken to increase the proportion of patients receiving treatment.Background to the debate: Schizophrenia affects an estimated 25 million people in low- and middle-income countries, with an average lifetime risk of about 1%. The illness is associated with excess mortality from a variety of causes. A 2001 Institute of Medicine report on mental illness in developing countries found that in 1990, over two-thirds of people with schizophrenia in these countries were not receiving any treatment ( Three psychiatrists give their different viewpoints on the current status of treatment efforts for schizophrenia in the developing world. Although schizophrenia is relatively rare, it is also arguably the most severe mental disorder. In many individuals, the disorder runs a chronic and relapsing course, leading to progressively worsening disability, loss of livelihoods and social networks, and increased risk of discrimination and human rights abuse. To consider what might be the best approach for treating schizophrenia in low- and middle-income countries (LAMIC), we must first address three questions: What is the burden of this disorder? What are the resources available for care? And what is the evidence base for the treatment of this disorder in LAMIC?Assuming that the point prevalence of schizophrenia in LAMIC is the median figure reported in a recent systematic review—4.6 per 1,000 population , then abWhat impact does this lack of care have on patients' lives? A recent household study from Mozambique reported that up to half of the patients with psychotic disorders were reported by key informants in their households to be currently in poor health . TraditiThus, the lack of evidence-based care, exacerbated by rapid changes in social and economic conditions in less developed countries that compromise the ability of informal systems to care for people with schizophrenia , represeHow can these treatments be delivered in low-resource settings? The most appropriate model of care is a community-based program that is affordable, feasible, acceptable, and evidence based. Who are the key health professionals needed to deliver such a model? Given the scarce specialist resources in LAMIC, the lion's share of the service delivery would need to be the responsibility of non-specialist health workers. Indeed, the front line of the community mental health-care system need not even be represented by health workers at all, but may be made up of people who live in the community and are trained to provide a range of family- and community-based interventions.Such care models are now being implemented by a number of community-based organizations such as Basic Needs , and have been shown in quasi-experimental designs to be superior to simple outpatient care on clinical and functional outcomes . These pThe first step in a population-based model must be to improve awareness about the disorder and the service. The community mental health worker needs to establish close networks with members of grass-root, health service, and social welfare organizations. Next, the community mental health worker must identify probable cases of schizophrenia, preferably as early as possible after the onset of the disorder. The ideal model for case identification is likely to be through the use of key informants , a cost-effective method for identifying mental disorders in LAMIC . Then thAfter this predominantly clinical phase, the focus of care shifts back to the community, involving three strategies: (1) Strengthening opportunities for paid employment; (2) building individual and family capacity to cope with the disorder ; and (3) ensuring that the costs of long-term care are at least partly borne by an equitable financing system, such as a voucher system, insurance plan, or fixed monthly payments. The role of the community worker may extend to care for people with other severe neuropsychiatric disorders, such as mental retardation and epilepsy, which share many characteristics with schizophrenia , and are also more likely to occur together. Community-based residential care will still be needed for the few individuals who are severely disabled and cannot continue to live either independently or with their families.The model that I have outlined is not a pipe dream. It is an affordable prescription for a commitment to ensure that people with schizophrenia receive the basic minimum package of evidence-based care in LAMIC, care that meets their human rights.In developing countries, treatment for schizophrenia is limited mostly to acute episodes and seldom involves primary care physicians. Developing countries typically spend less than 1% of their health budget on mental health , and oneOne approach to tackling the burden of untreated schizophrenia in low-income countries that may prove effective is directly observed therapy. This approach is the cornerstone of current global efforts to tackle tuberculosis (TB). Successful TB treatment, and the prevention of multi-drug resistant TB, requires long-term therapy and high adherence rates. The internationally recommended TB strategy known as DOTS   has two The DOTS strategy has led to remarkable improvements in TB control in many developing countries ,19. The Providing a regular supply of antipsychotic medication and supervising its administration may be one mechanism for addressing the enormous public health burden of long-term untreated psychosis in developing countries. This burden includes increased co-morbid substance abuse, suicide, treatment resistance, impaired cognitive and neuropsychological function, offending behavior, vocational failure, and overall poor outcome . In addiLong-term antipsychotic medication for treating schizophrenia in developing countries is a cost-effective intervention. Out of 20 recommendations for optimal treatment suggested by the Schizophrenia Patient Outcome Research Team, a research team funded by the US National Institute of Mental Health, 14 were related to pharmacological interventions . These iWe surely owe it to the families of patients with schizophrenia in poor countries to provide free drugs. The families have largely subsidized schizophrenia treatment for society and the state at large by providing the social, psychological, residential, and occupational support that constitutes the major proportion of the cost of treatment for this disorder. Provision of free drugs to these patients as a part of “DOTS-type” programme would help to share this burden in a small but very significant way.Drug treatment for schizophrenia is likely to be more effective if its administration is supervised. Such a system of supervision is feasible in low-income settings in view of the family's integral involvement in the patient's care. About 60% of patients with schizophrenia may fail to adhere to their treatment , in parthttp://www.clinicaltrials.gov/ct/show/NCT00392249?order=1).I suggest that patients with schizophrenia in the developing world be supplied free access to drugs for two years under close supervision. This will help to overcome non-adherence during the period of the illness  that has been shown to be the strongest predictor of long-term outcome and disability . Indeed,Would direct observation of schizophrenia treatment be overly coercive? In view of the wide treatment gap, there will always be a large population of those with schizophrenia who will be willing to take treatment under supervision, and they must be provided with effective interventions. Moreover, in view of the present poor state of mental health legislation in many developing countries, patients with untreated schizophrenia are likely to suffer from much greater human rights abuses than those who are treated.Effective treatments for schizophrenia have neither been applied optimally nor advocated as public health interventions in developing countries. A public health intervention for schizophrenia modeled on DOTS may lead to greater awareness of the benefits of treatment and may encourage untreated patients to seek help earlier in the course of their illness. Promoting awareness of the benefits of treatments may help to reduce the stigma of schizophrenia, just as the advent and effective implementation of anti-tuberculosis treatment did for TB. A community intervention for schizophrenia based on the principles of DOTS could also help to put mental health strongly on the public health agenda.SF is grateful to Prof. Arshad Javed and Dr. Christopher Potter for helpful comments and suggestions on earlier version of the article, and to Dr. Zahid Nazar and Dr. Javed Akhter for their participation in the pilot project and the randomized controlled trial.The incidence and prevalence of schizophrenia does not vary widely enough across the world to merit markedly different local treatment approaches or programmes ,31. HoweAn important reason underscoring these differences is that many developing countries have far too few mental health professionals , reflectCommunity care in India is almost synonymous with family care. There are no organized community-based programmes for people with chronic mental illness. The commonest site of treatment is the mental hospital, many of which are large and isolated, with little contact with the community they serve. Efforts are under way to improve the conditions of many of these hospitals. While the number of general hospital psychiatry beds has increased in the last decade, the total number is still grossly inadequate. Most private psychiatrists are located in urban areas. There are very few non-governmental organizations, and these are largely concentrated in the southern part of the country.India's National Mental Health Programme did envisage the diffusion of mental health skills to primary health-care centres at the village and district levels, and the integration of mental health with primary care. However, poor monitoring and lack of coordination with the local state governments meant that such diffusion and integration efforts were not implemented, with the exception of a few sporadic programmes.In India, people with chronic mental illness do not generally receive any welfare benefits, except for some minor benefits in just a few areas. Medical insurance seldom covers treatment of mental disorders. The result is that families have to bear the entire costs of the treatment and ongoing care of these patients. A heavy financial, physical, and emotional burden is therefore imposed upon family members. Indeed, over 90% of patients with schizophrenia live at home with their families . Such faStigma, and the presence of competing and conflicting explanatory models of mental illness (often based on “magico-religious” beliefs), have also contributed to the non-use of existing treatment facilities. A study that we conducted at the Schizophrenia Research Foundation in Chennai found that women with schizophrenia were more stigmatized than men with schizophrenia, and that female caregivers were more sensitive to stigma than male caregivers. Being single or divorced compounded the problem of stigma even further . Stigma In terms of the availability of medication for treating schizophrenia in India, both first and second generation antipsychotics  are available at fairly low prices. Both groups of drugs are being used as first-line medication. In my clinical experience I have found that Indian patients require a much lower dosage of medicines than patients in the West, in both the acute and maintenance phases of treatment. However, more research is needed to document whether there are indeed different dosage requirements in Indian patients and, if there are, to critically address the actual reasons for this difference. Unfortunately, a large proportion of patients in both rural and urban settings remain untreated ,35. EvenGiven all of these different factors affecting the current management of schizophrenia, what can be done to improve such care? Ensuring that patients receive effective treatments promises to be the best antidote to stigma. When patients' conditions improve, especially in the restoration of their social functioning, the community's explanatory model of schizophrenia often shifts from a magico-religious to a medico-social viewpoint. The National Mental Health Programme will have to be scaled up to ensure that mental health care reaches the masses. At the same time, the government should plan and implement awareness programmes for schizophrenia all over the country, as it did for leprosy and tuberculosis.Efforts will simultaneously have to be made to prevent Indian psychiatrists from going abroad, since their numbers have dwindled rapidly in the last few years. More psychiatry tuition in the undergraduate medical curriculum is also critical. Unless all these measures are implemented urgently and in a comprehensive manner, mental health care will continue to languish in the backyards of the health-care system.


Systemic, environmental, and socioeconomic conditions create the context in which community members deal with their health concerns. Comprehensive, community-based chronic disease prevention interventions should address community-wide or regional policy issues that influence lifestyle behaviors associated with chronic diseases.In two communities along the Arizona-Mexico border, community coalitions that administered a comprehensive diabetes prevention and control intervention expanded their membership to become policy and advocacy coalitions with broad community representation. These coalitions, or Special Action Groups (SAGs), identified and prioritized policy issues that directly or indirectly affect physical activity or nutrition.Local schools were one focus of advocacy. The Centers for Disease Control and Prevention's School Health Index was implemented as part of the overall intervention; the SAGs supported schools in advocating for more physical education programs, removal of vending machines, substitution of more healthful options in vending machines, and changes in health education curricula. In the broader community, the SAGs promoted opportunities for walking and bicycling, long-term planning by their cities and counties, and healthy food choices in local grocery stores.Advocacy tactics included attending and making presentations at city council, school board, parks and recreation, and planning and zoning commission meetings; participating on long-range planning committees; organizing an annual community forum for elected and appointed officials; and presenting healthy food and cooking demonstrations in local markets.After three years, SAGs were able to document changes in local policies and practices attributable to their activities.The SAGs contributed to systems changes in their communities and were able to obtain new resources that support protective behaviors. Also, the advocacy process itself provided strong positive reinforcement to all participants in this comprehensive diabetes intervention. Approaches to preventing and controlling chronic diseases, such as diabetes, must focus on broad lifestyle issues. Such an approach to preventing and controlling diabetes may include patients, their families, providers, and the entire community -3.More recently, and with increasing recognition of the extent to which individual health-related behavior is shaped by social and cultural norms and by the physical and policy environment of a community , attentiBorder Health ¡SI!) was a comprehensive diabetes prevention and control program that focused on border communities along the Arizona-Mexico border  with their own unique role — to effect policy changes that would promote health in the community.The Border Health Strategic Initiative  continue to meet as a technical team while the coalition expand to include other community members and agencies with a stake in policy. These coalitions — the SAGs — would be dedicated to planning and advocating for policy change.Along the Arizona-Sonora border, the University of Arizona and numerous community partners have been working together for the last twenty years to create health promotion programs and the joint capacity and infrastructure to address a wide spectrum of health issues. Based on this ongoing, evolving, and positive history of collaboration among community-based agencies and the University of Arizona and our common recognition of the need for systemic change, the partners in both communities responded positively to the recommendation that the programmatic partners of One of the university partners, the Cooperative Extension Service, was asked and agreed to be the facilitator for the SAGs. The Mel and Enid Zuckerman Arizona College of Public Health's collaboration with Cooperative Extension pre-dates this project, and the relationship was expanded and strengthened by the decision to have Cooperative Extension serve as SAG facilitator. As SAG facilitator, Cooperative Extension used its everyday, longstanding connection between community and university to strengthen the SAGs.promotores de salud), and other concerned citizens. Promotores de salud were critical to forming SAGs  develop more parks and recreation areas, 2) work with grocery stores to offer and promote more healthful foods, and 3) work with schools to emphasize health curricula and to change the use of candy and other junk food in the fundraising and reward structure.Health came to be seen among SAG members as an array of policy issues that extend well beyond the purview of the experts in the county health department, the community health center, or school nurses. SAG members realized that they needed to reach a number of change agents that included elected officials, business people, members of the faith community, and educational leaders. They also needed to bring this broader vision to other health professionals.Identifying and then recruiting new SAG members was a critical step in promoting a policy agenda. Convincing some of them that health should be one of their issues was a major achievement in recruiting and retaining them as SAG members . These nOnce issues were identified and prioritized, the SAGs formed subgroups to develop action plans for each major issue. Community A decided to make the SAG indispensable to the county's long-range development planning effort by volunteering to serve on the planning committee, offering the SAG's own recommendations for open space, parks and recreation, and walking/bicycle paths development, and offering data gathered by its university partner.Community A also adopted a short-term action plan that designated a three-month period for mounting a series of health promotion activities that would culminate in a presentation to the city council, stressing the need for reallocating  parks and recreation resources to promote physical activity among the entire community, and attending to neighborhood safety, including lighting, sidewalks, and animal control. The SAG in Community A contracted with a consultant to design a compelling fact sheet that would be used in its presentation to the city council and other policy-making bodies.In Community B, the SAG initiated an annual community forum designed to educate policy makers, advocate for policy change, and hold elected officials accountable for their support, or lack thereof, of policies to promote health. The forum was designed so that representatives of the SAG and other community groups could first present their activities and policy agendas to public officials who were invited to attend. After the community presentations, elected and appointed officials were invited to respond, and then the forum was opened to discussion.promotores in this community's SAG mobilized their constituents to advocate for new parks in one of the small towns near the border and in an unincorporated area of the county that provided few public services to its residents. These promotores had been leading the community walking groups and nutrition classes that were one component of Border Health ¡SI!. Now they and members of these groups went before the county board of supervisors to advocate for parks in their neighborhoods.The Border Health ¡SI! to promote changes in the curriculum and the use of junk foods. While the schools component of Border Health ¡SI! worked with the School Health Index and the school health teams, the SAG also kept in close contact with the school superintendent and individual principals to promote change and monitor progress.The SAG in Community B also worked with the schools component of Results that can be traced directly to the actions of the SAGs are described below.New walking paths were incorporated into the county's development plan.A new Wal-Mart Supercenter added a perimeter walking path to its construction plan.Plans to terminate physical education at a local school were halted.Health-related articles now appear regularly in the local newspaper.Two Community Development Block Grants were obtained for parks and walking paths. The SAG also succeeded in convincing the local school district to donate land for one of the parks. This donation made it possible to use the grant to fund landscaping and to purchase exercise equipment and other amenities.promotores.Grocery stores in the target communities initiated healthy food demonstrations one to two times per month. These demonstrations were organized and conducted by Stores began stocking more healthy products.Sales of food featured in the healthy food demonstrations increased.The SAG received the 2002 Mayor's Physical Activity Leadership Award.Of the many lessons learned from the SAGs, the following are among the most salient:A comprehensive approach to community health promotion requires a policy component.Commitment and organizational involvement of the key community-based health organizations are necessary.Promotores must be involved as change agents.raison d’être beyond merely coordinating activities, and can contribute to its sustainability.Social action focused on policy change can energize a coalition, giving it a The SAG created an engine for change on community health issues.Short-term successes contribute to long-term effectiveness of SAGs.Consciousness-raising about public health issues among those who are not public health practitioners is important to effecting policy change. Convincing people that health is their business regardless of what they do professionally is critical to recruiting opinion leaders to join a SAG and to activating local or regional policy makers.promotores to serve as community change agents.Sustainability is made possible by a SAG in several ways. SAG action motivates members to continue their advocacy efforts as new issues arise and successes are achieved. SAG advocacy creates links between programs and policies that may result in local or regional agencies incorporating successful programs and new policies into their standard mode of operation. SAGs create strategic alliances with non-health specific groups that may lead to new funding opportunities that help sustain multiple components of a community health intervention. SAGs provide an opportunity for Border Health ¡SI! and other border community health interventions of the Mel and Enid Zuckerman Arizona College of Public Health.The experience of the SAGs and the results of their advocacy have been reported to the community in a variety of ways. Foremost has been the publication of numerous articles in local newspapers — made possible, no doubt, by SAG membership of newspaper editors or reporters in each community. Presentations at conferences, including the U.S.-Mexico Border Health Association, Arizona Public Health Association, CDC Diabetes Translation Conference, and others provided a mechanism for dissemination of lessons learned to other border communities throughout the region. SAG activities are also reported regularly to the Community Action Board (CAB) of the Southwest Center for Community Health Promotion. The CAB is, in effect, a super-SAG for all communities involved in Border Health ¡SI! program without its SAG policy-change component. This is so not only because the SAGs contributed to systems changes in their communities and were able to obtain new resources that support protective behaviors but also because the advocacy process itself provided such strong positive reinforcement to all participants in this comprehensive diabetes intervention. The results of evaluation interviews with SAG members and the administration of the Wilder Collaboration Factors Inventory (After the fact, it is difficult to imagine the nventory  stronglyImproved health behaviors within members' own organizations.Better understanding of community needs.Closer relationships with other agencies represented on the SAGs.SAG members also took credit for:Building awareness among policy makers.Influencing community-wide resource allocation.Gaining support for SAG initiatives by city, county, and school-governing bodies.Working collaboratively with decision makers in the planning process.Context always plays an important role in defining the issues to be addressed and the boundaries of possible action and change in a given community. In this case, context included the border geography and demography, especially the preponderance of Hispanics in these communities, the persistent poverty and lack of formal education among much of the population, and the pervasiveness of diabetes. One might suppose that such a context would militate against effective organization for policy change. We did not find this to be true. On the contrary, the brief history of the SAGs confirms our prior experience — that in these have-not communities along the U.S.-Mexico border, there is a largely untapped reservoir of intelligence and thirst for knowledge, concern about community conditions, desire for change and willingness to take risks, and, most important, a willingness to act collectively for the common good.all of the partners that results in the kind of impact that lives on in the community.From the perspective of university-based participatory-action researchers, creating a collaborative policy-change initiative, whether stand-alone or as part of a broad health intervention, requires a strong, positive university-community partnership ,21. Thos


Canada has recognized that Aboriginal and northern communities in the country face unique challenges and that there is a need to expand the assessment of vulnerabilities to climate change to include these communities. Evidence suggests that Canada’s North is already experiencing significant changes in its climate—changes that are having negative impacts on the lives of Aboriginal people living in these regions. Research on climate change and health impacts in northern Canada thus far has brought together Aboriginal community members, government representatives, and researchers and is charting new territory.In this article we review experiences from two projects that have taken a community-based dialogue approach to identifying and assessing the effects of and vulnerability to climate change and the impact on the health in two Inuit regions of the Canadian Arctic.The results of the two case projects that we present argue for a multi-stakeholder, participatory framework for assessment that supports the necessary analysis, understanding, and enhancement of capabilities of local areas to respond and adapt to the health impacts at the local level. There is strong evidence that Canada’s North is already experiencing significant changes in its climate e.g., . The cliAssessing the impacts that these climate changes are having or may have on peoples’ lives requires a combination of disciplinary approaches and methods . ResearcA common definition of Canada’s North that we use here includes the three territorial administrative regions north of 60° latitude  as well as the region of Nunavik, north of 55° in the province of Québec and the Inuit settlement region of Nunatsiavut within Labrador. The latter two regions comprise communities with large Aboriginal populations and share many biogeographic characteristics with the territorial Arctic. Together, this region covers approximately 60% of Canada’s landmass .The vast coastline, islands, and permanent multiyear ice found in Canada’s North are rich in geography and biodiversity. The diversity of the regions’ ecosystems, climate and cultures forms a socioecologic collage across the top of the country . CommuniNortherners have witnessed profound environmental, social, political, and economic changes in recent decades . ResearcJust over half of the approximately 100,000 northern residents are Aboriginal and belong to distinct cultural groups including the Yukon First Nations (Yukon), Dene, Métis and Gwich’in (Northwest Territories), and Inuit . Many of the communities are characterized by an increasingly young and rapidly growing population: 54% of the population of Nunavut is under 15 years of age compared with the national average of 25% . Many stThe breadth of scientific research on the Canadian northern environment has grown significantly in recent decades. Scientific research, monitoring, and observations and the knowledge we have acquired from Aboriginal people have resulted in an awareness that changes are taking place. Observed trends vary depending on the region and period analyzed. For example, the western and central Arctic have experienced a general warming over the past 30–50 years of approximately 2–3°C . This waHealth data series and regional scale assessments in the Canadian North are limited. However, recent qualitative studies examining the potential health impacts of environmental change provide new insights with which to focus research and proactively develop response strategies. They show the need for community participation in filling information gaps and increasing our understanding of factors that enhance or inhibit adaptive capabilities . The casThe project Climate Change and Health in Nunavik and Labrador: What We Know from Science and Inuit Knowledge  was condNunavik is home to approximately 9,000 Inuit residents living in 14 villages distributed along the coasts of Ungava Bay, Hudson Straight, and the eastern shore of Hudson Bay . In 2005To identify potential impacts of observed climate-related changes on health, the project gathered information from various sources. Investigators reviewed the available scientific literature, conducted expert consultations with northern health and environment professionals and researchers, and documentation of Inuit knowledge and perspectives via focus groups with 16 Inuit hunters, elders, and women in the two communities. A process of thematic content analysis was then performed on the qualitative data, and common groups or categories of environmental changes and human impacts were developed . This anMost observations and impacts were common between the two regions. For the purposes of the our discussion here to present the scope of changes and impacts observed to date, the results of these two regions are combined. Participants in the two regions identified changes in climatic conditions over the past 10 years not previously experienced or reported in the region. Some changes were identified as having a direct impact on the health of individuals. Respiratory stress was reported among elderly participants and those with decreased respiratory health in association with an increase in summer temperature extremes that now exceed 30°C in both regions. The reported increase in uncharacteristic weather patterns and storm events had significant impacts on travel and hunting/fishing safety. As one focus group participant reported:it changes so quick now you find. Much faster than it used to. . . . last winter when the teacher was caught out it was perfect in the morning. . . then it went down flat and they couldn’t see anything. . . . Eighteen people were caught out then, and they almost froze, it was bitterly cold. Significantly more indirect associations between climate-related changes and health were reported by local residents, northern environment and health professionals, or were found in the pertinent scientific literature . For exaThis year and last year, we have been stopped when we were going to go fishing. The ice broke up quickly. We would have gone fishing more in the past. The implications of these changes on food security and potential implications on nutritional health among these populations which receive significant energy and nutrient contributions to their total diet from these country foods is only now being investigated. In fact, a number of focused research projects have been initiated with the communities involved in this present study and others in these regions. For example, work on climate and water quality, hunting behavior, women’s health, and emerging and chronic diseases in the North are currently under way.In general, the impacts identified by local residents in this project were supported primarily by scientific evidence and the published literature, although, in some cases, the effects represented new findings. Many impacts were based on individuals’ experiences in relation to observed climate-related changes in the local area. Other impacts were identified as “potential,” as they were logical extrapolations for residents considering the observed patterns of change in regional climate variables and the perceived relationship between Inuit health and the environment  and 2.In response to growing concern among Inuit communities about environmental changes being observed, the national Inuit organization in Canada, Inuit Tapiriit Kantami, initiated a project in cooperation with regional Inuit organizations and Canadian research institutions to document changes and impacts experienced in communities and to discuss how communities currently are adapting or may adapt in the future. In the first series of workshops in January and February 2002, a research team involving regionally based Inuit representatives visited three of the six communities in the Inuvialuit Settlement Region of the Northwest Territories  have been observing changes associated with warming in their region for a longer period than those living in the eastern Arctic communities. Changes in the ISR appear more pronounced. For example, increased mean summer and winter temperatures, temperature extremes, an increase in uncharacteristic weather patterns and storm events, a decrease in precipitation, and changes in the characteristics of the ice season similar to those reported in the eastern communities  were disFor example, in association with summer warming, residents are reporting an increase in the number and species of biting flies and insects, including bees. Many residents are concerned because of the potential for spread of disease or potential allergic reactions to stings, as many of these insects have never been seen before in this region. Consequently, a public education process was recommended by workshop participants to inform people about what action could be taken to minimize the risk of being bitten and to alleviate public fear. Currently, little information on these topics exists or is available in the communities .Locally appropriate strategies were suggested to address climate-related impacts on animal distribution and decreased human access to important country food sources . Currently, more reactive than proactive strategies are in place to adapt to climate-related health impacts in these communities. Changes in hunting behavior, increased investments in equipment or infrastructure , and the importance of increased education and information exchange were identified. As in the eastern Arctic communities, these initial workshops have led to the establishment of a variety of projects that address specific issues. Some of these projects will potentially lead to proactive primary adaptations to reduce exposure .A summary of examples of adaptive strategies from the work presented in The ability to overcome changes in access to or availability of country food resources, which are important for nutritional and sociocultural well-being, is significantly influenced by an individual’s access to economic resources and technology. The ability to invest more in the required tools and equipment for hunting and traveling, or the access to other forms of transportation  allows individuals to adapt more easily to changing environmental conditions .Similarly, the generation and sharing of local or traditional knowledge of regional environments and the relationship between the environment and humans further support this ability to adapt while on the land and safely navigate increasingly dangerous and uncharacteristic conditions. The ability to shift species, alter hunting behaviors, and read environmental cues  all increase hunting and travel safety and success. The importance of this knowledge is gaining recognition among scientific and policy communities e.g., ; howeverThe support provided through institutional or formal arrangements for aspects of traditional lifestyles and health may become increasingly important with climate change in Arctic regions. As many communities begin to represent more pluralistic societies in terms of livelihoods and lifestyles, establishing country food collection, storage and distribution programs, and economic support for the pursuit of traditional activities become important in reducing the vulnerabilities to and enhancing adaptive capabilities for climate-related changes. Also important is the formalization of traditional knowledge documentation and sharing mechanisms through the establishment of such things as community-based ice monitoring programs .With warming temperatures and the potential for the introduction of new water and foodborne agents and permafrost melting, which threatens built structures in coastal communities, some basic public health infrastructures  are increasingly vulnerable. The security of basic public health infrastructure in small remote communities that are already challenged regarding provision of some basic services is a significant determinant of adaptive ability in these locations.Finally, existing health status issues in Inuit populations  appear to be further exacerbated by changes in local climate. The combination of environmental change, basic health needs, limited economic choices, and shifts in northern society and lifestyle appears to increase vulnerability and limit the ability of some Arctic communities to respond. When many of these factors overlap and the population is already facing some critical health issues, the impact of climate change is greater because of the population’s vulnerability .Indigenous populations are often more vulnerable to climatic changes because of their close relationship with the environment, their reliance on the land and sea for subsistence purposes, the fact that they are more likely to inhabit areas of more severe impact such as coastal regions, often have lower socioeconomic status, are more socially marginalized, and have less access to quality health care services . In the The findings presented in these two small studies are supported by others e.g., . A worksAlthough a regionally based analysis was not possible with the data available, variations in vulnerabilities and adaptive abilities appear to exist between and within regions on the basis of a number of common factors  project and the workshops in the ISR are starting points in the collection of information to support community, regional, national, and international processes on climate change. Many new projects have since begun on components of the climate–health relationship in northern communities, and many of these are taking a similarly participatory approach e.g., . Arctic The studies presented here on populations in Canada’s North and a review of other recent research in this region e.g.,  identifyCommunity-based assessments and systematic research must be conducted on the issues of climate change impacts in the North and elsewhere in Canada. Local, regional, and national levels are interconnected in supporting and facilitating action on climate change; thus data at multiple levels and research that link scales to understand these relationships are needed. Fine-scale meteorologic data is required in many northern regions and must be collected in a way that allows the data to be linked to existing and future health data sets. Models of change and impact must be linked with currently used global change scenarios.Innovative approaches to health and climate assessment are needed and should consider the role of sociocultural diversity present among Arctic communities. This requires both qualitative and quantitative data and the collection of long-term data sets on standard health outcomes at comparable temporal and spatial levels. These data must include local observations and knowledge collected using reliable and standardized methods.Assessments that take a multi-disciplinary approach bringing together health scientists, climatologists, biologists, ecologists, social and behavioral scientists, and policy researchers and include demographic, socioeconomic, and health and environmental data are required to develop an adequate understanding of impacts, vulnerabilities, and capabilities in Arctic communities.Historical data  from appropriate locations with climate systems similar to those projected for Canadian northern regions must be used for integrated and geographic analyses of the spread of disease relative to climate variables. These analyses would make efficient use of existing information and increase our understanding of these issues and their interconnected nature.Developing and improving regional scenarios is needed for areas projected to experience significant impacts, such as the western Arctic. Socioeconomic scenarios to model and project impacts and changes within northern indigenous populations are needed. Such scenarios are currently sparse, poorly developed, and inadequate.Work is needed at both the conceptual and analytical levels to define and increase our understanding of vulnerability and community health, how best to measure these concepts, and the use of these concepts in making decisions about the health of the community and in risk management. This work should include local knowledge and informal institutions  to best understand these concepts in Aboriginal communities.To ensure success and sustainability of adaptation strategies, development of local and regional monitoring, analytical and decision making capabilities are needed to support cooperative and empowering approaches to research and action.In the Canadian North the debate is no longer solely about identifying and predicting effects of climatic change but rather about what can and should be done to adapt, as some communities are already reporting impacts. This research focuses on improving the understanding of the magnitude and timing of the impacts of climate change, how individuals and communities cope with current and predicted changes, and what public institutions should do to actively support adaptation.There is currently sparse information on the effectiveness of any current strategies for dealing with climate-related or environmental risks to health in the locations described here and in other areas of the country. This lack of information is an important gap in our understanding and ability to assess who, where, and when Canadians may be vulnerable to the effects of climate change. A significant component is the lack of an assessment of the Canadian health sector’s ability at various levels and in various locations to cope with and plan for the impacts of climate change. The cooperative planning, development, and conduct of projects in Inuit communities bringing together scientists, northern environment and health professionals, and community residents and experts, as presented here, has been essential to the success of the projects described in this article. The community-based, dialogue-focused approach has proven valuable in engaging communities and establishing a local baseline for understanding the changes, impacts, vulnerabilities, and the ability to respond at the local scale. Such an approach may very well prove useful in establishing this baseline in other regions.


We discuss potential lessons and recommendations from EU and U.S. successes in achieving healthier indoor environments through various policy mechanisms.Increasingly, policymakers in Europe and around the world are realizing the importance of healthy indoor environments for public health. Certain member states of the European Union (EU) have already achieved successes in improving indoor environmental quality, such as controlling certain contaminants  or developing nationwide policies that address indoor air generally. However, a common European approach to achieving healthy indoor environments is desirable for several reasons including providing a broader recognition of the problem of unhealthy indoor air, setting a policy example for all 27 EU member states, and achieving greater public health equity across the different European nations. In this article we address the question “Why is it so difficult in the EU to develop a coherent approach on indoor environment?” We identify and describe four main barriers:  People spend most of their lives indoors, especially at home. On average they spend about 16 hr/day during the week and 17 hr/day during the weekend inside their homes. For children and elderly people, the figures are even higher, ranging from 19 to 20 hr/day and appear to be increasing .Early findings indicate a link between housing conditions and human health and well-being. Although the indoor environment has attracted the interest of scientists in the public health sector since ancient times , more woMany countries in Western Europe are undergoing rapid decentralization, and as a result, local authorities have been given increased responsibility for housing. Further, the political and economic situations that have emerged in Central and Eastern Europe since the fall of the Berlin Wall have created dramatically new housing situations. In some countries the percentage of homeowners has increased to more than 95% . BecauseThe age of the population is increasing. In Europe the percentage of adults older than 65 years will increase from 15.5% in 2000 to 19.6% in 2020 (Doll and Haffner 2001). Care of the elderly and social inclusion are increasingly important problems from a housing standpoint. Life expectancy, on average, has risen in Europe from 50 to 80 years in less than a century, while during the same period the housing stock has been renewed by only 60%. Aware of these trends, the WHO Regional Office for Europe embarked on a study to review and enlarge the body of evidence regarding the relationship between housing conditions and health. This pan-European study took place in seven cities across Europe . The goaAlthough the concentrations of major indoor air pollutants may be different in the Nordic countries compared with the southern area of Europe, the main indoor environmental issues affect most European countries and therefore should be prominent on the EU agenda. However, until recently little interest was expressed in this topic and in developing a common European policy. In this article we address the question “Why is it so difficult in the European Union to develop a coherent approach on indoor environmental quality?” We begin by describing why a common EU approach would be beneficial and describe EU-wide initiatives that are now taking place to improve indoor environments. We then discuss potential barriers to EU-wide indoor air policy development. Finally, we give recommendations for EU-wide policy development, in part based on policy successes elsewhere.There are several reasons that a common EU approach to achieve healthier indoor environments is desirable. The first is to provide greater recognition of the indoor environmental quality (IEQ) problem throughout Europe. Although several nations already recognize the importance between indoor environments and public health, as indicated in the policies they have developed, others have no such policies, and IEQ may not be high on their agendas despite the crucial role it plays in the health of their citizens. A common EU approach would highlight the importance of IEQ and bring it to the attention of national and local policymakers throughout Europe.Second, a common EU policy approach would provide an example for individual member states and local governances to establish additional and more coherent national policies to improve IEQ. At present, such coherence is lacking.Third, linked with these two issues is the importance of achieving greater health equity across the 25 EU member states through a common EU IEQ policy. As the EU continues to expand, one of the most pressing issues is how to achieve a more uniform, higher quality of living for all EU citizens. Tackling the IEQ problem from a common perspective may be one of the most efficient ways to ensure greater equity in terms of health outcomes such as respiratory disease and well-being related to housing, workplaces, and public buildings.The need to address the indoor environment at the EU level is recognized by the EU  and WHO Several initiatives are currently under way within the EU to achieve healthier indoor environments. Below, we present these initiatives together with the main challenges for their success.The WHO European Strategy for Tobacco Control ESTC;  was firsAt the initiative of the EU, member states have agreed to take individual measures to control ETS . By ApriIn 2004 the European Commission and industry proposed the launch of European technology platforms. These platforms were initiated to bring together companies, research institutions, the financial world, and regulatory authorities in Europe to define a common research agenda. Such joining of forces would mobilize a critical mass of national and European public and private resources. Specifically, the European public relies on the construction sector to obtain better living and working conditions for its built environment. The formation of the ECTP is one of the initiatives responding to the Commission’s proposal. It brings together more than 300 committed stakeholders at all levels of the supply chain, including client organizations and public bodies.On the basis of their vision for 2030, the members of the ECTP drafted the first strategic research agenda , paving an accessible and safe indoor environment for all individuals (including semienclosed spaces such as open stations and the immediate outside area of buildings);a 50% reduction in the number of accidents that occur home;a 20% reduction of sick building syndrome; anda reduction of 20% of people who suffer from asthma, allergies, and other respiratory diseases.Importantly, in ECTP’s priorities, the end user (the citizen or the client) has a pivotal position. The examples are self-evident. The early and active involvement of the European Disability Forum, which is an umbrella organization representing more than 50 million disabled people in Europe, resulted in a clear set of common objectives ensuring disabled citizens full access in the built environment. The direct and indirect interactions with public organizations such as WHO and those involved in health care led to clear objectives in terms of end-user requirements, for example, the 2030 target date to reduce household accidents. This should be considered a major change in a sector that is not only highly fragmented but that also traditionally has a technology-driven orientation toward construction of products.The impact of the construction sector on society gives the ECTP an important European dimension. The continuous stakeholder interaction in the triangle comprising industry, research, and the public has introduced a mutual understanding of interests and priorities, including the issues of indoor environment and public health and safety. This bottom-up approach seems to tackle simultaneously both market and knowledge fragmentation and encourages the formation of new public–private partnerships and alliances.Industry’s involvement of the consumer in the definition of the strategic research agenda of the construction area appears to be a major step forward, making the indoor environment a priority of the sector. The strong commitment from industry is likely to guarantee that innovation, including health-related innovations, will find its way to practical implementation. Still, real progress toward identifying long-term priorities and needs is not an easy task, as market forces rather than the vision of tomorrow usually drives research and development in construction. The challenge is to turn the cautious change sketched above into a lasting one, even without the strong financial incentive of EC funding.The EU-initiated thematic networks may be an effective instrument for development of European research that produces and delivers findings to policymakers. At present, the Policy Interpretation Network on Children’s Health and Environment (PINCHE) is a running thematic network funded by the Directorate General Research, in the Quality of Life and Management of Living Resources (LIFE) Programme of the Fifth Framework Programme , 2005b. The main objective of PINCHE is to provide the EU with policy recommendations for protecting the health and environment of children based on results of scientific studies, both EU-funded and other national studies on environment and health. PINCHE focuses on children, a vulnerable population largely ignored by present day legislation that is concerned primarily with the adult population . This vuRegarding indoor air exposures, the network brings together knowledge on a wide range of pollutant sources including ETS, allergens, molds, organic dust (endotoxins), formaldehyde and other volatile organic compounds, chlorination by-products and cleaning products, polycyclic aromatic hydrocarbons (PAHs), bromated flame retardants, pesticides, radon daughters, and finally, asbestos. In addition, all stages of life are considered, including prenatal exposure and preconception exposure for compounds that accumulate in the mother’s body and compounds that influence the semen. PINCHE focuses on the “EU-27 region”  but intends to widen the scope of its policy implications to associated countries and potential candidate countries.a) environmental assessments, including estimates of ETS exposure, of indoor and outdoor air quality (b) classification of childhood respiratory diseases and symptoms; and c) a format for defining diagnostic groups and presentation of data. Furthermore, the importance of morphologic data on cancers in children and young people was recognized.Results of PINCHE indicate bottlenecks in the thematic network approach. Three main challenges for success have been identified. First, is data comparability . PINCHE  quality , and of Second, data accessibility must be addressed . AlthougFinally, there is a requirement to standardize definitions and methods to ensure that scientists and authorities speak the same language . This isA variety of barriers exists, however, to the development of EU-wide policies to achieve indoor environmental quality. Here we discuss four categories of barriers: the subsidiarity principle, fragmentation of expertise and purpose at various levels, the important climatic and governance differences among the EU member states, and economic issues.Among the barriers that prevent indoor environmental quality from reaching the EU policy agenda is the subsidiarity principle. This principle, common throughout EU regulatory decision making, states that policy action will be taken at the EU level only when it would be more effective than action taken at a national, regional, or local level. This principle is applied when both the EU and its member states have competence in a particular policy area, as is the case with the indoor environment. In such cases, the subsidiarity principle ensures decentralization, allowing member states to have their own policies. While this may allow for individual member states, or even individual regions within a member state, to develop IEQ policies that are well suited to their unique situation, the subsidiarity principle also makes it more difficult for the EU to provide guidance and expertise where national or local IEQ policies have not been developed. The risks of overregulation make it difficult to challenge the subsidiarity principle.A second barrier to developing an EU policy is fragmentation. This may occur in the areas of disciplines and expertise, interests, and responsibilities. At the discipline level, there is fragmentation of expertise in science, engineering, and health. The indoor environment encompasses such disparate topics as temperature, air quality, radiation, noise, and health effects, each with its own experts. For example, constituents of indoor air range from volatile to persistent organic chemicals, to biologics such as molds, and to particulates. As such, the expertise needed to address indoor environmental quality is scattered among diverse research fields and disciplines. This fragmentation of knowledge, inherently linked to the multidisciplinary nature of health and the indoor environment, makes it difficult to create an integrated comprehensive knowledge base that is needed to set an agreed-upon agenda for policymaking.At the stakeholder level there is a fragmentation of interests. The stakeholders in the indoor environment vary from builders, architects, raw material suppliers, producers of building materials and interior decorating materials, to owners and occupants. Often these stakeholders do not live with the consequences of their decisions, so there is little interest in ensuring a healthy indoor environment . Moreover, different stakeholders have specific  interests, making a European approach difficult. Health interests are often neglected in a market traditionally pushed by technology. However, recognition of the need for a more unified approach is growing.Also, there is fragmentation of responsibilities at the level of regulatory authorities and policymakers. This makes it difficult to find a protagonist who will push indoor environmental quality up the political agenda. At both the EU and the member state level, typically there is more than one department responsible for the area of IEQ, for example, the departments of housing, public health, environment, and trade. Therefore, many responsible parties need time to decide to pursue the subject and coordinate the various views and responsibilities. Because fragmentation is faced at all policy levels , much deliberation and coordination is needed to reach the EU policymaking agenda.A third barrier is the difficulty of uniting such disparate climates, social factors, and governances under a common EU policy regarding indoor environments. The 25 member states of the EU span a variety of climates, from polar to almost subtropical and from very dry to very wet. This variety can have an important effect on the types of indoor environmental contaminants that are relevant to different member states. For example, those living in more humid regions in the EU are more susceptible to the adverse health effects caused by mold and moisture in indoor environments, whereas those living in dryer regions may suffer little or not at all from these indoor problems. To develop EU-wide policies on this one IEQ problem alone, in addition to a multitude of potential IEQ problems, would therefore be very difficult.Moreover, among the factors that affect indoor environmental quality are human behavior, household products, and climate control systems. Certain crucial factors affecting IEQ, such as ventilation , depend on regional and social differences such as the warmth and humidity of the region, the quality of the housing, and the reliability of maintenance systems in that region. Differences in governance in different member states and regions would affect whether any EU policy on IEQ would be sufficiently enforced to ensure adequately healthy indoor environments. Some member states already have IEQ policies in place, whereas in other member states, indoor air issues do not receive much attention and their policies are not well developed.A final barrier to a common EU approach to indoor environments is economics. A common EU approach may invite overregulation on an issue for which economic incentives of individuals would not align with the goal of an “ideal” indoor environment. As an example, individuals furnish and maintain their indoor environments often based on cost-based rather than health-based decisions. Ventilation rates in private European houses are commonly determined by high energy costs rather than EU-wide regulations; thus, the value of its regulation is debatable. To a certain extent, even in the context of health effects resulting from IEQ, individuals should be allowed to choose for themselves what is more important to them—cost savings or a highly healthy indoor environment—rather than for a common EU approach to impose regulations on such choices.These issues and barriers described above are not relevant only to the EU but also to other parts of the world. In the United States, for example, there are similar barriers to erecting U.S.-wide policies to improve indoor environments. For example, fragmentation of interests and responsibilities can be addressed by providing certain stakeholder groups—architects, building designers and construction staff, and landlords—with awards or special labels to encourage them to design buildings that meet a specified level of indoor environmental quality. Benefit–cost analyses of the costs associated with poor indoor environments, and the benefits of healthier ones, will provide incentives for policymakers to make IEQ issues a priority, especially if these values can be expressed in economic terms.Jacobs et al. (2006) describe U.S. successes in regulation of lead and radon in indoor environments, which can provide further lessons for the EU in developing a common IEQ policy. For example, although the term “subsidiarity” is not typically used in the United States to describe division of responsibility among the federal, state, and local governments, many of the concepts continue to apply for indoor air. Lead, in part because of its former ubiquity in homes (primarily through paint) and fuel throughout the United States as well as its well-defined health effects, is regulated at the federal level through a variety of laws limiting human exposure. Radon, on the other hand, is regulated at state and local levels in part because radon levels in the ground, and hence in buildings, differ substantially throughout the United States.The EU might learn from these U.S. policies in order to divide governance of prominent indoor environmental hazards among the proper regulatory bodies—EU, member state, or local—depending on differences in exposure to the hazard. This would solve some of the problems associated with both subsidiarity and disparities in exposure. For example, an indoor air problem that is ubiquitous across EU member states could be regulated at the EU level , whereas indoor air problems (possibly mold) that are more prominent in certain areas of Europe than in others could be regulated at state and local levels.As for how disparities among different governing bodies can be united to the common cause of improving IEQ, we present one example of IEQ policies in one EU member nation, Denmark, where four relevant ministries divide or share responsibilities related to indoor air.The policy of the Danish government is that good quality indoor air should be maintained, and health risks related to indoor air should be reduced to the lowest possible level. In this context, dissemination of knowledge and best practices to the general public and stakeholders in particular is crucial.Four ministries in concert address regulation of indoor air quality (IAQ): the Ministry of Economic and Business Affairs, the Ministry of Environment, the Ministry of Employment, and the Ministry of Interior and Health. Each has a specific responsibility for defined indoor application areas, ranging from private housing to public buildings such as schools and hospitals. The ministries are involved simultaneously and share responsibilities from different viewpoints. For example, for schools, the Ministry of Employment is responsible for school employees, and the Ministry of Economic and Business Affairs is responsible for the pupils.Ministry policies are based primarily on research results produced by their own agencies. The Danish Building Research Institute is the agency for The Ministry of Economic and Business Affairs; the Working Environment Authority is run by the Ministry of Employment; the National Board of Health is the agency for the Ministry of Interior and Health; and the Danish Environmental Protection Agency (DEPA) is the agency for the Ministry of Environment. In addition to supporting policymaking, each agency has a specific area for dissemination of knowledge.The Danish Building Research Institute  providesThe Working Environment Authority  focuses The indoor environment is crucial to our health and well-being, as we in the western world spend the vast majority of our time indoors. Indoor environmental contaminants are associated with a variety of respiratory and other diseases and symptoms that range from asthma to depression to lung cancer. Throughout Europe, particularly in the years following World War II, housing quality has become an increasingly important issue. There are a number of reasons why a common EU approach to addressing healthy indoor environments would be desirable, among them, to increase the recognition of the importance of this health problem and to provide a policy framework for individual member states.Considering the importance of indoor environments, it would be expected to figure prominently in the European policy agenda. However, this is not the case. There are several examples of IEQ successes achieved in individual member states, such as the case of ETS in public spaces in six EU nations. However, at the EU-wide level, a more integrated policy approach is needed. Only recently has indoor air, one aspect of the indoor environment, made its cautious appearance in the WHO–Euro ministerial declaration  and the Several initiatives have begun to pave the way toward a common EU approach to IEQ. The EU and member states are using aspects of the open method of communication with varying degrees of success to counter these barriers. The ECTP approach uses the combination of the bottom-up approach with financial incentive, which seems to tackle simultaneously both market and knowledge fragmentation. Presently, both the strong commitment and firm involvement of the consumer in the ECTP appears to be a big step forward, making the indoor environment a priority of the sector. The challenge now is to surpass this initial stage of “good intentions” induced by external pressure and stimuli and to begin to act on the intentions. External feedback mechanisms and critical external auditing, coupled with the financial incentive, remain necessary to stimulate action. Cooperation must also be stimulated. To ensure this interaction, attention should focus on feedback and reward mechanisms. Because a large body of knowledge exists on issues of motivation and pay and performance management, we point to the possible usefulness of this knowledge in the design and underpinning of feedback and reward mechanisms.PINCHE is a valuable step toward the creation of a widely supported solid scientific basis for public health policymaking to protect the health and environment of children. The network has succeeded in bringing together scientists from a wide variety of disciplines. The next steps of data comparability and data accessibility are critically important. The science–policy interface that the network is committed to developing depends on successfully summarizing and updating the available knowledge for policymaking and in so doing, acquiring an undisputed scientific reputation. During the limited time that the network has existed, it is still working to establish this interface. This will remain the challenge. Obtaining funding to continue the work will be important. Although stimulation of networks is clearly a step in overcoming the barrier of fragmentation, much remains to be done to overcome the fragmentation.The topic of cooperation has reached the EU agenda. Although the EU member states, WHO, and the European Commission have each initiated activities to foster cooperation, they have not succeeded in finding the most fruitful way to incorporate the various activities and roles concerning the indoor environment. As the players are still scattered in their responsibilities concerning indoor environments, it will be a challenge to coordinate and better utilize the ongoing activities of each of the parties. A dialogue on an overview of the ongoing activities, both at the EU-wide and member-state levels, could be a useful first step.a) the subsidiarity principle in EU policy-making, which introduces decentralization of decision making to the member states; b) fragmentation of the topic of the indoor environment; c) the differences in climate and governance among different member states that make a common policy difficult; and d) economic issues. Lessons from successes in the EU and United States in achieving healthier indoor environments through various policy mechanisms may provide useful insights into achieving EU-wide policy successes in indoor environmental quality.Despite the progress already made, developing a coherent approach on the indoor environment is still difficult in the EU. We have identified and described four main barriers:


Colorectal cancer (CRC) is the second most frequent tumor in developed countries. Since survival from CRC depends mostly on disease stage at the time of diagnosis, individuals with symptoms or signs suspicious of CRC should be examined without delay. Many factors, however, intervene between symptom onset and diagnosis. This study was designed to: 1) Describe the diagnostic process of CRC from the onset of first symptoms to diagnosis and treatment. 2) Establish the time interval from initial symptoms to diagnosis and treatment, globally and considering patient's and doctors' delay, with the latter due to family physician and/or hospital services. 3) Identify the factors related to defined types of delay. 4) Assess the concordance between information included in primary health care and hospital clinical records regarding onset of first symptoms.Descriptive study, coordinated, with 5 participant groups of 5 different Spanish regions , with a total of 8 acute public hospitals and 140 primary care centers.Incident cases of CRC during the study period, as identified from pathology services at the involved hospitals. A sample size of 896 subjects has been estimated, 150 subjects for each participant group.Information will be collected through patient interviews and primary health care and hospital clinical records. Patient variables will include sociodemographic variables, family history of cancer, symptom perception, and confidence in the family physician; tumor variables will include tumor site, histological type, grade and stage; symptom variables will include date of onset, type and number of symptoms; health system variables will include number of patient contacts with family physician, type and content of the referral, hospital services attending the patient, diagnostic modalities and results; and delay intervals, including global delays and delays attributed to the patient, family physician and hospital.To obtain a nonrestricted sample of patients with CRC we have minimized selection risk by identifying the patients from pathology services. A greater constraint may be associated with information sources based on clinical records. Due to inherent features of coordinated studies, it is important to standardize the collection of information. Colorectal cancer (CRC) is one of the most common cancers in Western countries. In Spain, CRC incidence and mortality rates are close to the median values for European countries . CRC surSurvival of CRC patients depends mostly on their disease stage at the time of diagnosis. Most patients will be alive after 5 years if the tumor has not reached the intestinal wall (stage I). This rate decreases to 60% if the tumor has invaded regional lymph nodes (stage III) and to only 5–15% if the neoplasm has metastasized (stage IV) . Thus, iMost studies use the term delay to describe the time elapsed between onset of the first symptom to diagnosis or treatment. Conceptually, diagnostic delay in cancer is a complex process involving patient behavior, physician attitudes, response of the health system, biology of the tumor cells, and interaction between host and tumor. Studies on delay tend to distinguish between patient and health system delays:There are a number of reasons why a patient, facing a sign or symptom suspicious of malignancy, may decide not to visit a doctor. The patient may not be aware of the importance of symptoms , may be The general practitioner plays an active role in cancer diagnosis, participating in nearly 63% . His or Factors described as possible contributors to delay include specialist referrals' waiting lists, poor coordination, and complementary examinations. About 65% of patients affected by gastrointestinal tract cancers were initially diagnosed by a hospital emergency department, and over 50% had visited their general practitioners while having symptoms related to CRC .It is clear that more information is needed on the effects of delay on CRC. The factors associated with diagnostic delay are poorly understood, regardless of whether they are related to the patient, to the family doctor or to the hospital setting. In Spain, several Regional Health Plans have highlighted problems in continuity of care and have advocated a reduction in time interval between suspicion of cancer and diagnosis or treatment. To achieve these objectives it is essential to know the characteristics of the CRC diagnostic process, to identify the delays that may occur at various stages, and to gain a better understanding of the factors associated with each type of delay.1. To describe the diagnostic process of CRC from the onset of first symptoms until diagnosis and initial treatment in terms of initial symptoms and other symptoms appearing prior to and during the diagnostic process.Family doctor participation in diagnosis: Proportion of cases diagnosed by the family doctor; visits per patient, physical examinations; complementary tests requested according to the nature of symptoms; type of referral to specialist and clinical information included in the referral.Hospital specialist diagnostic procedures: hospital department, type of hospital; complementary examinations and their results .2. To establish the time intervals between first symptoms and diagnosis and/or treatment:Patient delay: Time interval from the onset of first symptoms of CRC to first contact with a doctor.Health system delay, separated into three time periods: from first contact with a doctor to referral to a specialist or emergency department; from specialist visit to diagnosis; and from diagnosis to treatment.3. To identify factors associated with these delays:Patient: sociodemographic variables; patient referred symptoms; attitude towards symptoms; confidence in the doctor; and family history of cancer.Health system: primary care, including physical examination and clinical assessment by the family physician; and specialist care, including access to diagnostic tests, referral paths, type of hospital, type of department, number and type of complementary examination tests and their results.Secondary objectives:4. To evaluate the reliability and thoroughness of information about symptoms from patient interviews and primary care and hospital records.5. To describe the variability in delay between different geographic areas and different hospitals included in the study.It is a descriptive and multicenter study in 5 participating health districts in Spain , including 8 acute public hospitals and 140 primary health centers. Information will be collected from medical records and structured interviews with patients.Subjects will be incident cases with histologically verified CRC (CIE9 153 and 154) diagnosed during 2006–07 in the study hospitals; patients have to be registered with a family doctor in the health center included in the study.Exclusion criteria: Prevalent and/or recurrent cases; patients with multiple tumors; and patients diagnosed at private hospitals.Cases will be identified by hospital pathologists. The doctor responsible for that patient will be contacted and informed of possible patient inclusion. Inclusion and exclusion criteria will be verified in the hospital clinical record, and written informed consent will be requested from the patient. Interviews will be carried out mainly during a patient's hospital stay, or at home if that is not possible. The sample size necessary for the whole multicentric project should be a minimum of 896 individuals to achieve the study objectives with an accepted 5% alpha error and an accuracy of one-tenth of the observed relative frequency of different variables. Moreover, the selected sample size will allow us to estimate symptom duration, despite the usual dispersion of a 'time' variable . In addition, this sample size will permit to us to achieve objective number 3, to assess if delay is related to any of the described factors, with an alpha error ≤ 0.05 and a power ≥ 80%. Having at least 150 patients in each region will allow a precise estimation of geographical variations.The number of persons included must be increased to 1,000, due to the inevitable collection of secondary and often incomplete information from primary care (PHC) and hospital (HC) clinical records.A preinclusion patient form will be designed to hold patient pathology results together with exclusion criteria. A data collection book (DCB) will be prepared to include information about interviews, primary health care and hospital clinical records. A pilot study with 15 patients in each sub-project will be undertaken to standardize data collection and solve any conflicts. We will also carry out a training workshop for field workers and interviewers. Patient interviews will be centered mainly on CRC symptoms, perceived attitudes to initial symptoms and demographic data. Each patient will be asked how long he/she has been feeling unwell and the type of symptoms noted . SymptomA database will be built with a unique numerical case code for each patient and checked for errors. Identifiable patient information will be kept dissociated. Each participating group will periodically send the patient data collection book to the coordinator node for centralized data entry. Number and reason for exclusion and missing cases will be noted.Objective 1. A descriptive analysis of the key variables of the CRC diagnosis process will be presented as frequency distribution and 95% CI, and as mean and median.Objective 2. It will be detailed total time delay; patient and health system delay and their contribution to total delay.t test, ANOVA or non-parametric tests for quantitative variables. To assess the effect of the predictive variables on delay times, a survival analysis will be performed as proposed by Latour [Objective 3. The relationship between different types of delay and the observed variables will be evaluated. The Chi-Square test will be used for qualitative variables, and Student's y Latour . In contObjective 4. The thoroughness of symptom information given by patients will be compared with information obtained from the PHC and HC clinical records, and a frequency distribution of variables in each of the different sources of information will be presented.Objective 5. The variability of different delay intervals will be evaluated by comparing median times and the inter-quartile range for the considered variables. Moreover, for each variable the proportional time variance of the study areas will be estimated, including hospitals with longer and shorter delay times and a graphic analysis.We have minimized the selection risk by identifying study patients from pathology reports instead of at admission for surgery. In Spain the percentage of histological confirmation of CRC is greater than 96%. Nevertheless it is still possible that some patients would not be included if they had no biopsy results, due either to very advanced age or severe ill-health. A potentially more important constraint could be associated with information sources based on medical records. Use of secondary information could increase the risk of missing data for some variables. Nevertheless, we consider that the patient interview process will strengthen the comprehensiveness of information obtained. Due to the inherent features of coordinated studies it is very important to make a special effort to standardize data collection, since multiple observers in the different participating regions can introduce problems of inconsistency.The author(s) declare that they have no competing interests.ME, MR, EC, JLL, and AR participated in the design of the study. SP, JMS, JMC, and LG reviewed the study protocol and made suggestions that improved the design. All of these individuals are involved in the management of the study. ME, MR, EC, and JLL drafted the manuscript. All authors read, revised and approved the final manuscript.The pre-publication history for this paper can be accessed here:


International Breastfeeding Journal is a new open access peer-reviewed journal with a multidisciplinary focus. The aim of International Breastfeeding Journal is to contribute to understanding all aspects of breastfeeding. Breastfeeding is recognized as an important public health issue with enormous social and economic implications. In order to help women breastfeed successfully there is a need to understand both the physiology of lactation and the social and cultural context within which breastfeeding occurs. International Breastfeeding Journal invites manuscripts from around the world, which address all of these aspects, including the impediments to breastfeeding, the health effects of not breastfeeding for infants and their mothers, and the management of breastfeeding problems. International Breastfeeding Journal, a new open access peer-reviewed journal with a multidisciplinary focus.Welcome to Breastfeeding Matters: What We Need to Know About Infant Feeding, first published in 1985, in which she described her own experiences of struggling through breastfeeding problems in 1976 [My interest in breastfeeding was sparked when I became a mother in 1984 and began to learn about feeding infants. I was intrigued by the pioneering studies of Niles Newton in which she experimented on the effects of stress on the let-down reflex – on herself [ in 1976  until sh in 1976 ,4.As a medical student in the 1970s I had received one lecture on infant feeding – with an emphasis on artificial feeding. Breastfeeding rates were low in many developed countries in the mid 1970s, until an interest in natural childbirth and infant feeding resurfaced and mother-to-mother support groups, such as the La Leche League International (LLLI) and the Nursing Mothers' Association of Australia  began grass-roots movements to help mothers breastfeed. By the mid-eighties, volunteer breastfeeding counsellors, such as Chele Marmet realized that it was time to create a new occupation: lactation consulting . The IntHuman Milk in the Modern World: Psychosocial, Nutritional and Economic Significance [Breastfeeding: A Guide for the Medical Profession in 1979 [The medical profession had shown little interest in breastfeeding, but pioneers such as Derrick B Jelliffe published ificance  in 1978  in 1979 . In Afri in 1979 ,12. In a in 1979 .Where would we be without the researchers who began to study breastfeeding and reassess what we "know"? A few of these immediately come to mind: the physiologists such as Roger Short , MichaelThe multidisciplinary nature of breastfeeding can be seen by looking at the professions that have been represented in this short list. However, many important professions have been left out because of the brief nature of my review: dieticians, speech pathologists, community nurses, general practitioners, psychologists, dentists, policy makers and others.International Breastfeeding Journal is an online journal, which aims to facilitate communication between researchers, clinicians and activists working in all of these fields. Apart from some cultural overlay, lactation, breasts, babies and breastfeeding are all pretty much the same worldwide. The IBCLCs, the mother-to-mother support counsellors, the health professionals and all the others who support breastfeeding in their own way – all deserve open access to quality information on breastfeeding.The journal is based on the factual scientific premise that breastfeeding is the normal or "default" method of infant feeding . Thus brInternational Breastfeeding Journal is a peer-reviewed journal, supported by a strong Editorial Board. All papers are reviewed by at least two experts in the field. Articles published in International Breastfeeding Journal will be listed in PubMed and permanently archived in PubMed Central as well as certain other national archives.International Breastfeeding Journal contributes to understanding all aspects of breastfeeding. Breastfeeding is recognized as an important public health issue with enormous social and economic implications. In order to help women breastfeed successfully there is a need to understand both the physiology of lactation and the social and cultural context within which breastfeeding occurs. International Breastfeeding Journal seeks to address all of these aspects, including the impediments to breastfeeding, the health effects of not breastfeeding for infants and their mothers, and the management of breastfeeding problems.The journal will consider the following article types: research, reviews, case reports, study protocols, short reports, methodology, commentaries, hypotheses, and debate articles.International Breastfeeding Journal is an open access journal, which means:• All articles will be freely and universally accessible online without any barriers to access, which increases their visibility.• You and your peers will be free to print out copies of your article, email it to colleagues, and post it on the web because of the BioMed Central copyright and license agreement.Open access journals are funded by article processing charges (APCs) rather than journal subscriptions. The costs are, therefore, borne by the authors, their institutions or their research grants, and access to the journals is free of charge via the web.BioMed Central membership offers a way for institutions to support open access publishing and reduce the cost of the APC borne by the author. This scheme enables BioMed Central member institutions to pay a fee that ensures their researchers are wholly or partially exempt from APCs. BioMed Central membership has a number of benefits. In addition to the direct benefits in terms of discounted or waived APCs there are public policy benefits in supporting an open access journal regime such as BioMed Central. Open access journals are one mechanism for putting pressure on regular journal publishers to moderate their price increases.There are several types of membership available tailored to the varying needs of BioMed Central's customers .Please note that no article processing charges will be payable on manuscripts submitted in the first six months following the launch of the journal. Article processing charges are also usually regarded as a legitimate charge against research grants. In the medium term, alternative arrangements, such as institutional support, should be encouraged, although after this time the Editor-in-Chief will be able to grant a limited number of discretionary processing charge waivers.LHA is a member of the Academy of Breastfeeding Medicine, Australian Breastfeeding Association, Australian Lactation Consultants Association, International Lactation Consultants Association, Public Health Association of Australia and the Royal Australian College of General Practitioners.