Social network analysis is an approach to study the interactions and exchange of resources among people. It can help understanding the underlying structural and behavioral complexities that influence the process of capacity building towards evidence-informed decision making. A social network analysis was conducted to understand if and how the staff of a public health department in Ontario turn to peers to get help incorporating research evidence into practice.The staff were invited to respond to an online questionnaire inquiring about information seeking behavior, identification of colleague expertise, and friendship status. Three networks were developed based on the 170 participants. Overall shape, key indices, the most central people and brokers, and their characteristics were identified.The network analysis showed a low density and localized information-seeking network. Inter-personal connections were mainly clustered by organizational divisions; and people tended to limit information-seeking connections to a handful of peers in their division. However, recognition of expertise and friendship networks showed more cross-divisional connections. Members of the office of the Medical Officer of Health were located at the heart of the department, bridging across divisions. A small group of professional consultants and middle managers were the most-central staff in the network, also connecting their divisions to the center of the information-seeking network. In each division, there were some locally central staff, mainly practitioners, who connected their neighboring peers; but they were not necessarily connected to other experts or managers.The methods of social network analysis were useful in providing a systems approach to understand how knowledge might flow in an organization. The findings of this study can be used to identify early adopters of knowledge translation interventions, forming Communities of Practice, and potential internal knowledge brokers. Despite gradually increasing interests , evidencAny organizational change happens in the social context, and its success or failure is affected by various organizational and social factors. The extent that innovations and new programs will be adopted by organizations is affected by the relationship between the people in the organization, their inequalities in terms of influence  and acceet al. on the adoption of new interventions by physicians, doctors who were considered as advisors, discussion partners and friends by more peers were more likely to adopt the new drug, in comparison to more isolate doctors , and 32 responded to no social network questions. The response rate considerably varied among job titles (Table vs. 10.7 year in information-seeking network).The 196 respondents, on average had 10 years experience working in public health. Approximately 90% were female, and approximately two thirds had a baccalaureate degree. Respondents were most likely to work in the ‘chronic diseases’ (36%) and ‘communicable diseases’ 25%) divisions. Table 5% divisiThe network sociograms are provided and explained in each section. Figures Ninety-eight percent of respondents identified 4 or less peers as their sources of information. The merged Q1Q2 network consisted of 170 nodes and 332 ties, and showed a large connected body, which consisted of a seemingly highly connected patch of nodes in the middle, and two less dense wings at two sides  that actor. Of the six nodes with the highest in-degrees, three were ‘professional consultants’, two were managers, and one an epidemiologist Figure. Two camOne epidemiologist, two managers, one ‘professional consultant’ and one AMOH were the people with the highest betweenness centrality. Of these people, three were from the OMOH, one from division #1, and one from #5  were located at the heart of the map, as the main bridge between divisions. Division #4 (circles) showed a centralized interconnected cluster in the lower region of the sociogram. In contrast, division #2 was scattered in two different locations of the network, and did not shape a single cluster. The staff of two divisions #1 (up-triangles) and #5 (down-triangles) were also mostly located together in the form of distinguishable partitions.The density and reciprocity of network connections varied among different divisions Table . The OMOThe Q3 network consisted of 163 nodes, which were connected by means of 310 ties. The density of the network was 1.2%. Ninety-four percent of respondents identified 4 or less peers as experts. The dyad based reciprocity of Q3 network was 2.3%, which was the lowest, in comparison to the information-seeking (Q1Q2) and friendship (Q4) networks. It is supported by the fact that the recognition of expertise is not generally a bi-directional relationship. The shape of the sociogram for Q3  was higher for recognizing experts, than in actually seeking people out for information (information-seeking network). Out of all recognition of expertise ties, in 24.4% the respondents identified experts from other divisions, as opposed to 10.5% in the information-seeking network. In other words, staff were inclined to seek information from people in their own division, even though they knew some experts from other divisions. Again, the staff in the OMOH stood at the middle of the network.The symmetrized friendship network had 159 nodes, 302 ties, and a density of 1.2% .The characteristics of the actors with the highest frequency of each brokerage role are reported below:Coordinators are staff who connect people in their own division to others in the same division. The actors with the highest coordinator roles, big circles in FigureRepresentatives connect people from within their own division to outside the division. The actors with the highest representative roles are shown as big squares in FigureGate-keepers connect people from outside to others within their own division. The four actors with the highest gate-keeping roles were from the OMOH  reported a density of 15% [According to our study findings, the density of the information-seeking connections was very low (1.2%). However, it rose considerably when the divisions were studied separately. The densest division of the network was the office of the Medical Officer of Health, with a density of 13.6%. It was the smallest division in the network, consisting of 19 actors (of whom 11 responded to network questions), in which the people had relatively close connections with each other, as well as with the other divisions. Merrill y of 15% . SimilarHowever, it is not possible to make a conclusive statement as to whether the observed low density was a real feature of this network, or due to the under-reporting of connections and missing values. The large proportion of missing values, big size of the organization, reliance of respondents on memory instead of choosing from a roster list, and limiting the number of answers to 5 individuals, all signify that the findings of this study might have under-estimated the real interchange pattern of information in the health department.A priori, we did not expect a high reciprocity in the information-seeking network. Since, there were individuals in the department who professionally served as the consultants and information sources, the majority of the staff were turning to them for getting information; and reverse connections were not happening frequently. However, the reciprocity within the managerial subgroup was still low (23%). Creswick and Westbrook similarly reported reciprocity of 43% for work-related problem solving, and 26% for medication advice seeking in the emergency department staff of a hospital [The reciprocity of information-seeking ties was around 20%. hospital . A high A group of ‘professional consultants’, managers and epidemiologists were the most influential people in the department. ‘Professional consultants’ and epidemiologists were also recognized most often as being experts with respect to research evidence by staff. The centrality of ‘professional consultants’ in the information-seeking and recognition of expertise networks was expected from their formal responsibilities. The ‘professional consultants’, including project specialists and health promotion consultants, have the role of experts and professional advisors in the network. Their primary role is to conduct reviews of the literature  so as to provide advice on the development and implementation of programs and policies.et al.[The centrality of two ‘professional consultants’ in division #4 was extraordinarily higher than that of their counterparts in other divisions. The highly centralized roles of these two ‘professional consultants’ could be due to the geographical proximity of staff, the exceptional capabilities of these ‘professional consultants’, or specific tasks and responsibilities in this division. The high number of individuals seeking information from a few people may result in overload and reduced productivity over time. Reducing the work load of overly centralized people through redesigning alternative information flow routes could be considered as an improvement strategy . Fujimotet al. in a netA number of managers in different divisions were among the people with highest centrality in information-seeking, recognition of expertise, and friendship networks. Managers have the responsibility of managing and controlling the programs and services. They have the financial and operational responsibility over the processes. They have the role of decision-makers and planners in the department. The mentioned formal roles explain the influential positions of managers who connected their divisions to the OMOH. West and Barron report a similar finding for hospital managers in acute-care hospitals in the United Kingdom . They foet al. found that the centrality of managers and group leaders in friendship networks with their sub-ordinates was positively and significantly associated with group performance and the leaders’ reputation [Due to effects of organizational hierarchy, it was expected that seeking information from managers by staff with lower organizational status might be limited to formal connections. According to social exchange theory , people putation .The OMOH formed a central cluster in the department, bridging different divisions, with the highest density in the network (12.4%). The OMOH is responsible for the management of public health programs and services; and advises the Regional Council; which are consistent with the central bridging place of the OMOH in our study. The exclusively central role of the OMOH as a directing and coordinating division of the health department may affect the knowledge flow between divisions. Tsai showed that, in multi-unit organizations, the more control headquarters exercised on their sub-units, the less those units interacted with each other . While tSummarizing various centrality and brokerage roles, we can assume a four-level semi-formal hierarchy of the information flow in this health department Figure. These iHierarchy is an important structural determinant influencing the diffusion of innovations . Increaset al. public health decision-makers stated their need for assistance managing the vast quantities of evidence [et al. described the relationship development, support, customization, and capacity development as the main roles of knowledge brokers [In a qualitative study by Dobbins evidence . A ‘knowevidence ,44. The evidence . Dobbinset al. reported that the SNA findings of staff in one public health department led managers in that department to develop cross-programmatic teams and to encourage teamwork through tasks that required distributed decision-making, in order to address the limited communication across program areas [Lack of optimal communication “and clear channels for input” between managers to the staff has been proposed as a barrier to EIDM in public health . Merrillam areas . Our stuThe findings of network analysis could also be utilized in the development of communities of practice (CoP). A CoP approach to KT has been utilized increasingly in recent years . The CoPTo our knowledge, this is the first study investigating the organizational structure and the formal and informal roles of staff of a public health department in Canada with respect to EIDM. The generalizability of the observed semi-formal hierarchy of information flow could be assessed in other public health organizations. There is also a need for more in-depth analysis of the roles and effectiveness of ‘professional consultants’ in public health organizations in building capacity for EIDM. In addition, the role of the OMOH as the bridging division, and its potentials for facilitating brokerage and communication between health disciplines should be investigated in interventional studies.This study provides a foundation for longitudinal network analysis of the effect of an organization-wide, tailored KT intervention on the capacity of one health department for EIDM. The evolution of the network over time, as well as the role of a tailored KT intervention on the overall shape and specific characteristics of the network are being assessed in the larger study. The impact of various network characteristics on the effectiveness of the KT interventions being implemented in the larger study, and which have been influenced by these SNA results will be investigated by the primary author in future studies.The notion of information seeking among the staff of the health department should also be investigated more thoroughly in a qualitative study, by seeing the social networks from the actors’ perspectives. While not commonly used in SNA context, a qualitative approach may provide important insights to aid in interpreting the findings from SNA studies.Some limitations in the current study were identified. People solely relied on their memory, and they might have easily forgotten to include someone on any or all of the four SNA questions. Recalling and enlisting the names of information sources and friends took much more time than was expected, which could explain why 32 people who participated in the larger study did not answer any of the social network questions.While the majority of top level and influential staff answered the SNA questions, the large proportion of the staff who did not answer these questions is an important threat to external validity. It implies that, the findings regarding the managerial and professional staff in the network, who are in fact the main targets and promoters of the EIDM, are more dependable. The patterns seen in the peripheries should be used cautiously, since the people with the lower organizational ranks (practitioners and administrative staff) were under-represented in the sample. Nevertheless, other potential biasing factors which might have resulted in low response rate should also be taken into account; for instance, the non-responders might not be interested in EIDM, might not consider it relevant to their practice, might not see the importance of participation, or simply might be too busy to participate.Additionally, there were a few managers and ‘professional consultants’ in each division who did not differ from other staff in terms of centrality. Due to the large proportion of non-respondents, it is not possible to conclude that managers and ‘professional consultants’ did not fulfill their consulting and coordinating roles very well. They might be central information sources for groups of people who did not answer the survey.Even though we provided detailed explanations of the meanings of some terms like ‘evidence’ and ‘decisions’ in the questionnaire, we cannot exclude the possibility of miscomprehension and diversity in understanding of the meaning of these terms, as a threat to internal validity of observed patterns.e.g. professional consultants, managers, members of the office of the MOH). Fostering stronger connections between locally influential actors and those recognized as experts may have potential as an effective KT strategy that warrants further investigation.Social network analysis revealed the subtle inter-personal and inter-divisional communication structure, which could not be visualized by means of conventional surveys. The public health department was clustered predominantly by division, and the staff generally limited their information-seeking networks to a handful of peers within their division. The office of Medical Officer of Health played the role of main bridge, connecting different parts of the network to one another and facilitating information flow. In each division, ‘professional consultants’ and managers were generally the central people (to whom people within the division turned for research evidence), and who also connected the division to the OMOH. Their high centrality in information-seeking and friendship networks is a valuable asset, which could be used to enhance future KT interventions in the organization, and/or enhance communication within and across the health department. In each division, there were also some local coordinators who were connected to front line staff, but who had loose connections with those higher on the organizational hierarchy .Click here for file


Financial relationships between physicians and industry are extensive and public reporting of industry payments to physicians is now occurring. Our objectives were to describe physician recipients of large total payments from these seven companies, and to examine discrepancies between these payments and conflict of interest (COI) disclosures in authors’ concurrent publications.The investigative journalism organization, ProPublica, compiled the Dollars for Docs database of payments to individuals from publically available data from seven US pharmaceutical companies during the period 2009 to 2010. We examined the cohort of 373 physicians in this database who each received USD $100,000 or more in the reporting period 2009 to 2010.These physicians received a total of $52,600,624 during this period . The predominant specialties were internal medicine and psychiatry. 147 of these physicians authored a total of 134 publications in the first quarter of 2011 and 77% (103) of these publications provided a COI disclosure. 69% of the 103 publications did not contain disclosures of the payment listed in the Dollars for Docs database.With increased public reporting of industry payments to physicians, it is apparent that large sums are being paid for services such as consulting and peer education. In over two-thirds of publications where COI disclosures were provided, the disclosures by physician authors did not include industry payments that were documented in the Dollars for Docs database. Financial relationships between physicians and industry are extensive in the U.S.,2, encomConcern over COI and resultant risk of bias has engendered a variety of approaches and policies by biomedical journals, academic institutions, medical and continuing education institutions, healthcare delivery systems, professional organizations, and public sector policy makers. Central to COI policies is disclosure, and recent efforts to address COI have focused on disclosure and increased transparency. One such policy in the US is the Physician Payments Sunshine Act, signed into law in the US in 2010 as part of the Patient Protection and Affordable Care Act. This policy requires that pharmaceutical, medical device, biological, and medical supply manufacturers report to the U.S. Department of Health and Human Services payments that are more than $10 to physicians and teaching hospitals[To date, drug companies have rarely disclosed payments to their speakers. Recently, however, a number of companies have begun posting doctors’ names and compensation on their web sites, some in anticipation of the Sunshine Act, others a result of legal settlements with the US government for illegal marketing of pharmaceuticals.The objectives of this study were to describe the physician recipients of large total payments from pharmaceutical companies and to examine discrepancies between those payments and payee disclosures in concurrent publications. This study explores the feasibility, utility, and limitations of using publically available payment data to examine these discrepancies.The source of our payment data was the Dollars for Docs database, developed by ProPublica, an investigative journalism organization. The DolProPublica obtained these data from open-access websites for each of the seven companies and aggregated them into a single database. The original data were available in a variety of formats, including unsortable PDFs. ProPublica programming staff used a variety of programs to scrape and clean the data, including Google Refine, FirebugFor each recipient of a payment from one of the seven companies, the database includes the recipient’s name, city and state, reason for the payment, company making the payment, and the quarter(s) when the payment was made. Companies varied in their categorization of the reasons for payments, for example AstraZeneca and Merck only reported payments to speakers, whereas Eli Lilly, Cephalon and Pfizer reported payments for a variety of services, including meals, travel, and consulting. The exact date for the payments was not provided, and companies varied in their aggregation of calendar quarters. The database has been continuously updated since its first release with the addition of more companies, individuals, and payments. For this study, we used payment data from the initial database, released in October, 2010.We selected as our study cohort individuals who received more than USD $100,000 in the period 2009 to 2010. We chose this cohort of payees because the large amounts of funds that these individuals received should likely be remembered and disclosed in concurrent publications, and we felt that these payees may have characteristics that make them somewhat homogeneous in their behaviors. Among these individuals, we examined only physicians, excluding other healthcare providers. We obtained demographic information on the cohort, including age, sex, years since medical school graduation, primary affiliation, specialty, and state of medical board certification. These demographic data were obtained from institutional websites, HealthGrades© and a general Internet search. All data were entered into Microsoft Access .In order to examine whether physicians disclose these payments, we identified publications by physicians in our cohort in any authorship position by searching Medline from January 1, 2011 through March 31, 2011 using the Ovid search engine. We included all types of publications , and confined our search to English language publications. Results were imported into an EndNote library . If we identified publications by authors with similar names, we reviewed the full text to further examine the institutional affiliation, credentials, and subject matter of the article to determine if the individual in our cohort authored the publication. If there was any uncertainty about whether a physician in our cohort authored a specific publication, a second member of our research team independently examined the publications and if there was disagreement, consensus was achieved.We then compared the COI disclosures to payments made to those individuals as indicated in the Dollars for Docs database. Because the lag time between completion of the COI disclosure and the date of publication (both electronic and print) is variable and unknown, and the database does not contain exact payment dates, we compared disclosures in 2011 publications to payments received in 2009 and 2010. This should produce a conservative (low) estimate of discrepancies, as COI disclosures in publications in 2011 should in all likelihood include payments to those authors in the prior 2 years.Since this is an observational, exploratory study, we did not perform sample size calculations. Descriptive statistics were used to summarize physician characteristics, total payments, and discrepancies in disclosures. An analysis of variance model was used to compare the mean total payments among specialties with adequate sample size (n > 20) and a linear regression model was used to assess the association between total payments and physician characteristics (age and sex). All analyses were conducted using SAS 9.3 .Of the 18,297 individuals listed in the database, 384 were identified by ProPublica as earning $100,000 or more during the time period 2009 to 2010  (TableP < 0.0001). In particular, the mean total payment to physicians in internal medicine was significantly higher than to physicians in family medicine  $1,533 to $41,482) and to psychiatrists . The mean total payment to surgeons was also significantly higher than to psychiatrists . The mean total payment to surgeons was not significantly different from that to physicians in internal medicine . Based on results from the linear regression, the total payment per physician per quarter was not associated with sex (P = 0.1730) or age (P = 0.4908).For specialties with five or more physicians represented in our cohort, mean payments ranged from $125,733 for psychiatry to $174,666 for anesthesiology. Four specialties  had 20 or more physicians represented in our cohort and the mean total payments per physician per quarter were significantly different among these specialties . Of the 134 publications by physicians in the first quarter of 2011, 103 (77%) provided author disclosures of COI in the publication while the remaining 23% did not. Among publications with disclosures, 42 (41%) reported that the index author had nothing to disclose, while in 29 publications (28%) the author disclosed a conflict other than the payment in the Dollars for Docs database. In the remaining 32 publications (31%), the payment in the database was disclosed. The percentage of publications with the payer in the Dollars for Docs database disclosed, stratified by the 7 companies, is displayed in FigureIn summary, among a cohort of physicians who were known recipients of large total payments from a select group of 7 pharmaceutical companies, nearly one-quarter of their concurrent publications do not report any COI disclosures. Furthermore, of the publications with disclosure statements, over two-thirds do not report payments listed in the Dollars for Docs database.Several prior studies have examined the accuracy of COI disclosures in journal publications, with similar results. Two recent studies compared disclosures in publications to payment information from an orthopedic device company. Chimonas and colleagues reportedOur study has important strengths. Our data originated with payer databases, which were placed in the public domain either voluntarily or by mandate of legal settlements. The use of physician payment data from pharmaceutical companies is novel, to our knowledge, and our study provides insights into the methods, feasibility, and limitations of using such datasets for studies of discrepancies between payments known to have occurred and disclosure in peer-reviewed journals. When datasets are more complete and journal policies more uniform, these approaches can be used to determine the accuracy and completeness of disclosures.Our study findings have important implications. Journal editors and readers rely on accurate disclosures by authors in order to assess the credibility and risk of bias in journal publications, and our findings suggest that the accuracy and completeness of disclosures cannot be assumed at present. As industry payment data increasingly become publically available, however, journal staff and readers will be able to verify the accuracy of author disclosures. Though in the US, until the Sunshine Act is implemented and there is a unified public reporting system for industry payments to physicians, it may not be feasible for journal editors and staff to check author disclosures. For authors, the increasing availability of payment data may promote more accurate disclosures or may discourage physicians from accepting industry payments, although there is as yet no evidence to support these possibilities. It is hoped that the standardized reporting form of the International Committee of Medical Journal Editors will impThere are a number of limitations to this pilot work. First, these are exploratory analyses on a small cohort of American physicians, whose characteristics and behaviors are likely not representative of US physicians in general, including those who receive much smaller total payments or those who do not receive funds from industry. Second, the database that we examined was limited to the payments of only 7 pharmaceutical companies during variable intervals in 2009 and 2010. The exact dates for payments were not available, and the categorization of types of payments varied across companies, making comparisons of the reasons for payments difficult.Third, we faced challenges identifying publications by our physician cohort: exact author names vary  and can resemble names of non-cohort authors. If we failed to identify all of the author’s publications, we may bias our assessment of rates of discrepancies if missing publications have a different disclosure rate than the rate in the publications that we identified. There is a delay in indexing publications in Medline thus more recent publications may have been missed.Fourth, our assessment of rates of discrepancies cannot be equated with inaccurate disclosures because of several assumptions that we made. We did not examine journal COI policies, but rather assumed that all journals required disclosures. We also did not examine how journal COI policies address relevance of the topic of the publication to the disclosure. We assumed that all payments in the database should have been disclosed in the identified publications.It was difficult to determine the relationship between the time of disclosure and payments as it was not possible to know exactly when authors completed disclosures relative to the time of publication, as this varies widely across journals. Although some journals request an update of disclosures at the time of publication, it is unknown how frequently authors comply and how accurate those updates are. In addition, we only had information on the quarter or group of quarters when payments occurred, and not the exact dates. Although unlikely, we could have overestimated rates of discrepancies if disclosure occurred well prior to publication and prior to drug company payment, or if a disclosure was close to the publication date and the required time period of disclosure was short, with payment preceding the disclosure period. We feel that our approach of examining 2011 publications should minimize these biases, as disclosures in publications likely encompass payments in the prior 2 years. Chimonas and colleagues used a sFinally, we were unable to determine the reasons for discrepancies, which are undoubtedly multifactorial, including forgetting, carelessness, misreading or misinterpreting COI policies, lack of clarity in disclosure forms, or purposeful nonreporting. From these retrospective, observational data we clearly cannot determine causality or impute motive.Future research can build on this work. Studies could further describe the characteristics of physicians and other healthcare professionals who accept payments across a broad range of values and payment types. The effectiveness of specific COI policies and disclosure forms for achieving accurate and complete disclosures should be explored for journals, institutional review boards, academic institutions, and other organizations. Predictors of the accuracy of COI disclosures can be examined when more complete payment data are available with implementation of the Sunshine Act. The effLittle is known about the effect of disclosure policies and practices on the intended outcomes of improving transparency and aiding in the interpretation of journal articles. The dominant opinions in the literature are that disclosures are essential because they enable the “readers to form their own opinions on whether a conflict exists and what relevance it has for the study”. HoweverTransparency of industry payments to US physicians is increasing because of new and anticipated government policies and practices. Large amounts of money are going to physicians from industry for non-research-related services. In a small and select cohort of physicians receiving large total payments from pharmaceutical companies, there are discrepancies between payments known to have occurred and disclosures in publications. Journal editors need to continue to develop policies and approaches that lead to accurate and complete disclosures. Failure to accurately report financial relationships with industry inhibits the ability of readers to assess the credibility and risk of bias of publications.AHRQ: Agency for healthcare and research quality; AZ: AstraZeneca; COI: Conflict of interest; CPG: Clinical practice guideline; GSK: GlaxoSmithKline; J&J: Johnson & Johnson; USD: United States dollar.SLN has received funding from the US Agency for Healthcare Research and Quality to study conflict of interest in clinical practice guideline development. HKH, LAO, BUB and RF received salary support from the Agency for Healthcare Research and Quality under grant number 1R01HS018500, to study conflict of interest in clinical practice guideline development. All authors declare that they have no other competing interests.SLN, HKH and LAO conceived of the study and participated in the design. SLN, HKH, BUB and LAO participated in the collection and management of the data. All authors contributed to the analysis and interpretation of the data and assisted in the preparation, review, and approval of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6939/13/24/prepub


Trachoma prevalence surveys provide the evidence base for district and community-wide implementation of the SAFE strategy, and are used to evaluate the impact of trachoma control interventions. An economic analysis was performed to estimate the cost of trachoma prevalence surveys conducted between 2006 and 2010 from 8 national trachoma control programs in Africa.Data were collected retrospectively from reports for 165 districts surveyed for trachoma prevalence using a cluster random sampling methodology in Ethiopia, Ghana, Mali, Niger, Nigeria, Sudan, Southern Sudan and The Gambia.The median cost per district survey was $4,784  while the median cost per cluster was $311 (IQR = $119–$393). Analysis by cost categories  and cost activity  revealed that the main cost drivers were personnel and transportation during field work.Population-based cluster random surveys are used to provide the evidence base to set objectives and determine when elimination targets have been reached for several neglected tropical diseases, including trachoma. The cost of conducting epidemiologically rigorous prevalence surveys should not be a barrier to program implementation or evaluation. per diems, allowances and accommodation) and transport costs driving the total cost of the survey. These findings can be used by program managers to budget for population-based prevalence surveys that are recommended for baseline and evaluation surveys, and periodic uptake surveys for neglected tropical diseases such as trachoma.The costs of conducting population-based prevalence surveys for neglected tropical diseases such as trachoma are often cited as a reason that program managers do not conduct baseline or impact assessments when guidelines suggest they are warranted. The authors conducted a review of actual costs incurred during the implementation of 165 district level surveys in 8 national trachoma control programs to identify the median and mean costs per district and per cluster. In addition, the costs of the principal activities that are the most expensive were measured. The data show that field work is the most expensive activity for a prevalence survey, with personnel ( Chlamydia trachomatis, which causes blindness. However, trachoma can be treated and prevented through the SAFE strategy, endorsed by the World Health Organization (WHO): Surgery for trichiasis; Antibiotic therapy through mass distribution; Facial cleanliness promotion through health education; and Environmental improvement with sanitation. Trachoma is endemic in 57 countries worldwide, with the burden of disease concentrated in sub-Saharan Africa and the Middle EastTrachoma is an eye disease, caused by infection with ocular Where trachoma is suspected to be a public health problem, the WHO recommends that the prevalence of the clinical signs of the disease are estimated using a cluster random survey methodology at the district levelIn brief, the PBPS method employs a multi-stage cluster random survey design to randomly select clusters, and households within the clusters. Once households are selected, all members of the household are examined for clinical signs of trachoma disease using the WHO Simplified Grading SystemTrachoma prevalence surveys provide an estimate of the burden of disease at the level of interest, usually the district. These data serve as the evidence base for determining how the SAFE strategy should be employed. For example, where the prevalence of the clinical grade TF  exceeds 10% in children aged 1–9 years, the WHO recommends district-wide mass treatment with antibiotics and facial cleanliness and environmental improvements—the “AFE” of SAFE. Prevalence survey data are also used to calculate annual intervention targets and ultimate intervention goals (UIGs), such as the number of people who require trichiasis surgery. These targets are used to plan annual activity budgets, forecast the need for donated pharmaceuticals and other supplies, and monitor progress towards the elimination of blinding trachoma.Although survey implementation may vary by location, there are currently no data on the cost of trachoma prevalence surveys in the peer-reviewed literature. There are examples in the literature where different survey methods were compared to determine the most cost-effective method to estimate immunization coverageThe analysis of prevalence survey cost data did not involve any research on human subjects. The prevalence surveys reviewed in this paper were conducted in accordance with the Declaration of Helsinki and reviewed by the Emory University Institutional Review Board or the London School of Hygiene and Tropical Medicine (LSHTM) Ethical Committee and each country's respective Ministry of Health. External funding for the prevalence surveys was as follows: LSHTM, The Gambia survey; Helen Keller International, Sikasso Region of Mali; The International Trachoma Initiative and The Carter Center, 18 districts in Ghana; The Carter Center, all other surveys.woreda in Ethiopia, region in The Gambia, local government area in Nigeria, locality in Sudan, and county in Southern Sudan). Included surveys were implemented from 2006–2010, and funded or co-funded by The Carter Center, LSHTM (The Gambia), The International Trachoma Initiative (Ghana), or Helen Keller International . All surveys were ‘cluster random surveys’ that used a two stage sampling process to select clusters  representative of the domain in the first stage and households within the cluster in the second. The numbers of clusters and households in the surveys was not constant between districts.A systematic review of trachoma prevalence surveys conducted in Ethiopia, Ghana, The Gambia, Mali, Niger, Nigeria, Sudan, and Southern Sudan was performed February through May 2010. This review of prevalence survey costs included surveys that employed a PBPS methodology to estimate trachoma prevalence at the district level, or the administrative unit equivalent to a district , transportation of survey field team, accommodation and supplies such as tetracycline eye ointment and magnifying loupes. Supervision included any per diem, transport and accommodation paid to Ministry of Health or NGO personnel retained for supervision of field work activities. Data entry costs included per diem of data entry clerks, cost of computer rental and information technology support (if required) and supplies. For each cost activity, data were collected on the number of people paid, the daily rate and the number of days paid. Transportation costs included any vehicle rental, fuel expense and driver per diem.A data collection tool was used to collect the actual costs incurred in local currency during survey activities from accounting records in the programs. The tool collected data for four cost activities: training, field work, supervision and data entry. Training included costs such as The data collected in this study captured the incremental cost of conducting prevalence surveys in the context of an existing national trachoma control program. Ministry of Health and NGO salaries and other associated costs were not included in the analysis. Integrated prevalence surveys (more than one disease measured) were excluded from this analysis. “Headquarters” expenses were not included in the primary analysis of prevalence survey costs. Although beneficial, consultant or other outside technical assistance is not required for a national program to conduct trachoma prevalence surveys. Furthermore, the cost of outside technical assistance is dependent on travel expense policies which are unique to each partner. The cost of Carter Center headquarter support for specific survey activities are reported in this review, but were not included in the district-level cost data, as these costs are organization-specific and cannot be generalized.Once completed, the cost data forms were verified against the financial reports from the Carter Center, Helen Keller International, LSHTM or the Ministries of Health. In Ghana, Ethiopia and Northern Sudan, exact data on distance traveled were not available; the data reported for these programs' distance traveled are estimates from the national programs.http://data/worldbank.org/indicator/PA.NUS.FCRF) for the years 2007–2009. Since most district-level prevalence surveys were conducted in groups , costs were not reported for each individual district. Rather, each “grouping” of surveys that were financed at the same time was analyzed as the same observation. For example, in the Kayes Region of Mali, all 7 districts were surveyed using the same survey personnel within the same period of time. Funds were provided to the Ministry of Health to conduct the survey work for the entire region, which resulted in efficiencies gained by conducting one initial training and reducing the amount of transport required. Where data were reported in this fashion, the districts are treated as the same observation in the analysis.Data were converted to US dollars using the mean of the weighted average exchange rate from the World Bank , four main cost categories were identified: personnel, transportation, supplies and other. The costs for each category were compared against the total cost for each activity to identify the main cost drivers of survey expenses.Normally distributed data are presented as the mean and standard deviation (SD). Not-normally distributed data is presented by the median and inter-quartile range (IQR).A total of 29 observations were collected from eight national trachoma control programs. The cost per district by observation is presented in When the costs for each survey activity were compared against the total cost , the datTraining and data entry activity costs were reported by observation as the cost for each activity. These costs were not always directly related to the number of districts surveyed as some programs did not incur cash costs for these activities. The mean cost of training was $1,342 (SD $659) while the median was $1,791.50 . The mean cost of data entry was $2,548  and the median was $1,028 .Although the cost of outside technical assistance was not factored into the district or cluster level cost analysis, there were 9 observations that were surveyed with at least one representative from The Carter Center Headquarters  present, covering a total of 58 districts. The average cost for airfare, hotel, meals and incidentals per person-trip was $1,779  from 2006–2010.per diem rates were low and the population is relatively dense, reducing both the travel costs and time spent travelling between clusters. In total, 7 observations cost less than $125 per cluster and these also had the lowest cost per person screened ($0.91–$1.31). In these surveys, the relative proximity of clusters and low per diem rates contributed to lower costs in comparison to the more expensive surveys.It is possible that trachoma control programs do not implement prevalence surveys due to a perception that the costs will be beyond the capacity of the program. However, the results of this analysis show that such surveys are not cost-prohibitive. The range of costs per district varied from $1,151–$25,409, in large part due to differences in accessibility and the number of clusters sampled in each survey. Of the 29 observations, only three surveys reported a cost per cluster exceeding $500: Ayod in Southern Sudan, Kidal in Mali and the Northern Region in Sudan. These surveys were characterized by both high transport and personnel costs. In Ayod County of Southern Sudan, where the average cost per cluster was $1,270 and average cost per person screened was $10.88, vast distances of water-logged and unforgiving terrain made vehicle transport impossible, requiring a chartered airplane to transport staff to airstrips from where they traveled to the clusters on foot over a period of days. These exceptional circumstances therefore required additional staff, working for a longer period of time, and transport by chartered aircraft. In Kidal Region , the second most expensive survey per cluster , the sparse population  and low population density (less than one person per square kilometer) resulted in the national program treating the region as the domain, with the consequence that the distances between clusters was hundreds of kilometers. To conduct this survey, the program rented vehicles instead of using Ministry of Health and NGO transport due to security concerns in the area. The Northern Region of Sudan  is also on the edge of the Sahara with similar demands on transport and time. Least expensive, at under $100 per cluster, were the surveys conducted in the Amhara region of Ethiopia  and Plateau and Nasarawa States of Nigeria  where per diem of field staff and supervisors and the cost of transportation accounted for 73% of the total survey costs. In settings where distances between communities are great, trachoma control programs may consider reducing the number of clusters surveyed and increase the number of people screened per cluster to reduce costs but maintain an adequate sample size. However, the risks to accuracy and precision around the prevalence estimate should be considered. Cost savings on transport and accommodation costs can be achieved by planning the route of vehicles between clusters carefully. A route for two teams can often be planned in which the teams share one vehicle, work in the first and second clusters simultaneously (with the vehicle shuttling between as necessary) and then travel together to the next cluster where they camp for the night and sensitize the village population of the survey to be conducted the following day. Such transport sharing and camping has been both effective and enjoyable in most of the countries in this analysis. Per diem and allowance costs vary by national program, level of trained personnel recruited to serve as survey team members and local supervision requirements. Per diem costs in the surveys studied ranged from $6.21 per day for graders  to $250 a day for senior supervisors . When designing surveys, due consideration should be given to assign roles and responsibilities consistent with the qualification and per diem given. Junior health staff who are comfortable with the climate, social circumstances and geography of the area to be surveyed make ideal field staff, and serve to lower per diem costs. It is appropriate for a National Coordinator or ophthalmology professor to spend a day or two testing the ability of the trained examiners before the survey starts, but costs can be reduced if that person does not spend many days in the field.Among the cost categories reported, the The review of data entry costs also presents new findings for Ministries of Health. Although data entry was not an expense for all surveys reported, data entry accounted for an average of 11% of total survey expenses. In this sample, the incremental cost of data entry ranges from 0% in surveys where existing program staff conducted data entry on existing computers incurring no additional cash cost to 25% of the total cost of the survey where external contractors were hired to complete the work. Survey planners should consider the cost of data entry in their own country context to ensure that costs for double entry, analysis and preparation of printed reports are included in budgets.By design, we did not capture the cost of each Ministry of Health and NGO employee who contributed time to conduct survey work, the incremental cost effectiveness ratio is likely to be underestimated since these costs were not taken into account. This could be included in the analysis as an opportunity cost. However, since the implementation of prevalence surveys is recommended as the standard monitoring and evaluation framework for trachoma control programs by the WHO, these surveys were within the mandate of the Ministry of Health personnel who were engaged in field work and supervision. Salary costs were excluded as they were considered part of the functional trachoma control program and we sought to establish the incremental cost of conducting surveys in the presence of a program. We also did not include the cost of technical assistance (including travel) for ‘headquarters’ staff. Although the average cost of a person-trip from The Carter Center for technical assistance was $1,779 , we considered this to be a non-essential cost for a program, subject to considerable variation between supporting NGOs who have different travel policies, and likely to come from a different operating budget which would not have an incremental effect on the cost of a national program.per diem of the drivers and assistants covered by the ‘parent’ survey.The selection of a sample representative of the underlying population presents an opportunity to collect data on multiple conditions and this has been done for trachoma and malariaAlthough the data presented show costs from a variety of settings, there are a few limitations. The data in this analysis were reported retrospectively and therefore, it is possible that some costs may not have been captured. For some surveys  log book entries for distance travelled were not available and we relied on the local knowledge of the national program to calculate distance travelled. Each of these surveys was conducted in the presence of a functioning trachoma control program; there was no need to purchase new vehicles or make other large capital expenses. Survey work performed in the absence of this infrastructure would be more expensive. New country programs may find it necessary to rent vehicles and seek technical assistance for training survey staff, the costs of which would need to be considered in addition to the incremental costs of conducting a survey presented here.per diem rates, the level of qualified health professional involved in field work, and the capacity to complete data entry. The variation seen in these data illustrate the context-specific nature of planning survey activities. However, these limitations should not discourage program managers from using the data presented in this paper as benchmarks for determining funding needs.There are variations in the number of clusters surveyed among the different observations, based on the population of each survey domain, which may affect the comparability of the survey costs among different countries. However, the authors expected variation among national programs due to differences such as Twenty-six out of the 29 observations were conducted with external funding exclusively from The Carter Center, which may imply the cost estimates are limited to those surveys supported by this NGO. However, there are similarities between the cost per cluster from The Gambia, which was fully funded by LSHTM, districts in Mali supported by Helen Keller International, and districts in Ghana co-sponsored by the International Trachoma Initiative and The Carter Center. This suggests that our findings are not unique to the operating principles of one NGO.per diem were identified as major cost drivers, it is possible to predict total survey costs for areas requiring surveys. It is also possible to use these data to project the cost of other survey methodologies by applying the average cost per cluster to the number of clusters required. Despite the potential limitations of this study, these data present the only summary of actual costs incurred during trachoma prevalence surveys in the peer-reviewed literature. For the goal of elimination of blinding trachoma worldwide by 2020 to be met, national programs will need to budget for impact evaluation at the district level. The cost of epidemiologically rigorous surveys should not been seen as a barrier to their implementation. With adequate baseline and impact evaluation data, national programs can maximize their limited programmatic resources. These data should inspire national trachoma program managers and ministry of health staff involved in other public health supervisory roles to consider implementation approaches that ensure surveys are designed in a cost-effective and efficient manner. These cost data will enable the international trachoma control community to create global estimates on the cost to complete trachoma prevalence mapping and estimate the financial needs to support impact assessments to measure progress towards the elimination of blinding trachoma.Since transport and


Background: Worldwide concerns regarding health effects after the Chernobyl and Fukushima nuclear power plant accidents indicate a clear need to identify short- and long-term health impacts that might result from accidents in the future. Fundamental to addressing this problem are reliable and accurate radiation dose estimates for the affected populations. The available guidance for activities following nuclear accidents is limited with regard to strategies for dose assessment in health risk studies.Objectives: Here we propose a comprehensive systematic approach to estimating radiation doses for the evaluation of health risks resulting from a nuclear power plant accident, reflected in a set of seven guidelines.Discussion: Four major nuclear reactor accidents have occurred during the history of nuclear power production. The circumstances leading to these accidents were varied, as were the magnitude of the releases of radioactive materials, the pathways by which persons were exposed, the data collected afterward, and the lifestyle factors and dietary consumption that played an important role in the associated radiation exposure of the affected populations. Accidents involving nuclear reactors may occur in the future under a variety of conditions. The guidelines we recommend here are intended to facilitate obtaining reliable dose estimations for a range of different exposure conditions. We recognize that full implementation of the proposed approach may not always be feasible because of other priorities during the nuclear accident emergency and because of limited resources in manpower and equipment.Conclusions: The proposed approach can serve as a basis to optimize the value of radiation dose reconstruction following a nuclear reactor accident.http://dx.doi.org/10.1289/ehp.1307120Citation: Bouville A, Linet MS, Hatch M, Mabuchi K, Simon SL. 2014. Guidelines for exposure assessment in health risk studies following a nuclear reactor accident. Environ Health Perspect 122:1–5;  Radiation exposure following nuclear accidents and emergencies is of great concern to the public and to the authorities tasked with emergency response and ensuring public health, safety, and well-being. Guidance has been published for many activities that are important after nuclear emergencies, accidents, and detonations see . Most guThe activities undertaken after the four major nuclear reactor accidents of the past are the best model we have for learning what needs to be improved to advance data collection for radiation exposure and dose assessment strategies. Here we discuss these accidents in the context of learning how to improve dose assessment for health risk studies see .Because of concerns about potential health risks, two questions will likely emerge after any reactor accident:Immediately after the accident: What adverse health effects should be expected as a consequence of the accident?Years after the accident: What were the actual health consequences caused by the accident?These questions call attention to two types of health risk evaluations that can be undertaken: risk projections and epidemiologic studies.In risk projections the types and number of expected adverse effects resulting from an accident are predicted based on the estimated or assumed extent of human exposure and epidemiologic data from previous studies. Risk projections can be conducted well in advance of the expected occurrence of the health consequences  or can be done many years after the radiation exposure . A characteristic of risk projections is that they only require the estimation of average doses over population groups.Epidemiologic studies are usually undertaken several years after the accident to allow time for the health consequences to be expressed, are based on the analysis of observed adverse health effects, and seek to ascertain risks of these adverse effects in comparison with the background or baseline rates. Such investigations typically involve the collection of exposure and outcome data for the study participants and require individual dose estimation.The basic difference in these two types of studies is that risk projections generate expected rates of disease whereas epidemiologic studies generate observed rates of disease. In this commentary, we discuss dose assessment and data collection guidelines to support both types of studies.Four past reactor accidents have each resulted in irreparable damages to the power plant and in substantial radiation exposures involving ≥ 1,000 people as a consequence of the releases of radioactive materials into the environment. The first of those accidents took place in 1957 at Windscale in the United Kingdom and was caused by a fire in the reactor, which was mainly used for the production of plutonium. The second accident took place at the Three Mile Island (TMI) power reactor in the United States in 1979 and was due to both mechanical and human errors. The third, and most severe, reactor accident was at the Chernobyl nuclear power plant in the former Soviet Union in 1986 and resulted from a series of human errors during the conduct of a reactor experiment. Finally, the Fukushima accident, which occurred in northern Japan in 2011, was the consequence of an earthquake-triggered tsunami that damaged the reactor cooling system.The radiation health impacts of the Windscale, TMI, and Chernobyl accidents were projected or assessed on the basis of estimated radiation doses to the affected populations; similar efforts to estimate dose are in progress for the Fukushima accident. The activities conducted after each accident are briefly summarized below.After the 1957 Windscale accident, the immediate concern was to evaluate the pathways of exposure to humans and to minimize exposure to radioactively contaminated foodstuffs. An early-phase risk projection was published 1 month after the accident . Late-phWithin a few months of the 1979 TMI accident, several early-phase risk projections estimated likely health effects to the population located ≤ 50 miles of the reactor site . EpidemiRisk projections were published within a few years of the Chernobyl accident . ExtensiRadiation-exposure data related to the assessment of doses received by the population affected by the Fukushima accident are still being collected. Early-phase dose assessment  and riskThe approaches for estimating doses to representative populations near Windscale and TMI, or to individuals near Chernobyl, varied according to the type, quality, and amount of information that was available. Future accidents will also likely vary considerably on specifics of the accident and the exposure conditions. The general strategy to support dose estimation that we present here will accommodate many variations and includesIdentification of the target populationCollection of as many individual-based radiation measurements as possible for persons in the target populationCollection of individual personal and lifestyle information that can be used for the estimation of individual doseCollection of information on the spatial and temporal patterns and variations of the radiation fieldCalculation of realistic radiation doses with efforts to minimize sources of biasValidation of the dose estimates by independent measurements or strategiesQualitative and quantitative evaluation of the uncertainties associated with dose estimates.These guidelines apply in large part to other types of nuclear accidents such as the Kyshtym accident in the former Soviet Union, which was caused by a chemical explosion of stored radioactive waste that occurred at the Mayak Production Association in 1957 , and to Guideline no. 1: Create as complete a roster as possible of persons in the exposed area. For long-term purposes, it is essential to compile as complete a list as possible of people exposed following a nuclear reactor accident. Although this will be difficult in the immediate aftermath, it needs to be accorded a high priority because the effectiveness of emergency/early response, and late-phase risk projections and epidemiologic studies, all depend to some extent upon having comprehensive population rosters with contact information.The rosters should include all relevant members of the affected population, particularly those exposed to the full range of doses and subsets of the population who may potentially be more susceptible to adverse effects, including pregnant women and fetuses, children and adolescents, the elderly, and the infirm. Potential data sources that could be useful for identifying such individuals include population registers, hospital emergency and other departmental records, rosters obtained by response workers and volunteers, lists of students at local schools, business employees, and voter registration lists in the exposed geographic areas. In addition, public health outreach programs and media campaigns with the affected community may assist in identifying persons who should be on the rosters. Some of the strategies noted here have been discussed in more detail elsewhere , 2007.Guideline no. 2: Obtain as many individual-based radiation measurements as possible. In this context, individual-based radiation measurements means measurements of radiation directly emitted from the body of exposed persons or from their excretions, secretions, or removed tissues. The ideal approach to a dose reconstruction for an epidemiologic study involves obtaining individual-based radiation measurements from all targeted participants of the epidemiologic study using well-calibrated measurement devices. This step is useful, but not essential, for a risk projection. Ideally, multiple measurements would be acquired for each individual.in situ hybridization up to many years after the exposure. Whenever feasible, we recommend collection and archiving of biological samples or teeth for eventual analysis.For estimating external irradiation, biodosimetric assays can be useful: for example, electron paramagnetic resonance of tooth enamel or fingernails and assessment of radiation-related chromosomal damage, such as dicentrics measured within weeks to months after exposure, or reciprocal translocations in chromosomes of lymphocytes, assayed by fluorescence a) direct bioassays, which measure radioactivity in the whole body or in specific organs using instruments external to the body such as whole body gamma counting or localized gamma spectrometry , and b) indirect bioassays, which include measurements of radioactivity secreted or excreted from the body. The first class of assays can provide an estimate of the internal contamination and, thus, the dose rate from internal radioactivity. If the measurements are repeated over the entire time of dose delivery, the cumulative dose can be determined. The second class of assays can provide an indirect estimate of the integral dose until the time of the measurement, but such assays need to be supplemented with physiological biokinetic models and knowledge of the kinetics of the radionuclide intake.For internal irradiation, there are two types of useful assays : a) direThe purpose of these measurements is to obtain data relevant to each exposed person so that the radiation dose specific to the person and to the organs of interest can be estimated with the greatest reliability and the least uncertainty. Generally speaking, the overall uncertainties in individual dose estimates are largest when no individual-based or environmental radiation measurements exist, smaller when there are radiation measurements in the environment, and smallest when radiation measurements are available for the exposed persons.Individual-based radiation measurements are very helpful, even if not obtained for every exposed person, because these can be used to estimate doses to representative individuals or to validate the dose estimates obtained by other methods.a) competing needs for urgent medical care, b) insufficient numbers of high-quality instruments and of qualified personnel to use them for measuring large numbers of exposed persons, and c) the high cost of measurements.If individual-based measurements of exposed persons can be obtained, it may be possible, in theory, to reconstruct doses received, and their uncertainties, directly from the data. Within the framework of an epidemiologic study, this can be done if a criterion for study participant selection is the availability of an individual radiation measurement—as was the case for some of the Chernobyl studies . HoweverUnder most realistic scenarios, dose estimation is more complex than directly using instrument readings because dose estimates need to be supplemented with data on the environmental radiation field and foodstuffs as well as information on the ways in which persons were exposed. The five other guidelines apply to the common situation where the available individual-based radiation measurements are not sufficient to determine the radiation doses received by all study participants.Guideline no. 3: Collect, for each study participant, information on whereabouts at the time of exposure and relevant dietary data that can be used for the estimation of the radiation dose. Detailed information on the manner in which each study participant was exposed is very important for reliable dose estimation. For risk projections, individuals are not identified but population groups are. For this type of assessment, the ideal approach for collecting information might consist of conducting interviews on representative members of each population group, stratified according to relevant factors such as age, sex, and ethnic group. For analytic epidemiologic studies, it would be ideal to collect individual information through administration of interviews to all study participants.For assessing external exposure, the relevant questions relate to the whereabouts of the exposed person during the period of exposure, the type of building where the individual resided or worked, and the number of hours spent indoors each day at each location. For assessing internal irradiation, the relevant questions relate to the geographic origins of water and foods consumed, consumption rates, and preparation methods of potentially contaminated foodstuffs. Personal interviews should be conducted by means of a carefully prepared questionnaire that has been tested on a sample of exposed persons and is administered by trained personnel. When interviews of the exposed persons are not feasible due to young age or death, or participation rates are low, less ideal approaches can be used, including the use of proxy respondents , focus gInterviews should be administered as soon as possible after the accident in order to maximize memory recall and the reliability of the responses, recognizing that confusion resulting from the trauma of the accident itself may limit the reliability of some interview data.Guideline no. 4: Collect as much information as possible on the spatial and temporal variations of the radiation field. Spatial and temporal data on the radiation field can be used to make estimates of dose for risk projection studies by assuming representative lifestyles and diets. For epidemiologic studies, however, lifestyle and dietary data obtained in interviews need to be combined with environmental radiation measurement data to estimate the dose rates in air and the radionuclide intake rates at all locations and at all times where exposure took place.For assessment of external exposure, it would be ideal to obtain accurate measurements of exposure rates of airborne radionuclides at all locations (both indoors and out) where the exposed persons spent time during the entire period of exposure. For assessment of internal exposure, the ideal approach would be in making measurements of the radionuclide concentrations in the air and in the foodstuffs that were consumed during the time of exposure. In general, measurements should begin as soon as possible after the accident, understanding that they may have to continue for weeks to years to properly characterize weathering and environmental losses of the radioactivity that, if unaccounted for, will lead to overestimates of doses .Guideline no. 5: Calculate realistic radiation doses, minimizing sources of bias. Radiation dose is usually not directly measured and, therefore, must be calculated or estimated from models that range from simple, for external exposure, to complex, for internal exposures. Unbiased and accurate dose estimates should be sought for all individual participants in epidemiologic studies and for population groups for risk projections. Developing unbiased estimates of dose implies that all pathways of exposure must be taken into account and that efforts be made to eliminate or minimize potential under- or overestimation in collected data and parameter values used in models.a) radiation exposure measurements on the participants themselves, b) radiation measurements on other people relevant to the study, c) environmental radiation measurements and, finally, d) mathematical models.To calculate doses for each participant in epidemiologic studies, relevant exposure information should be used first and supplemented, secondarily, with estimates from mathematical models as necessary. The amount and quality of available information will vary among participants and between studies, implying that the degree of reliance on models will also vary. An overarching principle is to give preference to data in this order: A common limitation for all health risk studies, regardless of whether they are risk projections or epidemiologic studies, is that some assumptions need to be made when performing the dose calculations. Assumptions should be carefully documented in order to meet the requirements for peer-reviewed publications and to enable modifications to the original assumptions in future analyses.Guideline no. 6: Validate the dose estimates. The validation of the dose estimates is the process used to ensure that the dose estimates are as accurate as possible and do not reflect systematic biases. Because the use of unbiased dose estimates is critical to epidemiologic studies, it is important to perform as many validation tests as possible and to consider making adjustments to the dose estimation process as a result of those tests.The ideal approach is to estimate the dose for a suitable proportion of the targeted population using a biologically related measure that correlates highly with dose and to compare the measurements made by the primary approach with estimates of doses made by other means . As noteMore difficult to validate are organ doses for which no assay exists, for example, the dose received from intakes of iodine-131. Here, the validation of the dose estimates can be performed using an alternative method such as model-based estimates of the atmospheric release, or an empirical approach [making use of environmental measurements of iodine-129 (a long-lived radioactive isotope)]. A validation approach based wholly on model calculations is discouraged if other alternatives exist because of the difficulties in choosing appropriate and unbiased model parameter values.Guideline no. 7: Evaluate dosimetric uncertainties. Evaluating the uncertainties in dose estimates is important because it addresses questions of the reliability, accuracy, and overall validity of the dose estimates. This is mainly important for analytic epidemiologic studies and for late-phase risk projections. There are many sources of dosimetric uncertainty in environmental radiation measurements, the mathematical models and the parameter values used to supplement the gaps in the radiation measurements, lifestyle data-based personal interviews, and in the case of internal irradiation uncertainties in the metabolic and anatomic attributes of each person.Dosimetric uncertainty has a number of characteristics that are relevant to making conclusions for both risk projections and epidemiologic studies. In particular, some measurements may pertain not to single persons, but to groups of people—for example, the average deposition of cesium-137 in a village. In such cases, not only is the parameter estimate shared among members of the group, but the uncertainty of the estimated parameter, including any bias that might be present, is also shared. As noted in Guideline no. 5, it is our recommendation that biases be minimized as much as possible. Because biases occur, by definition, with systematic or shared errors, sources of shared uncertainty need to be scrutinized carefully.Although a single ideal approach to evaluate and account for all dosimetric uncertainties is not available, this is an area of active research . Until rApplication of guidelines to two types of risk assessment. These guidelines cover the activities to be conducted after a reactor accident and are important for the two types of risk assessment, the first of which we divide into two subcategories: a) early-phase risk projections conducted soon after the accident, that is, prior to the development of the health outcomes (cancers and other diseases), and b) late-phase risk projections carried out years after the accident. The second type of risk assessment employs epidemiologic studies to quantify the actual consequences of the accident on the basis of the observed adverse health effects. The usual purpose of early-phase risk projections is to develop plans for remediation, recovery, and treatment of health conditions. For early-phase risk projections, the most important activity consists of collecting data on the radiation field (Guideline no. 4) so that unbiased doses can be calculated (no. 5) for representative but unspecified members of the exposed population. In so doing, individual-based radiation measurements (no. 2) are useful, but not essential. The creation of a roster of exposed persons (no. 1), the collection of personal information on exposed persons (no. 3), the validation of the dose estimates (no. 6), and the evaluation of uncertainties in those dose estimates (no. 7) are not necessary for early-phase risk projections.In contrast, the usual purpose of late-phase risk projections is to replace an epidemiologic study that cannot be conducted for various reasons including difficulty in assembling a cohort, attrition of exposed study participants without good documentation of causes of death, or infeasible costs. For late-phase risk projections, only Guideline nos. 4 and 5 are essential. However, for late-phase risk projections that strive for high reliability and that may be considered as substitutes for epidemiologic studies, all guidelines but nos. 1 and 3 will substantially improve their validity.For epidemiologic studies, all seven guidelines are important, but three are essential: the creation of a roster of exposed persons (no. 1), the collection of radiation field measurements (no. 4), and the calculation of realistic unbiased doses for all study participants (no. 5). The latter activity must be carried out using as many individual-based radiation measurements (no. 2) and personal interviews (no. 3) as possible. The dose estimates obtained should be justified by means of a validation process (no. 6). The evaluation of the uncertainties in the dose estimates (no. 7) also is important and “highly useful,” with the caveat that, because a great deal of subjectivity is involved in the evaluation process, the uncertainty results may vary substantially from one group of experts to another.Finally, it is important to emphasize that the conduct of epidemiologic studies requires the involvement and consent of the participants and, by extension, effective methods of risk communication with the affected community. Results of risk-projection studies, which are carried out without formal contact with the exposed populations, need to be explained in detail using nontechnical terms to prevent misinterpretation.In this commentary, we present seven guidelines for what we consider to be an ideal approach for collecting data to be used for estimating radiation doses to the affected populations following a nuclear reactor accident. Implementing a subset of these guidelines will facilitate development of unbiased projections of future risk of cancer or other adverse health outcomes. Implementation of all seven of the guidelines is optimal for determining the true health consequences from the accident. The practical limitations to the proposed approach are typically competing needs for emergency care and other special circumstances that would accompany any accident and that might preclude comprehensive collection of some relevant data, as well as insufficient availability of equipment, personnel, and financial resources.These seven guidelines should be carefully considered at the beginning stage of recovery from a reactor accident. All efforts to estimate future risks or to characterize actual disease incidence in the exposed population will benefit from implementing well-planned data collection strategies.


Health literacy has been recognized as an important factor influencing health behaviors and health outcomes. However, its definition is still evolving, and the tools available for its measurement are limited in scope. Based on the conceptualization of health literacy within the Health Empowerment Model, the present study developed and validated a tool to assess patient’s health knowledge use, within the context of asthma self-management.A review of scientific literature on asthma self-management, and several interviews with pulmonologists and asthma patients were conducted. From these, 19 scenarios with 4 response options each were drafted and assembled in a scenario-based questionnaire. Furthermore, a three round Delphi procedure was carried out, to validate the tool with the participation of 12 specialists in lung diseases.The face and content validity of the tool were achieved by face-to-face interviews with 2 pulmonologists and 5 patients. Consensus among the specialists on the adequacy of the response options was achieved after the three round Delphi procedure. The final tool has a 0.97 intra-class correlation coefficient (ICC), indicating a strong level of agreement among experts on the ratings of the response options. The ICC for single scenarios, range from 0.92 to 0.99.The newly developed tool provides a final score representing patient’s health knowledge use, based on the specialist’s consensus. This tool contributes to enriching the measurement of a more advanced health literacy dimension. The first definitions of health literacy in the early years entailed basic reading, writing, and numeracy abilities needed to perform adequately as a patient. These adecisions. Notwithdecisions. Nowadaydecisions-8.phronesis, introduced in the context of health literacy by Rubinelly et al.,[Among the efforts to broaden the early conceptualization of health literacy, the Health Empowerment Model proposes an additional dimension named judgment skills. These s et al.,. This fo et al.,. Thus, j et al.,. The incPatients regularly have to deal with a variety of situations related to their health condition, including recognition of symptoms, adjustment of medication, and use of treatment devices and therapies. Thus, patients develop their judgment skills over time through an interactive learning process of perception, action, and feedback. JudgmenThe self-management of asthma is encouraged in order to monitor symptoms, control allergens that trigger it, and comply with treatment. These practices, when carried out adequately, have improved health outcomes.Asthma is one of the most prevalent chronic conditions worldwide affecting approximately 235 million people around the world. It is aAssessing judgment skills of asthma patients can give an insight into the relationship between information use and self-management practices. Therefore, the aim of the present study is to develop a tool that assesses patients’ judgment skills on asthma self-management competencies.The questionnaire was developed based on the Situational Judgment Test format. This method has been used for years in different contexts such as healthcare, evaluating the clinical judgment of nurses, work psThe situational judgment test format was chosen for this study because it allowed the assessment of patients’ abilities on information use rather than assessing knowledge of facts. As stated earlier, one of the biggest limitations of the current health literacy tools is that they only measure functional skills. Several educational programs for asthma patients are aimed primarily at informing patients. HoweverThe questionnaire was built in three stages. In stage I, twenty two scenarios with their corresponding response options were drafted. These were built based on scientific literature regarding asthma self-management problems, information from online patients forums, one patients focus group, several patients interviews, and discussions with pulmonologists. In stage II, a Delphi study with a panel of eleven experts on the field of lung diseases was carried out to assess the content and accuracy of the scenarios. In stage III, a scoring scale was generated for the developed questionnaire.A review of scientific literature tackling asthma self-management was carried out. The purpose of this was to identify the main problems encountered by doctors and asthma patients regarding care and treatment of this condition. The databases, ScienceDirect, PubMed, and the Cochrane library were explored using several key words alone or in combination for the search. These key terms were identified by consulting The Global Initiative for Asthma guidelines (GINA) on general competencies and tasks that every asthma patient should have. This indoctor-patient communication, medicine usage, information seeking, triggers avoidance, symptoms recognition, and exercise. Under these general topics, several themes were tackled within the single scenarios  are specialist in lung diseases and internal medicine, and 4 (25%) in allergy and clinical immunology. In average, the participants have 23 years of work experience as specialists in the field of asthma. Most of them work at the main hospitals of the region and/or have their private practice in the cities of Lugano, Bellinzona, Mendrisio, or Locarno.The Delphi survey among physicians was used to determine medical opinion on the adequacy of the response options and to validate the scenarios in general. Experts were asked to rate, on a 4-point Likert scale , each of the four response options for the 19 scenarios and were encouraged to recommend changes and adjustments in both, response options and scenarios. A response option was considered to reach consensus when at least 60% of votes from doctors lay either on the adequate or the inadequate side of the scale. When a response option achieved consensus, it was shown in the next rounds, but with no possibility to be rated again.The questionnaire was self-administered, in a paper-pencil format along with an instruction sheet indicating how to rate the response options for each scenario. Table Content validity was assessed to determine the relevance of the content of the instrument. After the scenarios were drafted, their content was evaluated by two pulmonologists belonging to the Delphi panel. Later on, before starting the second round of the Delphi, each of the panelists was interviewed about the realism of the situations described on the scenarios and the frequency of these problems nowadays. All experts agreed that the content of the scenarios represented most of the common problems encountered in asthma self-management today.For this round, participants were recruited at the annual meeting of pulmonologists working in the Italian-speaking region of Switzerland. Nine out of eleven specialists attending the meeting agreed to participate, and eight of them responded the questionnaire. Therefore, two more specialists from the region were invited to participate, to complete a group of ten experts, as initially planned Figure . These tFrom the first round, 15 out of 76 response options contained in the questionnaire were rated similarly by more than 60% of the doctors. One scenario depicting the use of a new medicine and its side effects, and another referring to the use of Written Asthma Action Plans (WAAP) resulted in contradictory ratings due to a mismatch between the scenarios and their response options. They were discussed with one of the pulmonologists and replaced. The expert feedbacks and ratings helped to identify drawbacks of some scenarios, including coherence between the scenario and the response options, appropriateness of language used, clarity of the topic, and precision in the description of the symptoms. Amendments regarding these issues were made for the second round questionnaire.All ten experts who participated in the first round were available for the second round. Since only nine of them answered the questionnaire, two more doctors were invited to participate. Doctors were allowed to sustain their former answers, change them or indicate whether response options were inappropriate for the scenarios.From this second round, 40 response options out of the remaining 61 achieved expert consensus. Two scenarios tapping the use of WAAP and quitting smoking did not reach sufficient consensus neither in the first nor in the second round; therefore, both were reformulated using information drawn from the focus group and interviews material. The remaining 21 response options that achieved only partial consensus in the second round were discussed with a second pulmonologist and amended for the third round.Eleven doctors participated in an online survey designed to rate the remaining controversial response options. Only two of these responses did not achieve the established cut off point. The majority of experts who participated in the first and second round responded to this survey.A ranking of the response options was generated based on the results of the Delphi study. A few months after the Delphi study, doctors were invited to confirm the accuracy of the generated ranking, or to propose a different one in case of disagreement. Nine doctors responded to this survey and only three of the scenarios did not achieve a 100% agreement on the established ranking. Since, two of these scenarios reached a 78% agreement and the other a 67%, no modifications on the ranking were made.Each response option was scored from 1 (most inadequate) to 4 (most adequate). A sum scale of all 19 scenarios with 4 response options each resulted in a minimum score of 19 and a maximum score of 76. Higher values represent higher judgment skills, indicating improved competency to use health knowledge on asthma self-management  were calculated to measure the similarity of doctors ratings in the three Delphi rounds. The overall ICC for the 76 response options corresponding to the 19 scenarios was 0.97 Figure , and theIn the final round, only two response options belonging to two different scenarios achieved less than the established cut-off of point of 60% expert agreement. However, they were not modified again, since the ICC coefficients for both scenarios were high, 0.98 and 0.92 respectively, plus the most adequate and most inadequate response options for these scenarios were already identified in the prior rounds. One of the scenarios is about trigger avoidance (pets). The response option stating that the patient will ask the doctor for an alternative solution instead of giving away the pet created divided opinions among the doctors. The other scenario describes a situation of doctor-patient interaction with the doctor changing the patient’s medicine without further explanation. The response option where the patient asks the doctor to prescribe his former medicine instead of the new medicine recommended, created some divided opinions as well.Table You are in a public park talking with your friends, and after some time, you start feeling breathless. Fortunately, you have your rescue medicine with you. What would you do in this situation?” (a) use the inhaler on the spot, (b) look for a quiet place away from the public for using the inhaler, (c) judge the situation as uncontrollable, or (d) not use the medicine because you consider it is not necessary. Consensus for option (a) was achieved in the first round with a full agreement among the 10 doctors as the most adequate response. Consensus for the rest of the options was achieved in the second round. Thus, for option (b), eight in eleven doctors agreed that this was a rather adequate answer to the situation. For option (c), ten in eleven doctors agreed that this was inadequate, and for option (d), eight experts in eleven concurred that this response was as well inadequate. Thus, the level of adequacy of the 4 response options for this scenario was determined , and it is composed of 19 scenarios with four response options each, addressing the topics of Nowadays, patients are requested to have a more participatory role in the healthcare system, helping with the decision-making on treatments, self-managing their health condition, and interacting effectively with healthcare providers, in order to be autonomous patients. This in turn, requires health literate persons capable of carrying out these actions in a competent way. The majority of tools available for assessing health literacy skills tackle reading, writing, and numeracy capabilities. HoweverAs highlighted before, adequate self-management in asthma has a positive impact on achieving optimal asthma control, improvement of health outcomes, and quality of life,38.The strengths of this study rely on the use of the situational judgment test for the questionnaire, since this has been recognized for successfully predicting individuals’ performance, and appropriate use of knowledge according to the situation. FurtherThe developed tool contributes to enriching the measurement of health literacy on the dimension of health knowledge use. Assessing patient’s judgment skills will serve to design better health communication strategies to improve self-management.The authors do not have any potential or actual competing interest.Appendix I.Click here for fileAppendix II. Scoring sheet for the developed questionnaire.Click here for file