Human Genome Project zwar zum Gegenstand hitziger Diskussionen, aber Debatten und Reflexionen blieben meist im Polemischen verhaftet und zeigten eine begrenzte Wertschätzung für die Vielfalt und Erklärungskraft des Konzepts von Big Science. Zur gleichen Zeit haben Wissenschafts- und Technikforscher/innen in ihren Beschreibungen des Wandels der Forschungslandschaft die Verwendung des Begriffs Big Science gemieden. Dieser interdisziplinäre Artikel kombiniert eine begriffliche Analyse des Konzepts von Big Science mit unterschiedlichen Daten und Ideen aus einer Multimethodenuntersuchung mehrerer großer Forschungsprojekte in der Biologie. Ziel ist es, ein empirisch fundiertes, nuanciertes und analytisch nützliches Verständnis von Big Biology zu entwickeln und die normativen Debatten mit ihren einfachen Dichotomien und rhetorischen Positionen hinter sich zu lassen. Zwar kann das Konzept von Big Science als eine Mode in der Wissenschaftspolitik gesehen werden – inzwischen vielleicht sogar als ein altmodisches Konzept –, doch lautet meine innovative Argumentation, dass dessen analytische Verwendung unsere Aufmerksamkeit auf die Ausweitung der Zusammenarbeit in den Biowissenschaften lenkt. Die Analyse von Big Biology zeigt Unterschiede zu Big Physics und anderen Formen von Big Science, namentlich in den Mustern der Forschungsorganisation, der verwendeten Technologien und der gesellschaftlichen Zusammenhänge, in denen sie tätig ist. So können Reflexionen über Big Science, Big Biology und ihre Beziehungen zur Wissensproduktion die jüngsten Behauptungen über grundlegende Veränderungen in der Life Science-Forschung in einen historischen Kontext stellen.Ist Biologie das jüngste Mitglied in der Familie von Big Science? Die vermehrte Zusammenarbeit in der biologischen Forschung wurde in der Folge des  Nature editorial concluded: “Like it or not, big biology is here to stay” (2001: 545). This statement aimed to make a final conclusion in heated debates on big biology that started during the emergence of the Human Genome Project. In these discussions, the project was portrayed as the first big science project in biology  conceptualisations of transformations in science—such as Mode 2 science, normal and post-normal science, and the triple helix theory —as it exAs such, this interdisciplinary paper first presents the multi-faceted character of the big science concept, after which it explores how big science enables the understanding of transformations in biology. By combining historical and sociological studies, I outline the growth of biology through an empirical understanding of the concept, asking how big biology differs from big physics, explicitly paying attention to the interaction between the epistemic and organizational. Focusing first on technology as a driver for growth and second on the societal context which enables this scientific growth, I argue that in contrast to the centralized form of big physics, big biology has acquired a networked shape in interaction with the central role that information technologies play in bioscience research. In addition, ideas about the role of science and technology in society have changed substantively since physics grew big, resulting in some specific obstacles that life scientists encounter in their efforts to scale-up biology. For instance, and although current science policy favours research that combines focus and mass with clear societal implications, life scientists find it difficult to acquire funding for large-scale biology while presenting claims to improve human health and the environment. This is especially remarkable when compared to particle physics or space research that, with less straightforward societal effects, is continuously able to acquire substantial amounts of funding. Or as one of the life scientists puts it: “Even when these space shuttles explode, they still receive huge amounts of money and we are not able to acquire this kind of funding for our research”.My argument is based on a mix of philosophical, historical and sociological research methods. It combines a conceptual analysis of the concept of big science, with explorations into the history of collaboration in biology and its present forms. For the analysis of the latter, I used different data and ideas from a multi-method investigation of several large-scale research projects in biology, covering ecology, molecular biology and biomedical science. I have especially concentrated on the emergence, structure and functioning of various large-scale academic projects in the United States and Europe : “The large-scale character of modern science, new and shining and all powerful, is so apparent that the happy term “Big Science” has been coined to describe it” (ibid.: 2). In his book Reflections on Big Science (1967) Weinberg states that science has become big in two different ways: On the one hand, many of the activities of modern science—nuclear physics, or elementary particle physics, or space research—require extremely elaborate equipment and staffs of large teams of professionals; on the other hand, the scientific enterprise, both Little Science and Big Science, has grown explosively and has become very much more complicated (ibid.: 39).Opening the black-box of big science forms a starting point for exploring the way in which the concept can help to grasp contemporary large-scale biology research. The term was coined in 1961 by physicist Alvin Weinberg in the context of the enlargement of physics research in the United States  and furtBig Business (Big Government (Big Democracy (Big School (Big Cities (Big Foundations (Big Machine (Jungk 1986). Like the other authors of these big books, Weinberg and De Solla Price write about increasing dimensions full of wonder and admiration, while at the same time evaluating them critically. Growth is described as part of progress and an inevitable exponent of modern industrial society, but it is also seen as a source of problems. For instance, Small is Beautiful (1973). Thereby the books on bigness breathe the ambivalence of modern condition: “To be modern is to find ourselves in an environment that promises us adventure, power, joy, growth, transformation of ourselves and the world— and, at the same time, that threatens to destroy everything we have, everything we know, everything we are”  .4 Accord Science  primaril Science : vi. And Science .Philosophical Transactions of the Royal Society of London from 1662 to the 1930s, while teaching in Singapore (Price 1983). The pile of journals triggered his fascination for what he later would call big science. I took the beautiful calf-bound volumes into protective custody and set them in ten-year piles on the bedside bookshelves. For a year then I read them cover to cover, thereby getting my initial education as a historian of science. As a side product, noting that the piles made a fine exponential curve against the wall, I counted all the other sets of journals I could find and discovered that exponential growth, at an amazingly fast rate, was apparently universal and remarkably long-lived (ibid.: 18).In addition, De Solla Price introduces big science as an empirical concept for studying transformation in science. Originally a physicist, he became interested in the history of science when he received a complete set of the This discovery of exponential growth stimulated his work on the quantitative measurement of scientific development that turned him into a recognized information scientist and a founding father of scientometrics . De SollHowever, next to being a quantitative empirical phenomenon, the concept of big science became also used for the qualitative study of scientific transformation. Against the background of the development of the history and social study of science and technology, big science has been employed to look into historic and contemporary practices of research collaboration: “Where past studies on big science typically counted dollars and personnel, and tabulated the funding sources that nourished large-scale research, we can now see more of the causes and consequences of the growth of science” : 357. DeIn sum, big science is an historic concept formed in the 1960s to reflect on increasing scales and dimensions of research and scientific practice, and the term has taken on a variety of meanings and functions. Consequently, it now has both empirical and evaluative aspects, each with a double-edge. Empirical investigations can be divided into quantitative and qualitative approaches, while both positive and negative evaluations of the phenomenon of big science are distinguishable. As such, and when thinking about what big biology would entail, it is important to keep these different meanings of big science in mind. The debate about the Human Genome Project that questioned the desirability of the rise of big biology, clearly draws on the evaluative side of the big science concept, while failing to unpack what big biology actually entails in practice. How does big biology look, and how do increasing dimensions in biology research transform the character of this research? Such reflections on the process of biology becoming big science will need to use the empirical side of the concept, as the next section will demonstrate.Gaining a full empirical appreciation of big biology requires understanding its origins, development, and how it compares to large-scale scientific research in other fields.However, before exploring the history and current status of biology, it is important to emphasize that not all of academic biology research is becoming big, and this paper should certainly not be read as a promotion of bigness. Instead, I acknowledge that different forms of research into life require different organisational scales , and as Reflections on Big Science . Science  already Weinberg’s thoughts on big biology were inspired by Norman Anderson, a “biologist-cum-engineer” who in 1967 proposed the Molecular Anatomy program, aiming to catalogue and characterize all human proteins : 738. NeHowever, and in line with the dominance of physics research during most of the twentieth century, the predominant focus of historical and sociological analyses of big science have been on physics and the emergence of its large-scale instrumentation. The origin of big physics was traced back to the interwar period when universities in California began collaborating to find a solution for the problems of power production and distribution . Large-sWith physics commonly known as big science, biology is only recently portrayed as such, with the Human Genome Project functioning as a watershed. Too often ignored is the fact that large-scale physics research gave rise to radiobiology well before the current era, and that biologists collaborated in large-scale research enterprises long before large-scale genomics and post-genomics research . More spThis international institutionalization mirrored the centralization of research in particle physics, but it was followed by international mapping and sequencing projects that scaled-up research efforts through collaboration but without centralization in one place . CollaboAlthough perspectives on the Human Genome Project are diverse, all agree that the project has become an exemplar of new scientific, technological, and organizational transformations . The magWith the emergence of many large-scale research collaborations in biology it seems to have become legitimate to talk about big biology. Nevertheless, I argue that important differences can be noted between big physics and big biology. Most importantly, reasons for collaboration in biology have initially been found in the dispersed character of the research material instead of the increasing size of instruments. Large and expensive instruments are often seen as essential to the emergence of big science, as in big physics particle accelerators cause organizational gravitation . Large iFirst of all, biologists are employing larger research instruments, leading to higher levels of aggregation in the organization of biological research that resemble centralization around large instruments in physics, albeit on a smaller scale. To illustrate, the introduction of the Nuclear Magnetic Resonance SpectroscopeIt was during this period that in the Netherlands the idea developed that if you want to use expensive technologies—which means electron-microscopy, NMR spectroscopy, röntgendefraction, ultracentrifuges and that kind of things—you have to start thinking seriously about how to go along.10Dr. Rien de Bie—who spent a considerable amount of his career as research manager in the Bijvoet Centre for Biomolecular Research at Utrecht University in the Netherlands—witnessed these increasing scales of research arrangements around the instrument firsthand.Based on existing practices in physics, this resulted in a policy of concentration and the establishment of so-called, para-university research institutes’ for chemistry and molecular biology. Consequently, in 1988 three national collaborative centers were funded, including the Bijvoet Center in Utrecht. The next increase of scale was mainly policy-induced, as internationalization became a priority in research policy from the end of the 1980s onwards. As in the first European Union Framework Programmes no research infrastructures were funded on the biological side of chemistry, Utrecht decided to participate together with centers in Florence and Frankfurt in the third Framework Programme to fill this void, leading to the establishment of European collaborations for NMR spectroscopy that exist to this day. De Bie characterized this final step as the, Europeanisation’ of research arrangements.Next to the (inter)national aggregation of efforts around one single technology, a second organizational movement in biology consists of local centralization of people and ideas around several different technologies, as recognized in the establishment of local central technology facilities. Researchers and laboratories traditionally bought their own research technologies, but this strategy now limits the kinds of research to be conducted .11 It isYou can be interested in spiders or in plants or whatever, and they are all underpinned by the same technology platform. But individual research groups do not need to use those technologies 100% of their time, they just jump in and out when their research dictated the need. So the best way to do it, is actually to put all of these technologies in one place.13The Technology Facility in the Biology Department at the University of York in the United Kingdom is an early example of this trend towards centralization around the technological repertoire in biology.Such facilities give researchers access to otherwise unavailable technologies, shaping the character of their research and keeping them competitive with industrial research efforts. The central idea behind this center is not only the sharing of costs, but also the development of professional operational skills. With the growing complexity of instruments, the knowledge and skills required in using them increases, and operational expertise becomes evermore crucial. Nowadays, it is often a full-time job to keep up with the latest technology developments, thus requiring specialists. Therefore the Technology Facility in York does not only concentrate technologies, but expertise and training as well. Moreover, the center propels new collaborations as scientists with different research aims, skills and backgrounds get together through their need to use the same techniques, sharing their experiences and expertise in the process.14The third movement does not aggregate or concentrate research in biology but links researchers into networks. Building on the exchange of research material, and in interaction with the integration of information technologies and the informatisation of biology research , a netwoIn sum, the three organizational movements surrounding technology in biology resemble only partially the organizational configurations in big physics. On the one hand, (inter)national aggregation around larger instruments and local centralization around complex and expensive instruments resemble centralization in physics, although on a smaller scale. On the other hand the networked character sets big biology apart. Although in large-scale physics research the analysis of data now takes place in international dispersed networks as well, these network structures are still built around centralized experiments for data generation which makes it different from the network structures in biology in which both data production and analysis is dispersed.From the various organizational movements in biology it becomes apparent that not only technological developments have influenced the growth of research. Funding organizations have played a role in shaping connections between different disciplines and provided for the development of new ways to organize research, locally and in an international context. The political movements towards national concentration of research on the one hand, and the creation of the European Framework Programmes and the European Research Area on the other hand, have contributed to increasing scales in life sciences research. In addition, competition and cooperation with industry influenced academic research arrangements. Thereby, individuals play an important role, for instance in reshaping the local organization of research in line with international developments, connecting local, national and international levels. However, not only the internal dynamics of science shape research arrangements but also external factors influence big science complexes, and big biology can only be understood in the light of the social environment in which it emerged.While big physics emerged in the early twentieth century and was conceptualized in the 1960s, it was not until the end of the twentieth century that large-scale research arrangements in biology became prominent. These two periods are quite different in terms of international relations and the ordering of societies, and also with respect to the place of science in society, influencing specific forms of big science. After discussing the societal context in which big physics emerged, I will show how in the second half of the twentieth century a shift can be observed towards research into life, which grew big in quite a different societal context. Differences discussed will include the context of emergence, and focus on relations to government industry and society, as visible in Starting with a focus on the context in which big physics emerged, we have to look at the interbellum in the United States as well as the subsequent World War II and its aftermath. More specifically, Although the Manhattan Project is frequently named as reference point for the emergence of large-scale physics, it is important to note that not only its emergence can be traced back to an earlier time, but also that the term, big science’ was coined after the war. Therefore, big physics should not only be understood in the context of World War II but also in the context of American society in the 1960s. In this after-war period the project of modernization continued, while important transformations took place in the relationship between science and society. During wartime governmental investments in science increased enormously, but also strengthened the political grip on the direction of scientific research. The end of the war was therefore seized as an opportunity to renegotiate the relation between government and science . The socInterestingly, a clear connection exists between big physics and big biology. As investments in physics became controversial—first due to the devastating power of the Atomic Bomb and later because of the debate on Nuclear Energy—large-scale research in physics had to reposition itself, which also resulted into the incorporation of biology research. National physics laboratories in the United States started to include research into life in their strategy, as this brought less controversial societal benefits and also fitted increasing attention for environmental pollution. Consequently, the large-scale research organizations for physics gave a new impetus to biology research, which continues to the present day . MoreoveIn the meantime, the position of science in society has also changed substantively, shaping the creation of large-scale biology. National governments have mostly shifted from centralized steering to the decentralisation of power with a neo-liberal approach in a globalized world order . The traIn addition, big biology research has been an important factor in the broader movement towards the embedding of science in society . Within this post-war context, an organization like CERN was able to create a solid organizational machinery. Over time they acquired extensive lobbying experience, which assists them in continuously securing political support, funding, and hence sustainability. As a result, CERN still proves politically robust as it is impossible for individual countries to withdraw from the international organizational formation of CERN. So the continuous funding of traditional forms of big science is primarily an effect of their established bigness: once big science is build, it is difficult to break it down again . Or as aIn the concrete case of supersizing systems biology, it becomes apparent how complicated the building of large-scale biology in contemporary society actually is. Systems biology is an integrative approach that aims to synthesize information on different components of life into models that mimic cellular or organismal processes, organs or even whole living organisms, in order to understand, calculate and predict life . As the building of models of life requires multi-disciplinary collaboration, critical mass, and international standardization, scientists argue that the scale of collaborations should even exceed the Human Genome Project. As such, and in the process of establishing this new research approach, life scientists have lobbied both inside and outside the scientific community, convincing fellow scientists, politicians and policymakers, as well as industry, of its importance . HoweverInitially, many scientists were skeptical of the aims and ambitions of systems biology (e.g. Plasterk 1993), but now the label figures in different types of research , is firmReasons for this fragmentation of research can be attributed to the division between scientists and their approaches and a lack of (inter)national scientific coordination as well as to the fact that science policy mostly gets shaped at national level, resulting in local funding. While some scientists are content with the current fragmentation and relatively small-scale efforts, others continuously try to scale-up, searching for appropriate sources of  funding .In general, the temporary character of investments in large-scale biology distinguishes it from big physics, which is based on long-term funding investments in large instruments. Following the sequencing centers, national investments in large-scale biology have repeatedly taken the form of temporary projects or new centers—for example centers of systems biology and synthetic biology—funded over periods of five years, a time that is more in keeping with the political than the scientific cycle see also . As therAs already becomes apparent in the attempts to scale-up systems biology, it is difficult to find funding for large-scale international research projects. We are living in a globalized world where—and this is particular true in the scientific realm—internationalization prevails. Yet at the same time large-scale research projects that go beyond national and regional (e.g. European) borders report difficulties in finding funding . While oChaetognatha (arrow worms) pointed out: “This kind of collaboration has great additional value as people in Europe and the US have different specializations that we can now bring together which gives us new insights”.A good example of a project confronted with the problems of international collaboration is the Census of Marine Life (CoML). This large-scale international project dedicated the first decade of the twenty-first century to assessing the diversity, distribution, and abundance of marine life in the past, present and future . With anWhen comparing the problems of global expansion in current large-scale biology with big physics, it becomes clear that while research has become increasingly internationalized, science policy and especially its funding schemes have not been able to keep up with this trend. Big science is primarily a product of American society and initially did not cross national borders. As the United States is in itself quite big, it has been able to build big physics and large-scale space programs within its national borders during a time when science was used to create national power on an international playing field. However, big biology becomes big in a time when research is very much an international endeavor, while countries are still only prepared to fund national research, and only few scientific funding organizations have agreements to co-fund international research. Through its political, economic and scientific integration the European Union has also acquired a space that allows large-scale international research, but due to its cooperation structures scientific collaborations need to be formed within pre-defined spaces and timeframes, which do not always match with scientific requirements. Moreover, scientific projects funded by the European Commission need, in accordance with European Law, to contribute to innovation.The gap between international orientated big biology and national orientated funding obviously complicates the building of large-scale biology research. The more so as big biology with its distributed network character is more globally spread than the more centralized big physics. Although this network shape can also be turned into an advantage, since nodes of the network can ask for national funding in the country, creating a patchwork of projects that come together at international level, this strategy also has its drawbacks. First, the experience of CoML shows how additional funding for international coordination is the basic prerequisite for such a patchwork approach. In the case of CoML coordination funding came from the Sloan Foundation, but charitable funds are not always available and often only support specific types of research. Secondly, the patchwork approach excludes countries that have no national funds available for the research topic. In the case of CoML this implied that some important areas of marine biodiversity, most notably around Africa and South-America, could not be covered, thus affecting the research results. Finally, and due to all national research agencies having different requirements, the patchwork consists of a variety of projects with different stakeholders, methods and goals, as well as different timing and coverage of space. This diversity makes the harmonization of research difficult or even impossible. While CoML managed to solve this problem, as the database constructed is a quite loose form of research integration that accommodates the inclusion of various forms of research results, in the case of systems biology such a lack of harmonization is problematic when aiming to construct a functioning model of life, which requires a uniform research processes and standards.Another obstacle in big biology relates to the ways in which expectations of science have changed over time, as reflected in requirements for research funding. The solid organizational machinery of classic forms of big science was built in times of the old social contract, when the strong belief prevailed that basic science would lead to societal progress. In contrast, nowadays science is expected to present a clear concept of the economic and social benefits of its research for the public good in order to get funding  applications of their research. And while they are often able to invoke substantial potential impacts on the improvement of health, nutrition or environment, they also have to address failed promises and ethical issues. As a result system biologists, for instance, not only need to demonstrate the benefits of their own research, but must also explain how their promises will turn into reality, despite the fact that the Human Genome Project did not realize its promise of finding cures for all major diseases. In addition, they need to foresee ethical implications of their research in order to find ways to deal with these issues in a proper way, although these issues are rarely straightforward and often difficult to profess.For instance, the Dutch Genomics Initiative that was in charge of improving genomics research in the Netherlands, decided to fund so-called,innovative research projects’ which require industry to formulate the research question and lead the research consortium . So whenIn the summer [of 2003] we already knew that we were in second position concerning the science review of about seventy projects that would eventually get funded, so we knew we had a very big chance. But it took almost a year before we actually got the letter that we could start. That was around March or April 2004. And to make matters worse, we had to start retro-actively in January.27Yet, the VIRGO case shows how this requirement for innovation might also distract from performing good research that is applicable. To adapt to funding requirements, the virology research had to align with practices in both government and industry, which influenced scientific practice.If you can predict what will be the result of your research, you do not have to perform the research anymore […] And they want it [the number of patents] specified per year. It is like having to predict in which city you will live 10 years from now and also knowing in which street and at which number […] If I already knew, I would not be working in academia but I would work as an adviser to a company.28This also meant that the first evaluation took place just after the project started with the review report stating: “The Committee were really only able to review planned activities and preliminary data. Productivity for all Work Packages was impossible to assess” . Moreover, the emphasis of the Netherlands Genomics Initiative on innovation even made them ask the expected amount of patents from the project, neglecting the unpredictable character of research: As these difficulties of the innovative project VIRGO exemplify, possessing the potential for innovation may also complicate the establishment of large-scale research projects as well as the research practice.Moreover, the requirement to innovate fuels competition between individuals and groups, which can be an obstacle to collaboration. This became apparent for instance, through a largely empty database within a European Framework project on systems biology. While the sharing of data is a key objective when wanting to model life, the career of post-docs working on the experiments is depending on their ability to publish first-authored papers in good journals, something that can only be done based on sound and exclusive data showing innovation. As such, they are reluctant to share their data, and rightfully so, as their future is hanging in the balance.Miroslav Radman, a successful Croatian life scientists who works in the TAMARA lab in France and has set-up the Mediterranean Institute for Life Sciences in his homecountry, made an analogy between the collective performance of science and music.Taking this metaphor of big science as a big band or a symphony orchestra a step further, reveals that in both cases not only the musicians or the scientists are important, but that also the environment in which they act is crucial. The quality of the music does not only depend on the musicians and their instruments, but also on their musical education, the repertoires available, the skills of the conductor, the form of the building in which the music is played, the interest of the audience, and the cultural atmosphere of the country in which the orchestra is based. The same applies to big science. The character of big science is not only determined by the number of scientists involved, the amount of money invested in research, or the size of the instruments—scientific ensembles are also influenced by the subject of research, the questions they ask, and the social and political environment in which they are embedded.As such, and as I have argued in this chapter, taking a big science perspective, makes it possible to compare the construction of large-scale collaborations in biology to similar movements in other fields, not only comparing different types and structures related to epistemic differences, but also comparing specific forms of historical and cultural situatedness. By emphasizing this interplay between science and its context, the analysis of biology through the lens of big science, also exposes specific difficulties in the interaction between the building of large-scale biology and the contemporary societal context. Consequently, the concept of big science can improve the understanding of the dynamics of large-scale collaboration in biology and other research areas and still be a valuable addition to the contemporary studies of scientific collaboration e.g. .


Apis mellifera L.) are frequently used in agriculture for pollination services because of their abundance, generalist floral preferences, ease of management and hive transport. However, their populations are declining in many countries. Agri-Environment Schemes (AES) are being implemented in agricultural systems to combat the decline in populations of pollinators and other insects. Despite AES being increasingly embedded in policy and budgets, scientific assessments of many of these schemes still are lacking, and only a few studies have examined the extent to which insect pollinators use the floral enhancements that are part of AES and on which floral components they feed .Honeybees (Phacelia tanacetifolia in the field, collection of pollen pellets from hives, and pollen identification, to assess the value of adding phacelia to an agro-ecosystem to benefit honeybees.In the present work, we used a combination of observations on honeybee foraging for nectar/pollen from the Californian annual plant It was found that phacelia pollen was almost never taken by honeybees. The work here demonstrates that honeybees may not use the floral enhancements added to a landscape as expected and points to the need for more careful assessments of what resources are used by honeybees in AES and understanding the role, if any, which AES play in enhancing pollinator fitness.We recommend using the methodology in this paper to explore the efficacy of AES before particular flowering species are adopted more widely to give a more complete illustration of the actual efficacy of AES. Apis mellifera L.) are used most frequently in agriculture for pollination services because of their abundance, generalist floral preferences, ease of management and transport of hives, and revenue-generating by-products  (Paenibacillus spp.)  , pathogeus spp.) , fungal   have been developed to mitigate some of these declines in ES, and this paper provides an illustration of how the value of such schemes for pollinators can be better assessed.In response to pollinator population declines, the European Commission has recommended programmes aimed at improving pollinator fitness and efficacy as part of the wider fiscal policy of AES. Originating from the 1980s to protect biodiversity and important cultural areas in England, these schemes attempt to inform landowners and policy makers on methods to manage land sustainably and enhance ES . IncludeBombus spp.) benefited from wildflower mixes and mixes of flowers with known high-quality pollen and nectar through increased abundance and species richness. However, this study did not examine how the Bombus spp. used the added floral resources and whether the bumblebees preferred the added flowers. This raises a key issue with studies of insect pollinators through floral enhancement schemes. These schemes often lack comparisons of how these insects use the added floral resources compared to the other surrounding flowers. For example, there need to be more studies assessing the extent to which pollinators ‘prefer’ particular added flowers, their relative use of pollen and nectar on each plant species visited, diurnal and seasonal use of the resource, the value of the added flowers for other beneficial arthropods, and any associated ecosystem disservices  if these potential AES are to be adopted .Despite AES being increasingly embedded in policy and budgets, scientific assessments of many of these schemes still are lacking, such as quantifying the type, extent and quality of ES actually delivered . Also, f adopted . Our stuPhacelia tanacetifolia and collection of pollen pellets from nearby hives to assess the value of adding phacelia to an agro-ecosystem to benefit honeybees.Farmers and policy makers need to have a clear and straightforward way to assess the values of AES implemented on farms. In the present work, we used a combination of observations on honeybee foraging for nectar/pollen from Honeybees were used here not only because of their agricultural importance, but also because of their distinct foraging behaviours. Individuals collect pollen by gathering the grains from the anthers of flowers and they use nectar to keep the grains together. They carry the pollen in pollen baskets (corbiculae) on their hind legs, forming pellets of pollen grains . These bThere are a few studies that explore the use of AES by honeybees and the potential ways in which they benefit from them. Here, we used phacelia as a potential supplementary floral resource because this species is commonly included in florally-enhanced field margins AES . It is aP. tanacetifolia cv. Balo 8 m long and 1.5 m wide was sown every two weeks to ensure a continuous flowering period of at least six weeks. The honeybee hives used for this experiment were located about 25 m from the sown flowers. Two healthy hives with queens of similar age of 1–2 years old (determined by the beekeeper) were chosen, as the age of queens affects the pollen demand of the colony and thus the extent of pollen foraging . A single strip of foraging . While tPollen traps  were insThe pollen pellets from each of the hives were collected at the end of the 2-h period and placed in separate 25 mL containers and stored at −20 °C to eliminate fungal growth. The pollen pellets from one of the hives during one of the 2-h periods was considered to be one sample.P. tanacetifolia pollen and no other known flowers in the area were thought to produce purple pollen. To confirm that the purple pellets collected really did comprise phacelia pollen, DNA barcoding with ITS primers was used to verify the species identity of the P. tanacetifolia pollen pellets.The pellets in each sample were weighed together and counted. The purple ones were separated from the others using forceps and placed in individual tubes, as the purple colour is indicative of P. tanacetifolia by honeybees was examined through the pollen brought back to the hive and through the worker bees’ behaviour in the field.The extent of the use of 2 area over 5-min periods at 10:00, 12:00, and 15:00 for ten days between mid-December to end of January depending on weather conditions. Bumblebees were also visually counted to see whether other pollinators were also foraging on the phacelia. Twenty flowers of P. tanacetifolia were chosen randomly and the quantity of pollen on the anthers was scored; the scoring scale is shown in P. tanacetifolia flowers were also scored using the four stages defined by The numbers of honeybees foraging for nectar and pollen, respectively, were observed visually and counted in a 10 mP. tanacetifolia flowers blooming changed throughout the experiment because of the sequential drilling, honeybee counts were divided by the area of flowers present on each date.Since the area of For the pollen pellet collection experiment, we analysed the count data to determine whether the total number of phacelia pollen pellets collected was significant compared to the total overall number of pellets. For our field observation experiments, to see if the number of honeybees foraging for nectar differed from the number of honeybees foraging for pollen, we used a paired two-tailed t-test. To test whether the number of honeybees foraging for nectar and for pollen varied with the time of day, the maturity of the flowers, and the amount of pollen on the flowers, a mixed effects linear model was used to account for the day on which the observations were taken. The data were bootstrapped to determine the 95% confidence intervals around the data. Likelihood Ratio Tests were used to determine which of these factors (if any) was significant for pollen and nectar foraging bees. We also used a mixed effects linear model to test whether the total number of bees foraging for both nectar and pollen was affected by the time of day, maturity of the flowers, and the amount of pollen on the flowers. We used a Likelihood Ratio Test again to determine whether these factors were significant overall. The R software program was used to explore and analyse the data .P. tanacetifolia pollen pellet was found in a total of 23,431 pellets collected. The results of the DNA barcoding analysis confirmed that the purple pellet was from P. tanacetifolia. A preliminary DNA barcoding analysis of other pollen pellets showed that the honeybees also collected pollen from clover (Trifolium spp.), dandelion (Taraxacum spp.) and brassicas (Brassica spp.). No statistical tests for significance were run on these data as the number of P. tanacetifolia pollen pellets was negligible.Only one P. tanacetifolia pollen collected by honeybees is supported by the observations of their foraging behaviour in the field. Using a two-tailed t-test, the number of honeybees foraging for pollen was significantly lower than the number of those foraging for nectar . P. tanacetifolia, they readily use the flowers for nectar.The virtual absence of The boxplots in The results of Likelihood Ratio Test from the linear mixed effects model of number of pollen-foraging bees modelled by time of day showed that time was not significant  although there was a decrease in the number of pollen-foraging bees at 12:00 and 15:00. Neither pollen amount nor flower maturity had a significant effect on the number of pollen foragers .For the linear mixed effects models of nectar-foraging bees, the results of Likelihood Ratio Test for time of day showed that time was not significant  although there was a decrease in the number of nectar-foraging bees at 12:00. Flower maturity did not have a significant effect on the number of nectar foragers  and there was not a noticeable trend in the data either. For pollen amount on the flowers, there was a trend with increasing numbers of nectar-foraging bees with higher amounts of pollen; however this trend was not significant .For the linear mixed effects models of the total number of foraging bees (for both pollen and nectar), the results were similar to that of the nectar-foraging models. The results of Likelihood Ratio Test for time of day showed that time was not significant  although there was a decrease in the number of foraging bees at 12:00 and 15:00. Flower maturity did not have a significant effect on the number of total foragers . For pollen amount on the flowers, there was again a trend with increasing numbers of foraging bees with higher amounts of pollen; however, this trend was not significant .AES are being implemented in agricultural systems to combat the decline in populations of pollinators and other insects, such as butterflies, as well as birds and mammals . The worP. tanacetifolia, are supported by the study by P. tanacetifolia in an AES context. However, P. tanacetifolia is used in crop margins in AES because its pollen has a high protein content and that this resource, as well as its nectar, can improve the fitness and longevity of insects  is that this plant was a limited resource. Because honeybees as a colony tend to prefer to forage on the same species of plant when it’s in high densities (P. tanacetifolia may not have been a large enough resource to provide a large or consistent enough reward to the honeybee colonies. To test whether this plant can be a limited resource or is of inherently low preference by honeybees, it should be planted as a mass flowering crop, as recommended by 2 of P. tanacetifolia strips in a 5 km radius around honeybee hives, from which pollen was collected. That study found as much as 32% of the pollen that was collected from the hives was from the P. tanacetifolia strips, which supports the mass flowering idea.Another explanation for decreasing foraging activity later in the day (and for low rates of foraging on ensities , the P. Use standard and repeatable field observations of how pollinators use the added floral enhancement in the field.Identify the pollen that foraging bees bring back to the hive to determine the main plant species on which the bees forage and the extent to which pollen comes from the added floral resources.It follows that AES may be of limited efficacy for honeybees because of floral area; most that have been implemented are not appropriately monitored and evaluated to test for effects of floral area planted on the response of insect pollinators . For exaComponents 1 and 2 above were addressed in this study and were crucial for identifying how the honeybees were using the phacelia. By including observations of honeybees in the field and quantitative data from pollen brought back to the hive, scientists and stakeholders can determine the extent to which the honeybees were using the floral enhancements mainly for pollen or nectar, whether there were any temporal trends, and for which plant species the insects were mainly foraging.An assessment of ‘fitness’ should also be considered as a component of long-term AES assessments, especially because these schemes have been proposed to enhance pollinator fitness. Such fitness improvements, or proxies for them, are most likely to be expressed in female worker bee numbers, the quantity of honey stored, survival rates in the colony through winter, and the extent to which the colony produces swarms in the spring. Assessments focussing on unmanaged or wild bees such as bumblebees, should make us of fitness indicators suitable for these particular species.P. tanacetifolia, found that the insects hardly use the flowers as a pollen resource although nectar was readily taken. This work lays the foundations for future research aiming to evaluate the benefits of particular AES and other schemes which aim to enhance on-farm functional biodiversity. We provide a framework for the experimental design and analysis of the actual benefits to pollinators and other beneficial insects. Increased understanding of how pollinators use these potentially high-quality floral resources added to landscapes will lead to better-designed pollinator enhancement schemes and potentially higher fitness and populations of pollinators.The experiments here, which examined honeybees’ use of 10.7717/peerj.2677/supp-1Supplemental Information 1Data was collected at our field site at 10:00, 12:00, and 15:00 and the plot size of flowering phacelia was recorded in square meters. The following environmental variables were measured: cloud cover, temperature, wind speed, and soil moisture. Estimates of Flower Maturity and Pollen Amount were made using Click here for additional data file.


Computerised, population-based vaccination registers are valuable tools for assessing the vaccine uptake and impact in populations. However, reliable impact assessment is only possible if the data quality can be reviewed and monitored continuously. This report describes the establishment and maintenance of the National Vaccination Register (NVR) in Finland. Currently, the NVR covers nationwide records of vaccinations given within the frame of the National Vaccination Programme since 2009. All vaccinations registered in the NVR contain a record of the personal identity code, the administered vaccine, and the date of vaccination. The vaccine lot number is the key component for recording and identifying vaccinations, because of its broad availability across patient information systems and its importance in vaccine safety monitoring. Vaccination records are accumulated and updated daily into the NVR, and their completeness is monitored monthly to assess deficiencies in data entry and data collection. Additionally, an alert system reports unexpected changes in data accumulation prompting the validation of observed changes in vaccination coverage. The presented process documentation may serve as basis to improve the design and quality of other vaccination or healthcare registers and aims to inspire the set-up of vaccination registers in those countries which still do not have one. Computerised, population-based vaccination registers are valuable tools for assessing the vaccine uptake in populations in real-time. The performance of dynamic vaccination programmes can be evaluated, time trends monitored, and sub-populations with low vaccination coverage identified. Most importantly, by linking individual-level vaccination records with other medical records and health outcome databases, the impact of vaccines – both effectiveness and safety – can be studied comprehensively. This in turn will aid in formulating the best possible vaccination programmes.The need for a National Vaccination Register (NVR) was recognised in Finland already in the late 1990´s and the Finnish vaccination decree of 2004 , and theThis report describes how the National Institute for Health and Welfare (THL) established the NVR in Finland. The presented process documentation may serve as a basis to improve the design and the quality of other vaccination or healthcare registers. Moreover, the aim is to inspire the set-up of vaccination registers in those countries which still do not have one.Finland has a population of 5.5 million and an annual birth cohort of ca 55,000  are purcFinnish HCCs have adopted computer-based recording of patient files since the early 2000s. In the mid-2000s, nearly all HCCs were using electronic patient information systems . HoweverAs part of the nationwide eHealth information architecture  developeBoth the Finnish and the European Medicines Agency mandate a lot-level traceability for purposes of vaccine safety monitoring . The impIn this study, nationwide vaccination data collected from the HCCs’ patient information systems were linked to information from patient files collected from Finnish hospitals and reviewed by sleep disorder experts. Certain lot numbers occurred more frequently in patients who had developed narcolepsy . HoweverBased on these experiences, the vaccine lot number was recognised as the key content for identifying vaccinations in the NVR.The implementation of the NVR was guided by two principles: (i) to avoid double entry of data and (ii) to avoid double collection of data. The vaccination records in the NVR were therefore designed to be collected directly from the patient information systems and as part of other pre-existing nationwide register collections .In the late 2000s, in order to expand the accessibility of nationwide health-related information, THL initiated a project to collect nationwide information about primary healthcare visits and subsequently established the Register of Primary Health Care Visits (Avohilmo) as part of its statutory duties . The firThe definition of Avohilmo’s data content has been evolving over time and all vaccinations given within the public primary healthcare system are covered. Each software company designs the data entry into its patient information system software following its own guidelines concerning the use of coding and field validation rules. The process of extracting the data from the patient information systems and submitting them to Avohilmo at THL is fully automated and instructed to be dispatched every night, comprising new primary healthcare visit records and updates to existing primary healthcare visit records each time. The submission pace, i.e. the time interval between the day of submission and the day of vaccination varies between HCCs. In 2015, 84% (129/153) of the HCCs were submitting vaccination records in near real-time, which was defined as a median submission pace of 7 days or less.Avohilmo receives the patient information in batches. With regard to vaccinations, these batches contain new and updated records as well as duplicates of old records, i.e. records previously received from another HCC. At THL, the vaccination records  are extrThe default variable for identifying the administered vaccine is the lot number, because of its importance in vaccine safety monitoring  and its Matches over a certain level (data-driven set to 0.7) that unambiguously match against the known lot numbers of one vaccine are interpreted as successfully identified. If this identification process fails, the record of the trade name is used and evaluated by exact string matching including common spelling variations.Vaccination events are defined as unique combinations of three key variables: (i) personal identity code, (ii) identified administered vaccine, and (iii) date of vaccination. The record describing the vaccination event that was received first is kept for further processing and analysis.In addition to establishing nationwide coding standards, collaboration with the patient information systems’ software companies is pivotal, since they are responsible for designing the data retrieval based on their patient information systems, and for creating the data format for data transfers. In spring 2010, the collaboration was initiated by reviewing the data entry in each of the patient information systems. In autumn 2010, THL piloted a retrospective data collection of vaccination records as part of a planned nationwide collection of pandemic influenza vaccination records via the patient information systems’ software companies. This data collection was also used by THL to assess the availability, completeness, and quality of the available information. Subsequently, three additional retrospective data collections have been conducted in 2011, 2014, and 2015, respectively, covering all vaccinations, but limited to certain HCCs and time periods. By incorporating the retrospective data collections through the same record linkage steps that are applied to the Avohilmo data, the NVR currently covers nationwide records of vaccinations given in Finnish HCCs since 2009 .Guidelines for recording vaccinations are available online . The recCurrently, for any feedback from the HCCs or staff involved in the patient information systems, a NVR contact person can be reached via phone and email. Thus, feedback can be evaluated promptly and questions may even be answered immediately. Feedback is also exchanged during four to 12 annual field visits in the HCCs by teams composed of experts from the NVR, Avohilmo, and THL’s Vaccination Programme Unit. These visits are used for both education and guidance of healthcare professionals and investigation of deficiencies in data quality. Often including also representatives of the software companies, these joint dialogues have led to HCC-specific modifications in the recording conventions, as well as to software interface changes that have made the recording of vaccinations easier, more complete, and less error-prone.Moreover, THL organises monthly web-based seminars for those working with vaccinations. Depending on the topic, reminders on the need for accurate data entry and the different ways of using the data are covered during these seminars.Haemophilus influenzae type b (five-in-one) and measles, mumps, and rubella (three-in-one) vaccination visits and the number of children younger than 2 years living in the municipalities served by the HCC is calculated. The rolling 6-month average of these ratios is compared with a fixed cut-off, one for each ratio [From the start of the NVR, completeness of vaccination data has been investigated in order to assess deficiencies in data entry and data collection. Nowadays, the completeness of vaccination data is routinely monitored every month for each HCC  (i) for ch ratio . The choAdditionally, an alert system has been deployed that reports monthly unexpected changes in the HCCs’ reporting behaviour based on those ratios. Taking into account each HCC’s median submission pace of the last 30 days, it checks the data completeness of the last month and produces a list of HCCs with an insufficient amount of documented vaccination events. This system is devised to react early to systematic data entry and data dispatch problems. The development of the alert system has largely been guided through experience.In autumn 2012, after an update to one patient information system software, all vaccination records of newly and recently born children were accidentally omitted from real-time data submissions in the HCCs using that particular software. At this time, only one general indicator for vaccination data completeness similar to the first one described above (i) was available, but not regularly checked. Since records were still accumulating for the rest of the population served by these HCCs, it took several months to detect this deficiency, which led to the implementation of a more elaborate alert system including the indicator for childhood vaccination data completeness (ii) and automated, monthly alert reports. In spring 2014, a similar situation occurred affecting adolescent human papillomavirus (HPV) vaccinations after an update to another patient information system software. This time, the alert system was able to point out the anomaly in less than two months. After both incidents, the respective software companies were contacted and retrospective data collections were conducted in order to fill the identified NVR’s gaps.Starting with autumn 2013, THL has been reporting annual nationwide and HCC-specific vaccination coverage figures of the Finnish childhood vaccination programme, adolescent HPV vaccination programme and seasonal influenza vaccination programme  Figure . These aData on the absolute count of vaccinations are included in the reports as well, allowing a direct comparison with the HCCs’ own records. In addition, summaries of the vaccine identification process  are sharMoreover, the amount of incoming vaccination data is monitored weekly and internal online follow-ups provide near real-time vaccination coverage information for all vaccines and age groups.The constantly reshaping administrative areas  and the The vaccine lot number is used as the key variable for identifying the vaccine. From the coding point-of-view, the lot number is a suboptimal choice for vaccine identification, because it is not feasible to develop a pre-coded data entry for the lot number in the patient information systems. Instead, free text is required. A potential improvement would be to use barcode readers, but unfortunately vaccine manufacturers do currently not include the lot number in the vaccines’ barcodes in Europe. However, with the listed four quality control mechanisms in place, the quality of computer-based recording of NVP vaccinations in Finland has improved to a degree that almost all vaccines are currently identified on a lot level .When collecting a large amount of real-time data in an automated fashion, and from several data providers and software systems, special attention is required to detect any anomalies in data. Any unexpected changes in the process of data entry and data dispatch can lead to inadvertent omission of records, as exemplified by the problems experienced during the first years of the NVR. In order to detect these changes, an alert system has been deployed. However, since it is not possible to anticipate all possible anomalies, developing and maintaining the alert system based on previous experience, is a continuous process.Maintaining the NVR also requires continuous interaction and dialogue with the HCCs. A pivotal tool for such interaction is permanent provision of reports that summarise vaccination records at HCC-level. Due to regional and temporal gaps in the completeness of the data, only periodical  reporting has been employed so far. However, the plan is to gradually move towards continuous reporting. Continuous reporting was piloted during the influenza season 2015/16, when the accumulation of influenza vaccinations documented in the NVR was reported weekly on a public THL webpage , and is At the moment, the NVR contains vaccinations given within the public primary healthcare system. However, Avohilmo is currently being expanded also to the private primary healthcare. Furthermore, other national registers like the Hospital Discharge Register and the Medical Birth register are being prepared to include also vaccination information into their data content and collection. The purpose of these additions is to include also vaccinations given in hospitals and at birth clinics into the NVR.In parallel with the efforts to add the collection of vaccination records into other national registers, a project has been initiated, which explores the possibility to utilise the recently established Finnish National Patient Archive (Kanta) . Kanta iConstant monitoring of the quality of a population-based vaccination register is a prerequisite for a continuous and reliable evaluation of both the vaccine uptake and impact on a national level. The presented quality control measures developed to monitor the validity of NVR data in Finland have proven useful to improve the quality and completeness of the register. Thus, this process documentation may serve as a basis to improve the design and the quality of other vaccination or healthcare registers.


Objective: To describe patient satisfaction with pre-hospital emergency knowledge and determine if patients and professionals share a common vision on the satisfaction predictors. Methods: A qualitative study was conducted in two phases. First, a systematic review following the PRISMA protocol was carried out searching publications between January 2000 and July 2016 in Medline, Scopus, and Cochrane. Second, three focus groups involving professionals  and a total of 79 semi-structured interviews involving patients were conducted to obtain information about what dimensions of care were a priority for patients. Results: Thirty-three relevant studies were identified, with a majority conducted in Europe using questionnaires. They pointed out a very high level of satisfaction of callers and patients. Delay with the assistance and the ability for resolution of the case are the elements that overlap in fostering satisfaction. The published studies reviewed with satisfaction neither the overall care process nor related the measurement of the real time in responding to an emergency. The patients and professionals concurred in their assessments about the most relevant elements for patient satisfaction, although safety was not a predictive factor for patients. Response capacity and perceived capacity for resolving the situation were crucial factors for satisfaction. Conclusions: Published studies have assessed similar dimensions of satisfaction and have shown high patient satisfaction. Expanded services resolving a wide number of issues that can concern citizens are also positively assessed. Delays and resolution capacity are crucial for satisfaction. Furthermore, despite the fact that few explanations may be given due to a lack of face-to-face attention, finding the patient’s location, taking into account the caller’s emotional needs, and maintaining phone contact until the emergency services arrive are high predictors of satisfaction. In the 1950s, Koos  laid theThe concept of satisfaction has been related to attitudinal aspects, wherein the components had a distinct value depending upon the patient’s personal situation, and it was conceptualized as the result of the difference between how the patient had been attended to and his expectations about what such care should have been like . Until wStarting in the 1970s, patient satisfaction measures spread throughout the health services ,5, commoThe number of studies published regarding the satisfaction of patients who have accessed pre-hospital emergency services is limited considering the large numbers of patients who annually utilize this service . AlthouThe aim of this study was to describe the knowledge about patient satisfaction with pre-hospital emergencies  and determine if patients and professionals share a common vision on the key variables for satisfaction.This is a qualitative study conducted in two phases. First, a systematic review of the literature was carried out to identify methods applied to assess patient satisfaction with pre-hospital emergencies via the use of emergency telephone numbers  to request medical assistance or information from pre-hospital emergency services and search for improvement opportunities from their results. Second, three focus groups and a total of 79 semi-structured interviews were conducted to obtain information about what dimensions of care were a priority for patients and professionals . Dispatchers were trained to offer support over the telephone during an emergency. They use algorithms to make decisions and provide information or instructions. In this study, a pre-hospital emergency was defined as a demand for providing care for out-of-hospital health urgencies and emergencies. This includes telephone support, care provided in situ, and emergency healthcare transport. Pre-hospital emergencies are demanded by callers. Such callers are patients who dial the emergency telephone number (112 or 061) while in some cases, these calls are placed by others  who help the patient by calling, asking for support.The PRISMA protocol was followed to analyze published research, both in English and Spanish, on satisfaction of the patient (of any age) with emergency telephone assistance, requests for emergency assistance, and emergency transport to a hospital. Publications  indexed between January 2000 and July 2016 in Medline, Scopus, and Cochrane were reviewed by combining the following MeSH terms: emergency telephone number, emergency telephone call center, out-of-hospital emergency telephone, pre-hospital emergency telephone, caller satisfaction emergency, medical services, out-of-hospital emergency, pre-hospital emergency, and ambulance, which were combined with the Boolean operator along with caller satisfaction and patient satisfaction.The following inclusion criteria were established: research on any type of population, from elderly patients to parents of pediatric patients. Differences were not made based on the reasons for the call, pathology being dealt with, or who was making the call . All types of calls were included, no matter whether they were local, national, or international.Excluded research included studies dealing with hospital emergencies, those that only described or evaluated the clinical attention during some part of the process  without assessing the satisfaction of the attended user, those that described coordination mechanisms between units, those that assessed the satisfaction of professionals, and those that analyzed the quality of the decisions that healthcare professionals had to make .The studies were reviewed independently by two of the authors to decide whether they fulfilled the inclusion criteria using the titles, abstracts, or full article. The final decision was made jointly by both of them. Additional articles were retrieved from the reference lists of the articles found by the initial online search. From the articles selected, the following information was categorized: year, country, objective, method or measurement, sample, evaluated dimensions of perceived quality, and outcomes.This study, based on a qualitative research approach (using focus groups and semi-structured interviews), evaluated and compared the perspective of professionals with that of patients about what elements of perceived quality are most relevant for users of the services of the Sistema d’Emergències Mèdiques  of Catalonia.2. Its main access is via the telephone, with patients dialing 112 for emergencies and 061 for other health demands. The operational structure for the provision of this service includes a coordination center, 406 mobile units (326 basic life support and 80 advanced life support ambulances), and 4 medical helicopters.The Emergency Medical System is a public entity, dependent upon the Servei Català de la Salut , and is responsible for attending to, managing, and responding to demands for providing care for out-of-hospital health urgencies and emergencies in Catalonia. It serves 7 million people in an area of 32,000 kmIts coordination center is charged with taking and managing telephone calls. In 2016, it dealt with 1,473,609 cases, which was a 6% increase over 2015. Of these cases, 40.4%  were resolved without activating care resources, achieved by the consulting efforts and information provided by the professionals there. In patient care by pre-hospital emergency systems, two areas can be clearly differentiated: distance care and on site care. Distance care is provided by the professionals at the call reception center. The range of activities carried out at this level varies depending upon the central model. In the specific case of the SEM, these would be the following: taking the call, locating the patient, and triaging the situation with a computerized protocol. These functions are taken care of by the dispatchers, and based on the outcome of the initial triage, the call may be transferred to a second level of telephone dispatcher when the caller needs administrative information of a certain complexity; the call may also be transferred to health professionals, physicians, or nurses. This latter group asks about the patient’s medical history over the phone in accordance with some clinical procedures to better define the patient’s needs. The call may then finalize with the provision of health advice, or care in situ may be deemed necessary, resulting in the mobilization of a resource . When mobilizing a resource is deemed necessary, the coordination center decides upon the most suitable type depending upon the isochrone map and the patient’s pathology, it coordinates the activated resources, and when necessary, the transport to the health center, deciding which is most suitable depending upon its distance and saturation level, information that the coordination center has available at all times. On site care is that provided by the professionals from the teams of the care resources, ambulances, and helicopters. Once they reach the patient, care consists in learning the patient’s medical history, exploration, treatment and, if necessary, transport to a health center with care provided during the ambulance ride.Telephone calls by citizens are handled by two types of professionals: first there are demand managers (dispatchers), and then there are pre-emergency providers, and these include physicians and nurses. Dispatchers are responsible for taking calls, and after a short consultation with the caller and interaction using a computerized protocol, a response may be generated or the call may be referred to a second level of attention. These professionals have experience and have been trained on providing care for patients via telephone support platforms, and prior to working professionally at the SEM, they receive specific training on the tools to use, certain skills for telephone assistance in urgencies and emergencies, operational SEM protocols, and also on basic health knowledge. They also undergo continuous training. In the latter case, and provided the demand is for informative content, the call is attended to by a group of dispatchers who are not health professionals but nonetheless can spend greater time responding to the citizen in an appropriate manner. These types of calls make up the group of administrative consultations. Issues related to the services provided by the Catalonian Health Service are the main reason for telephone consultations, and in 2016, there were 211,702 such administrative consultations. In the event that a call referred to the second level corresponds to a consultation on a health urgency, the call is transferred to either a physician or a nurse (depending upon the content of the consultation). In 2016, there were 324,821 of these health consultations.Three focus groups were led by 23 professionals  and 9 professionals who provided care at the second level, urgent health transport). Sixteen semi-structured interviews see  were conTo select users who called SEM, a random sample of 264 callers who had used both the 112 and 061 services was identified from the CatSalut billing database. Of these users, 119 (45%) called for administrative or health consultations, and the remaining 145 (55%) requested urgent medical transport and were conscious when the care arrived in order to be able to report on the care they had received. Prior to conducting the semi-structured interview, each caller was asked whether they retained sufficient memory to assess different aspects of the quality of the service they had received. As such, 34 (13%) said that they did not retain sufficient memory of the events to report on the care that they had received, 41 (16%) were very active users of both emergency and non-emergency transport services but unable to assess the quality of both services differently, and 66 (25%) declined to participate in the interview.Ultimately, 63 callers (24%) participated in semi-structured interviews lasting 10–15 min; 33 of them had called for administrative consultations whereas the remaining 30 had dialed 061 for healthcare requests see . AdditioThe inclusion criteria included the following: be between 18 and 90 years of age and a caller of 061 in the preceding 6 months (September 2016–February 2017) for either an administrative or a health consultation. Those requesting emergency medical transport had to have called during the preceding year (2016) for the following possible varieties: advanced vital support (SVA), basic vital support (SVB), medical helicopter, rapid intervention vehicle (VIR), or the unit of continuous home care. Likewise, geographic origin was taken into account for callers of administrative and health consultations alike, as well as for callers requesting urgent health transport, since the territorial variable was a variable that could affect perception; thus, an attempt was made to distribute the sample in rural and urban areas.The search strategy produced 620 additional studies that were of potential interest for this study, and after reviewing their titles and abstracts, this figure was reduced to 67 . After cMost of the studies published on satisfaction with the telephone assistance provided by pre-hospital emergency services are of the descriptive variety (71%) that employed either surveys, questionnaires, or structured interviews with patients. Most of these were carried out in the United Kingdom (41%). Of the reviewed studies, 24% of them were systematic reviews of the literature, although not always using the PRISMA methodology. None of the published studies reviewed the overall care process; instead, they focused on parts of the process such as telephone triage, communications skills of the attending professionals, if the recommendations were ultimately carried out, and whether there was any follow-up.The most frequent origin for published studies on emergency healthcare assistance that included transport, normally via ambulance , was once again the United Kingdom (36%). The majority of these were descriptive studies (75%) that coincide in pointing out a very high level of satisfaction of callers and patients, although the fact of being attended to by various telephone dispatchers, technicians, or healthcare professionals during the same phone call is indicated in these as practically the lone cause for dissatisfaction. Delay with the assistance and the ability for resolution of the case are the elements that overlap in fostering satisfaction. No studies relate the measurement of the real time in responding to an emergency with the satisfaction of patients.The care elements that are recognized as generating confidence and professionalism include short wait times, receiving information on the reasons for the transport, the patient’s expectations coinciding with the action taken by the professional , and attending to both the physical as well as emotional aspects of the assistance. Studies that address the problems of language difficulties have not been found, for example, assistance for foreigners in tourist areas or cultural differences due to religion that require differentiated treatment, such as male/female relationships.Entirely all the studies on satisfaction with emergency services show that in all countries, continents, and systems, such as Malaysia, Japan, USA, Europe, and Australia, patients report feeling very satisfied with the dimensions evaluated in the instruments employed  ,13,14,15The patients  and professionals  concurred in their assessments about the most relevant elements for the patient when patients use the emergency telephone and also in the assessments they both made about said service . LikewisPatients generally know what telephone number to call in emergencies or when they need health information, and they use this telephone service correctly. In the same manner, both groups  agreed that the new communication channels  were not sufficiently known about or utilized, even for patients who usually accessed, due to their domestic situation, the emergency telephone number. However, the time required to resolve the call were higher when patients used 112 because this is a general entrance for all type of emergencies including health emergencies. Patients calling 112 usually needed to repeat the same information to a second professional.Both groups pointed out the delay by which telephone assistance is carried out as a critical criterion of quality, and the patients stated this was adequate. The professionals, for their part, properly sensed that the delay in providing care was key, and that the assessment by patients in this regard was positive. The main gap of having to repeat practically the very same information again and again when the phone call is transferred to different professionals during the same call was identified by both groups; one example of this is when the call is transferred after the patient has activated her medical alert button and already talked first to the providers of that service. Furthermore, in these cases, there could be sporadic delays or even waits before the physician or nurse returns the call a few minutes later (adjusted according to urgency).The professionals emphasized that if the caller was not the patient, obtaining reliable information was more complicated, and this aspect was also recognized by patients during the interviews.As for mobilizing resources , the impression conveyed by patients is that a delay in receiving assistance is the factor they valued most when judging the efforts by the emergency service and that, in all cases, the resource arrived quickly. The professionals agreed on that assessment, although they pointed out difficulties when the caller did not know about his location, or the problems of finding him in certain rural locations, especially mountainous terrain. Moreover, one variable that professionals pointed out that leads to delays in attending to the emergency call is when the caller is a tourist and does know exactly where he is; this makes pinpointing his exact location difficult.Another relevant aspect for patients is the professionalism in how the situation is handled, both when gathering information from the patient as well as when offering structured information in a logical and comprehensible manner. Patients assessed both of these aspects positively. Furthermore, the professionals correctly sensed the assessments that patients made. In general, the comments by patients who were interviewed indicate that they felt that they were correctly understood, including emotional aspects that accompany uncertainties during emergencies.Although patients did not indicate to be a problem the fact that telephone operators did not remain on the line with them once the emergency assistance request was made until the resource arrived at their location, the professionals did agree in pointing out that in this care, also attending to the emotional needs of patients entails a higher level of quality. Patients and professionals alike agreed in their assessments that the resources mobilized brought the appropriate means and professionals for dealing with the emergency care request and that, therefore, a suitable use of the means available was made. Patients and their companions (when applicable) received correct information about the patient’s situation, the treatment being administered, and where they were being taken.Patients did not pay special attention to the safety conditions during the emergency transport whereas professionals did value them and considered them important. However, the patients’ opinions about these conditions were that the transport was carried out correctly and safely. Callers of pediatric patients described how the transport went about for these minors (a child of theirs) in a manner that was consistent with the care protocol that the professionals described during the interviews for this young population. When the parents were aware of this protocol during the interview, they assessed it positively.Both groups agreed on this aspect as crucial for determining the quality of the care and in the positive assessments made by patients in this regard. There were many emergencies that were resolved in the same place as the incident . Thus, the capacity for resolving emergencies was not only related to safety and fast transportation to a hospital.The patients stated that the transport took place quickly and without incident, their personal belongings were not lost, and that in the transition to the emergency hospital personnel attending to them, teams there took charge of their care in the terms in which they had been informed. The professionals pointed out this transition as a critical point for patient safety and that the information between professionals and the patient should improve. The professionals also pointed out that a protocol should be applied to ensure that personal belongings are returned to patients.Treatment perceived as adequate, information about diagnosis, treatment and hospital to be transferred to, delays, conditions of transport, and capacity for resolution are the dimensions of patient satisfaction usually explored in the literature. More than 85% of patients are usually satisfied with pre-hospital emergency services, whereas repeating the same information when being served by several operators is a cause for dissatisfaction.The dimensions of satisfaction identified in this study coincide with those indicated in the literature as keys to the satisfaction of these patients. The results of this study have yielded new aspects to be considered, such as professionalism also including that the telephone operator is capable of finding the location from which the call requesting assistance is placed when the caller himself does not know where he is, and that the professionals also attend to the emotional needs of the person making the call.Patients, dispatchers, and healthcare providers share the crucial assistance and care quality perceived dimensions. The professionals correctly identify what patients consider crucial when receiving information or care and their level of satisfaction. These results also coincide that satisfaction with these services is very high. The expectancies of patients about emergencies are related to delays and resolution capacity while professionals considered other aspects related with safety, a dimension not considered by patients.Emergency services have expanded their services and offer agile and reliable information on a wide number of issues that can concern citizens and, for that matter, patients, such as resolving doubts about the correct use of a medication, information about how to correctly interpret a medical indication, knowing where to go when in search of health assistance, and requesting emergency assistance at home. This change has been shown to be useful and that it achieves a positive impact on the user population . The resFrom a methodological point of view, these results show that while the memory of the ambulance ride  remains over time, the same does not happen with memory when dialing 061 to obtain timely information, even during stressful moments. The reality is that, as was shown previously , users oThe result of studies on patient satisfaction have highlighted some of the predictors of satisfaction such as ,43,44,45There is a concentration of studies in Europe. The generalization of results to other countries might be limited as this uses a qualitative research approach. There was no random selection of professionals involved in focus groups. The assessments were not related with objective measures of assistance such as length of phone assistance, delays, claims or adverse events.As far as we have been able to determine, this is the first study that examines the entire care process that is carried out by emergency service providers, and it is designed to learn about what care aspects are relevant for patients and whether the professionals keep these dimensions in mind. Its qualitative methodology allows an alternative approach to that of survey-based studies and, as seen in this case, provides information for introducing improvements in the care process.Worldwide, there is high satisfaction with pre-emergency hospital services. The expanded services offering agile and reliable information on a wide number of issues that can concern citizens also yield high satisfaction. Pre-emergency patients, dispatchers, and healthcare providers share the crucial assistance and care quality perceived dimensions. The dimensions of satisfaction usually assessed include delays and resolution capacity that are crucial for fulfilling patients’ and callers’ expectation about this service. Finding the location from which the call requesting assistance is placed, maintaining contact with the patient until the emergency services arrive, and attending to the emotional needs of the person making the call are high predictors of satisfaction. These are key elements when callers (and patients) assess the professionalism of the dispatchers and the healthcare providers. Repeating the same information when being served by several operators is the principal cause for dissatisfaction.When satisfaction is assessed, the role of callers and patients must be considered because many times the callers cannot provide reliable information.This study describes some methodological issues to be considered when satisfaction instruments are developed and the gaps and strengths of the pre-emergency care that could contribute to improve the satisfaction of callers (and patients).