The length of stay (LOS) is an important indicator of the efficiency of hospital management. Reduction in the number of inpatient days results in decreased risk of infection and medication side effects, improvement in the quality of treatment, and increased hospital profit with more efficient bed management. The purpose of this study was to determine which factors are associated with length of hospital stay, based on electronic health records, in order to manage hospital stay more efficiently.Research subjects were retrieved from a database of patients admitted to a tertiary general university hospital in South Korea between January and December 2013. Patients were analyzed according to the following three categories: descriptive and exploratory analysis, process pattern analysis using process mining techniques, and statistical analysis and prediction of LOS.Overall, 55%  of inpatients were discharged within 4 days. The department of rehabilitation medicine (RH) had the highest average LOS at 15.9 days. Of all the conditions diagnosed over 250 times, diagnoses of I63.8 , I63.9  and I21.9  were associated with the longest average hospital stay and high standard deviation. Patients with these conditions were also more likely to be transferred to the RH department for rehabilitation. A range of variables, such as transfer, discharge delay time, operation frequency, frequency of diagnosis, severity, bed grade, and insurance type was significantly correlated with the LOS.Accurate understanding of the factors associating with the LOS and progressive improvements in processing and monitoring may allow more efficient management of the LOS of inpatients. Length of hospital stay (LOS) is an important indicator of the use of medical services that is used to assess the efficiency of hospital management, patient quality of care, and functional evaluation. Decreased LOS has been associated with decreased risks of opportunistic infections and side effects of medication, and with improvements in treatment outcome and lower mortality rates. Furthermore, shorter hospital stays reduce the burden of medical fees and increase the bed turnover rate, which in turn increases the profit margin of hospitals, while lowering the overall social costs. , 2Previous studies have examined effective management of LOS. Majority of these involved subjects stratified by condition or admitting unit, for example, patients admitted to specialized departments, such as psychiatric wards  or the iLOS among patients with the same disease or undergoing the same type of surgical intervention may vary owing to complex factors related to the individual or due to different process flows within different organizations or divergences in medical practice. For these reason , in ordeIn this study, electronic health records (EHR) data and process mining technology were used to analyze all event logs entered between admission and discharge of the patient. This allowed us to scrutinize issues regarding hospital processes that affect the actual LOS, as well as other related factors. The aim of this study was to determine a methodology that could be applied to help hospitals manage the duration of inpatient stay more efficiently.Log data recorded between January and December 2013 were extracted from the EHR of a tertiary general hospital to analyze factors correlating with length of hospital stay. The subjects were patients admitted (and discharged) in 2013. The extracted event log is shown in For the full year of 2013, we have collected 53,965 subjects except for 745 and 1,029 subjects who were in hospital at the first and last day of the year, respectively. Also, there was a lack of a discharge date for two subjects, and 8,295 patients were received the day surgery which does not have to be hospitalized. They were also removed from the set of target subjects being analyzed. In a nutshell, out of a total of 53,965 subjects, 8,419 subjects were excluded due to repeat admission for unexpected events (122), lack of a discharge date (2), and day surgery . Finally, data from 45,546 subjects were analyzed. For accurate data analysis, the following data were excluded: data presumed to have been wrongly entered, such as transfer note dates recorded before the admission date or after the discharge date; transfer completion dates recorded before the admission date; and procedures performed beyond the extracted date.The present study was approved (IRB No. B-1409/268-107) by the Institutional Review Board of the Seoul National University Bundang Hospital, which waived patients’ informed consent. All EHR data provided to the researchers for this study were de-identified.The methods of analysis used in the study are shown in First, performance analysis for LOS uses the basis performance analysis technique in proceSecondly, LOS analysis according to diagnosis using Z-scores  to analyAnalysis of long-term hospitalization aimed to determine the characteristics of long-term hospitalized patients. For this purpose, we used statistical analyses to observe patient clustering and applied performance analysis to each group, aiming to identify differences between the groups.The second analysis category was process pattern analysis using process mining techniques to analyze the association between the transfer pattern and the number of hospitalization days. We used the pattern analysis technique  of procet-test and Analysis of Variance (ANOVA), as well as machine running techniques  disorders showed the highest mean for the LOS. There have been studied the factors affecting the LOS in psychiatric patients., 22 As pAnalysis of patient transfer and diagnostic data revealed that LOS was high among patients who were transferred to RH. It was plausible that secondary problems caused by the primary disease were more likely to correlate with the LOS. Clinical pathways (CP), evidencLong-term hospitalization exceeding 30 days was associated with a higher percentage of surgical operations and transfer rates, as well as restricted antibiotic use compared to other patients. It is very important to manage antibiotic use indicators to appropriately and effectively manage the quality of medical care. While anFurthermore, this study found that the following factors were correlated with LOS: transfer time, discharge delay time, frequency of surgery, diagnosis frequency, patient severity, bed grade, and insurance type. Most studies examining factors that are associated with the length of hospitalization involved subjects affected by specific diseases or types of surgery, limiting associated factors within the patients’ individual characteristics. For example, a study on pediatric asthma  found thBased on the significant findings of this study, strategies to improve the process of transfer and discharge in the entire hospital, were recommended. Moreover, it is anticipated that effective management of LOS is possible with a sustained effort to manage patients undergoing frequent surgery, with multiple diagnoses, and with severe conditions.There were some limitations to this study which should be addressed. First, the analysis of patient process correlating with the LOS was based on data from a single hospital. As there are differences between hospitals in the admission process and treatment plans, generalizability was limited and it is important to collect and analyze data from multiple hospitals. Furthermore, data analysis was largely confined to the main hospitalization events of the EHR system; the general characteristics of the individual patients and the hospital’s environmental factors were not considered in the analysis. The LOS may also be related with month of the year or day of the week of admission/discharge date, for example, admissions on Friday not being discharged until Monday due to lack of senior staff on weekends.Despite these limitations, this study analyzed the LOS based on objective EHR data that included all medical events for each inpatient rather than some specific patients. Importantly, this study is of value as it analyzed the factors correlating with LOS and identified solutions to reduce this time.In future studies related to hospital stay, it may be necessary to collect multi-distribution data, as well as the general characteristics of individual subjects, their environmental factors and seasonal and date/time factors, which were not considered in this study.In this study, we analyzed different variables correlating with LOS by using EHR admission data. We considered how to improve the management of LOS among inpatients.Research on the duration of hospital stay is important because it helps hospitals to more effectively manage its resources and patients. Specifically, identifying factors which are associated with the LOS in order to accurately predict and manage the number of inpatient days, could be helpful in terms of managing hospital resources and may enable the development of a Clinical Pathway useful for inpatient treatment.Based on the variables identified in this study, it may be necessary to improve the financial structure of hospitals and develop institutional approaches to reduce patient medical fees, by promoting the effective use of hospital resources and reducing the length of hospital stay via a system subject to continuous monitoring. Eliminating unnecessary hospital stays is a strategy to reduce overall national medical expenses.


Augmented reality (AR) is increasingly used across a range of subject areas in health care education as health care settings partner to bridge the gap between knowledge and practice. As the first contact with patients, general practitioners (GPs) are important in the battle against a global health threat, the spread of antibiotic resistance. AR has potential as a practical tool for GPs to combine learning and practice in the rational use of antibiotics.This paper was driven by learning theory to develop a mobile augmented reality education (MARE) design framework. The primary goal of the framework is to guide the development of AR educational apps. This study focuses on (1) identifying suitable learning theories for guiding the design of AR education apps, (2) integrating learning outcomes and learning theories to support health care education through AR, and (3) applying the design framework in the context of improving GPs’ rational use of antibiotics.The design framework was first constructed with the conceptual framework analysis method. Data were collected from multidisciplinary publications and reference materials and were analyzed with directed content analysis to identify key concepts and their relationships. Then the design framework was applied to a health care educational challenge.The proposed MARE framework consists of three hierarchical layers: the foundation, function, and outcome layers. Three learning theories—situated, experiential, and transformative learning—provide foundational support based on differing views of the relationships among learning, practice, and the environment. The function layer depends upon the learners’ personal paradigms and indicates how health care learning could be achieved with MARE. The outcome layer analyzes different learning abilities, from knowledge to the practice level, to clarify learning objectives and expectations and to avoid teaching pitched at the wrong level. Suggestions for learning activities and the requirements of the learning environment form the foundation for AR to fill the gap between learning outcomes and medical learners’ personal paradigms. With the design framework, the expected rational use of antibiotics by GPs is described and is easy to execute and evaluate. The comparison of specific expected abilities with the GP personal paradigm helps solidify the GP practical learning objectives and helps design the learning environment and activities. The learning environment and activities were supported by learning theories.This paper describes a framework for guiding the design, development, and application of mobile AR for medical education in the health care setting. The framework is theory driven with an understanding of the characteristics of AR and specific medical disciplines toward helping medical education improve professional development from knowledge to practice. Future research will use the framework as a guide for developing AR apps in practice to validate and improve the design framework. Augmented reality (AR) is a leading topic in media consumption, education, health care, commerce, security and a range of areas involving the development of mobile technologies, such as wearable devices, cloud computing, mobile phones, and tablets. AR was coined to describe a worker-training app in which a computer-produced diagram is superimposed and stabilized in a specific position on a real-world object . AR is dEducation frequently intersects with the AR evolution because AR has the following characteristics:AR provides users with an authentic and situated experience, when connected with the surrounding real-world environment.AR enhances the physical environment around users with virtual information that becomes interactive and digital.AR shows users an indirect view of their surroundings and enhances users’ senses through virtual information.When companies were developing early versions of AR, an important focus area was workplace training.augmented reality and its synonyms, and medical education and its synonyms. A total of 439 full papers were checked and 77 matched the content criteria. We analyzed 25 of the papers that clearly described a research question and/or aim, research results, data collection, and analysis processes. The results showed that AR is useful for health care learning, and that learners accepted AR as a learning technology. The acceptance of AR was verified by our preliminary interviews with two managers and three physicians in two community hospitals in China.Within health care education, AR has been used across a range of subject areas. In our preintegrative review of papers published before November 2012 , we idenIn our preintegrative review, most papers claimed that AR is beneficial for health care learning. Specific benefits included the following: reducing the amount of practice needed, reducing failure rate, improving performance accuracy, accelerating learning speed and shortening learning curves, capturing learners' attention, improving one’s understanding of spatial relationships, providing experiences with new types of authentic science inquiry, and improving the assessment of trainees. However, few papers mentioned using learning theory to guide the design or application of AR for health care education. Instead, the traditional learning strategy, “see one, do one, and teach one,” was used to apply the new technology.A design framework connects concepts with applied problems in order to provide a comprehensive understanding of a phenomenon and to guide practice . An instThe spread of antibiotic resistance has become a major threat to global public health . A healtMobile technology, which is portable and can be easily immersed in different environments, is developing rapidly. According to a report by Morgan Stanley, by 2020 the use of mobile Internet computing is projected to surpass desktop Internet usage by over 10 times . There aIn short, AR with mobile technology has the potential to transform health education, yet lacks an effective framework for guiding the design, development, and application of such tools. AR can change the effects of GP training in the appropriate use of antibiotics, in an effort to reduce threats from existing global health epidemics.This study aimed to develop a mobile augmented reality education (MARE) design framework that would guide the development of AR educational apps for health care settings. We used the rational use of antibiotics as a context for piloting MARE. This study addresses the following research questions:What learning theories are suitable for guiding the design of an AR education app?What factors should be involved in designing the MARE framework to support effective health care education through AR?How can the developed design framework be applied in the context of a health educational challenge, such as improved prescribing of antibiotics?Translating new information into clinical practice depends on six types of systems, each with its own purpose and agenda . These sThe design framework for MARE was built using a conceptual framework analysis method (CFAM) . CFAMs, Jabareen suggested that a CFAM is composed of eight steps:...a) mapping selected data sources; b) reviewing the literature and categorizing the selected data; c) identifying and naming the concepts; d) deconstructing and categorizing the concepts; e) integrating the concepts; f) synthesis, re-synthesis, and making it all make sense; g) validating the conceptual framework; and h) rethinking the conceptual framework. To design the framework, we collected data from research papers, government reports, conference papers, and websites, as well as documentation of instructional experiences across areas such as medicine, public health, education, instructional design, information technology, and management. Directed content analysis was used to analyze the collected data. This analysis was guided by a structured process and was particularly useful for conceptually developing a theoretical framework . The iniThe MARE design framework was applied in designing AR for GPs’ rational use of antibiotics education. This application of MARE and a subsequent AR program could help solve a major health care educational challenge. The framework was also a step toward the validation of MARE through its application.First, following our development of the MARE design framework, a systemic architecture, which was provided by the main framework, helped handle the main factors of the application of MARE to GPs’ rational use of antibiotics. Second, the data—specific to education on rational use of antibiotics by GPs—were acquired and analyzed. We collected learner abilities and the rational therapeutic process from report authorities such as the World Health Organization and Public Health England, and then examined the results of rational use within medical and health education. Next we used expected learner abilities to describe the learning outcomes and analyzed the GP learners’ personal paradigm with the rational therapeutic process. Last, we compared the learning outcomes and the GP personal paradigm, and used the MARE function structure to define learning environments and design learning activities that would be useful for GPs to improve their ability and develop their own paradigm for the rational use of antibiotics. The learning environment and learning activity design were guided by the learning theories.The relationships among the key concepts we identified using the CFAM informed the following framework shown in The three main layers of the framework provide the hierarchical structure for the content objects. The design order started with defining learning objectives in the outcome layer. We then developed the foundation through examining theories that support the MARE framework and its associated AR characteristics. Finally, we focused on designing the function level, which was guided by the learning theories, in an effort to achieve the outcomes.The relationships between the layers and concepts are illustrated in the following figure through the use of arrows and colors. As the framework design was an iterative process, the AR function layer is the design object, while the foundation and outcome layers provide support to achieve the design aim. The factors within a layer (colored orange and purple) should be considered while designing each layer. The four key elements shown in orange are highlighted in the framework. The purple factors help to support each layer, as needed. One-way arrows pointing to a concept are influenced by their starting ideas. The two-way arrows align with the concepts, as both the source and the target of relationships.The foundation provides the reasons why MARE is useful for health care education and considers our first question regarding which learning theories are suitable. Different learning theories provide different views on learning. Learning theory is the foundation for devising learning activities, organizing study content and materials, and establishing learning environments. Guided by suitable learning theory, AR can perform optimally in health care education .Function tells us how health care learning could be achieved with MARE. The function depends upon the learners’ personal paradigms, which we will define and discuss more deeply below, and provides support for the outcome and foundation levels. Learning requires suitable material and activities in an appropriate environment. These learning materials and activities should be selected and developed by considering the learning objectives and the learners’ paradigm, along with the AR learning environment. The choice of activities and environments should be grounded in learning theory from the foundation level and the characteristics of AR.The outcome helps us understand which abilities health care learners may achieve through MARE and informs how to design the functional level of MARE. Professional certification requirements and the learner’s paradigm include preknowledge and influence the learning objectives. Meanwhile, the learning assessment standards, as part of the outcome level, should be ascertained according to the specific learning objectives.First, we consider the outcomes for MARE, which are concerned with the learner’s abilities. We combined certification criteria with learning objectives and assessment measures based upon well-established educational frameworks. Miller’s pyramid of clinical assessment provides understanding of transforming knowledge to action in medical education . HoweverBloom’s taxonomy and its development have been used for planning, designing, assessing, and evaluating training and learning effectiveness around the world. Three domains—the cognitive domain, the psychomotor domain, and the affective domain—have each been ordered by the degree of difficulty. The three domains, also known as cognition, skill, and attitude, are independent but influence one another. Knowledge is about knowing facts, information, descriptions, or skills. Knowledge includes procedural knowledge and declarative knowledge. Procedural knowledge, which is the skill within the knowledge level (KS), can be evaluated by imitating or manipulating. Declarative knowledge, which is the cognition within the knowledge level (KC), can be tested by remembering or understanding. Although attitude is not part of knowledge, attitude affects health care student learning knowledge. Knowledge can be assessed by tracking the students’ behaviors during the health care learning process in MARE.Competence is the ability to apply knowledge or a precise behavior in the practical context. Competence is about knowing and doing something the right way. Emotions and values not only affect the application of knowledge, but are also a foundation upon which to build competence according to physicians’ professional competence definitions . The cogPerformance is the quality needed to accomplish work, acts, and achievements in real clinical practice. Performance is based on competence, but is influenced by government, organizations, patients, and individual physician factors . PerformAction is the ability to run a series of events for a given set of processes in health care to optimize patient outcomes. The results of action come from one’s individual performance as well as collaboration with other colleagues and shared decision making with patients, caregivers, or advocates where appropriate. At the action level, the skill is naturalizing behaviors, and the core of cognition is focused upon creating new meaning or structure. The skill within the action level (AS) and the cognition within the action level (AC) can be evaluated through patient outcomes and the impact on other physicians.By applying this ability frame from knowledge to action, the expected abilities of GPs’ rational use of antibiotics are specifically described, as shown in Understanding learning theories and their interpretations can boost the use of effective teaching and learning strategies for medical education practice . HoweverThe reasons we chose these three learning theories are as follows:From the view of social practice, situated learning theory provides a holistic perspective on the interpretation of learning by exploring the situated characteristics of the learners, environment, and practice .Experiential learning theory emphasizes the dynamic state between the learner and the environment . This thTransformative learning focuses on discovering evidence that education facilitates changes in the learner’s frames of reference or schema by which the learner identifies his or her life world .These three learning theories provide different views of learning and enhance different characteristics of learning environments, which AR could provide. In addition, the learning activities suggested by these theories could be applied in MARE. Each learning theory can inform decisions for the learning environment, activities, and how to apply AR.Learning environments that encompass the physical, social, and psychological context of learning are of significant importance and require the attention of medical and other health sciences educators when they teach or design a course . The medMARE provides a prompt, portable tool for medical student learning within the clinical setting in order to transform knowledge into practice. The flexible personal paradigm, which is “more inclusive, discriminating, open, reflective, and emotionally able to change,” is more appropriate for guiding action . The mosWe propose the following function structure shown in Second, by comparing the learners’ personal paradigms with professional expectations, we can describe the learning objectives and check their problematic reference. The learning activities cycle, which focuses on improving one’s personal paradigm from feeling, watching, and thinking to doing, will help learners reflect on their practice and change the problematic frames of reference.After identifying the learning objectives, an AR environment of MARE framework should be designed. Four oriented learning environments, which can add different virtual objects to the real clinical environment, create multiple sensory channels for learning . AffectiThe real clinical environments are the immediate context in which a connection is needed between learning and practice. The real clinical environment is the anchor and scaffold upon which learners are encouraged to learn. The real clinical environment includes physical environments and social environments. The content in physical environments, such as patients and their disease, microbiological samples, documentation and clinical notes, medical equipment, drugs, and consequences of bacterial resistance, can be the anchor to trigger a learning activity, which then aims to fulfill a learning outcome within the appropriate therapeutic stage. The social environment  shapes the content and forms of learning, which should be more instrumental or communicative.Virtual environments, which are simulated with computers, extend the real-world environment with an assurance of safety and enable or increase opportunities for engagement. Although it may be necessary or attractive for medical learners to learn in the clinical context, observing a real-world context could be dangerous, expensive, or even impossible . ComputeIn these environments, learning activities are added, which will help medical learners to recognize and build their personal paradigm as they develop skills, gain insights, and determine the dispositions that are essential for translating what they learn into action. Each mixed environment in MARE has its own focus on different learning activities, and the environments should complement and reinforce one another.The personal paradigm is compiled from the frames of reference that shape learners’ beliefs regarding guiding action in transformative learning theory. The personal paradigm combines the individual’s mind-sets, habits, and meaning perspectives, and encompasses cognitive, conative, and affective components. This paradigm is affected by sociolinguistics, moral and ethical values, learning styles, religious beliefs, psychological heath, and aesthetic preferences , and is The learning environment provides the conditions and external stimuli that facilitate learning and transform the learners’ paradigms. Learning assets provide the content for learning . LearninIn recent years, one of the global health threats has been the spread of antibiotic resistance. Encouraging rational antibiotic use is of paramount concern to authorities worldwide in order to minimize the development of resistance . MultifaImplementing the MARE framework involves several steps: (1) defining the educational outcomes (based on the outcome layer), (2) defining the GP’s personal paradigm, (3) characterizing the learning environment, and (4) designing the learning activities.The different abilities for rational use of antibiotics were adapted from Public Health England and a number of authors -38. In TKnowledge-level expectations for GPs regarding the rational use of antibiotics are shown in The competence level expected of GPs regarding rational use of antibiotics is described in The performance level expected of GPs regarding the rational use of antibiotics is shown in The action level involving the rational use of antibiotics is explained in First, we use the expected abilities in The GP’s personal paradigm is the means by which he or she sets his or her prescribing behavior for antibiotics. In comparison to the expected abilities and the ideal paradigms for a GP’s rational use of antibiotics, GPs will need different abilities in each phase of the therapeutic process. As in Aside from the abilities that help construct the GP’s personal paradigm, many other factors affect a GP’s paradigm. MARE should help GPs build more accurate personal paradigms or transform problematic frames of reference. In After the learning objectives and the GP’s personal paradigm for the rational use of antibiotics are compared, the learning environment could be designed for GP rational use of antibiotics as follows:In affective-oriented environments, visuals or voice simulations are overlaid in the physical environments to affect the attitudes of GPs in specific settings. GPs are encouraged to share their values and feelings from their concrete experiences.In perception-oriented environments, GPs observe the process simulations of infecting and treating with the real object to reflect and change their habit of misusing of antibiotics. GPs will examine the problem-solving strategies that they used in clinical practice.In symbol-oriented environments, the tasks, guidelines, and alarms are integrated in the therapeutic process to show “the revealed and the concealed” aspects of a complex professional activity. GPs create personal knowledge and develop abilities through discovering, building, and testing hypotheses, and through changing variables and observing the results.In behavior-oriented environments, GPs interact with the virtual object in combination with the real clinical environment to practice what they learn and reflect upon what they do. GPs make their own choices and become more critically reflective to adapt to uncertainty and variable conditions through the decision to act upon a transformed insight.The learning activities are designed as design strategies for GPs to focus on personal experience during the entire therapeutic process, and to promote reflection on their own personal paradigm in the rational use of antibiotics. The personal paradigm includes four related processes, and correlation and difference functions (as shown in One specific example of the use of MARE as a software app involves examining the effect of AR on emotions and the emotional and cognitive development of physicians within community-based hospitals. Using MARE, we can develop a mobile phone-based software app to be used on the physician’s own mobile phone. GPs who work in community hospitals would be included in the study after they have given informed consent to participate in the trial. During the learning process, the physician participants would take turns role-playing as physicians and patients. As a physician, a GP could see, through his or her mobile phone, the virtual pneumonia infecting a patient via a bacterium or virus. When a GP chooses an antibiotic to treat viral pneumonia or the dose is wrong in the MARE app, the pathogen and commensal change in the patient’s body will appear on the GP’s mobile phone.AR, as well as many other information technologies, is expected to help the reform of health professional learning. AR is a promising technology that can amend curricula rigidity, traditional pedagogy, and adaptation to local contexts in health education . AR has Effective application of technology in education practice requires profound understanding of the potential of technologies and the specific disciplines, as well as appropriate learning theory support . The MARThis is the first AR framework based on learning theory with clear objectives for guiding the design, development, and application of mobile AR in medical education. To date, there is no standard methodology for designing an AR framework. MARE uses a CFAM, which is based on a theory that provides systematic understanding of the multidisciplinary, complex relationship from knowledge to practice in medical education. However, this MARE framework created through a CFAM from multidisciplinary publications and reference materials must be tested in practice.Validation of the framework was suggested by Jabareen , but he The MARE framework is a general instructional design framework that addresses functional conceptualism by explaining and predicting theory with a multidisciplinary perspective ,59. SimiThe proposed MARE design framework addresses the lack of theory for guiding the design, development, and application of AR to improve GPs’ rational use of antibiotics. Understanding the theory behind this framework could benefit instructional designers, AR developers, and GP professionals when they apply the recommendations and could ultimately lead to further development of this framework and its practical use.The first implication of MARE for AR designers is how to apply learning theories and learning outcomes to guide AR instructional design. Situated learning theory, experiential learning theory, and transformative learning theory share some views, but each has unique emphases. The learning activities from which the learning theories are based are effective substitutes for traditional medical instruction in AR environments. The fundamental change in pedagogical philosophy is better than the tinkering with “interactivity” levels by instructional designers to support deeper, richer levels of learning . The leaThe second implication of MARE for an AR developer is the function framework. It may help developers understand how to create mixed environments for learning, not just for technology-driven infotainment. Different environments offer different learning functions. AR developers may use the list of teaching activities shown with the MARE framework as guidance when they consider how to develop AR functions. In terms of the learning objective, learning environment, learning activities, GP personal paradigm, and therapeutic process, AR developers may think about how to build interactive models and interactive levels between MARE and GPs in different environments. The learning materials in different environments must be designed and developed.Another implication of MARE for GP educators and researchers is the new technology and learning activity supported by learning theory, which corresponds to technology characters. GP educators and researchers may integrate it in their instructional practice. They can use the list of broader opportunities of MARE outcomes to compare with their students’ learning needs to design an app. The framework could be used to guide other drug or therapeutic intervention education.Due to the traditional teaching focus on recalling facts, health care professionals face the challenge of transforming knowledge into practice in health care settings. AR could provide a means to resolve this challenge, but it lacked a theory-guided design. Most AR apps still use traditional learning activities—see one, do one, teach one—in medical education, which hinders its educational function.This paper has described a framework for guiding the design, development, and application of MARE to health care education. This includes consideration of a foundation, a function, and a series of outcomes. The foundation based upon three learning theories enhances the relationship between practice and learning. The function constituted by suggested learning activities and the requirements of the learning environment from the foundation and AR characteristics can amend the gap in the learning outcomes and medical learners’ personal paradigms. The learning outcome, which combines Miller’s pyramid and Bloom’s taxonomy, can clarify the objectives and expectations and avoid teaching pitched at the wrong level .Furthermore, we used a global health challenge—antibiotic resistance—as an application example and chose one important aspect that is the general practitioners’ rational use of antibiotics, to which to apply the MARE framework. With this framework, the expected abilities of GPs’ rational use of antibiotics are described specifically and may easily be executed and evaluated. The abilities were compared with the GP personal paradigm to solidify GP practical learning objectives and to help design learning environments and activities. Future work will focus on the implementation of the proposed framework by developing a mobile phone-based AR app for GP training and for conducting evaluations in China.


The relevance of effective and efficient solutions for vehicle traffic surveillance is widely recognized in order to enable advanced strategies for traffic management, e.g., based on dynamically adaptive and decentralized traffic light management. However, most related solutions in the literature, based on the powerful enabler of cooperative vehicular communications, assume the complete penetration rate of connectivity/communication technologies (and willingness to participate in the collaborative surveillance service) over the targeted vehicle population, thus making them not applicable nowadays. The paper originally proposes an innovative solution for cooperative traffic surveillance based on vehicular communications capable of: (i) working with low penetration rates of the proposed technology and (ii) of collecting a large set of monitoring data about vehicle mobility in targeted areas of interest. The paper presents insights and lessons learnt from the design and implementation work of the proposed solution. Moreover, it reports extensive performance evaluation results collected on realistic simulation scenarios based on the usage of iTETRIS with real traces of vehicular traffic of the city of Bologna. The reported results show the capability of our proposal to consistently estimate the real vehicular traffic even with low penetration rates of our solution (only 10%). The Intelligent Transportation Systems (ITS) research field has attracted careful consideration of the research and industrial communities in the last years, also because of its enormous potential in terms of economic and societal impact. It is widely recognized that, through the usage of vehicular communications, many novel valuable services can be enabled, spanning from enhanced safety of road users and provisioning of advanced applications to drivers/passengers , to optimized vehicular traffic flow management in order to efficiently exploit the available road infrastructure. Indeed, it is well accepted that the identification of good and economically sustainable traffic management solutions is becoming one of the top priorities for future Smart Cities ,2. In paGiven the recent advancements and the strong industrial interest in the related technologies, with ever-increasing frequency, ITS solutions for traffic optimization make extensive use of Vehicular Ad-hoc Networks (VANETs), which enable different forms of vehicular communications: between vehicles (V2V), between mobile nodes and fixed infrastructure points (V2I), and a combination of the two (V2X). To successfully apply VANET-related technologies to the field of vehicular traffic monitoring and surveillance in smart cities, however, some relevant and still open technical challenges have to be overcome, such as the low penetration rate of vehicles with wireless communication capabilities or at least of vehicles willing to trustfully serve in a traffic surveillance cooperative service, a scenario that will likely persist in the near future. In addition, even the future envisioned scenario of high concentration of communication-enabled vehicles poses serious technical challenges, e.g., because of wireless medium congestion and consequent performance degradation deriving from high quotas of vehicles locally participating to a cooperative service via their wireless connectivity capabilities. Moreover, to enable ready-to-use and reliable traffic management optimizations, e.g., via advanced traffic light control algorithms that alleviate traffic congestion based on traffic monitoring data and predictions, there is the need of traffic surveillance solutions that are at the same time: (i) easily and cost-effectively deployable and (ii) precise and robust enough to solidly support delicate traffic management tasks.Several interesting solutions for traffic surveillance solutions are available in the recent related literature, but tend to work under the strongly simplifying assumption of complete penetration rate of communication capabilities in the considered vehicle population  or, whenGiven the above limitations, we have worked to develop an original solution for traffic surveillance, by taking into special account low penetration rate of our proposal  and the goal of collecting a large array of different monitoring data about vehicles in targeted areas of particular interest. In particular, our proposal exploits V2I communications between vehicles and Road Side Units (RSUs), deployed at selected traffic lights at the occurrence of relevant intersections to collect various information about local traffic status. To enable a precise and robust view of traffic flow performance and indicators, necessary to enable effective and dynamic traffic management, our solution also discriminates the different roads converging to the intersection and in which direction the vehicles are travelling on these roads. The solution originally presented here is also a follow-up of and exploits the research experience made thanks to the research activities accomplished within the framework of the EU COLOMBO project , which ahttp://lia.disi.unibo.it/ Research/iTetrisUniboExt/ for additional details and downloads.To validate and assess the performance results achievable by our proposed solution, the paper also contributes to the literature in the field with a thorough reporting, analysis, and comparison of several performance indicators of our original technique with regards to the existing literature: the reported performance results have been collected over realistic simulation scenarios deriving from the usage of the state-of-the-art iTETRIS  frameworThe currently available and traditional traffic surveillance solutions usually exploit infrastructure-based detection devices such as inductive loops, pressure sensors, and traffic surveillance cameras, to be deployed on monitored roads . These sIn parallel to the aforementioned traditional traffic surveillance solutions, we are aware of other services based on the collection of location information from connected smartphones, ad mobile apps running atop, that have expanded dramatically in the last years. Some of the most well-known examples are Google Traffic and Waze. These systems are currently primarily focused on collecting gross traffic density estimations at a certain road trunk. Those estimations are traditionally made available to registered (public) users providing the data; only recently, these players  are making their information available also to city administrators and that could pave the way to their use for traffic management purposes. In this paper, we focus on vehicular communications that have the different goal of providing a precise, finer-grained, and punctual estimation of the traffic  at the intersection to be used to enable advanced strategies for traffic management, e.g., for optimized traffic light management as in the COLOMBO project.More recent solutions targeted at collecting information for traffic management systems are shifting the focus on local data collection through the use of local traffic control protocols. This has the potential to eliminate the need for a centralized collection and processing point: the goals are to reduce complexity and costs associated with traffic surveillance, as well as to increase reliability and scalability of the adopted solutions, while retaining appropriate levels of quality/performance indicators, such as accuracy and precision. These less traditional proposals are exploring the possibility to actively involve the participating vehicles, their growing communication capabilities, and their on-board sensors, enabled by the significant advancements in vehicular networking (and its decreasing costs) and related standardization efforts, such as European Cooperative ITS (C-ITS) or American Dedicated Short Range Communications (DSRC) . FurtherThe cooperative traffic surveillance solutions currently available in the literature can be classified according to several parameters: their architecture may be centralized, when all collected data from participating vehicles are sent to a central elaboration point, or decentralized, when monitoring data are distributed among the nodes; the protocols can use direct communication between vehicles, or can rely on groups of nodes with similar characteristics/features; the collected information may be either used locally or shared globally within the whole monitored area; finally, the type of collected data may be used as a classification criterion, from the simple visibility of the concise indicator of vehicle density in the targeted area, to more detailed monitoring information, e.g., including position, speed, acceleration, break usage, capable of discriminating the different roads and vehicle directions.As stated above, traffic surveillance systems can collect different types of information about the flow of vehicles depending on the particular type of sensors used, such as number of vehicles, their density inside a specific area, or the average speed on a specific street. Classic induction loops and pressure sensors installed on the road surface provide only a limited subset of the potential information of interest, for example, to optimize traffic light management. The use of wireless transmission interfaces that can share the large amount of data collected by the sensors already installed inside the single vehicles can enable the collection of more detailed information, which can be used to develop new and more accurate traffic control algorithms. However, up to now, this type of sensors has suffered from the significant drawback of low penetration rate in the current vehicle population. Although this problem should gradually become less relevant, it is nevertheless important to focus on the collection of traffic surveillance information that has a low dependence on the number of vehicles actively cooperating to their collection. Indeed, let us note that  the precision and accuracy of some types of collected data, such as the number of vehicles, are more sensitive on the penetration rate, while others, like the average speed, are less conditioned; also this element could represent a significant design/selection choice when considering cooperative traffic surveillance systems.Even if VANET is a very active research area, the majority of the attention so far has been focused on new and optimized routing protocols to overcome the numerous challenges posed by these mobile networks. In this paper, we focus only on traffic surveillance solutions, an area in which most literature has concentrated on estimating very basic indicators such as the number of mobile vehicles inside a targeted area, usually called density, thus gathering only a general concise overview of the traffic state. The methods used to collect the information can make use of a clustering approach to group the nodes together if they are moving in the same general direction  or if thAmong the traffic surveillance solutions available in the literature, we have decided to consider three relevant protocols that have become relatively well-known in the community in the field and that are sufficiently well described in the corresponding papers to allow us to implement them in our simulation work (reproducibility of their performance results). In addition, as it will be clarified in the following sections, these three protocols are fairly comparable with our original proposal because they share some similar characteristics and features.The first one is the MobSampling  protocolThe next two selected protocols, discussed in , were inN is obtained with the formula N = mn/r, where m is the number of distinguished nodes counted in the first sampling, n is the count of the second sampling, and r is the number of vehicles counted in both samplings. In vehicle-oriented traffic surveillance, a vehicle is counted if one of its messages is successfully received by a neighbor vehicle. To obtain appropriate and valid results with such a protocol, two assumptions are typically adopted: (i) a closure assumption dictates that the population should remain stable while the estimation samplings are performed; and (ii) a homogeneity assumption requires that the probability of being counted is equal for every node in the observed population. In the VANET scenario, the first assumption can be considered satisfied if the time between two samplings is small enough, while the second assumption is not accurately met because the message reception probability is significantly affected by the distance between sender and receiver, by their position, and by the road topology, among the others.In particular, the Capture-Recapture protocol estimates the total population by considering only a small number (at least two) of independent samples of “captured” vehicles. Considering the method with only two samplings, as in  and in tt collection rounds the protocol computes the total number of different sampled nodes, i.e., S. This parameter is biased, with its bias decreasing with the increase of t. To remove the bias of S, a series of estimators are used, which take into account the number of times the vehicles are captured in t successive rounds. Different approximations are possible, depending on the specific estimator used, called N1 to N5, which have increasingly less bias but higher mean square error. Additional details about the associated algorithm can be found in [Given the above limitations, to obtain a valid estimation even when there are variations in the capture probability, , studiesfound in ,19.As a follow-up of the relevant research results achieved within the framework of the EU COLOMBO project, we have worked to design, implement, and validate original traffic surveillance protocols with the aim of collecting a large set of monitoring data about traffic status near to intersections. The final goal is the identification  of decentralized algorithms and protocols for cooperative traffic surveillance that are able to generate reasonably accurate values of a series of indicators, useful for effective traffic light control algorithms.According to these general guidelines and by considering, since the beginning, realistic and practical usage scenarios for actual traffic optimization, we have designed an original local protocol called Traffic Surveillance for Low Penetration Rate (TraSLowPeR): the TraSLowPeR collection areas are limited to the transmission range of each RSU node, located at relevant intersections; in fact, in our preliminary work, we established that the limited traffic monitoring data in the RSU coverage area are sufficient to obtain meaningful indicators about traffic status near intersections, while the additional information obtained in the expanded coverage area provided by multi-hop routing protocols were not necessary to the aim of traffic surveillance for our local traffic light optimization system .In our targeted use cases only few communication-enabled vehicles are typically inside their respective transmission range, so we deemed appropriate the definition of a direct communication protocol between RSUs and all the vehicles inside their transmission range, with the goal of creating a very detailed view of the traffic flows at the central point of the RSU for each intersection locality. Given the focus on locality of our TraSLowPeR solution, we discarded the use of collaboration between vehicles for the collection of the traffic information . On the other hand, we separate in time and space the communications of mobile nodes traveling on the different roads leading to the considered intersection, thus reducing the sources that can simultaneously transmit. This separation is obtained by specifying an exact targeted road and direction in each request message sent by the RSU, which will be taken into consideration only by the appropriate nodes.In finer details, each RSU updates its traffic status indicators by periodically broadcasting request messages and exploring every road leading to its controlled intersection in a round-robin way. A request message sent by the RSU contains two data items: (i) the road that is currently being polled and in what direction (approaching or leaving the intersection), (ii) the time allotted by the RSU for the replies from the activated nodes. To identify a road, RSUs and nodes can potentially use many different conventions: from the cardinal direction of the road with regards to the intersection, to the actual name of the road, from pre-defined raw unique identifiers to increasing counters starting from the north direction and clockwise, etc. In our prototype and in the following experiments, for the sake of clarity and simplicity, we used road-name-based identifiers.When a request is received, the receiving node checks if it is traveling on the “currently investigated” road: if so, it will reply to the message on a random instant inside the time windows specified by the message to reduce the chance of transmission overlapping with other nodes; otherwise, it will discard the message. The reply sent by a node contains the node identifier, its current position, speed, and acceleration, and its mean speed and acceleration over a selectable (configurable) interval.Each request message defines a reply window within which targeted vehicles have to send their updated status to further minimize the chance of interference among nodes that travel on different roads: this time allotted for the replies is dynamically adapted according to the specific road network and/or to the current traffic status, e.g., by allowing more time for the streets with multiple lanes and in case of heavy traffic.To practically show the primary idea behind our TraSLowPeR protocol, Let us conclude this section by noting that in the reminder of the paper we will deliberately not consider security and privacy issues because the focus of the present work is on the performance evaluation of traffic surveillance solutions while considering communication aspects only and adopting a simulation-based approach. At the same time, by recognizing the importance of that aspect, we briefly note that the TraSLowPeR protocol itself is completely local and requires maintaining at the RSU only a soft state (stored for a very limited time span) about wireless network identity of the cars in the surroundings. As for other solutions and protocols considered in our performance comparison, instead, all of them completely neglect security/privacy, by considering related aspects as to be targeted in a second step.We have implemented our protocol to work over the iTETRIS framework, a platform specifically designed to simulate Intelligent Transportation Systems (ITS) scenarios by integrating, through a central component used for synchronization and coordination, two widespread and community-recognized simulators: the ns-3 communication network simulator  and the http://lia.disi.unibo.it/Research/iTetrisUniboExt/, together with some additional implementation details, which are not central to the scope of this paper.While developing our solution, we have also extended the general-purpose iTETRIS simulation framework, by adding an interface that can be used as the foundation for new user applications to facilitate the implementation of new protocols while avoiding most of the complexity of iTETRIS. In fact, notwithstanding its potential, iTETRIS is recognized to be scarcely usable by the community in the field, as also shown by its slow adoption. The main goal of the developed interface is the separation of all the iTETRIS-specific interactions from our protocol specification, thus also improving possible portability over different simulation platforms. Our original iTETRIS extension is available for download at In particular, our user application is organized into two layers: (i) a common layer shared by all the different protocols that manages the interactions with the framework and offers an API to send and receive messages; and (ii) a protocol layer that defines the logic of the specific protocol interacting with the API of the common layer. In iTETRIS, unlike in classic network simulators, the simulation is time-discrete, to allow the interaction between the various sub-simulator parts. At every time step, the central coordination component of iTETRIS sequentially commands the execution of the two sub-simulators and of the iTETRIS-based applications on top. This behavior exhibits significant advantages in terms of modularity and extensibility of the sub-simulator and the integrated framework, but introduces delays in the interaction between vehicles and RSUs, which can lead to degraded performance if compared with each of the sub-simulator separately.To compare the performance of TraSLowPeR with the three protocols mentioned in A central and strongly original aspect of our TraSLowPeR-related research is the willingness to analyze and evaluate the performance of all considered protocols under realistic conditions, by using real traffic flow data obtained from the actual sampling of real intersections inside a road network based on real intersections in the city of Bologna. Two different scenarios where investigated, named Pasubio and Andrea Costa , which represent two cross intersections of multiple lane roads regulated by traffic lights, particularly interesting in the city of Bologna because characterized by high traffic during the rush hours, with frequent slowdowns and tailbacks.Since both the iTETRIS framework and the examined traffic surveillance protocols rely on pseudorandom number generators, we executed 20 different simulation runs with the same configuration parameters, altering each time the configuration of the employed random number generator , and we averaged them to obtain the final results. About protocol configurations, we have selected the parameter values shown as optimal in the original papers see  for all N1 estimator, which demonstrated to be the best one in the considered scenarios in our preliminary experiments; anyway little performance difference was observed for different estimators in all the tested scenarios.In particular, the configuration settings used for the iTETRIS simulator were 50 ms as time step, ns-3 version 20 configured to use the IEEE 802.11p protocol at 5.9 GHz with 6 Mbps bandwidth, with a transmission power for the RSU and the vehicles of 20 dBm, which gives a transmission range of approximatively 170 m. The Jackknife estimator protocol has different outputs depending on the type of estimator used; for the sake of briefness, we present here only the results obtained with the To evaluate the performance of all the four traffic surveillance solutions, we used 30 min of real traffic traces collected during the morning rush hours period that provides a maximum vehicle density of about 100÷120 nodes inside the communication range of the RSU. To improve the readability of the reported charts, also by removing border effects that are not significant for the regular and continuous working of the protocols over real application scenarios, we present only the values collected between 500 s and 1500 s. Different penetration rates are simulated by randomly assigning wireless connectivity capabilities only to the selected percentage of vehicles , so that all the nodes (either connectivity-equipped or not) are still inside the simulation and “moved” by the mobility sub-simulator SUMO. We considered penetration rates of 100, 50, 20, and 10%.As confirmed in To better summarize the different behaviors obtained by the four compared protocols, we have also defined and determined an overall indicator, shown in Our original research work in the area of traffic surveillance solutions has demonstrated how it is possible to effectively and efficiently achieve good estimations of traffic indicators that are useful for traffic light management and optimization also with simple solutions that exploit only V2I communications in the proximity of intersections. In particular, our TraSLowPeR solution has shown to outperform the existing protocols in the literature, in particular with significant advantages in terms of collision reduction, with no degradation in the estimated traffic indicators; most relevant, this is achieved even with penetration rates of our technology (vehicles equipped with wireless connectivity and willing to cooperate in the execution of our protocol) that are around only 10%. In addition, the research work has confirmed with quantitative results that the adoption of traffic indicators such as the average node speed is far more stable and almost independent of the penetration rate that can be expected in the targeted deployment environment; other indicators, such as vehicle number and density are anyway usable when it is possible to predict the penetration rate in the addressed urban areas.The encouraging results obtained so far with the TraSLowPeR experimentation are stimulating our further research work in the field. In particular, on the one hand, we are currently extending the iTETRIS platform to reduce its resource consumption and to accelerate its simulations via more efficient (and less portable) sharing of simulation data structures between ns-3 and SUMO. On the other hand, we are evaluating other concise traffic indicators to dynamically adapt traffic light management, such as average acceleration and queuing dynamics in the proximity of intersections.


The use of information technology within sport has significantly increased over recent years. These data and information have the potential to make a significant impact on sporting performance, and the nature of its related sciences too. For example, the retrospective analysis of sporting performance data affords the possibility to identify the impact of various technological advances and rule changes on world record performances in sports such as, javelin throwing (+95% over 76 years), pole vault (+86% in 94 years), and 1-h track cycling , may be useful in strengthening the sensitivity and applicability of the current Athlete Biological Passport (ABP) in the fight against doping in sports  sports appears to be relatively small, with for example, the coefficient of variation ranging from 1.1 to 1.4% (90% CI: 1.0–1.6%) in track and field athletics  that should be used in an APM is yet to be determined. While the use of general performance metrics such as rank finishing position may offer advantages of broad applicability to the majority of sports, sport specific performance metrics (SSPM) are anticipated to increase the ability to identify changes in performance that provide more resolution for anti-doping purposes. In CGS sports , the competitive results themselves can effectively be used as a performance metric. In non-CGS sports, the development of specific metrics may need to be further explored. For example, in combat sports, the number of hits and take-downs per round could be a sport-specific performance metric, which changes over a fighter's career and may be associated with performance improvements in the sport. Furthermore, the performance of an athlete in relation to their competitors might also be a valuable tool  where the monitoring of race results via ranked finishing position  are being increasing used by athletes and coach to monitor exercise during both training and competition in order to provide a detailed analysis of performance patterns at a microscopic level (Esteve-Lanao et al., It may also be possible to include performance data as part of a wider risk prediction to identify athletes who are more likely to be involved in doping. For example, athletes who demonstrate large and unexpected increases in performance over time, both in relation to their previous performance trajectory, and that of their peers, might be flagged as being “high risk” for doping. Indeed, Marclay et al.  suggest Despite the perceived burden on IFs to generate databases of SSPM, the authors feel that the inclusion of sport-related performance data in the form of an APM will enhance the ability of anti-doping authorities to make more informed decisions on assigning athletes to registered testing pools. As such, the APM may also allow a more effective distribution of anti-doping testing resources to target those athletes who demonstrate potentially abnormal increases in performance, or are deemed more at risk of doping. It is envisaged that the APM could be integrated into the athlete monitoring tool-kit of any NADO or IF, and thus allow the combination of unique aspects of information from athletes in order to enhance current anti-doping efforts.All authors were involved in the conceptualization of the article and its contents. JH drafted the article, and all authors reviewed, edited, and approved the final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The epidemic of obesity and diabetes in the United States poses major challenge to the prevention and management of chronic diseases. Furthermore, when this is viewed in other components of the metabolic syndrome , the prevalence of the metabolic syndrome continues to rise in the USA continued challenge is how to deal with this epidemic from a medical and public health standpoint. Community Based Participatory Research (CBPR) is a unique approach and offers a novel perspective for answering this challenge. A critical set of goals for CBPR is to address health disparities and social inequalities while getting community members engaged in all aspects of the research process. Utilizing the West Virginia Diabetes Prevention and Management Program and trained Health Coaches as a model, we discuss topics of consideration related to CBPR, involving trained health coaches, optimizing early adoption of healthy lifestyle behaviors, and enhancing participation. Through careful project planning and design, questions regarding disparities increasing susceptibility and preventive efforts within the community can be addressed successfully. These topics are part of a broader integration of theories such as participatory research, community engagement, and outcomes measurement. The understanding of the pathophysiology and epidemiology of the metabolic syndrome can help frame an appropriate strategy for establishing long-term community-wide changes that promote health. In order to continue to improve investigations for preventing the metabolic syndrome, it will be necessary to have aggressive efforts at the individual and population level for developing culturally sensitive programs that start early and are sustainable in practical environments such as the workplace. In this comprehensive review, we will discuss practical considerations related to project design, implementation, and how to measure effectiveness in regards to reducing the burden of the metabolic syndrome. Type II diabetes is increasing worldwide with upwards of 58% of patients with diabetes developing the metabolic syndrome . Early iIn this review, we highlight our own experiences with a community-based program for diabetes prevention and management that focuses on participatory research, community engagement, and careful monitoring of clinical outcomes. Using this program as a reference, important principles are discussed including the selection site of the study, the importance of participant feedback, successful implementation of health coaches, and how to optimize the adoption of the interventions. These principle components will be addressed under the broader framework of lifestyle adjustments that were designed to decrease the risk associated with the metabolic syndrome, and associated diabetes and CVD risk. To understand how these interventions are intended to function within the community, we will briefly review the pathophysiology and epidemiology that contributes to the metabolic syndrome. Finally, future advancements will be suggested for the diabetes prevention and management program with the intention of improving avenues that reduce the burden of the metabolic syndrome, diabetes, and cardiovascular disease within at-risk communities.Insulin resistance is the underlying pathophysiological process defining the metabolic syndrome . Recent Furthermore, high stress exacerbates the risk for getting the metabolic syndrome among adults. Recently, a longitudinal study found that increased work-related stress had negative effects on four of the five metabolic syndrome diagnostic criteria: Blood pressure, HDL cholesterol, lipid profiles, and fasting blood glucose. Participants with work-related stress had 2.68 the odds for developing the metabolic syndrome compared to non-stressed controls ,13. In aApproximately 25% of United States adults have been diagnosed with the metabolic syndrome . Insulinth in the nation), obesity (1st in the nation), hypertension (2nd in the nation), cardiovascular disease (2nd in the US) and the metabolic syndrome. West Virginia is an Appalachian rural environment that has a culture of independence and historically does not trust outsiders. Additionally, they may not know how to take care of their health due to low education and social economic status. The utilization of the CBPR approach helps participants to “own” and contribute to program success. As Cargo and colleagues emphasize, the primary goal of CBPR is to address health disparities [Interventions that target a change in lifestyle habits thereby offer the best solution for reducing the risk factors via dietary, lifestyle and behavior modifications as a means of reducing the likelihood of developing metabolic syndrome, as associated risk for diabetes, obesity, hypertension and cardiovascular disease. The primary dilemma is addressing the gap between available knowledge and effectively applying that knowledge to lower the risk. A chronic disease such as diabetes, metabolic syndrome, and cardiovascular disease predominately affects those in the lowest social economic class and rural communities . Women iparities . DesigniThe Diabetes Prevention and Management program is an evidence-based program that is being implemented at two-sites: Morgantown and Charleston West Virginia, and it are currently in its second year of implementation. The program consists of twenty-two sessions taught by trained health coaches and community experts. The recruitment target was enrollment of 60 participants into the study for year 2; the study team reached 100% of their recruitment target in October 2015, with 70 participants recruited into the study. Participants voluntarily agreed to participate in the 1-year DPM program. In order to be eligible for the program, participants had to be over 18 years of age and have dysglycemia . The participants were eager to engage in a program with a focus on non-pharmaceutical lifestyle modification through education and group support. Data is being collected on multiple factors including demographics, anthropometrics, clinical outcomes, satisfaction with the program, and calorie consumption as well as step tracking. In this review, we will use the ongoing program as a basis for evaluating implementation strategies to address the metabolic syndrome .One of the most critical components for CBPR is selecting appropriate community partners and sites . PartnerChurches in West Virginia and other places of worship nationally often offer unique advantages in that many have an attached kitchen for cooking demonstrations and space for physical activity demonstrations. This is highly important for programs dealing with prevention of chronic diseases such as diabetes, obesity, metabolic syndrome etc. Prevention programs that show demonstrations of healthy food preparation and physical activity are more effective in changing lifestyle habits than programs without these demonstrations . Many diOnce the site was selected and the program is underway, it is important to garner feedback from participants. The key to a successful diabetes prevention and management program is ensuring sustainability. Focus groups offer an interesting and valuable means by which feedback can be obtained. A CBPR program for diabetes prevention in Harlem used mid-program focus group surveys to help restructure the second half of the program . SimilarA local community champion was selected for the site located 3 hrs away from the university. The community champion is a local female student and a health coach who grew up in the region and works for the state department. Adeniyi et al. found that enlisting the help of community champions was essential for decreasing risk factors for the metabolic syndrome . CommuniThe health coaches attended 20 hrs of training using a curriculum developed by the program team; undergraduate, master and doctoral students enrolled in professional programs and other majors , College of Physical Activity and Sports Sciences, Exercise Physiology, Human Nutrition and Department of Communication. The health coaches were provided opportunity to participate in the planning, participant recruitment, and screening of participants.For preventing chronic diseases and syndromes such as the one focused for this paper (metabolic syndrome), healthy lifestyle changes depend on three important components: Change in mindset, change in physical activity, and change in eating habits. A primary way to encourage these changes is through education. Health coaches trained in diabetes education have been shown to be highly effective ,32. SessThe use of advanced technology such as texting and email makes the feasibility of contact between coaches and participants efficient and productive. Texting has emerged as an effective way for coaches to provide positive feedback and important reminders to participants . In addiIn order to help participants' stay on track, calorie-tracking books and pedometer step counts were used in addition to weigh-ins at each session. Participants were encouraged to record their daily food intake by hand in the food logs provided. They were instructed to be honest, accurate, and complete it each week to build awareness of their eating behaviors. Food logs and dairies increase awareness of extra calories and have been shown to be a powerful tool in prior research . The heaA key component for participant adoption is to move CBPR from the margins to mainstream . One of The educational component provides valuable support and dissemination of ideas that allow participants to incorporate new habits. In addition to improving participant's knowledge of healthy lifestyle, other important educational pieces focused upon dealing with small setbacks, coping with stress, and how to get back on track after a perceived slip up. To address these hurdles, the systematic approach of consistent sessions with weekly feedback has been shown to be more effective than single interventions or unconventional approaches . Since tMaintaining a healthy diet and increasing physical activity will reduce the prevalence of metabolic syndrome by decreasing risk factors, such as diabetes and obesity. Many participants are knowledgeable of individual conditions such as increased blood pressure, blood sugar, and abnormal cholesterol, but have trouble understanding how the clustering of these factors increases the risk for cardiovascular disease. The more important struggle is that participants have to implement their knowledge into behavioral modifications. Green and colleagues argue that although knowledge is present, it is not readily being implemented into preventive programs by public health researchers . TherefoOne of the underlying core principles of participatory research is empowering people for change. Altman and colleagues showed that the combination of education, health screenings, and discussions about changing attitude and perceptions was successful in reducing the cardiovascular risk factors associated with the metabolic syndrome . InterviCollective solutions generated by participants of the DPM program in West Virginia include changing where they eat lunch, avoiding negative co-workers, and establishing better habits in the workplace. One successful action-based habit is parking the car further from the entrance to inspire increased physical activity throughout the day. Survey responses collected at baseline, 6 months, and 1 year will be analyzed and the data used to disseminate knowledge for the implementation of future programs . On a la2 [Another example of a successful participatory approach for metabolic syndrome prevention was pioneered in the Healthy Lifestyle Change Program. They emphasized the significance of increasing knowledge, skills, and self-efficacy. Programs are normally effective at increasing knowledge but potentially lack in the transfer of skills and self-efficacy. By employing peer mentors to help encourage walking and healthy diets, participants in the Healthy Lifestyle Change Program had an average BMI reduction of 0.5 kg/m2 . Peer me2 . ParticiCommunity engagement differs in its primary focus. For the lifestyle programs to address chronic diseases and metabolic syndrome, the community engagement approach would emphasize changes that benefit the collective community and not necessarily individual participants. The Vida Sana community engagement program translated the available diabetes and metabolic syndrome prevention literature into Spanish . By provFor the West Virginia Diabetes Prevention and Management program, pre-screenings were utilized at local mall, restaurants, and churches. The pre-screenings increase awareness about diabetes prevention and management, provided potential participants with important health information, and the posted fliers in clinics, hospitals, restaurants, grocery stores, and churches provided a community-wide reminder about improving health. Screening is an example of community engagement especially when it addresses an area of health disparities on a larger scale . AnotherA novel strategy for approaching diabetes prevention is to consider social environment, culture, and local values in designing programs . Values Uncontrolled metabolic syndrome can lead to life threatening cardiovascular events, diabetes complications, cognitive decline, and kidney failure . One of In order to track the effectiveness of preventing the metabolic syndrome throughout the course of a program, biometrics and blood work must be collected. Waist circumference has a high correlation with body mass index and can be used as a measure of obesity . ResearcHealth metrics such as dietary consumption and physical activity level can be correlated to changes in outcomes. Although not a randomized-control trial, the Diabetes Prevention and Management program in West Virginia tracks outcomes from baseline to completion of the program. This allows for careful tracking of metabolic changes at various times throughout the program and correlating changes to the educational intervention. A national consensus meeting in Canada just announced a renewed focus on implementing diabetes prevention programs that track long-term clinical outcomes . WeinholThe metabolic syndrome is quickly emerging as a global pandemic as both obesity and diabetes increase in prevalence . This syWoolf argues however that this heavily weighted T1 research focus is limiting translation. T3 research focuses on practice-based research, which has high practicality . RecentlFor the West Virginia Diabetes Prevention and Management program, Rotary International and the Eye Foundation of America were co-sponsors. Rotarians in West Virginia are heavily invested in the Action Group for Diabetes. Eliciting the help and funding support of co-sponsors is essential for sustainability. Israel describes the process of working with co-sponsors as a mutual learning and empowering environment that fosters unique changes that address social inequalities . By usinA key goal of CBPR is participant involvement in all stages of the research process. As data is gathered from the West Virginia Diabetes Prevention and Management program, it will be important to collect qualitative information from participants for inclusion in outgoing manuscripts and reports. Participants should also be offered positions on a community panel to decide appropriate targets of investigation for the community. Through relationship building during the course of the program, it will be possible to recruit and encourage research participants to take an active role in data analysis and program advocacy .Program improvement should be at the forefront of every CBPR study. Several of the first year participants decided to join the cohort for the subsequent year. Through feedback and guidance from these participants, sessions were improved to meet the needs of the community. Israel describes this process as both cyclical and iterative . The proResults regarding study effectiveness must be distributed to a larger audience as a whole. In order to maintain funding, it is necessary to demonstrate that prevention is more cost-effective than treatment. Healthy individuals are better able to contribute to the community through volunteering, work, philanthropy, and social activities. Koh in Vision for Healthy People 2020 proposes that environments must be established where people can contribute to advancing life quality and quantity . ReducinAs outlined in the pathophysiology section, workplace stress is a primary contributor to insulin resistance due to glucocorticoid signaling. Westfall encourages researchers to meet participants in settings where they are most likely to benefit . WorkplaAnother potential challenge is comfort level of the participants. Places of worship such as churches, synagogues, temples and mosques as well as community centers, such as the local YMCA/YWCA, offer safe and constructive learning environments. Working environments are typically stressful and filled with time constraints. The lack of comfort is offset by practicality. If participants can learn to implement changes in stressful environments, the changes will be more likely to endure over time. Adam pioneered a stress reduction component into a community-based prevention program, which was very successful and associated with significant improvement in health outcomes . Work enThe metabolic syndrome poses a unique problem for public health professionals as the prevalence continues to rise. Insulin resistance is the primary underlying pathophysiologic change associated with the metabolic syndrome. Diabetes, obesity, and cardiovascular disease prevention through a CBPR approach offers to be the most cost-effective solution for widespread community change. In this review, metabolic syndrome prevention was discussed in the broader context of the West Virginia Diabetes Prevention and Management program. The program incorporates important aspects of participatory research such as participant feedback, health coaches' weekly feedback and calls to participants, a localized church setting, use of weekly food logs and pedometers to track dietary habits and physical activity, and changes in behavioral, anthropometric and clinical outcomes over the program period. These aspects were part of a broader approach that contains elements of participatory research, community engagement, and health outcomes research. Going forward it will be critical to engage participants in evaluation and dissemination of the data. To maximize sustainability, it will be important to advocate for increased funding and to role out programs in practical environments such as the workplace. In future programs, it will be important to identify factors that contribute to successful implementation of lifestyle modifications in real-world community settings. Overall CBPR programs that are focused on diabetes prevention or prevention of chronic diseases can produce substantial results if applied vigorously across the nation.


This study aimed to determine the efficient factors that potentially lead to the barriers of developing medical tourism in South Korea.To explore the current medical tourism trend, a qualitative procedure was adopted. Besides analyzing the current situation of medical tourism in Korea through a systematic searching on the available information and publications, in-depth-interviews were conducted to collect data from relevant authorities and representatives of medical tourism associations in this country.The result revealed, although government have supported this industry, that lack of specialty and expertise among the health care practitioners in the scope of cross cultural communication, seems to be the core barrier to development of medical tourism in Korea. Demands for convenient promotional activities, policy making and action regulation are the other effective factors.Several strategies are required in order to address and combat these barriers, such as governmental support for cultural training, cooperative efforts to encourage health practitioners involved to enhance their cultural and linguistic competence in international scale. Medical tourism has emerged as a new type of tourism and healthcare service mobility , 2 sinceDespite the remarkable contribution of medical tourism in the country’s economy , 6, it dIn many Asian countries, as the main destinations for medical tourist, governments have invested into infrastructure and promotion of medical tourism . ThailanThe market environment of competition in Asia, lately, influenced on the growth rate of foreign patients coming to Korea. This country has faced a complex situation in which although many essential factors are available, in a high class and quality, lately the number of foreign patient has decreased . AcknowlAccordingly, the aim of this study was to investigate and explain the effective factors that influence the current trend of medical tourism of Korea. Particularly we aimed to inquire the lack of qualifications, which function as the barriers to medical tourism development in this country. The finding will contributes to the literature by clarifying the barriers in medical tourism and can be generalized and applied to countries with similar situation; also the conclusion might practically be noticed by the authorities in order to address the current shortages.th based on a variety of criteria ’ to lead the ‘communication activities with international patients’ , Korea hDespite designing such an accurate system, South Korea lately faced not a considerable increase in number of foreign patients, comparing to its competitors in East-Asia regain. Government has invested 400 million US dollar annually , while tYet, there are absolutely valid arguments on the issue of involved factors on development of medical tourism industry, but lack of consensus can be seen among them. By the way, the influence and requirements of medical tourism, in a national scale, have been conducted by several studies –23. MeanIn our study, similar to a research conducted in Hong Kong , we justAn exploratory approach through a qualitative research method was adopted since the initial information was required to lead the authors to identify the variables for their further research . ExtensiIdentifying the key issues enabled the authors to have a list of initial factors which could potentially contribute to the barriers and shortages of Korea to develop medical tourism. Next, the relevant authorities and experts -15 individual- were interviewed to confirm or modify the factors trough an in-depth and open-ended questions. During the interview, researchers tend to discuss the medical tourism trend in Korea, rather than asking a pre-framed question and expecting a specific response. This method provided more explorative-oriented information comparing to semi-structured interviews . The intMedical TourismIncludes the published papers regarding medical tourism development models and requirementsIncludes published papers regarding medical tourism in KoreaThe available information within the website of organizations in Korea associated with medical tourism industryThe conference of Medical Korea and K-Hospital.“Global healthcare policy and management forum”. This session was held with the aim of discussing the main shortages of Korea in terms of medical tourism and based on the current trend in other countries.Having all the clear information about the current situation of medical tourism in Korea, besides the valid opinion of relevant authorities in the scope of shortages, “content analysis” was undertaken on the gathered information; following are the particular stages of interpretation. All the information was reviewed for identification of any “data redundancy” in the format of concepts, phrases or words; accordingly, themes and sub-categories emerged. The main categories, refinement and identifying the relationship among them were manipulated by employing “Axial coding” . FinallyData were collected through an extensive literature review and in-depth interviews. Since the interviewees were all informed of general/current framework in terms of medical tourism in Korea, we considered their notions as the valid and potential obstacles to development. Noteworthy is the fact that their notion was a confirmation on the initial pool of barrier’s concepts collected from literature.Among variety of ideas those with a high range of redundancy were revealed, also finding the similarity with the available and pre-published information improved the validity of developed framework, presented in As shown, five main themes were selected as the barriers to medical tourism development in South Korea; each theme entails a number of categories which could participate in leading to the associated theme. This framework developed based on the “amalgamation” of the achieved themes and categories and the arrows illustrate the relationships among them. Based on the current situation, all the themes has the direct influence on the development of medical tourism in Korea, shown by solid arrows, namely, policy making and government regulations, expertise, promotion, communication skills and language. Meanwhile, dashed arrows represent the interrelationship among these themes; also particularly the key influence of “policy making and government regulations” on the other themes. For instance, in terms of addressing the problem of trained specialist in medical tourism, the policy making and expertise were found to have overlap.While it was widely accepted that a correct policy making and reconfiguring the goal could provide a positive development, providing a communication, from “patients’ own cultural perspective” was cited as the chief obstacle to the development of medical tourism in Korea, with the most redundancy level among the factors.Based on the gathered information, the framework was developed in order to identify the problems and obstacles that effect on development of medical tourism in South Korea. Comparing with previously stablished models, also suggested barriers in other countries and Korea; many similarities can be seen, especially in terms of general policies and communication skills. Nevertheless, there are some differences to pre-identified factors , 22 owinSome of the barriers identified in this study, are similar to those in Hong Kong , such asThe chief barrier, among the themes was “communication skills”. It implies on the effective and appropriate cultural competence that enables the health practitioners to avoid any generalization and offer a cultural service particularly for each patient with different cultural background and personal background as well. In terms of developing medical tourism in Korea, cultural competence of organization, besides global networking could participate on how a medical institute might influence the competitors . The abiPromotional programs through global marketing strategies, which is the second pivotal factor in our result, could become as a part of national and organizational goals; as for Korea, lack of a unique brand can be seen as an initial barriers comparing to the competitors , 32. KorBeyond all these themes, is the effective role of government in terms of centralizing the policy making, reconfiguring and action regulations; if fact, nowhere is the effect of government more apparent than in comprehensive policy making. Therefore, in In this study, only the internal barriers have been investigated, meanwhile, we mentioned to the influence of external factors, particularly the new emerging trend(s) in region. Similarly, this factor has been mentioned as “chance” in the Porter diamond model for the competitiveness of Korea in global healthcare market  which imThe result and discussion suggest that South Korea is among the top destinations for medical tourism in terms of high quality infrastructure and medicine designed based on new emerged technologies. Moreover, designing an accurate comprehensive plan, in advance, supports the details. Nevertheless, it appears that number of foreign patients coming to Korea is facing a decreasing trend. The factors identified here are the barriers which hinder the development of medical tourism. To combat these obstacles in Korea, government should reconfigure the policy and planning, especially in terms of promotion. Moreover, the problem of communication skills and training the specialist in medical tourism should be addressed. The key factor among the barriers is the lack of an efficient and centralized government support; Korea does appear to be moving forward in this issue, as indicated by the recent training support and encouraging plan.Ethical issues  have been completely observed by the authors.