Multimedia interventions can provide a cost-effective solution to public health needs; however, user engagement is low. Multimedia use within specific populations such as those affected by cancer differs from that of the general population. To our knowledge, there are no frameworks on how to accurately assess usage within this population to ensure that interventions are appropriate for the end users. Therefore, a framework was developed to improve the accuracy of determining data usage. Formative work included creating a data usage framework during target audience testing for smartphone app development and analysis in a pilot study.The purpose of this study was to develop a framework for assessing smartphone app usage among people living with cancer and their caregivers.The frequency and duration of use were compared based on manual data extraction from two previous studies and the newly developed Assessment of Data Usage of Cancer e-Interventions (ADUCI) Framework.Manual extraction demonstrated that 279 logins occurred compared with 241 when the ADUCI Framework was applied. The frequency of use in each section of the app also decreased when the ADUCI Framework was used. The total duration of use was 91,256 seconds (25.3 hours) compared with 53,074 seconds (14.7 hours) when using the ADUCI Framework. The ADUCI Framework identified 38 logins with no navigation, and there were 15 discrepancies in the data where time on a specific page of the app exceeded the login time. Practice recommendations to improve user engagement and capturing usage data include tracking data use in external websites, having a login function on apps, creating a five-star page rating functionality, using the ADUCI Framework to thoroughly clean usage data, and validating the Framework between expected and observed use.Applying the ADUCI Framework may eliminate errors and allow for more accurate analysis of usage data in e-research projects. The Framework can also improve the process of capturing usage data by providing a guide for usage data analysis to facilitate evidence-based assessment of user engagement with apps. Within the health care context, electronic health  technologies such as smartphone apps can assist people in managing their health by providing information, support, communication, and resources to track the progression of well-being or illness . In 2017Worldwide, there is a need for supportive eHealth technology in the cancer field as the provision of cancer care has shifted toward an outpatient setting . The adoMany adults living with cancer and their informal caregivers are managing cancer in the community; thus, the need for cost-effective supportive interventions is vital to inform patient and caregiver care needs. Smartphone app interventions have the potential to be more cost-effective than face-to-face interventions; however, this can depend on adherence and use . PositivTo fill this gap, the Assessment of Data Usage of Cancer e-Intervention (ADUCI) Framework was developed and validated using a three-step approach. Step one involved creating a framework for user testing during development . In stepAn app usage framework was developed during the planning, design, and evaluation phases of an app for cancer caregivers. This comprised two phases, user acceptance testing and user experience testing, during app development . ParticiAdult caregivers of people with colorectal cancer receiving chemotherapy in the outpatient setting were approached and invited to participate in the feasibility pilot study. Caregivers who participated in the study were provided with access to the “Carer Guide” smartphone app for 30 days. Carer Guide included access to information and resources to help manage the needs of people with colorectal cancer as well as the caregivers’ own needs. Caregivers were required to log in to access any information within the app. Data tracking was recorded using Google Analytics, and included the frequency of login, length of login, and number of pages visited. The ADUCI Framework was validated in this study by applying data cleaning methods to analyze and report usage data. On average, caregivers used the app for 22 minutes each time they logged in .Both studies were approved by the Human Research Ethics Committees at the relevant health care organizations and at Deakin University. Participants were informed in writing that usage data would be monitored to determine which pages were visited.The aim of this study was to corroborate the ADUCI Framework by applying it to data usage from a randomized controlled trial (study 3) involving a smartphone app for people diagnosed with cancer .Patients receiving chemotherapy in an outpatient setting in Melbourne, Australia were approached and invited to participate in the study. Following recruitment, participants were randomly allocated to either the intervention or control group. Participants in the intervention group had access to a smartphone app (“ACE” app), which provided static information and support resources to participants . ACE appThe ADUCI Framework comprises two components: assessment of duration of use and frequency of use. Duration of use was measured as the length of use in seconds for each app login, as well as the amount of time spent in each section of the app. Frequency of use included the number of logins overall and the number of times each section of the app was visited.Based on the findings of the pilot study , a 22-miCancer Information, Main Menu, Cancer Information), the frequency of use of the Cancer Information page was interpreted as 1 (Scenario 1). When navigation moved between several pages but page visits were repeated, the page visits were tallied (Scenario 2). For example, when navigation followed the order Cancer Information, Main Menu, Wellbeing, Main Menu, Cancer Information, this was interpreted as 2 views for Cancer Information and 1 view for Wellbeing.The frequency of page visits was cleaned and analyzed in the following format. When navigation moved from a content page to the main menu and back to the same content page  when comparing manually extracted data with the ADUCI findings . The mosThe manual extraction highlighted that, on average, the ACE app was used for 328 seconds at each login, and for a total of 91,256 seconds over the 4-month intervention period . When thApplication of the ADUCI Framework resulted in a reduction of time spent in each section of the app, with the exception of the Cancer Council Victoria (CCV) support service. During data cleaning, additional time was recorded in the CCV support service section .Cancer Information section was recorded as having been used for 16,072 seconds, whereas the total login duration of the app for that session was recorded as 4 seconds. Similar discrepancies occurred 15 times in the manually extracted data. These discrepancies were eliminated when the ADUCI Framework was applied.In the manual extraction, there were several errors in the data recorded. Errors showed that the duration of use of a specific section of the app exceeded the duration of login. For example, the This analysis informed the development of a framework for analyzing user usage data during the project planning/design and evaluation stages. In addition to the proposed ADUCI Framework, there are four recommendations for future eHealth interventions, which can provide a more effective approach to handling usage data as well as implementing user engagement methods to reduce the time needed for manual data cleaning. The ADUCI Framework offers a more accurate approach of analyzing usage data; however, there were gaps present in the data collected, and additional features and functionality would ensure that complete data are available for analysis. These features and functionalities are listed below as future recommendations.Due to the sensitive nature of health information and its potentially huge storage and maintenance requirements, most eHealth mobile apps cannot contain all of the information required by end users. Quite often, apps use linking methods to specific information outside the app. Researchers and developers should consider all possible issues with tracking usage data during the planning and design stage of project development to apply a suitable solution to avoid missing usage data. In the development stage, internal and external testing should be conducted at various times with small groups of end users to ensure that the system collects all intended usage data.An example of this situation within the ACE app is the feature that linked patients to external CCV webpages. In both the pilot study   star rating functionality, as a useful measurement of content and interactive media presence ; (2) intThese engagement tools will provide strong evidence-based guidelines for program content development in the future by highlighting which content is most highly rated, most favorited, and most respected. Such tools may also provide evidence as to which existing content needs attention from the program content developers. Developers should evaluate the engagement strategies with users at the end of the project life cycle to build better engagement tools for future studies.Usage data findings presented in the data collection and data analysis phase of ADUCI Framework development emphasize the importance of having frameworks to properly assess and manage usage data throughout the life cycle of development and testing of e-interventions. If implemented in the evaluation stage of an e-research project development life cycle, usage data can be more effectively analyzed. For example, it required approximately 40 hours to manually extract data from the ACE app study to determine a more accurate and useful dataset. By implementing the practice recommendations and ADUCI Framework, the final analysis of returned usage data will be performed much more efficiently, with both time and cost advantages.This paper provides an overview of the ADUCI Framework by comparing findings between manually extracted data and data obtained using the Framework. However, there was limited ability to assess the accuracy of user behavior and pathways data from this study. In future studies, developers and designers could conduct more specific target audience analysis to understand specific behaviors for building a tailored framework in the planning stage. The Framework could be validated by comparing expected use in different stages of the project. In the project planning stage, user acceptance testing and user experience testing could include scenarios and measurement methods for expected use. In the design, development, and evaluation stages, use could be observed and measured during user testing. After the launch of the project, usage data could be obtained through clinical trials. This comparison of expected versus observed use may also provide more opportunity to assess user mapping and determine pathways of user behavior.To ensure that vulnerable populations such as people with a cancer diagnosis are protected, users should be informed of the intent to collect usage data as proposed in this Framework. Clear identification of the type of data intended to be collected and the purpose for data collection is vital in promoting trust between users and app developers. Particularly within clinical trials, this can be achieved during the information and consent process to ensure that users are providing informed consent. In both of the studies used to develop this Framework, ethics approval was obtained and participants were informed of usage data tracking prior to providing consent. Usage data were collected to inform the evaluation of and engagement with the app interventions in line with a user-centered design approach, allowing for future iterations to build upon findings. To protect users’ privacy, only coded data were extracted that were linked to user IDs. No personal or identifying information was obtained or used.The ADUCI Framework facilitates the extraction of accurate usage data and informed approaches to reduce the burden of lengthy manual data extraction. However, the Framework has limitations because it is in the early stages of development. The proposed recommendations create the next opportunity to test and refine the Framework, and to assess user engagement based on tailored comprehensive target audience analysis. Recommendations 1 and 2 will prevent usage data leakage while allowing developers to understand target audience behavior, thereby providing more accurate usage data for analysis. Recommendation 3 will give target audiences enriched personalization to engage with the program. The collectable data from personalization methods, including star rating, favorite, and counting star rate functionalities, will supply evidence-based future planning sources. Recommendations 4 and 5 will allow for the development of a more robust framework for projects and will provide the opportunity to validate the Framework.Applying the ADUCI Framework can reduce errors and allow for a more accurate analysis of usage data. The ADUCI Framework describes how to incorporate and analyze usage data at each stage of the research life cycle, including development during user testing, pilot testing, and applying findings to a randomized controlled trial. This provides future research with a framework for measuring and testing functionality, usability, and user engagement.The importance of precisely reporting usage data is to provide an accurate representation of user engagement with e-interventions. Consideration of user engagement begins during the planning and design stages, and continues through the development and evaluation stages of an e-research project’s life cycle. Enhancing user engagement includes developing programs that are quick, easy, and intuitive to use . This prUser engagement continues to be monitored and assessed throughout the life of interventions. Satisfaction with interventions can have a positive impact on user engagement, by which people with high satisfaction may be more likely to continue using interventions . There iCancer Information section of the ACE app, with no navigation. Total duration of use of the app for the intervention period was 53,074 seconds when the ADUCI Framework was applied, which was recorded as approximately 72% higher  without the Framework. Combined with discrepancies evident in our report in which the duration of use in a specific app section exceeded the duration of login on several occasions, these findings highlight the inflation of results that can occur without the use of a framework. The use of the ADUCI Framework during development and testing highlight areas where data cleaning and analysis can be improved for future interventions.The ADUCI Framework was developed by applying the method to the ACE app study for adequate data cleaning. Data cleaning frameworks have been applied to other areas of health care technologies such as electronic medical records  to ensurWithin the psycho-oncology setting, there is a need for cost-effective assessments of interventions  that meeThis study was limited as the ADUCI Framework was developed from a sample of 43 participants who received the e-intervention. However, usage (over 250 logins) allowed for the Framework to be thoroughly tested in this cohort. A larger sample would enable verification of the Framework and a thorough comparison of observed use and expected use during user testing. With a larger sample, it may be possible to assess users’ behavior and provide additional information about the navigation patterns users follow.Accurate data usage analysis is vital in the growing eHealth environment to ensure that e-interventions are promoting engagement. In this study, we have proposed a framework to support the assessment of apps guided by user-centered design and human-computer interaction. This first iteration of the ADUCI Framework highlights how data can be accurately extracted, the potential for resource savings in a project life cycle, and provides recommendations for future studies to incorporate in their project design to enhance the usage data captured.


Despite the relative prosperity of Scandinavian countries, contamination of the drinking water supply with parasites has occurred on various occasions in the last few decades. These events have resulted in outbreaks of disease involving several thousand cases and/or the necessity for implementation of boil-water advisories. Against this background, in 2008, and again in 2019, the Norwegian Food Safety Authority requested a risk assessment from an independent scientific body regarding parasites in Norwegian drinking water. On each occasion, it was requested that specific questions were addressed.For the first assessment, data, both of general relevance and specific for Norway, were collected from appropriate sources, as available. Based on some of this information, a quantitative probability model was established and run to estimate the number of cases of waterborne cryptosporidiosis and giardiasis that may be expected in Norway, both in the general public and the immunocompromised, and under conditions where water treatment should be optimal, and also when water treatment efficacy may be compromised by weather conditions.For the second assessment, approximately a decade after the first, an update on the previous assessment was requested. Differences in information availability and other changes between the two assessments were described; although more data were available at the second assessment, considerable gaps still remained. For both assessments, data on the occurrence of these parasites in the Norwegian population, particularly those infected in Norway, were considered a challenge. However, due to changes in reporting requirements in 2020, the situation was improved for the second assessment. In addition, data were lacking for both assessments on whether animals or humans are most likely to contaminate water sources, and the species and genotypes of these parasites in Norwegian animals. It was also noted that some of the newer data on parasite numbers detected in water samples should be treated with caution. Due to this, further modelling was not conducted. The relevance of risk-based sampling rather than ad hoc sampling of water sources was also addressed.Despite the data gaps, this article provides an overview of the opportunities provided by conducting such assessments. In addition, some of the challenges encountered in attempting to estimate the risk posed from parasite contamination of water sources in Norway, particularly under predicted conditions of climate change, are described. •Cryptosporidium and Giardia.Norwegian drinking water has been contaminated with •Risk was assessed in both 2008–2009 and 2019–2020 by an independent body.•A model approach was used in the first assessment and data gaps identified.•In the second assessment, more data were available, but data gaps remained.•Main challenges were lack of reliable data on infection and contamination. Norway, which the World Bank ranked as the richest in the world in terms of wealth per capita in 2018 , is amonIn 2004, contamination of the drinking water supply in Bergen, Norway resulted in an outbreak of giardiasis. Over 1500 cases were diagnosed and probably around 6000 persons were infected . In 2007On the basis of such contamination events and waterborne disease outbreaks, the Norwegian Food Safety Authority (NFSA) has requested the Norwegian Scientific Committee for Food and Environment (VKM) to conduct risk assessments regarding parasites in Norwegian drinking water. The first of these assessments was requested in 2008, and the evaluation published in 2009 . In 2019Cryptosporidium and Giardia, in Norwegian drinking water. In particular, we provide some insights regarding the challenges associated with undertaking such an assessment, and the benefits that can be derived - despite those challenges. It should be noted that the documents from which much of the information provided in this article is based are freely available on the internet How important is drinking water, in total or relatively, as a transmission route for cryptosporidiosis or giardiasis in Norway? How might this change in the next few years?2)How many people in Norway are at risk of becoming ill due to these parasites?3)Are today's reporting systems adequate? What should be done if necessary?4)Are humans or animals the most common source of contamination of water in Norway with parasites?5)How is the risk associated with contamination of the water source compared with contamination of the distribution network?6)What effect do current water treatment methods have on the removal of these parasites?7)What monitoring methods are available for these parasites and to what extent are they suitable for waterworks for monitoring purposes?8)Are models available that owners could use to assess the risk in a specific water supply? If not, is it possible/appropriate to develop such a model for Norwegian water supplies?9)If current analysis methods are not sufficient or available to meet routine requirements, what should be done, based on an assessment of what is necessary?10)What general advice can VKM provide to NFSA regarding the risk of parasitic infection via food and drink? If NFSA wants to advise the public on this subject, what should such advice entail and how should it be communicated.In the first mandate from NFSA to VKM  regardinCryptosporidium and Giardia in Norwegian drinking water with the goal that owners of waterworks should be able to make the best possible plans for sampling, and that drinking water inspectors should be able to assess these sampling plans and determine whether the samples and analyses necessary are included. As part of the mandate, NFSA included three specific points to be addressed:1)Giardia and Cryptosporidium in both water sources and treated drinking water in Norway.An update of information on the occurrence of 2)Information on factors that make it more likely that parasites can be a challenge for the production of sufficient, safe drinking water .3)Giardia and Cryptosporidium.Criteria that should be met by methods used for analysis of water in order to be adequate, and an update on information regarding the available methods for analysis of drinking water for contamination with In the second mandate from NFSA to VKM , NFSA st2.2For the first mandate , a non-sCryptosporidium and Giardia) to which the population of Norway may be exposed, and the risk associated with such exposures, were based on five sets of data.1)The occurrence of parasites in Norwegian water under normal conditions.2)The effects of water treatment on the parasites in terms of removal or inactivation.3)The consumption of drinking water by the Norwegian population.4)Dose-response in both immunocompetent and immunocompromised.5)Morbidity.In addition, a quantitative probability model was established using the Norwegian data available, and with awareness of the uncertainty associated with detection of the parasites, variations over time and space, and distribution of parasites within the water mass. The model was made in Microsoft Excel with @Risk as an add-in . The model was run with 30,000 iterations and with Hypercube sampling and random seed. Details of the model are available online in Appendix II of the risk assessment report . In the 1)When the water has been treated by a method such as ultraviolet radiation or membrane filtration that is approved as a barrier against parasites and considered to give at least a 2-log reduction in infective parasites under optimal conditions.2)In other situations, when untreated water or water that is treated by methods that are less effective, is consumed.In running this model, two situations were considered:In addition, the effects of a situation with excessive precipitation were considered, as this can result in reduced efficiency of water treatment methods that are otherwise considered to be effective (at least 2-log reduction in infective parasites). However, extraordinary events, such as contamination of drinking water with sewage, were not taken into consideration.Cryptosporidium will result in infection in the general population can vary by a factor of up to 200 , and (2) that all exposures were always for the first time . In addition, it was assumed that among the immunosuppressed all exposures to parasites would result in the establishment of infection.In addition, assumptions were made within the model that were of a “worst case scenario” nature. These included: (1) that all For the second mandate , a primaFurther information regarding Norwegian laws and regulations for drinking water, treatments in place in Norwegian water treatment plants, status of the water distribution network, and data on the occurrence of both parasites in water based on analyses were also obtained. This information was compared with data available when the 2009 assessment was conducted to determine whether there was sufficient new information to develop the assessment model further or to re-establish and run the model again with updated information.For both mandates, there were extensive knowledge gaps and considerable uncertainty was associated with the data available. Both the knowledge gaps and the uncertainty around the available data were considered in the assessments.33.1Cryptosporidium and 415 for Giardia); the positive samples contained between 1 and 3 cysts or oocysts. Whereas 6 samples were found to contain 3 Cryptosporidium oocysts, only 1 sample was found to contain 3 Giardia cysts. The recovery efficiency of the analytical method used was based on the results of 15 spiking studies. At that time, the waterworks register at the Norwegian Public Health Institute indicated that around half of the Norwegian population were supplied with drinking water treated by UV disinfection . Furthermore, although most notified cases of giardiasis had been infected abroad, samples from people presenting at their doctor with diarrhoea, but who had not been abroad, were usually not analysed for parasites. This presumably resulted in considerable underdiagnosis of giardiasis among people who had been infected while in Norway. Nevertheless, it was suggested that despite the large waterborne outbreak of giardiasis in 2004, the lack of other outbreaks or cases associated with water indicated that Norwegian drinking water was probably a minor transmission vehicle for Methods were, in general, available at that time for analysis of water samples for contamination with these parasites, but monitoring illness in the community and ensuring water treatment processes were operating as intended are important for early detection of outbreaks and for ensuring water safety. It is also important to be aware of occasions when parasite removal/inactivation is compromised or suboptimal. Parasite analysis of water samples was noted to be especially important for risk mapping of water sources and for investigating outbreaks or cases in the community. The importance of water providers having knowledge of relevant water catchments and potential contamination sources was also emphasised.The conclusions from this first mandate  were tha3.3The second assessment  was consCryptosporidium oocysts, again without any further information. Information was also lacking regarding whether molecular analysis had been conducted to determine species in these instances.Other information accrued since 2019 regarded further outbreaks of cryptosporidiosis and giardiasis in Norway. However, none of these were shown to be definitively associated with water contamination, but largely associated with animal contact , contactDespite the recommendation from 2009 that only accredited laboratories or laboratories providing documented ring-test results  should be used for analysing water samples, this recommendation has apparently not been followed. Thus, the unexpected results of high contamination in some raw water samples or oocysts in treated drinking water samples, with no further information, should therefore be considered with caution. Furthermore, these questionable data suggested that repeated running of the model developed in the previous mandate  would no3.4In addition to comparing the status of both information and data with that available for the first assessment , the sec3.4.1Giardia and Cryptosporidium in both water sources and treated drinking water in Norway, the circumstances for the analysis were unknown. Thus, it could not be determined whether the sampling was based on a risk-sampling strategy or not, nor whether the analyses had been conducted by an accredited laboratory; in several cases this did not seem to be the case. Therefore, knowledge on the occurrence of these parasites in Norwegian water sources seems to be no clearer than over a decade previously; where remarkable results were reported, information on whether this was associated with a particular event was lacking and any actions following this finding, including molecular analysis to determine species and/or genotype, were not provided.Although further information had been accrued on the occurrence of 3.4.2Cryptosporidium and Giardia were not detected in water samples collected at the study sites during the dry/warm period, but samples collected after rainfall contained both parasites , which, in turn, could affect the efficacy of some drinking-water treatment methods . For exace water . In addice water . Transmice water .3.4.3Cryptosporidium and Giardia. These methods have not been substantially altered since publication. The recovery efficiency of the method varies according to water quality and other factors, but, in Norway, in low-turbidity samples, this is often around 60%. In the one laboratory in Norway that is accredited for these analyses, recovery efficiencies over 30% are necessary to be considered acceptable. One relevant problem of the method is that any contamination in a reservoir is likely to be distributed unevenly (a Poisson distribution); given the relatively low volume of water analysed compared with the volume of the reservoir, false negative results may be obtained. It is therefore recommended that sampling should be risk-based; the sampling point for a given water source should be selected with care and that sampling occasions should also be targeted towards the question to be addressed.The standard methods  used wor3.5Cryptosporidium and/or Giardia is without doubt well intentioned and understandable, based on the outbreaks of waterborne giardiasis and waterborne cryptosporidiosis that have occurred in Norway and in neighbouring countries. The initial mandate resulted in the presentation of relevant information on basic questions and attempted to use these data, along with other necessary data from the international literature, within a modelling approach to estimate cases of waterborne giardiasis and cryptosporidiosis. Places where data were absent were also pinpointed. These gaps included the lack of information on the occurrence of these parasites in the Norwegian population, particularly those who had been infected in Norway; an absence of information on whether animals or humans were most likely to contaminate Norwegian water sources; limited information on genotypes and species of parasites in different Norwegian animals; an absence of information on the effects of different weather conditions on the likelihood for contamination. In addition to these Norway-specific information gaps, more general information was also found to be lacking, such as the duration of immunity following exposure, and the extent of cross-immunity between species or genotypes.NFSA's request to obtain an assessment of the risk from contamination of drinking water with Cryptosporidium and Giardia. The latter, however, represents a challenge, as not all laboratories that conduct these analyses are accredited to do so, and information on unexpected results (such as detection of Cryptosporidium in treated water or high quantities of parasites in raw water) is lacking, including the basis for the analysis, any follow-up investigation, and any resultant disease in the community. Furthermore, many of the data gaps identified in 2009 remain, including the extent of infection in the human population, whether animal faeces or human sewage are the predominant source of water contamination, and the effects of weather conditions  on water contamination.Within the decade between mandates, more relevant data had become available due to improved diagnostics, a potentially broader algorithm for investigating patient samples for parasites, and cryptosporidiosis being a notifiable infection. In addition, more water samples have been analysed for contamination with As with the previous assessment , the morThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


People with migration background and dementia are a vulnerable group. Providing care for this group is a public health challenge in Europe. An increasing number of countries are issuing national dementia plans, but a systematic overview of national dementia plans of European countries focusing on care for people with migration background is lacking. This study aims to illustrate how European countries identify the dementia-related needs of people with migration background and whether there are specific healthcare services for them at the national level.A qualitative analysis of national dementia plans of the EU and EFTA (European Free Trade Association) countries was carried out. Using the discourse analysis model according to Rainer Keller (2011), documents were systematically screened for their relation to migration via keyword and context analysis. The content of the migration-related sections was analyzed using the methods of paraphrasing, memos, comments, and open coding.Twenty-three of the 35 EU and ETFA countries have a national dementia plan, ten of these documents refer to migration and one country (Austria) has a national dementia plan with a chapter on migration. Eight national dementia plans identify that people with migration background and dementia have special needs, and actions to care for this group are planned in nine countries. However, only Norway, Northern Ireland, and the Netherlands refer to available healthcare services for people with migration background. Overall, the topic of migration plays a subordinate role in the national dementia plans of European countries.The current lack of migrant-specific healthcare services in almost all European countries may lead to denying the right to appropriate care to a growing population. The topic of migration must be given greater attention in national dementia plans. European countries should develop strategies with specific services that address the needs of people with migration background. To improve comparability at the European level, a common definition of migration is needed. Further studies should include country-specific problems related to dementia and migration. In 2010, the number of people with dementia (PwD) in Europe was estimated to be 9.95 million . There aThis study aims to determine to what extent the special needs of PwM with dementia are identified in European countries, whether specific actions are taken at the national level to ensure their care and how attention is paid to the relationship between dementia and migration. The issue of actions for PwM with dementia is divided into two sub-questions: 1. Do specific healthcare services for PwM with dementia currently exist at the national level? 2. Are specific actions for the care of PwM with dementia planned? In this study, healthcare services at the national level are defined as all services involving healthcare, such as information, support, advice, diagnose, or treatment plans, which are not limited to specific regions, companies, or institutions and are referred to in official national documents by country representatives .For this study, a qualitative discourse analysis by Reiner Keller 2011) was conducted. This approach is based on the open research logic of qualitative social research. The proposed methods offer assistance in structuring the analysis process but do not represent regulations for the research process. The discourse analysis focused on the analysis of natural communication processes in different contexts. In the case of this study, discursive practices in the form of national documents were used. This knowledge-sociological approach aims to identify the processes and practices of knowledge production at the level of institutional fields. This method can be used to reconstruct whether and to what extent discourses establish or organize relations between phenomena [11 was coThe information sources for the identification of NDPs were: the online platform of Alzheimer Europe , the DemThese documents were systematically screened for their relevance to migration. The first step was to examine whether the documents included separate chapters on this topic. Then, the NDPs were screened for these key terms: minorities, minority, migration, culture, ethnic, background, migrant, sensitive, cultural, diverse, diversity, and language. If the migration topic was considered, a content analysis of the section in which it could be located was carried out. For this purpose, the contents were paraphrased, memos, and comments were added and the text passages were coded, using the strategy of open coding. The categories were derived from the contents of the documents. First, the content was roughly structured according to the categories’ problem description and actions and then fine-tuned according to the categories presented in Table In the search for NDPs, primarily English and German terms were used. If no documents could be found in this way, a search was conducted using terms translated into the respective national language. 16 of the 25 NDPs examined were available in English and one NDP (Liechtenstein) in German, the native language of the first author. 5 of the remaining 8 NDPs  were translated using the translation program DeepL. The documents of Slovenia, Czech Republic, and Cyprus were screened after a Google search and with the help of the Google translator via keywords in the respective national language. The results of this study were discussed with various experts on the topic of dementia and migration from different EU and EFTA countries at a workshop in The Hague (Netherlands) in 2019.Twenty-three of the 35 EU and EFTA countries have issued a national dementia plan (NDP). More than half 13) of the countries with a NDP do not refer to migration. Ten countries discuss this topic in their documents . However, only one state (Austria) has a NDP with a chapter on migration  notes that the prevalence of dementia among migrants is significantly higher than among people without migration background and that there is a relation between ethnicity and the development of dementia. Flanders has set the goal of developing culturally sensitive care services. For this purpose, Flanders would like to use the knowledge on culturally sensitive care for migrants from Erasmushogeschool’s research and implement it in specific projects such as dementia-skilled training and the consultation platform of dementia. Thus, the Dementia Consultation Platform (Overleg Platform Dementie) can initiate targeted neighborhood initiatives and bring together care stakeholders and relevant local stakeholders .The 2012–2017 dementia plan identifies ethnicity as a risk factor for dementia. Cyprus aims to ensure equal access to diagnostic tests, treatments, medicines, and care for all population groups and to prevent discrimination in dementia care based on race or origin. A strategy to implement this aim is not mentioned .The Dementia Strategy 2009 and the All Party Parliamentary Group Report 2014 do not identify ethnic minorities as a vulnerable group for dementia. However, it is recognized that they may have special needs. England would like to provide them with specific information. Curricula for dementia-specific training of health and care professionals should address the needs of ethnic minorities . In addiWhile the public version of the dementia standard 2016 does not address migration  the versWhile the Dementia Strategy 2011 does not refer to migration , the NorThe Dementia Plan 2020 describes the problems that older migrants often receive healthcare services only at an advanced stage of the disease and that language barriers between professionals and patients pose a threat to patient safety. It refers to a plan to take the needs of Sami and language minorities into account in the construction of nursing and residential homes. Norway would also like to involve PwD from different cultural groups in the development of a pilot project for post-diagnostic observation. Since 2015 there is a national program for PwD from Sami and language minority groups .According to the Dementia Strategy 2017–2020, Scotland wants to ensure that cultural aspects are taken into account in early detection and that competent local services and post-diagnostic support channels are available for people from protected characteristic groups with dementia. However, it is not mentioned which specific groups these are. Further research is also announced to increase understanding and awareness of dementia among different population groups .The Dementia Strategy 2014–2019 describes the growing proportion of the migrant population in older age groups and the resulting changes in quality requirements of healthcare services. It also addresses the problem of language barriers associated with the diagnosis of dementia and the failure of common diagnostic tests in migrants. Switzerland intends to extend the current program on migration and health to include dementia .The Dementia Plan 2018–2022 describes the problems of diagnosis, which are complicated by cultural and language interpretations, the lower utilization of care services, and the change in communication skills during the dementia process in ethnic minorities. Wales wants to ensure that these groups have easy access to suitable services and provide culturally appropriate care and support. To this end, linguistically diverse and culturally appropriate diagnostic tools are to be used, staff training courses conducted, specific information materials developed and the individual culture of PwD must be evaluated .In most NDPs the focus is on the problem description. The most frequently addressed problems are: difficulty or later diagnosis and lower utilization of care services. Cultural and language barriers, as well as inappropriate diagnostic instruments, were named as causes for this. While in some countries such as the Netherlands or Belgium/Flanders, PwM are identified as a risk group for dementia, and in almost all countries as a risk group for underdiagnosis and a lower level of care, England does not perceive PwM as a vulnerable group. Concerning the planned actions, attention will be paid to the conception of specific information materials, training of caregivers, medical and nursing professionals or staff of migrant counseling centers, and the development of language and culturally appropriate diagnostic tools. Additionally, several countries would like to take greater account of cultural aspects in the prevention or early detection and the needs of PwM regarding living space.In the individual countries, the importance of the topic migration varies due to the different extent of immigration and emigration, the different size of the migrant population, and the different history of migration. On the one hand, there are immigration countries such as Austria, Belgium, France, Germany, Italy, Spain, Sweden, Switzerland, and England, whose migrant population (born abroad) consists of more than one million people , where the proportion of migrants in the total population is more than 10 % (Switzerland: 29.9%) and where the net migration figure per year (immigrants minus emigrants in the last 5 years before 2020) is more than 100,000 (Germany: 2.7 million). On the other hand, there are some countries such as Bulgaria, Romania, Slovakia, the Czech Republic, and Hungary, whose migrant population has also grown over the past two decades but currently still accounts for a small percentage of the total population  and countries such as the Baltic States and Poland, whose migrant population is shrinking and some of which have a clearly negative net migration (Poland and Lithuania) . PuttingThis study aimed to determine to what extent attention is paid to the relationship between dementia and migration in the EU and EFTA countries, whether special needs of PwM with dementia are identified and if specific actions for the care of PwM with dementia are taken at the national level. A central finding of this analysis is that the topic of migration plays a subordinate role in the NDPs of European states. In more than half of the NDPs, the topic of migration is not considered. In most of the NDPs reviewed, the topic of migration is only briefly acknowledged and addressed. The Austrian Dementia Report is the only document containing a separate chapter on migration issues for PwD. Eight of ten countries identify that PwM have special needs that are relevant to dementia care . Nine countries are planning actions for dementia care of PwM. A study on addressing the issue of dementia among PwM in NDPs of the member states of the World Health Organization found that nine of 32 NDPs mentioned migration and eight of them, including five European countries, proposed actions for migrants or ethnic minorities . This anIn the Netherlands, special attention has been paid to PwM in the early detection and prevention of dementia. Overall, the Netherlands adopts an inclusive approach regarding healthcare for PwM. Healthcare services for this vulnerable group are organized through municipal service providers , 39. HowIn Northern Ireland, the healthcare for PwM is organized through the Department of Health, Social Services and Public Safety (DHSSPS). Together with the Public Health Agency, the DHSSPS develops guidelines for screening PwM and provides resources for medical services. The Department promotes an inclusive healthcare system. Primary care is provided at the municipal level, where various organizations support PwM in meeting their healthcare needs . NortherNorway is improving the skills of staff members working with language minorities and developing a program of post-diagnostic follow-up models including PwD and their relatives from other cultural groups. At the municipal level, PwM are offered both mainstream primary healthcare services and specialized services . At the national level, Norway also has a competence center for migration and minority health (NAKMI). Together with further national organizations such as the National Competence Centre for Ageing and Health and the Ministry of Health, the NAKMI has developed nationwide available healthcare services for PwM with dementia .Such concepts, communicated at the national level by representatives of the state, can help to raise awareness on the topic of migration among providers of dementia-specific care services and can serve as models of good practice for other countries.The results of this study are based on the analysis of NDPs. As some EU and EFTA countries (12) do not have such documents, more countries may have specific national healthcare services for PwM with dementia. In addition, some NDPs have been published several years earlier than others. The topic of dementia and migration should be more important in large parts of Europe today than it was a few years ago due to the increase in prevalence and the growing number of older migrants. Thus, the different dates of publication can also be a cause for the country-specific differences concerning the reference to migration. A reason already discussed in the results section are the different levels of importance of migration in individual countries. This study shows that immigration countries with a large proportion of migrants are more likely to have migration-related NDPs than emigration countries with a low proportion of migrants. Another striking feature is the disparate terms used in the context of migration (e.g. language minorities in Norway , people This study supplements the current literature with a systematic description of the role that migration plays in the NDPs of the EU and EFTA countries and the actions communicated by some to ensure the care of PwM. At present, the topic of migration in the context of dementia plays a subordinate role at the national level in most European countries, and there are hardly any specific care plans for PwM. Since a significant increase in the prevalence of dementia among PwM is expected in the coming years and this group is currently utilizing fewer healthcare services, partly due to inappropriate services, greater attention must be paid to the topic of migration in NDPs. All European countries should develop a strategy at the national level and define services that address the individual, language, and cultural needs of PwM. However, from our analysis specific recommendations cannot be given. There is a need for further research and discussion about the implementation of current governmental agendas. Furthermore, more attention should be drawn to other forms of support for this vulnerable group. However, we assume that the current lack of migrant-specific care at the national level, if not remedied in a timely manner, may lead to a growing population being excluded from care.


Challenges remain for policy adoption and implementation to tackle the unprecedented and relentless increase in obesity, diabetes and other non-communicable diseases (NCDs), especially in low- and middle-income countries. The aim of this mixed-methods study is to analyse the contextual relevance and applicability to low-resource settings of a sample of evidence-based healthy public policies, using local knowledge, perceptions and pertinent epidemiological data. Firstly, we will identify and prioritise policies that have the potential to reduce the burden of diabetes in low-resource settings with a scoping review and modified Delphi method. In parallel, we will undertake two cross-sectional population surveys on diabetes risk and morbidity in two low-resource settings in Ecuador. Patients, community members, health workers and policy makers will analyse the contextual relevance and applicability of the policy actions and discuss their potential for the reduction in inequities in diabetes risk and morbidity in their population. This study tackles one of the greatest challenges in global health today: how to drive the implementation of population-wide preventative measures to fight NCDs in low resource settings. The findings will demonstrate how local knowledge, perceptions and pertinent epidemiological data can be used to analyse the contextual relevance and applicability of potential policy actions.  Diabetes mellitus is a global health emergency: it affects all age groups in all countries across the globe , being eThe International Diabetes Federation estimates that 5.5% 3.5–8.5) of Ecuador’s population aged 20–79 years suffers from diabetes, of whom 40% are undiagnosed . Conside.5 of EcuGiven these dramatic global projections ,7, most Observational studies that explore the nature of existing inequalities, and studies that describe experiences of tackling upstream determinants of health  have an important role in generating evidence for policy action to fight NCDs globally, but implementation remains limited in many parts of the world. Implementation in LMICs may be especially challenging, given that the evidence base for action on NCDs comes primarily from high income countries. Innovative ways to drive the implementation of population-wide preventative measures are desperately needed to fight NCDs globally. The process of knowledge translation requires evidence being weighted up, interpreted, assessed for relevance, applied to the here and now of a particular local setting and considered in light of competing priorities and concerns . FurtherThis current protocol is part of a five year (2019–2023) European Research Council -funded research project which aims to explore the process by which global recommendations can be translated into context-specific, evidence-informed action for diabetes prevention in low-resource settings. “Contextualizing Evidence for Action in Diabetes in Low-resource settings”, acronym CEAD, is an implementation science project and, as such, we do not propose to analyse the impact of public health interventions, but to analyse how contextual factors may affect their relevance, and to explore the processes involved in their adoption and implementation. The project design combines quantitative epidemiological research and qualitative methodologies, involving an intricate feedback loop to generate the rich and varied knowledge that is required to trigger policy action . This current report describes the protocol for the first part of the project, which deals with the relevance and implementation of healthy public policies at local or municipal levels. The aim of this study is to analyse contextual relevance and applicability to low-resource settings of a sample of evidence-based healthy public policies, using local knowledge, perceptions and pertinent epidemiological data.Mixed methods study: firstly, we will identify the sample of evidence-based policies that have the potential to reduce the burden of diabetes, given the available evidence, using a scoping review. In parallel, we will undertake two cross-sectional population surveys, with representative samples of two selected health districts  to estimate the prevalence of diabetes, impaired glucose tolerance, and NCD risk factors locally. The knowledge generated from the scoping review and the population surveys will be discussed in contextualization discussion groups, where participants will discuss the contextual relevance and applicability of the policy actions identified and their ability to reduce the health inequities observed in their district . The aim of the scoping review is to map the evidence regarding policies that are recommended at local or municipal level to promote healthy diets and increase physical activity in different contexts in both high-income countries and LMICs. Only policy actions that are focussed on modifying the environment rather than addressing individual behaviour modifications will be considered. We will follow Arksey and O’Malley’s six-stage methodological framework  and the This scoping review will consider guidelines and recommendations from principal international health agencies. First, we will identify public health agencies or organizations that generate evidence-based recommendations and are supported by governmental departments, but which operate independently, such as the Community Preventive Services Task Force of the USA and National Institute for Health and Care Excellence of the UK, and the WHO and regional offices. Agencies or institutions will be included if they have an explicit description of procedures to produce evidence-based recommendations. We will then systematically search the recommendations made by each agency/organization to extract the information related to policy actions. The search strategy will go on until: (a) no more agencies/institutions that provide evidence-based recommendations and are supported by governmental departments or multilateral institutions are found; or (b) saturation of information regarding policy recommendations is reached.Two reviewers will extract data related to the policy actions independently and any disagreements will be resolved through discussion and consensus, or by a third reviewer in cases of disagreement. The following information will be extracted: the guidelines or documents that support the action; year of publication; general recommendations ; specific actions ; intervention source (organisation); target environment ; target population ; and the intended audience of the recommendation , according to the powers and responsibilities of the local governments. We will use an adapted Delphi method with experts and members of the research team to prioritise a set of policy actions, taking into consideration their applicability in low resource settings and, more specifically, to the health districts included in the study. The Delphi technique has emerged, since its inception, as one of the most powerful and frequently used formal consensus techniques . We willWe will carry out the fieldwork for this case study in two carefully selected, low-resource settings in Ecuador: (1) District 17D06, Quito, an urban health district with 507,499 residents (est. 2017); and (2) District 08D02, in Esmeraldas Province, a rural area in the northern coastal region of the country with a population of 44,498 (est. 2017). The decision was made in part due to the higher diabetes prevalence in the capital and coastal areas  will be excluded. A sample of 720 people per district will lead to a total sample of 1440 individuals for the population surveys. We propose this sample size assuming the prevalence of diabetes is no higher than 10%, to provide an estimate with an absolute precision of ±3%, with a 95% confidence level. We assume a design effect of 1.5  and furWe will use multi-stage cluster sampling. Sampling in urban settings will consist of a random selection of neighbourhoods (primary enumeration unit), whose probability of being chosen will be proportional to the population density. Once we have selected the neighbourhood, we will identify buildings or homes by randomly generated GPS points and will randomly sample one person at each point. In rural settings, we will conduct a multistage stratified cluster sampling. Villages in the rural settings of Esmeraldas are distributed along the Santiago River, where the Cayapas River and Onzole River also converge. In line with the existing geographic and demographic organization, we will randomly select ‘micro-areas’, defined as groups of villages pertaining to a single primary health facility. We will then select a random sample of villages stratified by ethnicity  with disproportionate allocation, and by isolation (distance from the main urban area following the riverbeds). Finally, we will undertake simple random sampling of eligible individuals from within the villages by using an existing census developed by voluntary health promotors, digitised by the Centre of Community Epidemiology and Tropical Medicine (CECOMET), collaborators in the project.The questionnaire used in the population survey will include sections of the WHO STEPS NCD risk factor survey forms . DetaileTwenty-four interviewers will establish survey eligibility, solicit informed consent, and carry out the survey in the participant’s home. The composition of the survey team will be gender balanced, and include staff who represent local cultural, ethnic and religious groups. They will carry out the survey in Spanish but some interviewers will also be fluent in Quechua, Chachi and any other relevant indigenous language to translate questions verbally if required. Data collection in rural areas will engage the volunteer health promotors under the supervision of CECOMET research staff. The surveyors will arrange an appointment for physical and biological measurements together with the participant, considering geographical convenience and availability. Weight, height, waist circumference and blood pressure will be measured according to the technical specifications recommended in the STEPS guideline  in a sepAll participants will receive the results of their physical measurements and blood analyses and information about diabetes, cardiovascular risk, renal function and the importance of a healthy diet and physical activity. Information regarding adverse effects associated with incidental findings in otherwise healthy populations will be shared with the survey staff in order to avoid over-diagnosis and over-medicalization. Only individuals with abnormal glucose levels, blood pressure, renal function or hypercholesterolemia according to the current National Clinical Practice Guidelines will be referred to their local health facility for confirmation and consequent care as per the national protocols.http://www.kobotoolbox.org/) free open source software (or ODK collect if necessary). We will add prompts for immediate error checking of unlikely values. We will pre-pilot the survey tool before the survey, after training the data collection team. We will use stickers with Quick Response (QR) codes that can be scanned by the tablets in order to ensure the linkage of data collected in participant’s home, their physical and biological measurements and laboratory results. For data collection in the survey, we will use the WHO STEPS forms where possible and import them to Kobo toolbox  Version 15 for statistical analysis. We will calculate the prevalence of impaired glucose tolerance, diabetes, and the other NCD risk factors with 95% confidence intervals. We will disaggregate outcomes by sex, age group, ethnicity and socioeconomic position. We will also describe geographical variation in survey outcomes. Steps will be taken to prevent missing data, but some level of missing data is unavoidable and we will incorporate methods analysing missing data or data from uncertain sources when necessary ,19.We will organise 10 contextualization discussion groups, five in each setting: Quito and Esmeraldas. Discussion will be based on information obtained from two different sources: (1) a sample of approximately 10 potential policy actions obtained from the scoping review and modified Delphi procedure  that can be implemented at a local level; (2) the results obtained from the population survey showing the prevalence and distribution of diabetes, hypertension, obesity and other NCD risk factors.Contextualization discussion groups will include 4–8 participants and last approximately 90 min. Participants must be older than 18, residents in the study area, and they must provide written informed consent. The sampling method used for the selection of contextualization discussion groups participants will be purposive and will include diabetic patients and family members, community members, healthcare workers and decision-makers . In eachDiscussions will be guided by the information obtained from policy actions prioritised using the Delphi methodology previously described and the results of the population survey of the prevalence and distribution of diabetes, hypertension, obesity and other risk factors for non-communicable diseases, focusing on health inequalities. We will present all information in a visual and simplified format. Participants will receive the written information and a short explanation at the beginning of the activity and they will have approximately 10 min to read it and ask clarification questions. At this point, researchers will inform participants that they will be audio recorded in order to have all the information. Participants are expected not only to talk about their personal experiences, ideas and opinions, but also to listen to and respect other members of the contextualization discussion groups. We will divide discussions into two parts. During the first part, we will ask participants about the feasibility and applicability of the selected potential actions in their context. During the second part of the discussion, facilitators will display the survey results. Participants are expected to talk about the differences observed between population groups , suggest potential reasons for the observed inequalities and suggest solutions. Finally, participants will analyse the policy actions one by one and discuss the capacity of the health policies to tackle health inequity in their context. At least two members of the research team will be present at the discussions; one will facilitate the discussion and the other will have an observatory role, quietly noting observations related to body language, timepoints and his/her perception of the power dynamic. All group discussions will be audio recorded and transcribed. We will analyse digitised transcripts using thematic analysis, assisted by Atlas.ti 8.0 . The study protocol has been reviewed and approved by the Universidad Miguel Hernández (UMH) project evaluation board (registration number 2018.291.E.OEP), the nationally accredited ethical board at the Pontificia Universidad Católica de Ecuador , and ethical clearance has been provided by the European Research Council Executive Agency  5827042-14/11/2018). An independent Ethics Adviser has been appointed and we will monitor ethical and participatory issues, paying particular attention to gender and other equity concerns throughout the research. Furthermore, written authorization to conduct the study and review clinical records in public health facilities will be obtained from the National Health Intelligence Directorate of the Ministry before any data collection in Ecuador takes place. Informed consent is required prior to participation in the population survey and the discussion groups. On all forms, it is clearly stated that the participant is free to withdraw from the study at any time for any reason without prejudice to future care, and with no obligation to give a reason for withdrawal. Specific arrangements will be taken in order to avoid any inequity derived from any social condition, giving the participants as much time as needed to consider the information, and the opportunity to question the researcher, their health care provider or other independent parties before they decide whether they will participate in the study. Written informed consent will be obtained by means of the participant’s dated signature and the dated signature of the person who presented and obtained the informed consent. Although participants will be able to withdraw consent at any time, a special explanation will be given to participants of the qualitative components of the research. Specifically, while focus group participants may choose to leave the debate at any time, after the group discussion is completed and thematic analysis has been carried out we will be unable to erase their input because no personal data will have been collected. CECOMET, unpublished data). While existing activities in the area focusing on patient education are clearly important, they are not sufficient. This study aims to analyse population-wide preventative measures (policies) to create health-promoting environments that help individuals make healthy choices and avoid death or disability due to diabetes. Furthermore, by applying the equity lens we will consider whether such population-wide initiatives to promote physical activity and a healthy diet are able to reach the people who need them most. The current proposal is a timely one. The political basis for concerted action to address diabetes is integrated into the Sustainable Development Goals , the UniGiven the nature of the research question, patient and public involvement is essential to the analysis and interpretation of key findings. A description of their selection and role is described above. Furthermore, two project advisory committees consisting of health workers, patients and community members will be established at the start of the study . The committees will represent the interests of study participants, meeting regularly throughout the study period to obtain information on the concerns of patients, health workers and the community. Community engagement activities will involve specific events in health centres and other community meeting-points to share the findings of the research, giving members of the community the opportunity to question or comment. The findings will be shared in a non-paternalistic manner, integrated with culturally appropriate entertainment and healthy refreshments.Regarding knowledge dissemination, we will encourage interaction with stakeholders through sharing and discussing findings at professional meetings  and academic events at participating universities. This will be a two-way process that will encourage the generation of contextually tailored evidence for the Ministry of Public Health in Ecuador, as well as generalised tools that can help contextualize local policy options in other low-resource settings. We will also share key messages drawn from the research on the study website (under development). We will use social media to encourage the circulation, interpretation and contestation of knowledge in both professional and lay networks. Finally, aside from community engagement in Quito and Esmeraldas, we will organize an event in Spain coinciding with World Diabetes Day (14 November 2020) where stakeholders will have the opportunity to share their opinions and reflect on the relevance of the findings in other low-resource settings. Results will also be presented in scientific conferences and seminars, and will be written up for publication in peer-reviewed journals.The datasets generated by the project CEAD will be archived in the data repository Zenodo, and will be linked in the study website (under construction at time of writing). Zenodo will assign a Digital Object Identifier (DOI) to make the upload easily and uniquely citable. Zenodo will allow us to store our (meta) data safely and will allow us to establish different licenses and access levels depending on the type of data .The DOI of (meta) data will be included in the relevant publications to find the raw (but de-identified) data easily. Raw data will be freely available after the publication of research articles, including the transcripts of the interviews and focus groups. Furthermore, we will make the full research protocols, standard operating procedures, and analysis plans publicly available.