Watersheds are recognized as the most effective management unit for the protection of water resources. For surface water supplies that use water from upstream watersheds, evaluating threats to water quality and implementing a watershed management plan are crucial for the maintenance of drinking water safe for humans. The aim of this article is to establish a risk assessment model that provides basic information for identifying critical pollutants and areas at high risk for degraded water quality. In this study, a quantitative risk model that uses hazard quotients for each water quality parameter was combined with a qualitative risk model that uses the relative risk level of potential pollution events in order to characterize the current condition and potential risk of watersheds providing drinking water. In a case study of Taipei Source Water Area in northern Taiwan, total coliforms and total phosphorus were the top two pollutants of concern. Intensive tea-growing and recreational activities around the riparian zone may contribute the greatest pollution to the watershed. Our risk assessment tool may be enhanced by developing, recording, and updating information on pollution sources in the water supply watersheds. Moreover, management authorities could use the resultant information to create watershed risk management plans. Source water protection is the first barrier to drinking water contamination in the multi-barrier approach to safe drinking water . MaintaiHuman health risks from any set of stressors can be evaluated based on the probability of an unwanted and harmful event occurring, and the severity of consequences should it occur. Furthermore, the probability and severity of risks are directly influenced by three major components: sources of potential risks, receptors of concern (human or other), and environmental pathways that potentially connect the receptors to the source inputs .Currently, drinking water quality standards are used to regulate the treatment of water at plants in Taiwan. These standards are applied to water destined for human consumption and are established for select physical, chemical, microbiological, and radiological parameters . For patQuantitative and qualitative risk assessments have been applied to some watershed management plans in order to acquire priority information for implementing protection actions . Quantit2 and encompasses three basins: Bei-Shih, Nan-Shih, and Sin-Dian Creek Basins, as shown in The TSWA is a unique area that has been delineated for protecting source water in Taiwan. It covers an area of 697.57 kmThis study divided the TSWA into 22 sub-watersheds  based onLand-use data were obtained from the National Land Surveying and Mapping Center, Taiwan , and impThe quantification of risk for the Taipei Metropolitan drinking water supply was carried out by comparing the measured levels of a potential pollutant that humans might be exposed to against the threshold level for negative consequences of that pollutant. The indicator, the hazard quotient (HQ), is the ratio of the expected exposure to the estimated safe threshold (Equation (1)). Results from past sampling programs in the TSWA were used to estimate human exposure. A hazard quotient greater than 1.0 implies that the degree to which humans are exposed exceeds allowable limits established to prevent undesired effects:In this study, past sampling data of the TSWA were used for estimating human exposure, and the established water quality criteria for Class A surface water  were useA qualitative risk assessment model was developed to identify sub-watersheds within the study area that were at greatest risk of impaired water quality. The model required information on watershed attributes and land use.The qualitative risks were analyzed using a matrix that considered the consequences of a hazardous event and the likelihood of identified hazards causing harm in exposed populations over a specified period. Three components were considered to frame the assessment matrix :Source characteristics (S) were used for hazard identification. Higher priority was given to possible sources of human pathogens ; lesser priority was given to sources of turbidity, chemical contamination, or nutrients.Proximity to water (P) was used to evaluate the pathways introducing pollutants to source water.The spatial extent (E) of an activity, land use or other issue was used to assess both source and transport pathways in the watershed.These three factors were ranked into four levels for each sub-watershed, as shown in Watershed attributes that can influence water quality include human land uses as well as natural characteristics. Several attributes were included in the qualitative risk assessment in this study :▪ Sub-watershed slopeAverage sub-watershed slope was considered because it provides a generalized indication of slope stability and potential for runoff; steep terrain increases the chance of landslide or debris flow and has the potential to deliver more surface runoff to streams. Average sub-watershed slope was determined from digital elevation model mapping data and calculated in this study using ArcGIS 9.3. ▪ AgricultureIn the Bei-Shih Creek basin, tea-growing was the major source of potential contamination resulting from its use of fertilizers and pesticides. Although organic farming was initiated over a decade ago, most growers in the area continue to use traditional methods.▪ Recreationet al. [Although the TSWA is a delineated protection area, recreational activities such as camping and playing in the water are popular during the summer. In addition, the Nan-Shih Creek Basin is a famous and scenic area with hot springs, and there are dozens of inns and restaurants around the creek. According to the investigation of Lin et al.  untreate▪ Built-up areas and urban developmentUrban development can have significant impacts on water quality. Runoff in urban areas generated from roofs, parking lots, and streets can contribute fertilizers, grease, organic contaminants, heavy metals, pesticides, salt, sediment, nutrients, pathogens, and fecal matter to receiving bodies of water . Urban aUsing the means and maxima of past sampling data from 2008 to 2010 to estimate exposure, and the Class A water quality standards as the thresholds, we calculated the HQs of those three sites located nearest to the inlets of treatment plants . The resThe HQs for total phosphorus (TP) were also greater than 1.0 in analyses using both average and maximum values as the estimated exposures. TP is considered to be associated with toxins released by cyanophytes. Comparing the values for the three sites, the TP HQ of Sin-Dian Creek was higher than that of the other two basins. The limit of TP (≤0.020 mg/L) for Class A surface water standards corresponds to rivers in near pristine condition, and the value is difficult to achieve even for undeveloped, natural forestry. Many risk indicators have been developed to assess the risk of phosphorus loss from agricultural land to surface water. Phosphorus-related impacts on water bodies are a major environmental and economic problem, and are manifested as an increase in primary production, which leads to eutrophication and even toxic blue-green algal blooms. However, there is little information regarding the correlation between phosphorus concentrations in raw water and water treatment loading. The high HQs for phosphorus in the study area need further research in the form of a review of surface water standards (thresholds for designated uses) based on specific source properties and characteristics of the receiving systems. Ranking potential phosphorus sources by applying qualitative risk analysis, and reducing these sources before they are introduced into the watershed, could supplement the shortcomings of quantitative analysis.The HQs for ammonia nitrogen were greater than 1.0 only when using the maximum as the threshold. Ammonia accumulates easily in aquatic systems because it is a natural byproduct of fish metabolism. Human activities, such as playing in the water and camping, may also increase the nitrogen loading. Agriculture activities, especially from the spreading of fertilizer and manure are also considered as major sources of ammonia nitrogen. However, according to sampling data at least, hot spring effluents did not increase the nitrogen concentration in the Nan-Shih Creek. Suspended solids (SS) is a parameter that may be influenced by rainfall and urban development. The existence of SS in source water may reduce the efficiency of chlorination in treatment process. Maximum HQs for all three sites were greater than 1.0, while that in Nan-Shih Creek was higher the others. Although the correlation between average monthly SS concentration and monthly rainfall was not significant, due to fast flowing streams and hydropower operations in the basin, The average biochemical oxygen demand (BOD) HQs of Bei-Shih and Sin-Dian Creeks were greater than one, and indicated potential anthropogenic pollution in these two basins. Other parameters, such as dissolved oxygen and pH, were always within a safe range and indicated a low risk to human health. Nevertheless, the variation of dissolved oxygen and pH may cause chemical reactions that result in changes to other parameters, such as the dominant forms of nitrogen in the water, and these fluctuations should still be monitored.The characteristics of each parameter for the other 19 sites were similar to those of the three sites nearest to the intakes discussed above, and showed no significant trends along the river from upstream to downstream.A list of activities and situations for the three basins was developed based on concerns about the watershed and drinking water supply , using wet al. [Results from this study indicated that intensive tea-growing was the greatest risk for the TSWA due to the location of plantations in or near the riparian zone and their occupation of a relatively wide area in some sub-watersheds. The distributions of the tea-growing areas are shown in et al. , tea culRecreational activities around the creek and reservoir were a common source of potential pollution for the three basins. All recreational activities were classified as minor sources of possible non-pathogenic contaminants, and all were located close to the bodies of water but often sparsely distributed. Therefore, a risk level of “low” or “medium” was derived from the qualitative risk model . HoweverIn the Nan-Shih Creek Basin, landslides from mountains near the riparian zones were included as a potential risk event. The slopes range between 24–30 degrees for the six sub-watersheds and were considered steep enough to generate slides . ConfirmIn the Sin-Dian Creek Basin, residential development was considered a pollution source. The percentage of built-up area was relatively high in the TSWA and the activities of residents were concentrated along the riparian zone. All potential contamination sources considered in the qualitative risk analysis were ranked according to the risk level of factors and the results are illustrated in Summarizing the potential risk of each potential pollution source and taking an average of the risk levels, there are five sub-watersheds of the Bei-Shih Creek Basin classified as very high risk resulting from intensive tea plantation.Integration of the analyses of quantitative and qualitative risks revealed total coliforms and total phosphorus to be the top two parameters of concern for source water. Intensive tea-growing in the Bei-Shih Creek Basin, together with all types of recreation around the creeks and reservoirs in all three basins, are highly ranked risk sources for humans that drink water supplied by this area. Suspended solids increased in the summer season in the Nan-Shih and Sin-Dian Creek Basins primarily due to the natural factors of sub-watershed slopes and rainfall events. Watershed management plans, based on land use restrictions, seek to reduce or eliminate sources of potential risk before they are introduced into the watershed. In addition, riparian zone protection is intended to decrease the potential exposure pathways within a watershed, so that the magnitude of movement from source to drinking water intake point is effectively reduced. Isolating all possible pollution sources is the most direct control measure for reducing the risk to drinking water while the watershed remains in pristine condition and has no residential development. However, the TSWA is located around the Taipei metropolitan area, with a large population: substantially changing existing land use and activity patterns is not practical. Therefore, best management practices, riparian zone restoration, and restrictions to the spatial extent of activities are practicable strategies that can be implemented quickly. Maintaining cleanliness in scenic areas and public education about recreational activities in source water protection zones would also constitute effective control measures.The present integrated risk management model can be applied to the susceptibility analysis for a public water system which consists of determining the target pollutants and level of threat within the watersheds. Furthermore, a watershed management plan can be implemented based on the indicator of hazard quotients and the determined risk levels for sub-watersheds.Various watershed attributes and types of land-use activities have the potential to degrade the water quality within watersheds. Quantitative and qualitative risk assessments, which consider watershed attributes that influence water quality, as well as the threshold of sensitivity of humans that drink the water, could be valuable tools for identifying areas at high risk of degraded water quality. The results could be used as part of a screening tool to prioritize watersheds for assessment, particularly in systems that lack detailed inventories of potential pollution contributions. If target activities are identified through a watershed assessment, further monitoring and investigation could be undertaken to identify the quantitative risks of pollution.Future risk analyses should continuously revise the process maps of water quality hazards using updated knowledge of contaminants. In addition, detailed assessment of “high” risk hazard events that influence water quality is essential for preemptive reduction of source water risk. The value of this risk assessment tool relies on continuously developing, recording, and updating information on pollution sources in the water supply watersheds, and management authorities should establish risk management plans based on such information.


Although war-trauma victims are at a higher risk of developing PTSD, there is no consensus on the effective treatments for this condition among civilians who experienced war/conflict-related trauma. This paper assessed the effectiveness of the various forms of cognitive-behavioral therapy (CBT) at lowering PTSD and depression severity. All published and unpublished randomized controlled trials studying the effectiveness of CBT at reducing PTSD and/or depression severity in the population of interest were searched. Out of 738 trials identified, 33 analysed a form of CBTs effectiveness, and ten were included in the paper. The subgroup analysis shows that cognitive processing therapy (CPT), culturally adapted CPT, and narrative exposure therapy (NET) contribute to the reduction of PTSD and depression severity in the population of interest. The effect size was also significant at a level of 0.01 with the exception of the effect of NET on depression score. The test of subgroup differences was also significant, suggesting CPT is more effective than NET in our population of interest. CPT as well as its culturallyadapted form and NET seem effective in helping war/conflict traumatised civilians cope with their PTSD symptoms. However, more studies are required if one wishes to recommend one of these therapies above the other. Warfare and torture occur on a large scale in many countries resulting in widespread death, disability, and trauma . In 1997PTSD was first recognized following the devastating war experiences of soldiers serving in Vietnam. Since then, the concept has been adequately applied in the assessment of various types of traumatic experience . Most stEven in instances where only a few women are on the front line of combats, they and their children bear the brunt of its physical, socioeconomic, and emotional impacts . In factPhysical and sexual violence committed against women during war time have always being condemned by institutions but more needs to be done to help the victims pick up the remaining pieces of life, regain confidence, and recover from their trauma. Unfortunately, there is limited and disparate information on what intervention is the most appropriate and effective for this category of victims. The primary objective of this systematic review is to assess whether the different forms of CBT can successfully help adult civilians  who experienced war-or-conflict-related trauma  cope with the symptoms of PTSD and depression. Secondary, we identify which form of CBT is more efficient in reducing the severity of the previously cited outcomes.Given the clinical complexity of PTSD, it is not surprising that the development of treatments is quite challenging. Cognitive-behavioral therapy (CBT) includes a number of diverse but related techniques such as exposure therapy, stress inoculation training, cognitive processing therapy, cognitive therapy, relaxation training, dialectical behavior therapy and acceptance, and commitment therapy .Exposure therapy (ET) refers to a series of procedures designed to help individuals confront thoughts, and safe or low-risk stimuli, that are feared or avoided [Narrative Exposure Therapy (NET). NET is a standardized short-term approach in which the classical form of ET is adapted to meet the needs of traumatized survivors of war and torture [ avoided . Applied avoided . In 2002 torture . As most torture . Instead torture . This tr torture .Stress Inoculation Training (SIT) is a multicomponent anxiety management treatment program that includes education, muscle relaxation training, breathing retraining, role playing, covert modeling, guided self-dialogue, and thought stopping [Cognitive therapy (CT) predicated the idea that it is one's interpretation of an event rather than the event itself that determines emotional reactions. It involves identifying erroneous or unhelpful cognitions, evaluating the evidence for and against these cognitions, and considering whether the cognitions are the result of cognitive biases or errors, in the service of developing more realistic or useful cognitions [Cognitive processing therapy (CPT) implements exposure to the trauma memory via writing a trauma narrative and repeatedly reading it, and is combined with CT focused on themes of safety, trust, power/control, esteem, and intimacy [Dialectical behavior therapy (DBT) is a comprehensive treatment developed for the treatment of individuals with borderline personality disorder. An important aspect of DBT is skills training in affect regulation and interpersonal regulation. Some trauma survivors may have deficits in these skill areas that render it difficult for them to tolerate or benefit from trauma-focused interventions such as ET [stopping . Cognitignitions . Cognitiintimacy . A cultuintimacy . Dialectch as ET .CBT is the most studied treatments in the general population, and current guidelines recommend it as a first-line treatment for patients . The difCochrane Central Register of Controlled Trials (CENTRAL), CINAHL, EMBASE, Entrez-Pubmed; PsycInfo, Web of Science, MEDLINE (OvidSP), and USA clinical trials databases were searched. In addition, the dissertation and thesis database was also reviewed for relevant publications. The keywords related to trauma  were first used to extract publications on the subject. In order to refine the results to the population of interest , studies conducted with the combatants (with keywords veterans and military personnel) and the young traumatised civilians  were excluded. Since a lot of the interventions in countries affected by war/conflict are conducted by diverse humanitarian organisations , these organisation websites were scanned for useful publications on the subject. A manual search was also performed using the reference list of reviews and books published on PTSD treatment in the population of interest [The recommendations of the Cochrane Handbook for Systematic Reviews of Interventions were followed in the design of the search strategy. The first author worked in collaboration with professionals at the Paramedical library of University of Montreal. Their role was to evaluate the research strategy and advise on the possible missed channels of search. The interest , 19, 20.The inclusion criteria consisted of studies describing a randomised controlled trial in which the intervention compared any form of CBT to a control . The study needed to be designed to reduce PTSD symptoms among civilians who experienced one or multiple trauma during war-or-conflict. Study participants were required to be adults with the status of refugees, asylum seekers, or internally displaced. Trials conducted with participants traumatised by war/conflict related violence who were still living in their country of origin were also included. Studies with participants with comorbidities were accepted provided the primary objective of the trial was the reduction of PTSD symptoms. The main comorbid conditions found in the included studies were depression, anxiety, suicidal ideations, neck-focused and orthostasis-triggered panic attacks, with flashbacks during attacks and somatoform disorders. Most of the studies excluded participants with organic mental disorder, bipolar disorder, mental retardation, schizophrenia, psychosis, and drug abuse. The instruments used for the assessment of PTSD symptoms and severity had to be based on DSM's or ICD's criteria for a study to be eligible.The Cochrane Handbook for Systematic Reviews of interventions  was usedThe first author assessed the risk of bias in included studies considering criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions  and the Data was analysed with the available information for each group participants according to their allocation.A meta-analysis method with a random-effect was chosen since different instruments were used to assess PTSD or depression severity in the included trials. In fact, the use of a random-effects meta-analysis allows the incorporation of the heterogeneity existing among studies.Two subgroup analyses were conducted with the Review Manager software (RevMan 5): the first assessed the effects of the treatments on PTSD score and the second assessed the effect of the treatments on depression score. The subgroup analyses also compared one form of CBT to the other. Each analysis investigates potential sources of heterogeneity, as differences in the type of intervention, participants' profile, or intervention setting  may affect the treatment effects. The analyses were conducted according to Deeks et al.'s method, integrated in RevMan 5 software .Out of 738 trials initially identified from the databases, 33 publications studying the effectiveness of one of the forms of CBT were found.  The two outcomes of interest in this paper (PTSD and depression severity) were monitored with different psychometric instruments and reported on a continuous scale (scores of PTSD and depression) . Furthermore, different circumstances of the refugee camps (independent of the treatment) could explain those dropouts which will then be random.We did not exclude the Neuner et al., 2008  study wh One trial was excluded from the meta-analysis because rather than providing a global score, it provided the scores of severity for each criterion of PTSD symptoms .P < 0.00001). One should note that there is no heterogeneity between the culturallyadapted CPT trials as indicated by the I square percentage (I2 = 0%).The results indicate that culturallyadapted CPT can successfully help the adult civilians who experienced war-or-conflict related trauma. The effect size of 7.04 indicates that the intervention group (immediate treatment) outperformed the control group in terms of reduction of symptoms severity (delayed treatment) by seven times the standard deviation. This effect size is also highly significant at a level of 0.01 (P = 0.02). Contrary to the culturallyadapted CPT, there is a high heterogeneity between the NET trials (I2 = 79%).P < 0.00001).According to the results of our analysis, CPT compared to a control group  can also successfully help reduce the severity of the PTSD symptoms in patients of our population of interest. The effect size of 7.40 was highly significant at a level of 0.01 . After comparing the effect size, one can say that culturallyadapted CPT and CPT are more effective than NET in reducing the severity of PTSD symptoms.P < 0.00001). Regarding the PTSD outcome, there is no heterogeneity between the trials (I2 = 3%). The effectiveness of NET in the reduction of depression severity is low with an effect size of 1.67, which is not significant at a level of 0.01. However, the test of subgroup differences is significant at a level of 0.01 (P < 0.00008). This indicates that the effectiveness of culturallyadapted CPT in depression severity reduction is higher than NET's. As indicated in This paper summarises the results of ten trials, which recruited a total of 473 men and women, all traumatised during war-or-conflict. The studies took place in different countries  characterised by a variety of health systems and existing protocol for psychological support offered to war- and conflict-traumatised individuals. Participants included Cambodian refugees resettled in USA , 24, 25,The first subgroup analysis revealed that CPT, culturallyadapted CPT, and NET can significantly contribute to the PTSD severity reduction. However, the first two forms of CBT seem to have a higher effect on PTSD severity reduction than NET. We cannot exclude the possibility that those two forms of CBT might be the most adapted to the needs of patients of the population of interest. However, other reasons might have resulted in the superiority effect observed. First, it is possible that culturallyadapted CPT and CPT had a higher effect on PTSD severity reduction because they were all conducted in the participants' native language by people familiar with their culture. In fact, not all of the NET trials were conducted in the participants' native language, and the amount of trials available was too low to conduct a subgroup analysis that assesses the impact of interpreters on PTSD severity reduction. The observed difference might have also resulted from the variety of participants included in the NET trials compared to the other forms. In fact, the NET trials were conducted in different countries  with different settings and participants from different origins, while all the culturallyadapted CPT were conducted in Massachusetts with participants living in a more stable economic/politic context. It is possible that participants who are still living in the conflict-affected country are less inclined to fully benefit from the success of psychotherapy even when they need it. This idea derived from the comparison of the trial conducted by Bichescu et al.  to the oThe second subgroup analysis conducted revealed that culturallyadapted CPT and NET were effective in reducing the severity of depression in our population of interest. However, the effect size of NET therapy compared to control condition  was not significant. With regards to PTSD outcome, results show that culturallyadapted CPT is more effective than NET in depression severity reduction. The reasons described earlier might have also caused the results obtained.A finding that is also important to discuss concerns the heterogeneity between the included trials. As reported earlier, there is a high homogeneity between the culturallyadapted CPT trials, results that can be explained by the fact that the three trials were led by the same therapist with similar participants in terms of type of trauma experienced (Cambodian genocide). In contradiction, a high heterogeneity between the NET trials was found, results that can be easily explained by the different settings of NET trials .CPT is the most studied treatment in relation to PTSD symptoms and severity in the general population. Moreover, it is the most recommended treatment in the general population based on the studies conducted in the industrialised countries. This form of CBT also seems efficient in helping war-traumatised adult civilians. In fact, when amalgamated with a meta-analysis, the CPT trials revealed a stronger effect size of the treatment compared to the control group (waiting list or delayed treatment). Our results also indicate that CPT seems the most indicated treatment to reduce depression severity. However, the trials' small sample sizes and the fact that every trial was conducted with patients originating from three countries  make it impossible to generalize CPT's effectiveness to every post war and conflict traumatised patient. Our results also emphasize the necessity of taking culture into account while designing interventions for PTSD patients or refugees of non-western countries since the culturallyadapted CPT seems more effective than the NET in PTSD and depression severity reduction.In comparison to CPT, NET is a more contemporary method and more researched method of treatment in the population of interest . NET also seems to be the most adapted method to our population of interest because it is designed to suit their need and its effectiveness has been proven in different trials. Our meta-analysis also confirmed that it can help subjects of our population of interest in lowering the severity of their PTSD and depression symptoms. Even if NET does not appear to be the most effective treatment, the fact that it has been applied with success to participants from diverse origins  makes it easier to generalise its effectiveness among the population of interest. We also think that this form of CBT will probably benefit from integrating the variable of culture into the design of their sessions.As indicated in the title of this paper, we were interested in assessing the effectiveness of the different forms of CBT according to the sex of the participants in order to find which treatment is the most effective for women. Unfortunately, this was not possible because even if most of the trials included men, and women none of them reported their results according to the sex or gender of participants. We think that subsequent trials should assess the difference of treatment effect between men and women since previous studies on PTSD symptoms and its severity revealed a difference of its rate between men and women in the same population, women being at higher risk of developing it –34. ThusFirst, the selection of a specific category of war-traumatised patients (adults) might seem arbitrary. We thought that it is important to separate adults from young ones because the type of CBT and NET treatment used in those categories are not the same. We also separated those categories of age because we felt that the process of healing might be different between an adult who is usually the victim of violence and a child/adolescent who is usually a witness and/or victim of that violence. Secondly, although an extensive list of databases was used for study selection, we cannot rule out the possibility that some articles may have been missed with our research strategy. In fact, since five out of ten of the studies were conducted by German researchers we cannot exclude the fact that some of their studies were not found in the English databases used.This systematic review demonstrates that culturallyadapted CPT, CPT, and NET can successfully help war-or-conflict-traumatised civilians in reducing their PTSD symptoms. However, only the culturallyadapted CPT seems effective in reducing the depression score of civilians who experienced war-or-conflict related violence. Even if the subgroup analysis clearly demonstrates that CPT and its culturallyadapted form are more effective than NET, more evidence is needed in order to specifically recommend one of the forms of CBT over the other for our population of interest.n = 111) in the intervention group, but also reported a high number of losses to followup, which made the results partly subject to the risk of bias such as incomplete outcome data.More research needs to be carried out on CBT  and NET treatment effectiveness in PTSD severity reduction within our population of interest. In fact, these people need to cope with the symptoms, in order to be able to contribute to the prosperity and well-being of their societies. It is also important that researchers agree on common characteristics which will allow conduct of a better comparison between studies in the future, in order to recommend a specific treatment. They should agree on the instruments, the number of sessions given, and their length. For example, in the CBT trials the number of sessions was different from one study to another. It is also important that the same type of control group be used for each trial . In fact, there was a difference in the type of control group between the trials that used NET as an intervention. Trials comparing these two methods to a standard treatment might also be a good idea and collaboration between the varying teams (Hinton and Neuner teams) would certainly help this. To ensure the quality of the trials, researchers must also be sure to conceal allocation (none of the reviewed studies did so) and blind the assessors (followed by a test of the blindness integrity). Moreover, researchers must make certain that enough participants in the intervention and control group are included in the trial. In fact, a key limitation in most studies is the sample size. Only one study included an adequate number of participants , but also the instruments and specialists used to assess it remain important. In fact, some argue that PTSD symptoms may have various values or meanings depending on the different cultures, and some symptoms may not be perceived as distressing among certain groups . The valtestimonial psychotherapy, was used as treatment for the intervention group in an RCT [Family group therapy has also been described as potentially efficient in the population of interest. This treatment might be even more effective when several patients or traumatized persons belong to the same family, a situation that is fairly common [Aside from NET and CPT, different therapies have been studied in our population of interest. One of them, n an RCT . This inn an RCT . As NET,y common –43. This


Campylobacter is a common cause of bacterial gastro-enteritis characterized by multiple environmental sources and transmission pathways. Ecological studies can be used to reveal important regional characteristics linked to campylobacteriosis risk, but their results can be influenced by the choice of geographical units of analysis. This study was undertaken to compare the associations between the incidence of campylobacteriosis in Quebec, Canada and various environmental characteristics using seven different sets of geographical units.For each set of geographical unit, a conditional autoregressive model was used to model the incidence of reported cases of campylobacteriosis according to environmental  and demographic  characteristics. Models were compared in terms of number of significant predictors, differences in direction and magnitude of predictors, and fit of the models.In general, the number of significant predictors was reduced as the aggregation level increased. More aggregated scales tend to show larger but less precise estimates for all variables, with the exception of slaughterhouse presence. Regional characteristics associated with an increased regional risk of campylobacteriosis, for at least some geographical units, were high ruminant density, high poultry density, high population density, and presence of a large poultry slaughterhouse, whereas a reduction in risk was associated with a lower percentage of people with diplomas, a lower level of precipitation, and warmer temperature. Two clusters of elevated residual risk were observed, with different location and size depending on the geographical unit used.Overall, our results suggest that the use of municipality or census consolidated subdivision were the most optimal scales for studying environmental determinants of campylobacteriosis at a regional level. This study highlights the need for careful selection and analysis of geographical units when using ecological study designs. In Canada, as in many industrialized countries, infection with Campylobacter spp. is a leading cause of bacterial gastro-enteritis, with an annual average of 39 cases reported per 100,000 people over the last decade . ConsumpBecause of the regional-level intrinsic influence of environmental characteristics, the use of an ecological study design  is a valid choice when studying these factors in relation to campylobacteriosis occurrence in populations. In the past, few ecological studies had been conducted to identify regional factors associated with the incidence of human campylobacteriosis. In Sweden, a positive association was found between the incidence of campylobacteriosis and both ruminant density and drinking water quality measures . In the The objective of this study was to estimate the effect of selected environmental and demographic characteristics on the regional incidence of human campylobacteriosis in Quebec using different geographical segregations of the study area, and to assess the impact of the choice of geographical units on epidemiological inference.An ecological study was conducted using human cases of campylobacteriosis reported in the province of Quebec, Canada, between 1996 and 2006 inclusively. The area under study was defined as the populated areas of the province, with the exclusion of non-organized territories, incompletely enumerated Indian reserves and settlements, and northern areas (Nunavik). Populated areas were defined as regions covered by census blocks in which at least one person was living according to the 2001 census of Statistics Canada.Following approval of the research protocol by the research ethics board of the Faculty of Medicine at the University of Montreal and by the research ethics board of the Agency of Health and Social Services of Montreal, available data on all laboratory-confirmed cases of Campylobacter infections reported in the province of Quebec for the study period were obtained from local health authorities. Cases were geocoded to the full 6-digit postal code areas, municipalities, and local community service center (CLSC). Recurrent cases occurring within less than 5 years of the first episode were excluded .For the purpose of our study, we defined a geographical framework as a set of boundaries delineating an administrative or natural organization of the study area. These frameworks may include different subsets at various scales, which relates to the “aggregation effect” of the modifiable areal unit problem . The dif2 of populated areas.Demographic and environmental variables were selected based on current literature and availability of data. They are defined in Table Slaughterhouse data for the year 2006 were obtained from the websites of the Canadian Food Inspection Agency and the Ministry of Agriculture, Fisheries and Food of Quebec. Slaughterhouses were geocoded using their civic number and street address within GeoPinPoint 2008 software ; manual Demographic information was obtained for the census years 1996, 2001, and 2006 from Statistics Canada at the Dissemination Area level . For each census year, data from each Dissemination Area within a geographical unit were averaged, weighted by their population size. For each geographical unit, data were then averaged over the 3 census years using weights of 2.5, 5, and 2.5, respectively.Climate variables were obtained from the National Land and Water Information Service of Agriculture and Agri-Food Canada for 1996 to 2003, inclusively. These values represent a 10x10 km cell size, generated by the interpolation  of meteorological data collected from weather stations across Canada. The rasters were first transformed at a cell size of 0.5 km using the Spatial Analyst extension of ArcInfo 9.2 , and theAll covariates were categorized prior to modeling in order to get a constant set of predictors for all models and/or because the variable to outcome relationship was assumed to be non-linear in form. Animal density variables were put into 3 categories: absence, medium levels, and high levels of production. The cut-off for high levels was set at the 85th percentile of the respective empirical distribution at the level of municipalities. The slaughterhouse variable was organized into 3 categories: absence of any kind of slaughterhouse, presence of large poultry slaughterhouse(s), and presence of small poultry slaughterhouse(s) or slaughterhouse(s) for other species. A poultry slaughterhouse belonging to one of the four largest poultry transformation companies in Quebec, which have a combined market share of over 90%, was defined as “large” . For demFor statistical modeling, the dependent variable was defined as the average number of reported cases of campylobacteriosis per 100,000 people per year. The incidence was directly standardized for age group , using the study population for the year 2001 as the standard population. Prior to modeling, the incidence rate was smoothed using the empirical Bayesian estimation in order to improve normality and variance homogeneity . This prIn the presence of spatial structure in studentized residuals from the ordinary regression models, a conditional autoregressive (CAR) model was fit in R using the “spdep” package  for eachThe geographical sets of units were first compared based on the estimated associations between outcome and exposure variables. More specifically, the number of exposure variables with statistically significant associations was compared between sets of units. Among significant variables, differences in direction and magnitude in risk estimates were also described. For the comparisons in terms of magnitude, the maximal percentage of variation between statistically significant coefficient estimates for each explanatory variable was calculated as follows:2) between observed and predicted outcome (a good fit is indicated by strong correlation); 2) spatial dependence in model residuals as measured by Moran’s I using the same neighborhood definition as used in the conditional autoregressive models; and 3) presence of areas of unexplained higher risk. This was evaluated with a spatial scan test scanning for primary and secondary clusters of high residual values based on the normal model, performed in SaTScan version 8.1.1. [The geographical sets of units were then compared in term of model fitting. Three criteria were used: 1) Pearson’s coefficient of correlation  or to a combination of changes in scale and zoning. Different criteria were used to compare the results obtained from different sets of geographical units, selected for their epidemiological relevance. First, the difference in estimated associations between campylobacteriosis incidence and exposure variables was explored, since different results can lead to a different understanding of the environmental factors influencing the spatial distribution of the disease. Next, residual clustering or hotspots of unexplained risk were explored. Local zones of unexplained risk were detected, which potentially identify different scales at which disease processes are occurring and specific areas and scales warranting further investigation.The number of significant variables in the CAR models was reduced as the level of aggregation increased. This was likely driven by a reduction of statistical power due to lower sample size rather than reduced strength of association as the point estimate in regression coefficients were in general larger in more aggregated data. It should be noted that, with the exception of covariates referring to animal density, significant effects on regression coefficients were only observed for those covariates showing less variability at lower level geographical units . Choice The direction of the associations was consistent and in agreement with current biological knowledge. Poultry and ruminants are frequently colonized with Campylobacter and can shed the bacteria in high numbers ,42-44. CThe slaughterhouse variable was associated with campylobacteriosis incidence, with a significant decrease in magnitude with aggregation and non-overlapping confidence intervals between geographical units. This met our expectation for this particular variable, since its effect would likely be limited to the nearby areas where workers live or environmental contamination occurs, and a reduction of the coefficient in the aggregation process would occur due to a dilution effect. We further explored these associations by multiplying the point estimate of large poultry slaughterhouse coefficients with the total populations at risk living in areas with large poultry slaughterhouses. In summary, the case load due to the presence of large poultry slaughterhouses in the study area ranged from 9 to 172 cases, depending on the framework. This illustrates the impact of choice of geographical units on potential public health conclusions.2). This is suggestive of colinearity between these two variables, and so the effect attributed to poultry or ruminant density for frameworks at a larger scale is probably a cumulative effect of both types of production. Indeed, any epidemiological study aiming to study the distinct effect of poultry and ruminant density should avoid any use of geographical units at a scale larger than census consolidated subdivisions. From another perspective, the large regression coefficients for animal densities observed at the watershed scale could be indicative of real biological processes occurring at that specific scale, which is not impossible considering the importance of aquatic environments in the ecology of Campylobacter [For all other variables, the estimated coefficients of regression tend to increase in magnitude as the units become more aggregated, but this increase was not consistent across all geographical sets of units and thus not predictable. This increase is in accordance with previous work based on simple linear regression models, although another study conducted in a multivariate regression setting reported that the results were essentially unpredictable . For thelobacter .For the demographic and climatic variables, the point estimates of regression coefficients also increased with aggregation, although confidence intervals increased and point estimates were not statistically different between geographical units . It should be noted that high values of estimated regression coefficients for climate variables as seen for the “smallest” and “CLSC” geographical units compared to “municipality” are probably misleading. In fact, 51 and 39 of the divisions constituting these units were located on the islands of Montreal and Laval, respectively, urban areas characterized by warm temperatures and low amounts of precipitation. At the scale where it was measured, almost no variation in weather variables was seen within this area; indeed, these areas were probably over-represented in the estimated relationship between campylobacteriosis and weather variables.The fit of models was explored in different ways. As previously reported, an increase of the correlation coefficient between observed and predicted data was seen as the level of aggregation increased. This is attributed to the smoothing effect of aggregation ,29 and hThe choice of framework and scales included in the study were limited to the ones at which cases could be located. Additionally, only cases reported through the surveillance system were included, limiting the generalization of results to all cases occurring in the population. In fact, case reporting involves multiple steps, which could be influenced by health care system, physician, or patient characteristics. In the province of Quebec, health care services are accessible to all, with universal health insurance plan allowing the entire population to receive free hospital and medical services, which should limit any related reporting bias. Regarding physicians, their propensity to ask for a stool sample have been reported to vary according to their speciality and severity of illness of their patients . Also, tOur study allowed us to evaluate to what extent the modifiable areal unit problem influences the epidemiological conclusions on the spatial distribution of campylobacteriosis. In general, the various geographical units gave consistent results for the direction of the associations between incidence and various environmental and demographic characteristics, which were in agreement with current knowledge on campylobacteriosis epidemiology. However, the strength and statistical significance of the associations observed at one scale should be used with caution when inference is made at another scale. In general, municipality or census consolidated subdivision scales are recommended for the study of the spatial distribution of campylobacteriosis in our study area, based on theoretical grounds  and low The authors declare that they have no competing interests.JA designed the methodology, performed the statistical analyses and drafted the manuscript. OB supervised the analyses. PM, AR and PG assisted in designing the methodology and drafting the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/12/318/prepubChoice of distance matrix.Click here for file


Nutrients recently became the target of an unprecedented internet campaign by an individual who disagrees with the content and conclusions of a paper published in the journal last year, viz. “The Australian Paradox: A Substantial Decline in Sugars Intake over the Same Timeframe that Overweight and Obesity Have Increased” by Alan W. Barclay and Jennie Brand-Miller, Nutrients2011, 3, 491–504. Regrettably, his criticism has extended to the journal and its peer review processes for permitting publication of the article.Nutrients is one of an extensive series of on-line open access journals published by MDPI, who abide by internationally accepted standards of anonymous peer-review publication. Moreover, as one of the first MDPI journals addressing a field of biomedical/clinical sciences, our editorial team has endeavoured to adopt all appropriate conventions regarding ethics approvals, clinical trial registrations and declarations of perceived conflicts of interest. I have been grateful for the efforts made by members of the MDPI editorial team, our editorial board, our reviewers and our contributors for helping to ensure that the desired standards of publication are attained. I believe these standards were applied to the review of the paper in question and, despite inferences to the contrary, neither author had a role in the editorial process.As you may know, Nutrients does not have a policy of inviting correspondence to the Editor, nor has the journal received any formal correspondence regarding this manuscript. However, in view of the widely circulated criticism of the paper by Barclay and Brand-Miller, I believe that it is in the interest of the journal as well as the authors to afford them an opportunity to address these criticisms and provide further clarification of their research. This correspondence now appears on the Nutrients website at http://www.mdpi.com/2072-6643/3/4/491/.I will leave our readers to judge for themselves.


In support of professional practice, asynchronous communication between the patient and the provider is implemented separately or in combination with Internet-based self-management interventions. This interaction occurs primarily through electronic messaging or discussion boards. There is little evidence as to whether it is a useful tool for chronically ill patients to support their self-management and increase the effectiveness of interventions.The aim of our study was to review the use and usability of patient-provider asynchronous communication for chronically ill patients and the effects of such communication on health behavior, health outcomes, and patient satisfaction.A literature search was performed using PubMed and Embase. The quality of the articles was appraised according to the National Institute for Health and Clinical Excellence (NICE) criteria. The use and usability of the asynchronous communication was analyzed by examining the frequency of use and the number of users of the interventions with asynchronous communication, as well as of separate electronic messaging. The effectiveness of asynchronous communication was analyzed by examining effects on health behavior, health outcomes, and patient satisfaction.P=.07, P=.07). Increases in self-management/self-efficacy for patients with back pain, dyspnea, and heart failure were found. Positive health outcomes were shown in 12 studies, where the clinical outcomes for diabetic patients (HbA1c level) and for asthmatic patients (forced expiratory volume [FEV]) improved. Physical symptoms improved in five studies. Five studies generated a variety of positive psychosocial outcomes.Patients’ knowledge concerning their chronic condition increased and they seemed to appreciate being able to communicate asynchronously with their providers. They not only had specific questions but also wanted to communicate about feeling ill. A decrease in visits to the physician was shown in two studies (The effect of asynchronous communication is not shown unequivocally in these studies. Patients seem to be interested in using email. Patients are willing to participate and are taking the initiative to discuss health issues with their providers. Additional testing of the effects of asynchronous communication on self-management in chronically ill patients is needed. Self-management is a central concept of health care that is increasing in popularity. This is because people strive to be autonomous and also because there is an increase in the global population, in the number of chronic diseases people have, and in the length of time people endure a chronic disease . To makeThe transition towards self-management is also visible in the new definition of health that experts have recommended to the World Health Organization (WHO): “the ability to adapt and self-manage in the face of social, physical, and emotional challenges” . The earModern information and communication technologies (ICT) provide new ways for patients to participate in their own health care. Internet interventions have been developed to record, measure, monitor, and manage the delivery of health care . These iThe above-mentioned Internet interventions are created according to a standard pattern based on one-way communication with not much scope for interaction. However, Internet interventions can also be combined with interactive communication tailor-made for individual patients ,20,21. IThis review examines publications that describe the effect of digital asynchronous communication between chronically ill patients and health care providers. The first research question is whether this type of communication works: do patients and providers actually use this form of interactive communication and how do they evaluate the usability? The second question reviewed is whether this form of interactive communication helps: does it have an effect on health behavior, health outcomes, and patient satisfaction?Digital asynchronous communication is defined as electronically mediated communication in which the participants do not communicate concurrently. Examples of asynchronous communication in health care are electronic messaging (email) and bulletin boards. Patients with chronic conditions have one or more chronic diseases, which are defined as diseases with a long duration and generally slow progression .The systematic review was conducted using the PICO method . The keyPubMed and Embase databases were searched.Duplicates were removed.Titles and abstracts were scanned for Internet-based interventions.Full text analysis was undertaken to select studiesdescribing asynchronous communication between patient and provider, alone or as part of an intervention;where patients were able to initiate communication at any time of the day (24/7);directed at self-management;where control groups were free of any digital intervention and received usual care.The bibliographies of the articles included were manually searched to identify additional relevant articles.The methodological quality of the studies was evaluated by applying the National Institute for Health and Clinical Excellence (NICE) criteria for RCTs ,24,25. STo answer this question, the use of asynchronous communication in digital interventions by patients was assessed by determining frequency of access; number of patients who use the digital intervention; number of messages; and usability of interventions, including asynchronous communication  use of the ICT with a focus on ease of use, clarity, and attractiveness).To answer this question, the present study assessed the effects of using digital interventions, including asynchronous communication, on health behavior ; health outcomes ; and patient satisfaction.P<.05.The results were reported as significant if As shown in In 9 studies, the mean age of participants was approximately 50 years (range 45-57) -36,38,39An assessment was carried out to determine whether the interventions were complementary or a substitute for usual care because of the consequences for the interpretation of the results. One might evaluate interventions that are complementary to usual care as effective if the study shows improved outcomes, whereas interventions that are a substitute for usual care can be evaluated as effective if the study shows no differences compared with usual care. Most interventions were complementary (n=11), but some were a substitute for usual care (n=4).In Risk for selection bias, or systematic differences between the comparison groups, existed in three studies ,36,38. TRisk for performance bias, or systematic differences between groups in the care provided (apart from the intervention under investigation), was low. In all studies, the comparison groups received the same care except for the intervention studied. In all 15 studies, it was clear that participants were not blinded to the treatment allocation due to the physical character of the intervention. In the studies by Ghahari , Nguyen The investigators were kept blinded in three studies. In the study by Bond , it was Risk of attrition bias, or systematic differences between the comparison groups with respect to dropouts, hardly existed in the studies. All groups within the studies were followed for an equal period of time. They were comparable with respect to the availability of outcome data and for treatment completion. Only Weinert  did not Risk of detection bias, or bias in how outcomes are ascertained, diagnosed, and verified, showed more diversity. The length of follow-up was found to be on the short side in Berman (6 weeks)  and CruzIn conclusion, a total score for the studies was derived that summed up the risk for the four categories of bias, showing that Berman , Hill 3, and WeiIn To use the asynchronous communication, the patients accessed a website and then logged in to a patient portal. It was then possible for them to communicate asynchronously with their providers by using email, viewing their EHR, or using a discussion board. Three studies that examined sharing EHR ,31,34 deThe accessing of the intervention was also reported by Berman , who fouThe use of electronic messaging was reported on in six studies ,31,34-36A large percentage of subjects used electronic messaging. Ralston  found thIn three studies, the content of the asynchronous communication ,34,35 waThe usability of electronic messaging was shown for a variety of experiences, and overall, patients were positive about using electronic messaging. In one study, patients found the intervention helpful, easy to navigate, and would recommend it to others . In anotProblems concerning usability can be expected when using technology, and these problems might influence usage. Minor usability problems were described in three studies in this review ,27,39, bIncreased knowledge was realized in a study involving rural women with a chronic disease who lived a long distance from the clinic .P=.07) [P=.07) [Health care utilization in the form of visits to physicians did not decrease significantly, but a decrease was shown in the case of back pain patients (P=.07)  and asth [P=.07) , althougIn the area of Internet-based support of self-efficacy/self-management, several results were reported. In the case of pain management, Internet-based interventions seemed to increase patients’ self-efficacy in using non-medical techniques , self-caHealth outcomes are important indicators for providers to guide the therapy of chronically ill patients. Health outcomes as a result of using an intervention with asynchronous communication were described as clinical and physical symptoms, psychosocial outcomes, and satisfaction. They were reported in 12 studies -37,39,41Outcomes for clinical symptoms were shown in four studies of diabetic patients. Improvements were shown in HbA1c level ,29,31,32Improved physical symptoms were also observed when using Internet-based self-care techniques. Berman and Lorig demonstrated a decrease in back pain in patients ,36, and Varied psychosocial outcomes were shown in the studies of interventions with asynchronous communication for chronically ill patients. In one study, personal well-being increased  for bothSatisfaction with the overall care from the clinic increased in one study when patients used the Internet-based connection with their provider via the patient portal .The literature search revealed that there are few studies of the effects of asynchronous communication on self-management of chronically ill patients. Only Lin had an Internet-based patient-provider communication system as the focus of an RCT . The litWhen reviewing the methodological quality of the studies, a certain amount of lack of blinding was noted. This lack of blinding is inevitable for technical reasons when the use and effect of digital communication on health behavior and health outcomes is being examined. In assessing the performance bias in RCTs using these techniques, it can be argued that not too much weight should be given to this aspect of quality appraisal.Although 12 studies report on the frequency of use of the intervention, none specifically examined why and when patients log on to the intervention. The results of this review suggest that it might be interesting to find out more about the meaning of the frequency of use by patients. Comparisons with other publications about the frequency of access of Internet and communication technology by patients show varied results from increasing use  to decliIn the studies where email use was measured, a high percentage of patients (>75%) used it ,34. PatiFrom the viewpoint of transition to integration of modern communication technologies, several threats to successful integration can be identified. It is certainly a threat if patients are not able to distinguish issues that are acute or (life)threatening versus non-acute, but we found no evidence to support this. We found that patients know when to use the telephone, because urgent messages were conveyed by the telephone . They alAlso with regard to integration of ICT, it is interesting that patients are prepared to pay for email service with their provider . The facThe content of the electronic messages suggests that patients are willing to participate actively because they share more information than strictly necessary. They have a variety of issues they want to communicate about when using asynchronous communication. Understanding what these issues are is important for further implementation. In addition to “for your information/feeling ill” messages, they have health issues that they want to clarify, such as biomedical and medication concerns and receiving test results and assistance to interpret them. What seems to be happening is that asynchronous communication is used to communicate information that may or may not be relevant, but it satisfies patients to send it. They have taken action by sending the information, and it is now up to the health care provider to say whether it is relevant and if action is needed. This is the start of “shared-decision making”. With asynchronous communication, patients seem to make use of the option to share their worries and their psychosocial condition with their provider. This is an indication for willingness for further patient participation.Age does not seem to be a factor in the use of asynchronous communication, given the advanced age of the participants. This is relevant because most patients with a chronic disease belong to the older segment of the population . In the In the seven studies where health behavior is described, improvements are shown when using the interventions ,33-38. TThe meaning to the patient of the digital connection to the provider is interesting. Does having the connection at your fingertips give a reassuring feeling? Does sitting down and logging on to the connection feel like the first step in self-management and being assertive about your needs? Some results on health behavior may point in this direction. The two studies that used an intense (with an online coach) and a less intense intervention (without an online coach) show that a less intense intervention is just as effective ,38. ThisTwo studies found a trend to a significant decrease of health care utilization in the form of visits to physicians when using an Internet-based intervention ,37. It mThe content of the communication in the study by Ross shows that patients have precise questions about medication and tests, but that they also want to communicate about “feeling ill”. The results show that general adherence increases. However, the question of whether asynchronous communication about these issues affects the general adherence is not raised . There mImproved health outcomes were shown in 11 studies using Internet-based interventions, including electronic messaging. In studies where the intervention was complementary to usual care, an improvement could be expected. In studies with an intervention as a substitute for usual care, similar outcomes from intervention and usual care can be seen as a positive result. However, improvements were also reported in studies in which the intervention was a substitute, thus showing that the Internet intervention has better results than face-to-face care. This calls for more testing of these interventions as a substitute for usual care in larger samples of diverse patients.The Internet-based interventions in the studies consisted of different components, such as peer-support groups, sharing medical records, self-management programs, and patient portals. The component they all had in common was electronic messaging. The multicomponent aspect of the studies made it difficult to trace the exclusive effect of the intervention to the asynchronous communication.Electronic messaging was not evaluated separately in these studies. It can be concluded that the effect of asynchronous communication is not adequately shown in these studies and that many questions can be raised about the precise effect of Internet-based asynchronous communication between patients with a chronic condition and their providers. This is a limitation. However, there were many positive findings about electronic messaging in relation to telephone messages and other forms of messaging.Research is needed to determine the technical characteristics of effective asynchronous communication with patients for specific disease categories where specific health behavior is needed by specific patients. The meaning of the virtual connection with the provider should be explored. This may be a very basic intervention with a large effect.Additional testing is needed to clarify what patients want to discuss with their providers and how shared decision making about these issues can be effective.The effects of asynchronous communication on self-management for larger samples of diverse patients with a chronic condition require examination. A clear definition of desirable outcomes is needed. The desired results for health behavior should be operationalized with regard to “the ability to adapt and self-manage in the face of social, physical, and emotional challenges” . In thisWe also advise further testing of Internet interventions as a substitute for usual care because significant health outcomes were found in this review.It can be concluded that using asynchronous communication in health care may be an important instrument to increase patient participation leading to self-management. After reviewing the literature, the answer to both research questions seems to be positive: asynchronous communication is used by patients and it helps to increase the effects on health behavior and health outcomes, at least for some. Patients seem to be interested in using email and understand how to use it. They use email for questions about biomedical concerns, medication, and test results, as well as to inform the providers about non-urgent health issues. They tend to prefer email to telephone for this communication. They also understand when they can use email or when contact by telephone is needed.From the viewpoint of the new definition of health with an emphasis on self-management and patient participation, it seems possible to take steps towards sustainable health care by implementing asynchronous communication, as it enables patients to communicate effectively about their perceived health problems and their adaptation to health problems.


The area of Gela was included among the 57 Italian polluted sites of national interest for environmental remediation because of its widespread contamination from a petrochemical complex. The present study investigates mortality and morbidity of the cohort of Gela petrochemical workers with the aim of disentangling occupational from residential risk.blue collars, white collars, and both – workers who shifted from blue to white collar (95%) or vice versa. An ad hoc mobility model was applied to define qualitative categories of residence in Gela, as residents and commuters. Standardized Mortality Ratios (SMRs) and Mortality Rate Ratios (MRRs) were computed, the latter by using a Poisson regression model. Morbidity was analyzed in terms of Hospital Discharge Odds Ratios (HDORs) through a logistic regression model. While performing the internal comparisons, white collars was the reference category for the job analysis, and commuters was the reference category for the residential analysis.Mortality was assessed for 5,627 men hired from 1960, year of the plant start-up, to 1993; it was followed up for vital status in the period 1960–2002. Morbidity was analysed for 5,431 workers neither dead nor lost to follow-up from 1960 to 2001 and was based on Hospital Discharge Records in the period 2001–2006. The work experience was classified in terms of job categories such as CI 90%; 0.96-4.63) in blue collars; 1.71 (1.09-2.69) in residents], respiratory diseases  and genitourinary diseases .In the light of epidemiological evidence about health risk from petrochemical industries in both occupational and environmental settings, and/or on the basis of information about occupational and residential contamination and health risk in the area of Gela, noteworthy results are shown for lung cancer [MRR: 2.11 (The results support a role of the exposures in the occupational and residential settings, the latter due to the local ascertained contamination, in affecting the workers’ health. These results underline the urgent need of water, soil, air and food-chain monitoring programs, to discover active sources of exposure and consequently define public health interventions. Gela is a town of approximately 80,000 inhabitants located by the sea in the South West coast of Sicily Region, in Southern Italy. Crude oil was found in the underground in the late ‘50s; since the early ‘60s a vast area of Gela municipality, nearby Gela town, has hosted a large oil refinery, together with a thermoelectric power plant and petrochemical plants for production of organic  and inorganic  chemicals. From 1998, a part of Gela municipal area — the entire petrochemical complex and an extended sea portion — was included among the 57 Italian Polluted Sites (IPSs) of national interest for environmental remediation. Data collected in this site after year 2000 documented groundwater, soil and air contamination. Maximum concentrations of arsenic, vinyl chloride, mercury and benzene were some orders of magnitude higher than the threshold values , the emiIn 1970, the case of Gela was described as an example of “industrialization without development” , becauseAfter year 2000, the public prosecutor in Gela started an inquiry on potential industrial pollution-related health risks concerning both the workers and the general population. Workers employment rosters were seized, and a mortality study of Gela petrochemical workers was carried out ,18. The Workers employed in the petrochemical plant in Gela from January 1, 1960, namely from the start of plant operation, to January 31, 2002, were 7,147 . The cohort considered in the present study comprised 5,627 workers for the mortality analysis and 5,431 for the morbidity analysis.In the mortality study, all men hired from 1960 to 1993 and born in Sicily were included. The vital status was ascertained for the period 1960–2002 through a request to the municipalities’ registry office; the workers hired after 1993 were excluded to allow a minimum 10 years latency time for delayed exposures effects [a priori interest was selected; the information on main diagnosis was used in the analysis. The Sicilian HDRs Registry covers all the residents’ hospital admissions in or out of their own Region. For each HDR, the fiscal code  was reconstituted. HDRs containing no valid personal data were excluded. Day-hospital admissions, rehabilitation, long stays and duplicate records were also excluded. HDRs were linked to cohort subjects using fiscal code as a key.In the morbidity study, 5,431 men hired from 1960 to 2000 not deceased or lost to follow-up, and born in Sicily were included. The Hospital Discharge Records (HDRs) available for the Sicily Region in the period 2001–2006 were analysed; the outcome was hospitalization. For each subject the first hospitalization for any given cause of blue collar or white collar were registered. The majority of workers were employed in different companies inside the complex; the duration of employment could not be determined as the only reliable information was the hiring date, and the termination date of employment was not recorded. No data were available about occupational exposures at individual or group level.Twenty employment rosters of eight different companies were used to collect workers’ personal and employment data. Data from most of the workers were available in different employment rosters; in each roster, besides personal data, the date of start of employment and the job category in terms of Workers had different origins: 85% of them came from Sicily and approximately 15% from other Regions . The latSome main diseases groups and single specific diseases, for which the epidemiological evidence had shown an association with occupation in petrochemicals or residence in the neighbourhoods, were analysed ,22. The only white collars if they were registered only as white collar in all the employment rosters, only blue collars if they were registered only as blue collar in all the employment rosters, both white and blue collars if they changed from blue collar to white collar or vice versa in different employment rosters; from now on white collars, blue collars, both.Workers were classified into one of the following three job categories: The reconstruction of the residential history was unfeasible. The companies’ rosters provided information on residence at hiring for about 90% of the workers, but this information was not used as it was specific for a given point in time. Moreover, the hiring might have happened before the official change of residence . The companies’ rosters registered also workers’ birthplace abstracted from the identity document or driving license; the birthplace was available for almost all the workers (98.5%). This information had already been used in a previous study to classify workers as residents in Gela or commuters, but the criterion to define commuters was not robust . In the Firstly, birthplace data were used on the basis of two assumptions: a) the workers born in Gela were likely to have been residents in Gela at least during the employment period; b) the workers born in Sicilian municipalities other than Gela might have been or not been residents in Gela during the employment period. The assumption b) was based on anecdotal information from several documents ,23 succeSecondly, a gravity-type mobility model was adopted to identify commuting workers. The mobility model has been described elsewhere ; it was Finally, the mobility model results were applied to define two qualitative categories of likelihood of residence in Gela:Commuters - workers born in Sicilian municipalities, excluding Gela with a probability of commuting defined by the model as >=0.5 ;a) Residents - workers born in Gela  and in Sicilian municipalities with a probability of commuting defined by the model as <0.5 (N. 709). The latter were fixed as “moved to Gela at hiring”.b) To compute Standardized Mortality Ratios (SMRs) the expected number of deaths was based on the Sicilian death rates specific for gender, 5-year age and calendar time periods. Mortality data are registered by the Italian National Bureau of Statistics, and are electronically available starting from 1970; therefore the mortality rates for the period 1970–75 were applied to the period 1960–1970. The unknown causes of death contributed to the SMRs calculation; that is, a distribution of unknown causes equal to the known ones was assumed and the number of unknown deaths was added to each group on a proportional basis [White collars was the reference category for job and Commuters was the one for residence. A multiple imputation strategy was adopted for missing data on job category  using 20 imputed datasets in both the regression models [For the internal analysis, Mortality Rate Ratios (MRRs) were calculated applying a Poisson regression model using as predictive variables job and residence categories, age, calendar period, and time since first employment. Hospital Discharge Odds Ratios (HDORs) were calculated applying a Logistic regression model, using as predictive variables job and residence categories, age, and time since first employment. n models ,26 underOnly causes with at least 10 observed cases were considered for the internal analysis.The Confidence Intervals (CIs) were estimated by the maximum likelihood method. The 90% level was chosen to limit the use of CIs as significance test thus avoiding the selection of relevant results on the sole basis of “statistical significance” .The statistical analysis was performed using STATA 11.0 software .Table In the main diseases groups, the SMRs analysis shows that the observed mortality is lower than expected for most of the causes of death Table . A slighTable blue collars than among workers belonged to the both job category. Among blue collars an increase is detected for all causes, all malignant neoplasms and digestive system malignancies. For colon and lung cancer, disease of respiratory system and chronic obstructive pulmonary diseases (COPD) an increase is suggested. An increased risk with imprecise estimates for the category of all lymphatic and haematopoietic tissue neoplasms is observed in occupational and residential mortality analysis.For the majority of the analysed causes, MMRs are higher among MRRs for residents are increased for all malignant neoplasms of the respiratory system and lung cancer, and decreased for genitourinary neoplasms.Table blue collars for all neoplasms, diseases of circulatory system, COPD, diseases of genitourinary system, nephritis and nephrosis is shown. An increase is suggested for respiratory malignancies.An increased risk among both job category an increase in bladder cancer is observed. In the same category an increase for nephritis is suggested.Among workers in HDORs among residents are augmented for CNS neoplasms and genitourinary diseases; a decreased risk is shown for skin and bladder cancer. For kidney cancer and COPD an increase is suggested.The procedures adopted for cohort enumeration, follow-up, vital status ascertainment and causes of death coding complied with recommended standards in occupational epidemiology . Based oThe main limits of the present investigation are the lack of information on individual residential history, occupational and environmental exposures. Sometimes defining occupational exposure in quantitative terms in a retrospective cohort study is not possible . This coThe observed deficit in SMR estimates can be mainly attributed to the Healthy Worker Effect (HWE). This effect is common in occupational cohorts and typically characterized by lower mortality from all combined causes of death, cardiovascular, respiratory, and neoplastic diseases . The HWEblue collars than in white collars[Work and residence categorizations suffer from intrinsic data limitations. As in most occupational cohort studies, data on confounding from lifestyle habits such as smoking, were not available. As for smoking, its prevalence is usually higher in e collars, but thie collars. This wae collars,40.both job category, changes from blue collar to white collar (95%) or vice versa might not always correspond to a change in the work environment because it could only be a change in the professional level.For the blue collars and an underestimation in the both job category result from the classification of person-years; on the other hand, an underestimation of risk estimates in blue collars cannot be excluded if they had a major risk due to the work environment, because changes from blue collar to white collar might not always correspond to a change in the work environment.The job classification adopted in the present study has consequences for the internal analysis which deserve specific comments. On one hand, an overestimation of MRR in commuters have been resident in Gela is greater than the likelihood that residents have been resident elsewhere; this is because the majority of residents (70%) were defined only on the basis of place of birth, while all commuters were identified using both information on place of birth and applying a mobility model that might include further uncertainties in the classification. As a consequence, if differences in risk are really due to a residential risk in Gela, when comparing residents vs. commuters underestimation of MRRs and HDORs are expected. For some causes, confounding could be due to residential risky exposures (e.g. urban air pollution) other than to industrial pollution in Gela, but there are no data to infer this point. As far as confounding from lifestyle habits, it is a minor problem in residential analysis because there are no reasons to assume differences between residents and commuters. Internal residential analyses are adjusted for job categories, thus taking into account, at least in part, possible confounding factors associated with the occupational context. Moreover, confounding for some causes might still occur because of differences in lifestyles between blue collars and white collars.The categorization of residence is intrinsically affected by misclassification, since the likelihood that Causes selected for analysis in the present study differ in terms of prognosis and duration. Some conditions are highly fatal, others have a more favourable prognosis and may cause repeated hospital admissions. For these reasons, mortality and morbidity data are complementary, and provide a deeper and more realistic description of the population health profile.survival cohort selected because of good health status. This could lead to an underestimation of the occupational risk, when performing the morbidity analysis, because of major risk observed in the mortality study in the blue collars category. The cohort was restricted to workers born in Sicily; the average age was 55 at the start of the morbidity follow-up. This indicated that most of them were likely to be resident active workers in Sicily in the period at study. The number of the subjects possibly lost to the morbidity follow up because of migration outside Sicily, might have been negligible and there are no reasons to believe that the hypothetical losses were differential for the job and residence categories.The restriction criteria adopted for the morbidity analysis implied the exclusion of subjects deceased before 2003, possibly resulting in a a priori interest; computation through a multiple imputation approach of missing data on job categories. Furthermore, in the present study results from the mortality study were considered together with the ones of the morbidity analysis, to disentangle occupational from residential risk. Results of previous mortality studies, whose internal analyses were limited to all causes, all cancer and lung cancer, are consistent with the present ones.The periods of hiring and follow-up considered in the mortality study coincide with the ones of previous analyses ,18. NeveIn the light of the observed increased risks, some considerations and comments on specific diseases follow.blue collars is also observed in hospital discharge analysis.The available epidemiological evidence of health effects of residence in the neighbourhood of petrochemical plants is coherently pointing to an increased risk for respiratory diseases, including lung cancer . An augmresidents and in blue collars; the latter also show higher HDORs.As for lung cancer, the main risk factor for COPD is tobacco smoke, but outdoor pollution and occupational exposure may contribute to the risk of developing the disease ,43. COPDLymphohematopoietic tissue neoplasms showed a 10-15% increased risk for employment in chemical industry . In 1989blue collars, shown by hospital discharges.Because of documented air and water contamination from mercury and other heavy metals in the area of Gela , and givAccording to Wrensch et al. review of primary brain tumours , the queboth blue and white collars, but not among blue collars alone, is not easily interpretable.For bladder cancer, tobacco smoking is the major established risk factor. Occupational exposure to aromatic amines (for example 2-napthylamine and benzidine) and polycyclic aromatic hydrocarbons are found to increase the risk . Other pIn the light of epidemiological evidence about health risk from petrochemical industries in both occupational and environmental settings, and/or on the basis of information about occupational and residential contamination and health risk in the area of Gela, noteworthy results are shown for lung cancer, respiratory and genitourinary diseases. They support a role of exposures in the occupational and residential settings, the latter due to the local ascertained contamination, in affecting the workers’ health.ad hoc air pollution program should be implemented.These results underline the urgent need of water, soil, air and food-chain monitoring programs, in order to look for active sources of exposure and to define adequate preventive strategies. In particular, as recommended since 1995 , an ad hCNS: central nervous system; COPD: chronic obstructive pulmonary disease; HDORs: Hospital Discharge Odds Ratios; HDRs: Hospital Discharge Records; HWE: Healthy Worker Effect; ICD: International Classification of Diseases; IPSs: Italian Polluted Sites; MRRs: Mortality Rate Ratios; SMRs: Standardized Mortality Ratios.Roberta Pirastu and Pietro Comba served as technical consultants for the Gela public prosecutor in the first phase of the study.RP contributed to all phases of the study: design, data collection, data analysis, manuscript preparation; AZ contributed to design, data collection and management of the morbidity study, and in manuscript preparation; RPirastu contributed to design and data collection of the mortality study, and in manuscript preparation; AC contributed to design and data collection of the morbidity study; GD contributed in discussing study design; SPA contributed in the morbidity data collection and management; SS contributed in discussing study design; PC contributed in study design and manuscript preparation. All authors read and approved the final manuscript.