To examine the quality of HIV sero-surveillance systems in 127 low-income and middle-income countries by 2007, as well as gaps in data needed for reliable estimates of HIV prevalence and size of populations at risk for infection.The quality of countries’ surveillance systems was scored using information from 2001 through 2007. Sero-surveillance data were compiled from the US Census Bureau’s HIV/AIDS Surveillance Database, from countries’ national HIV surveillance reports available to UNAIDS, from demographic and health survey (DHS) data, from the scientific literature and from countries’ Estimation and Projection Programme (EPP) data files. The quality of systems was scored according to the classification of the epidemic in each country .The number of countries categorised as fully functioning in 2007 was 40. 43 countries were identified as partially functioning while 44 were categorised as poorly functioning. Low scores were most often attributed to a lack of recent data or data from appropriate risk groups.Many countries still have poorly functioning surveillance systems. The inclusion of HIV testing in national population-based surveys in recent years has resulted in some countries with generalised epidemics receiving higher coverage scores, but many countries with concentrated or low-level epidemics continue to lack data on high-risk populations. Tracking and monitoring the HIV epidemic remains heavily dependent upon the quality of national surveillance. As noted in earlier reports,In generalised epidemics, sentinel HIV surveillance among the general population can provide essential information for planning care and support and for indicating the success of the current response. Surveillance based on women attending antenatal clinics can be used to assess trends in HIV prevalence over time. Antenatal clinic surveillance has also been used to estimate the population levels of HIV.3While countries with concentrated or low-level epidemics often rely on case reporting to track their epidemics, surveillance systems that rely solely on AIDS or HIV case reporting are not effective because of the long incubation period between infection and the development of AIDS, and because people who are infected with HIV are often not detected until they become sick with AIDS. In addition, as noted by other authors,In countries with generalised epidemics, sentinel surveillance of pregnant women attending public health antenatal clinics has been recommended for monitoring the course of the epidemic since the mid-1980s.–Since the quality of surveillance in Western Europe, the United States, Canada, Australia and other high-income countries have been analysed and reported elsewhere,6This main objective of this paper is to score the quality of surveillance systems in low-income and middle-income countries and to identify gaps in the data that are needed to guide future research and infrastructure development.http://www.census.gov/ipc/www/hivaidsn.html), all countries participating in the UNAIDS/WHO bi-annual training workshops on HIV estimation methods were asked to provide up-to-date information on the surveillance activities and reports in their countries. Additionally, all participants were followed up by email in which they were provided with a country score from the last round of assessment in 2004, a copy of all documents used to develop the last score and that have been received from the countries since then, and a request to provide more recent documents should they exist. Finally, literature searches were conducted for recent studies on high-risk populations.Data on surveillance of HIV in countries come from a number of sources. In addition to the HIV surveillance database from the United States Census Bureau,  in urban areas. At this level of the epidemic, surveillance should continue in the groups at highest risk and surveillance should be started in the general populations in urban areas.In countries with generalised epidemics, HIV prevalence is firmly established in the general adult population, and HIV surveillance activities should be conducted among adults in the general population in urban as well as rural areasIn countries with generalised epidemics, HIV prevalence data from pregnant women attending antenatal clinics have been used to monitor epidemic trends in the general adult population.et al.In the past, coding schemes representing four dimensions related to the quality of the surveillance system were developed by Walker Frequency and timeliness of data collection;Appropriateness of populations under surveillance;Consistency of the sites/location and groups measured over time; andCoverage/representativeness of the groups for the adult populations.A spreadsheet was developed for each country to record available data for each year during the time period of interest (2001–7) (frequency and timeliness), the type of data available (appropriateness of populations under surveillance), consistency of the sites included in surveillance and the representativeness of the sites. Different spreadsheets were used for low level/concentrated epidemics and generalised epidemics, with the low level/concentrated epidemic spreadsheets allowing the reviewer to identify which high-risk populations had been included in surveillance.Scores were computed for each of the four dimensions of quality, which were then combined to create an overall score of the quality of the surveillance system for each country included in this process.The scoring for frequency and timeliness remained a simple arithmetic calculation. The number of times national sentinel surveillance or a national population-based HIV prevalence survey had been conducted between 2001 and 2007 was counted (range 0 to 7). This total was then divided by the potential maximum (7) to obtain a ratio between 0 and 1. Since frequency was deemed important for trend analysis, this value was then doubled. Countries where data had been collected in the last two years were given an additional 1, others 0 for timeliness. The sum of these two values (with a maximum of 3) was used as the overall measure of frequency and timeliness.An appropriate surveillance system was defined as one in which data had been collected in the last seven years in urban as well as rural sites from antenatal clinic surveillance. In this round of assessment, if a national population-based survey had been conducted between 2001 and 2007, it was also counted as “appropriate”. Countries with an appropriate system were scored as 1, all others were scored as 0.Scoring for consistency was a judgment made by the reviewer of the country data. As stated by other authors,Coverage was scored differently in this round of assessment compared to the assessment in 2004. Coverage was scored on a 4-point scale, 0–3, with 0 reflecting poor coverage, 1 reflecting some evidence of an increasing surveillance capacity, 2 if the surveillance system in antenatal clinics is fully representational in urban and rural areas, and 3 if a DHS or national population-based survey with HIV testing was conducted in addition to sentinel surveillance. This value was then divided by 3 (the maximum score) to obtain a ratio between 0 and 1.The overall quality of the surveillance system was determined by the sum of the scores for each of the four dimensions. The sum of these four dimensions ranged from 0 to 6, with frequency and timeliness contributing to half of the total. As in the past, three categories of quality were used; fully implemented, partially implemented and poorly implemented. Countries scoring more than 4 out of 6 were regarded to be fully functioning, representing surveillance systems that were timely, frequent, appropriate and representative. Countries scoring from 2 to 3.9 were rated as partially implemented, characterised by having some features of a high-quality system, but not all. Many of these countries needed more frequent surveillance. Countries scoring lower than 2 were characterised as poorly functioning in which none of the countries were determined to have sufficient data to track the trends in the epidemic. As a result of this analysis, gaps in surveillance systems can be identified and utilised to enhance country-specific surveillance systems.Scoring quality of surveillance systems in countries with low-level or concentrated epidemics was different from scoring for countries with generalised epidemics . In counA separate spreadsheet was used for countries with low-level or concentrated epidemics. Surveillance systems in these countries were assessed based on the presence of data from four of the groups most at risk for infection: commercial sex workers (CSW), clients of CSW, men who have sex with men (MSM) and injecting drug users (IDUs). Data were also collected on surveillance conducted among patients seeking care for sexually transmitted infections (STI), which might serve as a proxy for high-risk individuals in some settings. For each category, the years in which data were collected were also recorded.Frequency was scored as described above, as was timeliness, with a summed score ranging between 0 and 2, but assessing surveillance systems among population at higher risk for infection over time.As for countries with generalised epidemics, quality of surveillance systems in low-level or concentrated epidemics were scored based on the four dimensions outlined above. Appropriateness and coverage were combined and defined by those populations that had been under surveillance. In low-level and concentrated epidemics it has been determined that it is not necessary to be concerned about full geographical coverage, since these populations are often clustered in urban areas.13–For low-level epidemics, data should be collected from all groups at risk for infection in order to be considered fully implemented. For countries with concentrated epidemics, there should also be surveillance among pregnant women in urban areas.et al,As initially proposed by Walker As in the case of countries with generalised epidemics, a summary score was developed by combining different dimensions of surveillance, with the total ranging between 0 and 4. Different cut-off scores were used for concentrated and low-level epidemics. For both concentrated and low-level epidemics, poorly functioning surveillance systems received a score of 0 to 1.6, partially functioning systems were scored 1.7 to 3.3 and fully functioning were score 3.4 or higher.Results of the quality of HIV surveillance in 127 low-income and middle-income countries are presented in Among the 127 countries whose surveillance systems were rated, 40 countries were judged to have fully functioning surveillance systems; 43 have partially functioning systems and 44 were rated as having poorly functioning or non-existent sentinel surveillance systems.This region is the most affected by the HIV pandemic.Surveillance efforts in Chad and Cameroon have declined considerably in the last three years. As a result, the surveillance system in these two countries is categorised as only partially functioning in this assessment. Namibia and Togo have evidence of ongoing antenatal clinic surveillance, yet have not conducted a national population-based survey, However, their antenatal clinic surveillance is consistent, appropriate and timely and, as such, these countries are determined to have fully functioning surveillance systems.Among the 18 countries assessed in this region, eight are characterised as having fully functioning surveillance systems. The epidemics in most of these countries are centred in high-risk populations, are mature and, as such, surveillance of infections and tracking of the epidemic are well established. Of the remaining countries, six were partially implemented and four were functioning poorly. The region as a whole has sufficient data on IDU and CSW populations, but has limited information on MSM populations.The Chinese surveillance process has improved greatly over the past decade. There are considerably more studies in the literature that address population sizes for groups at highest risk and in 2007 the national government released an estimate of HIV prevalenceIndia has historically relied on data from sentinel surveillance to monitor the epidemic. However, it has long been suggested that, in fact, there was no single epidemic in the country, but many different foci of infections that were regionally diverse. A recent national population-based survey in the country provided a more robust measure of the actual prevalence and, as such, the estimated national prevalence was lowered.The 14 countries in this region all continue to have low-level or concentrated epidemics. The epidemics in Russia and the Ukraine continue to grow, however, with Ukraine surpassing a prevalence of 1.6%.There are 27 countries in this region, and unlike what has been reported in the past,The 20 countries in this region all have low-level or concentrated epidemics. Although five countries have data available on HIV prevalence in high-risk populations, only two of these countries, Egypt and Morocco, have the quantity and quality of data required to partially track the epidemic. There is a need to conduct behavioural studies in the region to determine if the behaviours placing individuals at risk for infection are rarely present, or simply not visible.The analysis of the quality of surveillance systems for HIV continues to reflect wide variations in monitoring the epidemic, within and across regions. Fewer countries in this round of assessment have been categorised as fully functioning (40 vs 48) and fewer have been categorised as poorly functioning (44 vs 57) compared to the previous round of assessment in 2004.Surveillance systems judged to be of higher quality are also found in South and South East Asia. As in sub-Saharan Africa, the epidemics in some countries in this region are older and more mature than in other regions and surveillance systems in the majority of these countries are well functioning. Only about a third of the surveillance systems in Latin America and the Caribbean have sufficient information to be a fully functioning surveillance system. In the rest of the countries considered in North Africa and the Middle East, and in Eastern Europe and Central Africa, surveillance systems are either partially functioning or not functioning well at all. The exception in Eastern Europe was the Ukraine with a well functioning surveillance system, particularly among IDU.The results of this analysis reveal general overall weaknesses in most (68%) of the evaluated countries’ surveillance systems. The number of countries with low-level or concentrated epidemics with studies considering MSM is limited almost exclusively to countries in Latin America and South Asia. This is also true for CSW. This may represent the true nature of the disease burden, the focus of prevention interventions or may represent populations more easily accessible and accepted by the local culture. In countries in Central and Eastern Europe, the preponderance of information about the epidemic comes from studies focusing on IDU.Additionally, even in those countries where data exist for the populations most at risk of infection, consistent data collection over time does not, and trends in the epidemic are difficult if not impossible to monitor. Though the methodology used in this assessment attempted to address representativeness and coverage of surveillance, the actual size of high-risk populations remains difficult to quantify. Most HIV prevalence data in these high-risk populations are found in specific studies with limited sample size and limited sampling frames. Accurate extrapolation of the results of these studies to the specific high-risk population would require an estimate of the population size. The value of data from studies such as these would be enhanced by estimations of the size of the high-risk populations. Further, just as correction factors have been suggested for prevalence estimates based on ANC data using data from population-based surveys, studies are needed to determine if such adjustments are needed for estimations among high-risk populations .22The analysis presented here has several limitations that must be considered. First, there is the possibility that some data in countries have not been considered in this analysis. Every effort has been made to ensure that available data have been identified by contacting national epidemiologists from each country and requesting the most recent data available. The scope of the data considered appropriate for the analysis in low-level or concentrated epidemics was limited to data on high-risk populations, and for the analysis in generalised epidemics was focused on antenatal clinic surveillance and population-based surveys that include HIV testing. If a country uses data from other sources for monitoring the epidemic, such as data related to blood screening, those data were not captured here. Additionally, publications were considered in English, French, Spanish and Russian. Other languages were not considered.Surveillance of infections such as HIV is of course problematic because of the asymptomatic nature of the infection for most of the duration of the infection. For many individuals in countries with low-level and concentrated epidemics, barriers to testing (such as access and stigma) make it difficult to adequately assess the true burden of infection in certain populations.This paper considered the most recent data available for the last seven years in assessing the quality of surveillance systems for monitoring the HIV epidemic. In countries with the largest disease burden, surveillance has continued to improve over time, and the addition of large population-based HIV prevalence surveys in these countries has greatly enhanced the reliability of the data. In many other countries, specifically those with low-level and concentrated epidemics, the quality of data has also improved, though many countries still lack the consistency required to follow trends over time in these high-risk populations. There are gaps in some countries’ data on high-risk populations, and behavioural data are generally scarce. Estimating the size of high-risk populations and the frequency of exposure to HIV remains a difficult task.The quality of HIV surveillance seems to be improving.However, some countries still lack the necessary data to accurately assess the course of the epidemic. Trend analyses will be difficult.Many countries with low-level and concentrated epidemics could improve their surveillance by collecting data from all groups at risk for infection.


Five to ten percent of chiropractic patients are children and adolescents. Most of these consult because of spinal pain, or other musculoskeletal complaints. These musculoskeletal disorders in early life not only affect the quality of children's lives, but also seem to have an impact on adult musculoskeletal health. Thus, this is an important part of the chiropractors' scope of practice, and the objective of this review is to assess the evidence base for manual treatment of musculoskeletal disorders in children and adolescents.Randomized, quasi-randomized and non-randomized clinical studies were included if they investigated the effect of manual therapy on musculoskeletal disorders in children and/or adolescents. The MEDLINE and MANTIS databases were searched, and studies published in English, Danish, Swedish or Norwegian were included.Only three studies were identified that in some way attempted to look at the effectiveness of manual therapy for children or adolescents with spinal problems, and none of these was a randomized controlled clinical trial. As for the rest of the musculoskeletal system, only one study of temporomandibular disorder was identified.With this review, we have detected a paradox within the chiropractic profession: Although the major reason for pediatric patients to attend a chiropractor is spinal pain, no adequate studies have been performed in this area. It is time for the chiropractic profession to take responsibility and systematically investigate the efficiency of joint manipulation of problems relating to the developing musculoskeletal system. All over the world, chiropractors treat a large variety of conditions in many ways. However, the core area of chiropractic practice is the musculoskeletal system, with special focus on the spine. Surveys of chiropractic patients in different countries have shown that spinal pain is the most common reason for seeking chiropractic care with 64%-86% reporting spine-related symptoms -5. OtherThere are only few descriptions of pediatric patients' use of chiropractic services. A Danish survey showed that 64% of patients, aged 2 to 18, had primary complaints from the musculoskeletal system and 13% had headache as primary complaint . OverallThese disorders deserve more focus than they receive at present. Traditionally, spinal pain has been considered an ailment of adulthood. However, there is a growing understanding that such problems originate early in life with up to 50% of children and adolescents experiencing low back pain within the course of a year and a third of these will experience recurrent pain -12. EvenChiropractic treatment covers a range of non-surgical and non-medical types of treatment such as exercise, dietary advice, ergonomic advice, soft tissue treatment and others, but the core treatment for the chiropractic profession is joint manipulation,21. The Since musculoskeletal disorders are the most common disorders seen in pediatric patients in chiropractic practice, we decided to do a systematic literature review of the effectiveness of manual therapy for musculoskeletal disorders in children and adolescents. However, as it turned out, there was hardly anything to review, turning this into a very brief report.Randomized, quasi-randomized  and non-randomized clinical studies were included if they investigated the effect of manual therapy on musculoskeletal disorders in children and/or adolescents. Therefore, we excluded reviews, case reports/series, letters, editorials, guidelines and comments.Children and adolescents (2-18 years of age) with musculoskeletal disorders. Studies relating to infants below the age of two were excluded due to uncertain diagnoses. Studies of fractures, dislocations or structural anomalies were excluded.All types of manual therapy.Only studies published in the peer-reviewed literature in English, Danish, Swedish or Norwegian were included.MEDLINE and MANTIS were searched from their respective beginning to December 2009. In MEDLINE, the following search strategy was used:  NOT case report NOT fracture. A similar strategy was used in MANTIS in an adapted form. Finally, the reference lists of relevant reviews were screened.Both authors independently screened the titles and abstracts from the search results. Potentially relevant papers were obtained in full text and independently assessed for inclusion.Data were not extracted nor pooled for meta-analysis because the included studies were few and disparate and data could not rationally be pooled. For the same reasons, no attempt at evaluating the methodological quality was done. The identified studies are simply briefly described.1) a cohort time-series trial investigating the effect of chiropractic interventions on small scoliotic curves. This study concluded that chiropractic was not effective in reducing the severity of scoliotic curves [2) a prospective cohort study evaluating chiropractic management of pediatric patients with low back pain, including 54 patients. This study concluded that patients responded favorably to chiropractic management with no reported complications [3) a pilot study published in 2006, investigating chiropractic manipulation in adolescent idiopathic scoliosis including six patients [http://controlled-trials.com or at http://clinicaltrials.gov, indicating the larger study is not being performed. The fourth, and the only non-spinal, study pertained to the temporomandibular joint. This was a randomized controlled trial of 28 children evaluating osteopathic manipulative treatment (OMT) of temporomandibular disorders. The results suggest that OMT can improve mandibular kinematics [The MEDLINE search revealed 478 titles, of which three articles were retained in full text -30. The c curves , 2) a prications . In neitpatients . The conIn light of the very few studies that met our inclusion- and exclusion criteria, we wanted to obtain a superficial overview of all the published literature in the field. We used the same search terms in MEDLINE, but limited the search to different types of publications. There were 32 reviews, 118 letters, editorials, addresses or comments, and 113 case reports/case series. We screened the titles of the case reports and found 35 studies of dislocations. Excluding dislocations, we were able to identity 23 studies describing the effect of manual therapy in children. Eleven of these dealt with musculoskeletal disorders and 12 with non-muscular disorders. The objective of the rest of the case studies could not be determined based on the titles alone.Only three studies were identified that in some way attempted to look at the effectiveness of joint manipulation for children or adolescents with spinal problems, and none of these was a randomized controlled clinical trial. In other words, there is no first level evidence available in relation to the effectiveness of manual therapy for spinal disorders in the young population. As for the rest of the musculoskeletal system, only one randomised trial of temporomandibular disorder was identified.We might have missed some studies due to a limited search strategy. Mainly, we only searched the Medline and MANTIS databases and might have missed articles not indexed there. We did not have access to Embase, which could have expanded the search. There are probably also reports in the non-indexed literature, the so-called "grey literature", which we have not included. We intentionally did not search the grey literature, since there is no minimum of quality control in such publications and they are not accessible to the majority of health care providers. However, we believe that we have not missed a body of literature large enough to change the overall impression of a poorly researched area.With this review, we have detected a paradox within the chiropractic profession: Although the major reason for children and adolescents  as well If the chiropractic profession wishes to undertake the task of caring for children's musculoskeletal problems, an important area for which no other profession has taken responsibility, we can not simply treat children as small adults. We must build up scientifically sound knowledge focusing on the developing spine. We should also provide the opportunity to specialize in pediatrics. To do this, we are in dire need of evidence on which to build daily practice as well as a specialist education. It is necessary to produce research that documents the type of pediatric patients chiropractors treat, the type of treatments offered, the effect of these treatments, and potential side effects. This means that randomized controlled clinical trials evaluating the most common treatments for the most common conditions in chiropractic pediatric patients must be performed, including proper registration of adverse effects.It is time for the chiropractic profession to take responsibility and make an effort to provide an evidence-based treatment for problems relating to the developing musculoskeletal system.effect of manual therapy on musculoskeletal problems in children, one of which was a pilot study and two lacked a control group. It is long overdue that we, as caretakers of musculoskeletal health, face reality. As the story goes: "But he has nothing on at all," said a little child at last. ...... "But he has nothing on at all," cried at last the whole people. That made a deep impression upon the emperor, for it seemed to him that they were right; but he thought to himself, "Now I must bear up to the end." And the chamberlains walked with still greater dignity, as if they carried the train which did not exist." [That which appeared at first to be a large body of literature in relation to chiropractic treatment of children turned out to be a case of the emperor's new suit. Of the almost 500 identified titles, there were several hundred case studies, reviews, letters etc., but only four clinical studies related to the  exist." . HoweverAs researchers, our interest is to further research in this area. This might be considered a competing interest by some. The views expressed in this manuscript are our sincere opinion to promote evidence-based treatment of children for the common good.Both authors independently performed the literature search and the screening of titles and abstracts. LH drafted the manuscript, MJS did the critical revising and both authors read and approved the final manuscript.


Health problems, health behavior, and the consequences of bad health are often intertwined. There is a growing need among physicians, researchers and policy makers to obtain a comprehensive insight into the mutual influences of different health related, institutional and environmental concepts and their collective developmental processes over time.SMILE is a large prospective cohort study, focusing on a broad range of aspects of disease, health and lifestyles of people living in Eindhoven, the Netherlands. This study is unique in its kind, because two data collection strategies are combined: first data on morbidity, mortality, medication prescriptions, and use of care facilities are continuously registered using electronic medical records in nine primary health care centers. Data are extracted regularly on an anonymous basis. Secondly, information about lifestyles and the determinants of (ill) health, sociodemographic, psychological and sociological characteristics and consequences of chronic disease are gathered on a regular basis by means of extensive patient questionnaires. The target population consisted of over 30,000 patients aged 12 years and older enrolled in the participating primary health care centers.Despite our relatively low response rates, we trust that, because of the longitudinal character of the study and the high absolute number of participants, our database contains a valuable set of information.SMILE is a longitudinal cohort with a long follow-up period (15 years). The long follow-up and the unique combination of the two data collection strategies will enable us to disentangle causal relationships. Furthermore, patient-reported characteristics can be related to self-reported health, as well as to more validated physician registered morbidity. Finally, this population can be used as a sampling frame for intervention studies. Sampling can either be based on the presence of certain diseases, or on specific lifestyles or other patient characteristics. Good health is highly valued. For centuries with varying success scientists have tried to find causes of illness and ways to prevent ill health. A lot of progress in improving and maintaining health has been made, especially in the area of infectious diseases. Chronic diseases, however, do not respond to the simple formula "identify the cause and eliminate it" , becauseThis has resulted in a growing need among physicians, researchers, and policy makers to gain insight into the mutual influences of different health related, institutional and environmental concepts and their collective developmental processes over time. Only substantial insight into these factors and their relations can help to improve public health by effective interventions in the areas of public health, occupational health, disability management, and care in the home. Such insight can be obtained by combining both physician-registered medical data and patient self-reported data. Often, researchers have of either medical data or questionnaire data at their disposal, which both have their limitations.Health problems and health behavior are often intertwined, and it is therefore relevant to gather both medical data as registered in general practice and health related data as reported by the patients. Although this notion seems trivial, very few studies do so. The collection of this combined data, albeit more complex and expensive, will have several advantages. First a better understanding of health problems can be developed. Secondly, it is possible to evaluate 'natural' occurring phenomena. E.g. the results of a recent study on health problems of victims of a fireworks disaster in the Netherlands could have been more explicit if self-reported data on patients' perception were also available .Moreover, an integral approach collecting medical, health behavioral, psychosocial and care consumption data, has substantial advantages.Study of Medical Information and Lifestyles in Eindhoven, in short SMILE.The goal of the SMILE study is to develop a hybrid database containing both medical data and questionnaire data, attempting to resolve the problems described above. Although results of outcomes of elements of this study are already described -7, this Based on the scientific input of the various disciplines , cooperating in SMILE, the main points of interest are captured in the research model  life styles and health. Examples concern the role of parenting styles on the smoking behavior of adolescents ,7 and faThe "saddle" represents the environmental factors. Important research questions from this perspective concern the longitudinal relation between health, health behavior, and their (work-related) determinants among the working and the non-working population, with special attention to psychological complaints and musculoskeletal complaints, in order to be able to analyze the influence of work-related factors on health and health behavior. Another major study from this perspective in combination with the "front wheel" is the influence of socioeconomic status-combined with psychological characteristics on the occurrence of cardiovascular diseases.A number of research projects have been performed, or are currently being performed using the data available from SMILE. These studies concern: parenting styles and smoking behavior in adolescents; personality and intake of fruit, vegetables and soft drinks in adolescents; inequalities in health perceptions between the employed and the unemployed; clustering of life style behaviors; self-esteem, self-efficacy and depression in adolescent headache sufferers; the influence of life style on the development and prognosis of headache in adolescents; rebelliousness, conformity and socio-economic health differences; material versus psychosocial explanations of socio-economic health differences; change of the health insurance system and quality and accessibility of care; multimorbidity and income in relation to self-reported physical and mental health.SMILE, is a large prospective cohort study, focusing on different aspects of disease, health and lifestyle of people living in Eindhoven, the Netherlands. Eindhoven is a city in the Southern part of the Netherlands of approximately 200,000 inhabitants.In November 2002, 2,178 adolescents (aged 12–18 years) and 28,879 adults (aged 18 and older) enrolled in one of the participating health care centers were invited to participate in SMILE. SMILE is a dynamic cohort study, meaning that new participants will enter the population sample when they either reach 12 years of age or when they are enrolled as a new patient in one of the participating centers, and they give their informed consent. Respondents may leave the population either through leaving the participating practice or due to death or drop-out. Furthermore, after two succeeding moments of non-respons patients don't receive any more questionnaires. The dynamic character of SMILE is expected to result in a sufficiently large patient population over time and it prevents vanishing of the study population.The fundamental goal of SMILE is to study health and disease and their determinants and their consequences in a comprehensive approach for an extended period of time (15 years). Apart from serving data for examining and analyzing relationships between several health-related concepts, SMILE can also serve as a sampling frame to select specific patient groups such as elderly with osteoarthritis,, adolescents with low self-esteem, or adults with a sedentary life style.To realize this goal, the structure and contents of the SMILE study has two unique characteristics:1. Two data collection strategies are combined: firstly, data on morbidity, mortality, medication, and use of care facilities are continuously registered using electronic medical records (EMRs) in primary health care centers. Secondly, information about lifestyles and the determinants of (ill) health, sociodemographic, psychological and sociological characteristics, and consequences of disease are gathered by means of patient questionnaires.2. Researchers from various disciplines , are actively involved in the study. They all contribute to the theoretical framework and the contents of the questionnaire and the analysis of data. As a result different perspectives are explicitly incorporated  working in 9 primary health care centers of the Eindhoven Corporation of Primary Health Care Centers are participating.®). The GP registration is continuously updated, because registration pertains to daily routine. These data concern disease episodes  (Medicom in ICPC ), of whiIn November 2002 both adolescents and adults received the first questionnaire. Participants receive a questionnaire every year in November. Adolescents and people aged 55 years or older receive an additional questionnaire every year in May.For adolescents aged 12–18), a special version of the patient questionnaire was developed, as several concepts required different questioning for adolescents, or the use of words had to be adapted to appeal to adolescents. When reaching the age of 19, the adolescents are included in the adult sample, and will consequently receive the 'adult' version of the questionnaire. The concepts monitored and measured through the patient questionnaires are enlisted in table 2–18, a sFor each measurement a selection of concepts is made is such a way that on the one hand time needed to fill in the questionnaire is acceptable, and on the other hand basic concepts are measured on a regular basis and all disciplines involved are consulted at the construction of the questionnaires at each measurement. Until now, patient-reported data were solely collected using paper questionnaires. Currently, the use of the internet for data collection is explored.Data both from the medical records and the patient questionnaires are stored in a relational database (Oracle). Data are available through a web browser. Variables and processes are defined in XML format that can be used to generate queries to access the relational database. The data infrastructure is based on a number of HL7v3 information models, which will be compatible with national data infrastructure. Data will be available on different levels of detail for different persons and organizations, consistent with the conditions stated in the informed consent. Questionnaire data of individual patients can never be provided to GPs. All study data are stored and kept anonymously at Maastricht University.Written informed consent allowing matching of self-reported and medical data, as well as allowing matching of own data with data of family members is asked when a patient registers in one of the participating health care centers. Privacy regulations are in agreement with the Dutch legislation. The medical ethical committee of the Maastricht Academic Hospital has approved of the study protocol of the SMILE study. Furthermore, the study was registered at the Dutch Data Protection Authority. When appropriate, additional studies evaluating interventions will be sent to the medical ethical committee for approval.This manuscript describes a new scientific initiative, the SMILE study: a longitudinal dynamic cohort using both routinely collected medical information from the EMRs in general practice and periodically collected patient information using questionnaires.To measure health related processes in time, a long-term prospective cohort study is the most convenient study design. A powerful feature of cohort studies is the opportunity to collect both repeated exposure data and repeated outcome data, which provides many analytical opportunities to deduce the effects of random measurement error and to evaluate various hypothesized temporal relations between exposure and outcome . The dynThe SMILE study comprises a dynamic population, contrary to most of the other health related large cohort studies, like the Framingham Heart Study ,13, or tPossible disadvantage of this approach are: difficulties in deciding which (limited set of) concepts to measure. This was, however, solved by intense communication within SMILE.Because the establishment of a large cohort typically represents a major investment in resources, it is efficient to examine all major health outcomes . Since SMore extensive use of the data will be stimulated by continuous efforts to maintain and to further improve data quality. In this regards continuous participation of both GPs and patients is of the utmost importance in a longitudinal study. For this type of research the setting of general practice linked to academic departments is especially suitable, covering both an unselected patient population and a broad scope of morbidity. This is especially true in the Netherlands, where all people are enrolled as a patient in a general practice.Several efforts are made to stimulate participation, like raffling of record tokens among adolescents. Once a year a newsletter is sent to all participants, containing results, interviews etc. to stimulate participants' engagement in the SMILE study. Also, at each measurement a press release is sent out, which is usually elaborated by the local press and posters are distributed in the practices reminding patients to fill in their questionnaire.GP involvement is stimulated in other ways. First of all registration is as close as possible to daily routine, so that keeping up the EMRs does not take much additional time.Benchmarking is another tool which can result in better quality of registration (completeness as well as correctness), and which at the same time helps GPs to improve the quality of their care. Finally, the Eindhoven Corporation of Primary Health Care Centers is receiving a reimbursement to compensate for additional efforts in the context of the SMILE study.There has been a sharp increase in the scientific use of electronic medical records (EMRs), collected on a routinely basis . These rThe author(s) declare that they have no competing interests.Marjan van den Akker participated in the design of the study and drafted the manuscript. Mark Spigt critically revised the manuscript. Lore de Raeve contributed to the design of the questionnaire and critically revised the manuscript. Ben van Steenkiste participated in data collection and critically revised the manuscript. Job Metsemakers contributed to the conception of the study and participated in its design and coordination. Ernst van Voorst was responsible for data acquisition and GP management. Hein de Vries conceived of the study and participated in its design and coordination. All authors have approved of the final version of this manuscript.The pre-publication history for this paper can be accessed here:


Several studies on patient safety have shown that a substantial number of patients suffer from unintended harm caused by healthcare management in hospitals. Emergency departments (EDs) are challenging hospital settings with regard to patient safety. There is an increased sense of urgency to take effective countermeasures in order to improve patient safety. This can only be achieved if interventions tackle the dominant underlying causes. The objectives of our study are to examine the nature and causes of unintended events in EDs and the relationship between type of event and causal factor structure.Study at EDs of 10 hospitals in the Netherlands. The study period per ED was 8 to 14 weeks, in which staff were asked to report unintended events. Unintended events were broadly defined as all events, no matter how seemingly trivial or commonplace, that were unintended and could have harmed or did harm a patient. Reports were analysed with a Root Cause Analysis tool (PRISMA) by an experienced researcher.522 unintended events were reported. Of the events 25% was related to cooperation with other departments and 20% to problems with materials/equipment. More than half of the events had consequences for the patient, most often resulting in inconvenience or suboptimal care. Most root causes were human (60%), followed by organisational (25%) and technical causes (11%). Nearly half of the root causes was external, i.e. attributable to other departments in or outside the hospital.Event reporting gives insight into diverse unintended events. The information on unintended events may help target research and interventions to increase patient safety. It seems worthwhile to direct interventions on the collaboration between the ED and other hospital departments. Several studies in various countries have shown that a substantial number of patients suffer from adverse events in hospitals. -9 These The ED is a challenging hospital setting because high patient throughput, heavy dependence on services outside the ED  and the diversity of clinical conditions presented. EmergencEvent reporting systems can provide valuable information for detecting patient safety issues in hospitals. GenerallWith the present study, we want to examine the causes of various types of unintended events in the ED by analysing unintended event reports. Event reports can be helpful in capturing system defects (latent errors) and near misses that may not be detected by reviews of patient records. Two earlThe objectives of our study are to gain more insight into (1) the nature of unintended events in the ED, (2) the causes of unintended events in the ED and (3) the relationship between the type of event and the causal factor structure.From October 2006 to December 2007, an observational study was performed to examine the causes of unintended events at the emergency department (ED) of ten hospitals in the Netherlands: one university hospital, three tertiary teaching hospitals and six general hospitals. Unintended events were broadly defined as all events, no matter how seemingly trivial or commonplace, that were unintended and could have harmed or did harm a patient. The studThe intake of departments was phased, because -for logistical reasons- we did not want all EDs to participate in the study simultaneously. The study period per ED was eight to fourteen weeks depending on the reporting speed. Healthcare providers  and clerks at the department were asked to report all unintended events that occurred, both when they were involved in an event and when they witnessed an event. In order to find the causes underlying the reported unintended events, the events were analysed by an experienced researcher using a Root Cause Analysis (RCA) tool called PRISMA-medical.,20 In adBefore the start of the study, ED-staff received an oral and written instruction about the aim and procedure of the study. They had two alternatives for reporting the unintended events: a report card or report form. On the pocketsize report card, the name of the reporter, the moment in time, and a description of the event were requested. The report form was more elaborate and additionally requested the involvement of the reporter, the phase of care, place, some patient characteristics and consequences for the patient. A letter box was placed at the department to drop the report cards and forms. Our intention was to gather at least 50 reports per department to be able to dray valid causal factor profiles of each department. A minimum of fifty reports is recommended to capture the variety of possible unintended events . Staff were encouraged to report unintended events by a two-weekly newsletter, reminders during team meetings and appealing activities to direct staff's attention to reporting.Once or twice a week a researcher visited the ED to collect the written reports and ask the reporters some questions about the reported events in short interviews. Each event report was followed by an interview with the reporter, mainly to get information on contributing factors. In case the reporter had used a report card, the additional information requested on the elaborate report form was also obtained during this interview.Occasionally, questions were asked by telephone. No interviews were held with staff in other hospital departments than the ED.All unintended events were analysed with PRISMA-medical. PRISMA is a tool to analyse the root causes of a broad set of unintended events.,20 The cPRISMA examines the relative contributions of latent factors , active failures (human) and other factors (patient related and other). Unintended events are analysed in three main steps. Firstly, a causal tree is formulated. At the top of the tree a short description of the event is placed, as the starting point for the analysis. Below the top event, all involved direct causes are mentioned. These direct causes often have their own causes. By continuing to ask "why" for each event or action, beginning with the top event, all relevant causes are revealed. In this way a structure of causes arises, until the root causes are identified at the bottom of the tree .,20,26 ThEventually, by aggregating the classifications of root causes of at least 50 events, a so called PRISMA profile can be delineated, which shows in a graphical representation the relative contributions of the different root causes and gives direction to the development of preventive strategies.,20The analyst of the unintended events in the ED was a PhD candidate on patient safety in hospitals and also one of the authors of this paper (MS). She was trained in the PRISMA method. In a previous paper, we examined the inter-rater reliability of formulating root causes in causal trees and classifying the root causes with the ECM. The reliThe data of the reports were first summarised using descriptive statistics and frequency tables. All analyses were performed with 522 cases (N = 522 unintended events), except for the analysis of the relative frequencies of causes per event type. The frequencies per event type were calculated using the 845 root causes as cases (N = 845 root causes), because we wanted the percentages in the bars to sum up to 100% to increase the comprehensibility of the figure. SPSS 14.0 was used to perform the statistical analyses.The total number of events reported was 522, ranging from 46 to 71 per ED, with an average of 52 reports (SD = 7.6). In total, there were 743 reporting days during which 189 different employees reported one or more unintended events. Most reports were made by nurses (85%). Resident physicians or consultants reported 13% of the unintended events and clerical staff reported 2%. In 83% of the unintended events, the reporter was directly involved in the event.In Table Table All 522 unintended events were analysed with PRISMA, resulting in 845 root causes. Fifty percent of the unintended events had one root cause, 39% had two root causes, 10% three root causes and 1% four root causes. The mean number of root causes per unintended event was 1.62 (SD = 0.71).In Figure Table When looking at the internal causes inside the ED, human intervention errors (HRI) stand out (22% of unintended events with human causes). Examples of intervention errors are: not recording the time when medication was administered or not plugging the battery of a medical device in the socket. Moreover, errors with regard to protocols (OP) and management priorities (OM) are relatively frequent organisational causes , for example protocols that were incomplete or old medical devices that were not replaced by hospital management.We gathered and analysed a large number of unintended events (522) using a root cause analysis tool based on the sound theoretical frameworks of Reason and Rasmussen, which is accepted by the WHO and which has a good reliability.The results show that a large number of unintended events occur in the collaboration with departments outside the ED . Staff in the ED are heavily dependent on these services. The problems in the cooperation with outside services can also be noticed in the phase of care in which unintended events mainly come about -medical examinations and tests-, since a lot of tests are performed in other departments.Half of all reported events reached the patient directly, most often resulting in inconvenience or suboptimal care. The causes of the unintended events were mainly human, though system factors  were established as well. Predominance by human causes is also found in the aviation industry. It is estimated that approximately 75 percent of all aviation accidents are related to human errors. Nearly hUnintended events related to materials and equipment were relatively often caused by technical factors. Incorrect data and substitutions were for a relatively large part caused by human errors, while organisational factors contributed most to unintended events related to protocols and regulations.Some comments have to be made for a good interpretation of the causes of the unintended events. Firstly, the reported unintended events were related to patient care, and healthcare providers were somehow involved in all events. This resulted in involvement of human causes in many cases. The PRISMA analysis, however, did focus on identifying accompanying system factors, beside these human causes. Secondly, as we strived for objective information about underlying causes, presumptions of the reporters about possible organisational or technical causes were not recorded in the causal tree. Finally, a lack of organisational or technical barriers was not labeled as an organisational or technical cause. An example: when two healthcare providers make the same laboratory request for a patient, blood is taken unnecessarily once. An automatic electronic signaling system would have prevented the double laboratory request, but as long as such a system does not exist at the ED, this system can not be regarded as a cause. Yet, improvements of organisational procedures or technique can arise from the identification of human errors.The unintended events identified in our study are unlikely to be a random sample of all unintended events occurring in the ED, whereas not all unintended events that took place will have been reported. Since the healthcare providers making the reports were often directly involved in the patients' care and since the reporting was not anonymous, it is possible that certain mistakes were under-reported because they were embarrassed or afraid of condemnation by the researchers or colleagues. This may have biased the results towards the reporting of less significant events, events without consequences for the patient and errors originating in other departments, because these are 'safer' to report. Anonymous reporting would perhaps have yielded more events, but interviewing the reporters -essential for obtaining information on contributing factors- would not have been possible in that case. Some unintended events occurred multiple times at one ED, and some healthcare providers informed us not to be willing to report these events over and over again. Examples are long waiting times for laboratory test results or for (paper) patient records from the records archive. We do not know exactly which events were under-reported, how frequently they occurred and whether they had the same underlying causes in every case. Therefore, we were not able to correct for this under-reporting by giving different weights to these types of events and their causes. Finally, most unintended events were reported by nurses. Consequently, the study mainly gives an idea about events related to nursing care and to a lesser extent to care processes by residents and specialists in the ED.Another limitation may have had an effect on the root causes identified. The interviews about the events depend on the recall of the reporter. However, we strived for a small time lag between the occurrence of the event and the interview. Events were discussed within a few days, with a maximum time lag of three weeks in some exceptional cases.As we mentioned in the introduction, two other event reporting studies have been performed in hospital EDs in the past. Fordyce et al. examinedIn both studies, as well as in our study, only small numbers of events had severe consequences for the patient: Fordyce et al. found adWe recommend improving the collaboration between the ED and other hospital departments, while a large number of unintended events occur in the collaboration with departments outside the ED and nearly half of all causes were external. A reduction of the external factors is not only the responsibility of these external departments. We believe that EDs and other departments should jointly discuss these causes and work on improvement plans for safe patient care across hospital departments .Causes of unintended events were predominantly labelled as human. In 2008, the Dutch Society of Medical Specialists, among others, has formulated a national patient safety action campaign for hospitals 'Prevent harm, work safely' that contains interventions directed at reducing human error. Elements of the programme are: education about patient safety, team training and evaluations of the Individual Functioning of Medical Specialists (IFMS), including the construction of a personal portfolio, a personal progress plan and annual interviews about quality of care and communication with colleagues and patients. These inFinally, we believe that event reporting and analysis gives valuable insight into the nature and causes of unintended events. The PRISMA method to analyse events is a useful tool to examine large numbers of events to uncover latent and active causal factors. It can be taught to and used by researchers, clinicians and managers. In the Netherlands, many hospitals start using PRISMA to study events reported by their staff. Most hospitals are taking on decentralised (department-level) event reporting with in each department a special committee that has the task to analyse the reported events, give staff feedback and design and implement improvements.While in most unintended events in our study no harm for the patient was involved, only a small number of the unintended events would have met the criteria of an adverse event: 1) an unintended  injury which 2) results in temporary or permanent disability, death or prolongation of hospital stay, and is 3) caused by health care management rather than the patient's disease. The events in our study were not assessed by physician reviewers on these criteria. It is unclear whether the results regarding the causes of the broad group of unintended events we examined are also applicable to the specific group of adverse events. Although the common cause hypothesis of near misses and accidents is supported by research in the railway sector, future Our study mainly gives an idea about events related to nursing care. To get a more complete view of all unintended events that occur, we recommend expanding the reporting of events with patient record review. The report of Wagner et al. showed tOur study shows that event reporting gives insight into diverse unintended events that occur within healthcare, especially nursing care. The majority of unintended events had no consequences for the patient or resulted only in minor patient inconvenience. However, since large numbers of patients visit the ED, the accumulated effect of the events on patient well-being and the healthcare delivery system is likely to be large.The information on unintended events may help target research and interventions to increase patient safety. It seems worthwhile to direct interventions on the collaboration between the ED and other hospital departments, because a large number of unintended events occur in the collaboration with departments outside the ED and nearly half of all causes were external.The causes of the unintended events were mainly human, though since latent factors -organisational and technical- were established as well, and believing that various human causes can be captured by building organisational and technical defences, we recommend to explore effective system interventions to improve patient safety in the emergency setting.The authors declares that they have no competing interests.GW and CW obtained research funding. MS, CW and DT were involved in the design of the study. MS coordinated the data collection, analysed the events and wrote the manuscript. MS and CW performed the statistical analyses of the data. CW, PG, DT and GW were involved in revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


There is considerable evidence about the effectiveness of audit coupled with feedback, although few audit with feedback interventions have been conducted in long-term care (LTC) settings to date. In general, the effects have been found to be modest at best, although in settings where there has been little history of audit and feedback, the effects may be greater, at least initially. The primary purpose of the Data for Improvement and Clinical Excellence (DICE) Long-Term Care project is to assess the effects of an audit with feedback intervention delivered monthly over 13 months in four LTC facilities. The research questions we addressed are:1. What effects do feedback reports have on processes and outcomes over time?2. How do different provider groups in LTC and home care respond to feedback reports based on data targeted at improving quality of care?The research team conducting this study comprises researchers and decision makers in continuing care in the province of Alberta, Canada. The intervention consists of monthly feedback reports in nine LTC units in four facilities in Edmonton, Alberta. Data for the feedback reports comes from the Resident Assessment Instrument Minimum Data Set (RAI) version 2.0, a standardized instrument mandated for use in LTC facilities throughout Alberta. Feedback reports consist of one page, front and back, presenting both graphic and textual information. Reports are delivered to all staff working in the four LTC facilities. The primary evaluation uses a controlled interrupted time series design both adjusted and unadjusted for covariates. The concurrent process evaluation uses observation and self-report to assess uptake of the feedback reports. Following the project phase described in this protocol, a similar intervention will be conducted in home care settings in Alberta. Depending on project findings, if they are judged useful by decision makers participating in this research team, we plan dissemination and spread of the feedback report approach throughout Alberta. The evidence for specific interventions to implement evidence-based practices in various healthcare settings is mixed at best -6. Many Audit of performance, including both process and outcome measures, is an essential but probably insufficient condition for any quality improvement effort. Without audit of key indicators, it is not possible to assess the quality of care being provided. Audit requires access to data regarding processes and outcomes of care, and may require additional data elements depending on the sophistication of the audit system, the audit targets, and the indicators being monitored. As the evidence-based care movement has developed over the last several years in Canada and other developed countries, audit has played a major role in providing information about adoption of evidence-based practices in many settings and contexts.When coupled with some form of feedback mechanism in which data are fed back to providers, audit becomes the backbone of one of the most commonly applied and widely tested initial methods of achieving quality improvement or attempting to facilitate the adoption of evidence-based practices. There is considerable evidence about the effectiveness of audit coupled with feedback, although few audit with feedback interventions have been conducted in long-term care (LTC) settings to date. In general, the effects are modest at best, although in settings where there has been little history of audit and feedback, the effects may be greater, at least initially ,8. The pThere is a wide range of possible outcomes that may be affected by interventions to implement evidence-based practices. These include patient or resident outcomes , provider outcomes , and system outcomes . In addition, process outcomes may be relevant in assessing whether or not interventions are fully implemented. Process outcomes include measures of uptake of feedback reports, numbers of staff attending education sessions, and intent to change behavior ,15. ThisThe primary purpose of the Data for Improvement and Clinical Excellence (DICE) Long-Term Care project is to assess the effects of an audit with feedback intervention delivered monthly over 13 months in four LTC facilities, using data from the Resident Assessment Instrument (RAI).We address these research questions:1. What effects do RAI feedback reports have on processes and outcomes over time?2. How do different provider groups in LTC and home care respond to feedback reports based on RAI data targeted at improving quality of care?The overall intervention evaluation uses a controlled interrupted time series design with monthly feedback reports in nine LTC units in four facilities. Surveys to assess uptake of the audit with feedback intervention are conducted one week after feedback report distribution. The purpose of this survey is not to assess change in behavior, but intent to change, as well as to assess staff response to the feedback reports.The process evaluation, conducted concurrently with the prospectively collected survey data, uses observation and self-report to assess uptake of the feedback reports. We define uptake as reading the feedback reports, discussing with colleagues and managers, and reporting some degree of intention to change behavior based on the reports.This project has received ethics approval from the Health Research Ethics Board, Committee B, at the University of Alberta, and operational approval from the two LTC organizations participating in the study.http://www.chsrf.ca/funding_opportunities/reiss/index_e.php), and the team works on a linkage and exchange, integrated knowledge translation model. Our team existed before this project was conceived, and most members had considerable experience working together in a project called the Knowledge Brokering Group (KBG), a network of Alberta healthcare decision makers and researchers that focused on data-driven approaches to improving quality of care in continuing care settings. KBG was funded for three years from 2004 through 2007, and sponsored several researcher-decision maker collaborative projects, as well as a newsletter, breakfast series, and other events such as workshops and conferences. Much of its work focused on the implementation and application of RAI data to continuing care settings in Alberta.The project team comprises both researchers and decision makers; team member details are provided in Appendix A .The settings are nine LTC nursing units in four facilities or nursing homes (NHs) in Edmonton, Alberta, Canada. The facilities have all implemented the Resident Assessment Instrument Minimum Data Set (RAI) version 2.0 , physical therapists, recreational therapists, occupational therapists, pharmacists, social workers, and other allied health providers. We use the TREC survey  to assesThe feedback reports were developed during a pilot study conducted in two NHs in the Edmonton area in late 2007 and early 2008. We use data from the RAI 2.0 as the source data for the feedback reports as well as to measure resident-level outcomes. The RAI 2.0 covers a wide range of process and outcome data at the individual resident level, and assessments are generally updated quarterly for each resident unless there is a new admission, or a major change in a resident's demographics or in functional or cognitive status. We report on measures of pain frequency and intensity, occurrence of falls, and depression prevalence, all aggregated to the unit level. These three areas are among the top eight domains identified as important by LTC staff through the pilot project, and were agreed upon by senior leadership in both participating organizations. Data are extracted from each facility at the resident level, without personal identifiers except for the unit in which each resident lives. We use only data from assessments completed in the month being reported to ensure that reports cover current status for residents. Reports provide data from four months previously, the most current data we could process into reports, given the time it takes for assessments to be completed and processed through the vendor software. Data are obtained directly from the vendor by staff at the participating organizations, de-identified, and made available to our research team.Reports are primarily graphic with minimal text bullets, contained on one sheet of paper front and back, printed in color. A cover sheet is always included that provides details about the data and the comparison units. An example is provided as Appendix B .We will analyze RAI 2.0 data from all nine units in four facilities to assess resident outcomes. Data in the intervention facilities are extracted monthly during the intervention period to facilitate feedback report generation. Data will be extracted in the control facilities at the end of the post-intervention surveillance period, and will be analyzed after this period. Our primary analysis, using time series with and without adjustment for covariates, including unit level context, will allow us to assess change related to delivery of a feedback report over time. We will assess outcomes included in the feedback reports  and other outcomes not included in the reports (We will measure each intervention episode (delivery of reports), and chart these graphically with the time series. This will provide a graphic depiction of changes in outcomes over time and follows the approach used in a previous study . We willWe will code themes, specific barriers, and facilitators, and use the data from post-feedback interviews to assess degree of penetration of reports, problems with penetration, degree to which reports were used by which types of staff, actions taken in response to reports, and other information from the interview data. We will count the number of times themes recur as one quantitative measure from the qualitative data, and merge counts, at the unit level, with outcomes data from the RAI 2.0, to assess the impact of uptake of the audit with feedback intervention on resident-level outcomes using multi-level regression modeling to adjust for clustering by resident.The audit with feedback intervention in the four NH facilities began in January 2009 and will continue until February 2010. The second phase of the overall DICE project, implementing a feedback intervention in home care settings using the RAI instrument designed to assess clients receiving long-term home care services (RAI-HC) will begin in fall 2010. Following a yearlong intervention with quarterly report distribution to several home care offices, the DICE project will enter its final year, focusing on dissemination and spread of the intervention throughout the province of Alberta.Putting RAI to work: Network of RAI data users and researchers, funded from 2008 to 2010 (http://www.rairesun.ca/).As noted in the timeline, we will spend the final year of the program implementing the tools developed through the research conducted in the first three years. We will develop toolkits and training materials. Decision makers on the team will guide us in recruiting participation throughout the province for the implementation effort. A number of health authority representatives and LTC organizations approached DICE decision-maker research team members about interest in and willingness to continue engagement in a network focused on use of RAI data. This network was funded through a separate project by the Canadian Institutes for Health Research (CIHR), http://www.albertahealthservices.ca/204.asp). The organizational structure of Alberta Health Services consists of a matrix with province-wide strategic management and planning, and ongoing operations managed through the geographic zones .One of the factors affecting Alberta's healthcare system at the time of this project was a large-scale reorganization of the healthcare system that began in April 2008, and is still being formalized in mid-2010. The nine regional health authorities were disbanded and centralized into a single provincial health authority , which now consists of five geographic zones (We believe that we will have a ready group of willing zones and organizations to participate in dissemination and spread activities. We will approach senior leadership in each zone and solicit their participation. If the zone is willing to participate, we will approach the administrators of the LTC facilities as well as the local home care services leadership to request their participation. Participation by facilities and home care services will be voluntary. We will offer the RAI coordinators in each facility and home care office the tools and training in how to create feedback reports, as well as guidance in delivering reports, and lessons learned from the research in Edmonton. We will continue to offer technical assistance through the next six to eight months as they implement a program of feedback reports.We will evaluate the implementation effort through two approaches. First, we will conduct a one-time survey in each participating facility, with all willing staff, to assess response to the feedback reports. Second, we will request RAI 2.0 and RAI-HC data for the participating local health authorities to assess changes from the year prior to the implementation of the feedback reports to six months after the training, to enable us to complete the analyses during the funding period. If we are successful in securing additional funding for further work, we will extend the monitoring period. Key researchers will take a lead role in delivering this implementation plan, and will participate in site visits to each of the participating facilities in the regions with the research assistant. The site visits will be coordinated with distribution of feedback reports, which will be the responsibility of the RAI coordinators in the zones and facilities. During these visits, the researchers and RA will administer post-feedback surveys to assess feedback report distribution, uptake, perceived usefulness, and intent to change behavior. We will monitor actual outcomes using RAI data from the provincial data repository, due to become available in 2011.A provincial project now underway will help pave the way for these dissemination activities. Six of the DICE project team members are involved in the committee overseeing the LTC Quality Improvement Project funded by Alberta Health and Wellness to provide support to LTC facilities in using RAI data for quality improvement. In that project, facilities have been provided with access to quality consultants to learn how to use their data and to implement quality improvement processes. This support will lay the groundwork for facilities to see the value of using these data, which will create interest in using feedback reports.1. A robust, replicable process for identifying quality improvement priorities across provider groups that will reliably develop actionable feedback reports;2. A toolkit, including a manual and programming guides, to create actionable quality improvement feedback reports from RAI data;3. A functional web site to deliver tools for assessing priorities, creating feedback reports, and delivering a feedback intervention based on data from RAI-MDS 2.0 and RAI-HC tools;4. A cadre of decision makers and researchers who are well-versed in developing and using these tools within diverse continuing care settings.We will use findings from this study to identify best practices and implement process improvements in the use of RAI clinical data. We believe our work will be an important contribution to the care delivery community. We expect the results of this study to be widely applicable and useful to managers in many jurisdictions, well beyond Alberta. In addition to providing important guidance about use of feedback reports in LTC settings, our highly structured approach may provide some guidance to researchers in implementation science in terms of organizing and planning audit with feedback interventions.The authors declare that they have no competing interests.AES conceived of the study, drafted, and revised it, and is responsible for its conduct. CS conceived of the study, reviewed, and contributed to drafts, and shares responsibility for its conduct. All authors read and approved the final manuscript.Team Description. This file contains a brief description of the members of the research team and their role in the project.Click here for fileExample of Feedback Report. This file provides an example of the type of feedback report distributed to staff as part of the intervention in this project.Click here for fileObservational checklist. This file contains the checklist used to assess staff behavioural response to the feedback report at the time of distribution.Click here for filePost-feedback Survey. This file contains an example of the survey administered to staff in the long term care facilities a week after report distribution.Click here for file


The purpose of this study was to establish whether the "bottle assay", a tool for monitoring insecticide resistance in mosquitoes, can complement and augment the capabilities of the established WHO assay, particularly in resource-poor, logistically challenging environments.Aedes aegypti and field collected Anopheles darlingi and Anopheles albimanus were used to assess the suitability of locally sourced solvents and formulated insecticides for use with the bottle assay. Using these adapted protocols, the ability of the bottle assay and the WHO assay to discriminate between deltamethrin-resistant Anopheles albimanus populations was compared. The diagnostic dose of deltamethrin that would identify resistance in currently susceptible populations of An. darlingi and Ae. aegypti was defined. The robustness of the bottle assay during a surveillance exercise in the Amazon was assessed.Laboratory reared An. albimanus populations. A diagnostic dose of 10 μg a.i./bottle was identified as the most sensitive discriminating dose for characterizing resistance in An. darlingi and Ae. aegypti. Treated bottles, prepared using locally sourced solvents and insecticide formulations, can be stored for > 14 days and used three times. Bottles can be stored and transported under local conditions and field-assays can be completed in a single evening.The bottle assay  and the WHO assay were equally able to differentiate deltamethrin-resistant and susceptible The flexible and portable nature of the bottle assay and the ready availability of its components make it a potentially robust and useful tool for monitoring insecticide resistance and efficacy in remote areas that require minimal cost tools. Aedes aegypti and Anopheles darlingi. Anopheles albimanus is the main vector of malaria on Peru's Pacific coast  for analysis by ANOVA and t-test. Data are presented as back transformed means and 95% confidence limits.Mosquitoes exhibited no differences in mortality associated with the use of different solvents . This was true at every time interval  reacted similarly to our diagnostic dose of 10 μg a.i/bottle. After 15 min, average mortality was 85-95%. By 30 min > 99% of all mosquitoes had died  easily Figure The WHO assay is used on a global scale, including the Amazon basin ,16,18-20In comparison, the bottle assay has rarely been used to monitor resistance in South American countries . It is iThis paper shows that ethanol (95% purity) can be used as an alternative to acetone, and that at least some formulations can be used in place of technical grade insecticides. It was also determined that once treated, pre-prepared bottles that had been capped and stored in the dark at ambient temperatures could be stored for at least 14 days and re-used on three occasions . Wherever bottles are to be pre-prepared and stored, similar tests should be used to define their effective shelf lifes.An. albimanus populations as effectively as the WHO assay. This suggests that it may be a valuable complementary or alternative tool under some conditions. It is important to note that, in our comparisons, a wettable powder formulation was associated with greater mortality than technical deltamethrin, and a suspension concentrate with less. These differences are unsurprising given that the uptake of insecticide is strongly affected by formulation, but it is clear that separate baselines will have to be defined for each one.Ethanol and formulated insecticides are readily available in local public health laboratories. The purchase of six clear 250 ml bottles (available in Peru from a number of suppliers), which will duplicate the capacity of the basic WHO kit outlined above, will cost less than 10 USD. The current study showed that the bottle assay characterized differences in deltamethrin susceptibility between Peruvian Ae. aegypti and An. darlingi in the bottle assay reflects the absence of pyrethroid resistance in either species in the Peruvian Amazon. This is confirmed by the results of the local public health laboratory, who undertook WHO assays in the same year that the bottle assays described in this paper were conducted. They used the same strain of Aedes, and populations of Anophelines from the villages of Libertad, Intuto and Zungarococha. They tested > 400 individuals from each locality and found no survivors at the WHO diagnostic dose [Anophelines at these same sites and also in the village of Ullpayacu. This surveillance exercise confirmed the deltamethrin-susceptible status of all Peruvian An. darlingi populations. All bottle assays were conducted and completed on field-caught Anophelines, on the night of capture. In comparison, the usual procedure for the WHO assay is to collect the mosquitoes at night, maintain them at a health post or school house until the following day, and then expose them to WHO insecticide-treated papers for 1 hour. Mosquitoes are then transferred to clean holding tubes and held for a further 24 hours until the designated WHO assay endpoint [The identification of 10 μg a.i. technical deltamethrin as a diagnostic dose for both tic dose . In the endpoint ).The total cost of the bottle assay surveillance exercise, coordinated by the technical team at the public health laboratory in Iquitos, and including all transport, materials and personnel costs, was 1,328 USD. Comparative costs for an identical exercise using the WHO kit are not available but might be considerably greater given the greater cost of the monitoring kits, the increased time needed to conduct the assays, and the centralised nature of the surveillance programme. The costs of a resistance monitoring programme utilising either method will, however, be negligible when contrasted with the economic impacts of vector borne disease and of mosquito control programmes overall. In Peru, 60% of the 87,500 malaria cases reported in 2005 occurred in the Amazon department of Loreto . Each caThe bottle assay is a simple, flexible and robust resistance monitoring tool that, at least under the conditions examined here, was able to discriminate between pyrethroid-susceptible and resistant mosquito populations as effectively as the WHO assay. It demands further operational studies regarding its suitability for other species, and other insecticide classes and formulations. One of its main advantages is that it is not dependent on centrally-sourced materials, but this also requires that local laboratories prepare their own insecticide dilutions, treat their own bottles and establish new diagnostic doses for each new formulation that they test. Thus, an element of quality control is lost. Nonetheless, the calculations required and the coating techniques are simple  and any Given the familiar and established nature of the WHO assay for many health authorities, the bottle assay might initially be best used as a cheap and flexible tool for local resistance surveillance. National coordinating networks might retain the WHO assay as a quality control tool against which to ensure the reliability of the bottle assay results.The authors declare that they have no competing interests.EZ coordinated the assays and managed the logistics of the surveillance programme. RB and EZ facilitated the WHO assays in Piura. MP and WB contributed to the study design and concept. GD oversaw the study and wrote the paper. All authors read and approved the final manuscript.


Sickle Cell Disorder is a global health problem with psychosocial implications. Nigeria has the largest population of people with sickle cell disorder, with about 150,000 births annually. This study explored the psychosocial impact of sickle cell disorder in 408 adolescents and adults attending three hospitals in Lagos, Nigeria. A questionnaire was designed for the study, with some of commonly described areas of psychosocial impact including general public perceptions and attitudes, education, employment, and healthcare issues, and emotional responses.The majority of participants thought that society in general had a negative image of SCD, and reported negative perceptions and attitudes. Some issues in education, employment, and healthcare were expressed, however these were in the minority of cases. The results also showed that depressive feelings were experienced in almost half the study population, even though feelings of anxiety or self-hate were uncommon. Clinical implications of these findings are considered. Sickle Cell Disease (SCD) and Thalassaemia are classified as the two main Haemoglobin Disorders, and in recent years have been acknowledged to have a global impact by the World Health Organisation (WHO). SCD comprises a group of inherited red blood cell conditions that result from the synthesis of variant or mutant haemoglobins. Over 300,000 babies are born worldwide with SCD mostly in low and middle income countries, with the majority of these births in Africa . SCD oriGenerally, the prevalence of healthy carriers (sickle cell trait) ranges between 10% and 40% across equatorial Africa and decreases to between 1% and 2% in Northern Africa and less than 1% in Southern Africa. In West African countries such as Ghana and Nigeria, the frequency of carriers is 15% to 30% while in East African countries such as Uganda and Tanzania it shows wide variations of up to 45% in some areas [SCD is a chronic condition with recurrent episodes of pain and symptoms persistent throughout the lives of individuals. The clinical syndromes include anaemia, infection, and the consequences of blood vessel blockage (vaso-occlusion). The latter deprives tissues of oxygen and is suggested as the cause of the acute painful episodes, the hallmark of SCD, and other clinical syndromes such as stroke, chest complications, priapism, leg ulceration and chronic organ failure. The prominence of the pain is the basis upon which SCD has been named in certain cultures in West Africa . These iThere is no universal cure for SCD and treatment options are rather limited, however improved knowledge has greatly advanced medical management over the past four decades. Antibiotic prophylaxis is used to prevent infections especially in children . Other tBlood transfusions may be required for stroke and other complications, and hydroxyurea has also been found to be very effective in reducing the 'sickling' process and consequently the frequency of pain and hospitalisations experienced by patients . Bone maPsychosocial issues for people with SCD and their families mainly result from the impact of pain and symptoms on their daily lives, and society's attitudes to SCD and those affected. In Africa, cultural factors are particularly relevant to these problems because of beliefs and traditional practices. In Nigeria, beliefs are usually influenced by cultural and religious values, which influence health behaviour such as coping strategies. For example, among the Igbo communities, SCD is believed to be the result of malevolent 'Ogbanje' (reincarnation) that is repeated cycles of birth, death and reincarnation . Other sThe object of this study was to explore the psychosocial impact of SCD within a Nigerian population. It is acknowledged that psychosocial interventions for people with SCD are as important as medical treatment for comprehensive management.Pre-study focus groups were conducted earlier to explore and identify issues in general and specific concerns of individuals with SCD in order to develop or obtain appropriate measures to be used in the studies. These groups comprised of adolescents and adults aged thirteen years and over, were non-directive, but semi-structured with open-ended questions, and facilitation towards a goal at the end of each session. There were two group sessions with 6 to 8 participants, and each group talked about the same issues with the same set of questions. A number of open-ended questions were discussed in each group session, and answers were written down. The main areas explored included knowledge and understanding, beliefs, pain experience, coping, health service utilisation, social issues including education and employment, and quality of life. This led to the development of the questionnaire, which was subsequently used in the study. However, the questionnaire was not utilised in the focus group sessions.Psychosocial Impact of Sickle Cell Disorder - a self-complete questionnaire designed for the study  were from a Yoruba ethnic origin. The attitudes and perception about SCD were examined under three broad categories of general public, education and employment, and health services Table . These wThe responses of the adolescents were mostly similar to the adults. The majority of participants thought that society in general had a negative image of SCD through its attitudes and perceptions, although they did not feel that people had a negative approach towards them because of their SCD. Nonetheless, a very large proportion of respondents thought that SCD as an illness is less known in society and needs more awareness, and if society was more aware of people with SCD it would be more positive about those with the condition. Participants had not experienced much teasing and bullying during their education in school, college or university. Discrimination from employers was also not widely reported. Experiences of health services were mostly positive especially among adolescents, as the vast majority of them felt that medical staff had a good understanding of SCD compared to adults. Despite their age group, most participants acknowledged that medical staff offered them fair treatment.Emotional responses to SCD are presented in Table The impact of chronic illness such as SCD on individuals may be grouped into a set of illness-related tasks: adjusting to the symptoms and incapacities; maintaining adequate relationships with health-care providers; and managing the emotional and social consequences of the illness . The extThis study sought to explore the psychosocial impact of SCD in a Nigerian population. The results support the notion that society's attitudes and perceptions had a psychosocial impact on people with SCD. Health beliefs could be influenced by external factors such as advice given by health workers, family support, and work responsibility. Beliefs can also be influenced by their culture. For example, it has been suggested that Nigerians have tried religious healing (prayer) as an alternative approach or in addition to routine medical treatment . This maAbout three-quarters of the study population were students, and over a third were adolescents aged 14 to 18 years. Anecdotal evidence suggests teasing and bullying are common complaints among school going children with SCD. This was reported in 23% of the study population. Other major psychosocial problems experienced by young people with SCD during their school going years have also been described in focus groups [Mood is an important consequence of SCD. People with SCD commonly report low self-esteem and feelings of hopelessness as a result of frequent pain, hospitalisations, and loss of schooling (in children) and employment (in adults). These accounts could indicate depressive symptoms. Some studies have revealed anxiety and depression in children with SCD , and depThere is considerable variability in the ability of people with SCD to cope with their condition. People with SCD experience different levels of health, and such variations can lead to differences in psychosocial functioning. Some people cope relatively well, attend school or work, and are active physically and socially. Others cope inadequately' leading more limited and secluded lives. Nonetheless, this may not necessarily be a consequence of severity of their condition, and the reasons for these should be sought and addressed. Quality of life in people with SCD may therefore be more impaired than that of the general population.There are some limitations to the study. The use of dichotomous questions was mainly to address possible literacy problems in some patients who may have found it difficult to grade their responses on a Likert type scale, thus avoiding confusion. Dichotomous questions are useful in situations where the intention is to direct participants to express a clear opinion between opposing perspectives. However, a major drawback is that questions have only fixed alternatives, that is 'Yes' and 'No' in this case. Closed questions do not allow respondents to qualify or explain their answers, which may lead to bias in the interpretation due to the categories imposed. No standard questionnaires for the psychosocial impact of sickle cell disorder were identified from previous research, nor were there generic psychosocial impact measures in the chronic illness literature that could be employed for the purpose of this study.Furthermore, information obtained was cross-sectional, longitudinal data would have enhanced the results. More information on socio-economic status would have been useful. Also, the opportunistic selection of patients in a clinic setting may have been biased; a community-based study may have yielded different results, given that the views of patients not receiving medical treatment could be different. Nonetheless, the study contributes to our understanding of the psychosocial impact of SCD within the African setting.The findings of this exploratory study indicate that there is a need to develop appropriate psychosocial interventions within a global context. The aim should be more public education about SCD to change beliefs, attitudes, and stigma as a starting point. This should be followed by other interventions that are tailored depending on access to health care at different levels, and in different settings. In developing countries such as Nigeria, the focus would be initiating basic psychosocial interventions by non-specialised health workers in a primary care team at a Community Health Post (Level 1) or Primary Health Centre (Level 2), where psychologists or social workers are not be available. This would be in line with the WHO's current priority of primary care as a hub of coordination for person-centred care .Within the global context, the aims of psychosocial interventions in chronic illnesses such as SCD are to help reduce negative thoughts and feelings about the condition, and encourage the acquisition or maintenance of coping strategies. In the case of SCD, psychological therapies should be offered as standard care in the management of SCD adjunctive to routine medical treatment, where studies of these therapies have shown encouraging results . The oveThe authors declare that they have no competing interests.KA conceived, designed, and participated in the co-ordination of the study. FE participated in the co-ordination, data collection, and performed the statistical analyses. OO was involved in the design and supervision of the study. KA took the lead in the write up with support from FE, and review and editing by OO. All authors read and approved the final manuscript.Ethics Approval was not sought for the study, however each individual had to give their consent for participation in the study.Psychosocial Impact of Sickle Cell Disorder. A 29-item self-complete questionnaire designed for the study.Click here for file