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1.  Eggshell membrane: A possible new natural therapeutic for joint and connective tissue disorders. Results from two open-label human clinical studies 
Natural Eggshell Membrane (NEM®) is a novel dietary supplement that contains naturally occurring glycosaminoglycans and proteins essential for maintaining healthy joint and connective tissues. Two single center, open-label human clinical studies were conducted to evaluate the efficacy and safety of NEM® as a treatment for pain and inflexibility associated with joint and connective tissue disorders.
Eleven (single-arm trial) and 28 (double-arm trial) patients received oral NEM® 500 mg once daily for four weeks. The primary outcome measure was to evaluate the change in general pain associated with the treatment joints/areas (both studies). In the single-arm trial, range of motion (ROM) and related ROM-associated pain was also evaluated. The primary treatment response endpoints were at seven and 30 days. Both clinical assessments were performed on the intent-to-treat (ITT) population within each study.
Single-arm trial: Supplementation with NEM® produced a significant treatment response at seven days for flexibility (27.8% increase; P = 0.038) and at 30 days for general pain (72.5% reduction; P = 0.007), flexibility (43.7% increase; P = 0.006), and ROM-associated pain (75.9% reduction; P = 0.021). Double-arm trial: Supplementation with NEM® produced a significant treatment response for pain at seven days for both treatment arms (X: 18.4% reduction; P = 0.021. Y: 31.3% reduction; P = 0.014). There was no clinically meaningful difference between treatment arms at seven days, so the Y arm crossed over to the X formulation for the remainder of the study. The significant treatment response continued through 30 days for pain (30.2% reduction; P = 0.0001). There were no adverse events reported during either study and the treatment was reported to be well tolerated by study participants.
Natural Eggshell Membrane (NEM®) is a possible new effective and safe therapeutic option for the treatment of pain and inflexibility associated with joint and connective tissue (JCT) disorders. Supplementation with NEM®, 500 mg taken once daily, significantly reduced pain, both rapidly (seven days) and continuously (30 days). It also showed clinically meaningful results from a brief responder analysis, demonstrating that significant proportions of treated patients may be helped considerably from NEM® supplementation. The Clinical Trial Registration numbers for these trials are: NCT00750230 and NCT00750854.
PMCID: PMC2697588  PMID: 19554094
arthritis; pain; stiffness; eggshell membrane; joint; connective tissue; complimentary; alternative
2.  Effect of Training on Adoption of Cancer Prevention Nutrition-Related Activities by Primary Care Practices: Results of a Randomized, Controlled Study 
The National Cancer Institute (NCI) developed a manual to guide primary care practices in structuring their office environment and routine visits so as to enhance nutrition screening, advice/referral, and follow-up for cancer prevention. The adoption of the manual's recommendations by primary care practices was evaluated by examining two strategies: physician training on how to implement the manual's recommendations versus simple mailing of the manual. This article reports on the results of a randomized controlled trial to evaluate the effectiveness of these two strategies.
A three-arm, randomized, controlled study.
Free-standing primary care physician practices in Pennsylvania and New Jersey.
Each study practice was randomly assigned to one of three groups. The training group practices were invited to send one member from their practice of their choosing to a 3-hour “train-a-trainer” workshop, the manual-only-group practices were mailed the nutrition manual, and the control group practices received no intervention. For training group practices, training was provided in the four major components of the nutrition manual: how to organize the office environment to support cancer prevention nutrition-related activities; how to screen patient adherence to the NCI dietary guidelines; how to provide dietary advice/referral; and how to implement a patient follow-up system to support patients in making changes in their nutrition-related behaviors.
The primary outcomes of the study were derived from two evaluation instruments. The observation instrument documented the tools and procedures recommended by the nutrition manual and adopted in patient charts and the office environment. The in-person structured interview evaluated the physician and staff's self-reported nutrition-related activities reflecting the nutrition manual's recommendations. Data from these two instruments were used to construct four adherence scores corresponding to the areas: office organization, nutrition screening, nutrition advice/referral, and patient follow-up.
The adoption of the manual's recommendations was highest among the practices in the training group as reflected by their higher adherence scores. They organized their office ( P =.005) and screened their patients regarding their eating habits ( P =.046) significantly more closely to the recommendations of the nutrition manual than practices in the manual-only group. However, despite being the highest in compliance, the training group practices were only 54.9% adherent to the manual's recommendations regarding nutrition advice/referral, and 28.5% adherent to its recommendations on office organization, 23.5% adherent to its recommendations on nutrition screening, and 14.6% adherent to its patient follow-up recommendations.
Primary care practices exposed to the nutrition manual in a training session adopted more of the manual's recommendations. Specifically, practices invited to training were more likely to perform nutrition screening and to structure their office environment to be conducive to providing nutrition-related services for cancer prevention. The impact of the training was moderate and not statistically significant for nutrition advice/referral or patient follow-up, which are important in achieving long-term dietary changes in patients. The overall low adherence scores to nutrition-related activities demonstrates that there is plenty of room for improvement among the practices in the training group.
PMCID: PMC1495352  PMID: 10718895
nutrition education; nutrition counseling; cancer prevention; primary care physicians
3.  Formative Evaluation for a Healthy Corner Store Initiative in Pitt County, North Carolina: Assessing the Rural Food Environment, Part 1 
Obesity prevalence in the rural United States is higher than in urban or suburban areas, perhaps as a result of the food environment. Because rural residents live farther from supermarkets than their urban- and suburban-dwelling counterparts, they may be more reliant on smaller corner stores that offer fewer healthful food items.
As part of a Communities Putting Prevention to Work (CPPW) healthy corner store initiative, we reviewed audit tools in the fall of 2010 to measure the consumer food environment in eastern North Carolina and chose the NEMS-S-Rev (Nutrition Environment Measures Survey-Stores-Revised) to assess 42 food stores. During the spring and summer of 2011, 2 trained graduate assistants audited stores, achieving interrater reliability of at least 80%. NEMS-S-Rev scores of stores in rural versus urban areas were compared.
Overall, healthful foods were less available and of lower quality in rural areas than in urban areas. NEMS-S-Rev scores indicated that healthful foods were more likely to be available and had similar pricing and quality in rural corner stores than in urban corner stores.
Food store audit data provided a baseline to implement and evaluate a CPPW healthy corner store initiative in Pitt County. This work serves as a case study, providing lessons learned for engaging community partners when conducting rural food store audits.
PMCID: PMC3716336  PMID: 23866165
4.  Art-making in a family medicine clerkship: how does it affect medical student empathy? 
BMC Medical Education  2014;14(1):247.
To provide patient-centred holistic care, doctors must possess good interpersonal and empathic skills. Medical schools traditionally adopt a skills-based approach to such training but creative engagement with the arts has also been effective. A novel arts-based approach may help medical students develop empathic understanding of patients and thus contribute to medical students’ transformative process into compassionate doctors. This study aimed to evaluate the impact of an arts-making workshop on medical student empathy.
This was a mixed-method quantitative-qualitative study. In the 2011–12 academic year, all 161 third year medical students at the University of Hong Kong were randomly allocated into either an arts-making workshop or a problem-solving workshop during the Family Medicine clerkship according to a centrally-set timetable. Students in the arts-making workshop wrote a poem, created artwork and completed a reflective essay while students in the conventional workshop problem-solved clinical cases and wrote a case commentary. All students who agreed to participate in the study completed a measure of empathy for medical students, the Jefferson Scale of Empathy (JSE) (student version), at the start and end of the clerkship. Quantitative data analysis: Paired t-test and repeated measures ANOVA was used to compare the change within and between groups respectively. Qualitative data analysis: Two researchers independently chose representational narratives based on criteria adapted from art therapy. The final 20 works were agreed upon by consensus and thematically analysed using a grounded theory approach.
The level of empathy declined in both groups over time, but with no statistically significant differences between groups. For JSE items relating to emotional influence on medical decision making, participants in the arts-making workshop changed more than those in the problem-solving workshop. From the qualitative data, students perceived benefits in arts-making, and gained understanding in relation to self, patients, pain and suffering, and the role of the doctor.
Though quantitative findings showed little difference in empathy between groups, arts-making workshop participants gained empathic understanding in four different thematic areas. This workshop also seemed to promote greater self-awareness which may help medical students recognize the potential for emotions to sway judgment. Future art workshops should focus on emotional awareness and regulation.
PMCID: PMC4256925  PMID: 25431323
Medical humanities; Empathy; Art; Reflective writing; Family Medicine; Medical student
5.  Recovery after Minor Traffic Injuries: A Randomized Controlled Trial 
PLoS Clinical Trials  2007;2(3):e14.
To assess the efficacy of an acute multidisciplinary group intervention on self-perceived recovery following minor traffic-related musculoskeletal injuries.
Open, randomized controlled trial.
A large inner-city hospital.
127 patients (≥15 y) with traffic-related acute minor musculoskeletal injuries and predicted to be at risk for delayed recovery were randomized into an intervention group (n = 65) or a control group (n = 62).
Four 1½-h sessions in open groups with the aim of providing information about injuries in general, calling attention to the importance of self-care and promoting physical activity. In addition, both groups received standard medical care by regular staff.
Outcome measures:
The main outcome measure was self-reported recovery at 12 mo. Secondary outcome measures were ratings of functional health status (SF-36, SMFA), pain and mental distress on visual analog scales, and self-reported duration of sick leave.
At 12 mo, there was a 21.9 percentage point difference: 52.4% of the patients in the intervention group and 30.5% in the control group reported self-perceived recovery (95% confidence interval for the difference 5%–38%; p = 0.03). There were no statistically significant differences between the groups regarding the secondary outcome measures.
A simple group intervention may accelerate the self-perceived recovery in selected patients. As we did not find evidence of improvements in the secondary outcome measures, the clinical significance of the treatment benefit remains to be defined.
Editorial Commentary
Background: Worldwide, road traffic accidents contribute substantially to the number of deaths and also to the burden of disability. However, there is a lack of research into road traffic accidents as compared to other causes of ill-health. In particular, minor injuries resulting from traffic accidents are not well-studied even though some people with such injuries might be unwell for a long period of time. Support programs that provide people who have had minor traffic-related injuries with psychological help, physical training, and other types of interventions might help people to recover more quickly. However, there is little evidence that would help to answer this question. In the trial reported here, the researchers aimed to find out whether a support program would increase the chance of recovery in people who had experienced minor traffic-related injuries and who were thought to be less likely to recover. Trial participants were randomized to receive either standard medical care or to receive standard care and also to attend a series of workshops where surgeons, psychiatrists, pain specialists, and other staff gave advice about healing, pain management, exercises, and other aspects of self-care. The primary outcome of the trial was whether participants considered themselves to have recovered, 12 mo after the injury.
What the trial shows: 127 patients were recruited into the study, 62 of whom were assigned to receive standard care only and 65 of whom were assigned to also attend the support workshops. Most participants assigned to the support arm did attend all of the workshop sessions. Patients assigned to attend the support workshops were more likely to report that they had recovered as compared to patients receiving standard care only, and this difference seemed quite substantial. However, there were no statistically significant differences between these two groups in the trial's secondary outcome measures. These secondary measures included scores on rating scales which attempt to measure physical and mental distress and coping ability and the amount of sick leave taken.
Strengths and limitations: Although the trial was fairly small, it did recruit enough participants to detect an effect in the primary outcome measure, recovery at 12 mo. Additionally, a large proportion of the participants randomized to attend support sessions did actually attend the sessions, and follow-up for the primary outcome measure was virtually complete. Limitations of this study include low follow-up of patients for the secondary outcome measures in the trial. This meant that there was low power to detect clinically relevant changes in these outcome measures. Finally, although many patients were eligible for the trial, only a small proportion could be successfully contacted after being discharged from hospital, and it is possible that those people who did agree to participate were more motivated to recover than patients in general who have these injuries.
Contribution to the evidence: Most evidence relating to the benefits of support programs such as these have evaluated their effects in patients who have whiplash injuries rather than general traffic-related injuries. However, the results from this trial are compatible with those of similar trials in patients with whiplash injuries and suggest that support programs such as these may be beneficial in patients at risk of not recovering well from their injuries.
PMCID: PMC1829405  PMID: 17380190
6.  Optimizing data collection for public health decisions: a data mining approach 
BMC Public Health  2014;14:593.
Collecting data can be cumbersome and expensive. Lack of relevant, accurate and timely data for research to inform policy may negatively impact public health. The aim of this study was to test if the careful removal of items from two community nutrition surveys guided by a data mining technique called feature selection, can (a) identify a reduced dataset, while (b) not damaging the signal inside that data.
The Nutrition Environment Measures Surveys for stores (NEMS-S) and restaurants (NEMS-R) were completed on 885 retail food outlets in two counties in West Virginia between May and November of 2011. A reduced dataset was identified for each outlet type using feature selection. Coefficients from linear regression modeling were used to weight items in the reduced datasets. Weighted item values were summed with the error term to compute reduced item survey scores. Scores produced by the full survey were compared to the reduced item scores using a Wilcoxon rank-sum test.
Feature selection identified 9 store and 16 restaurant survey items as significant predictors of the score produced from the full survey. The linear regression models built from the reduced feature sets had R2 values of 92% and 94% for restaurant and grocery store data, respectively.
While there are many potentially important variables in any domain, the most useful set may only be a small subset. The use of feature selection in the initial phase of data collection to identify the most influential variables may be a useful tool to greatly reduce the amount of data needed thereby reducing cost.
PMCID: PMC4077265  PMID: 24919484
Community survey methods; Data mining; Data collection; Ecological and environmental concepts; Nutrition
7.  The impact of China’s national essential medicine system on improving rational drug use in primary health care facilities: an empirical study in four provinces 
The National Essential Medicine System (NEMS) is a new policy in China launched in 2009 to improve the appropriate use of medications. This study aims to examine the outcomes of the NEMS objectives in terms of the rational use of medicines in primary health care facilities in China.
A total of 28,651 prescriptions were collected from 146 township health centers in four provinces of China by means of a field survey conducted in 2010–2011. Indicators of rational drug use were extracted and compared using a pre/post design and then evaluated with regard to the World Health Organization (WHO) Standard Guidelines and data from previous research.
The average number of drugs per prescription decreased from 3.64 to 3.46 (p < 0.01) between 2009 and 2010. Little effect was found for the NEMS on the average number of antibiotics per prescription, but the percentage of prescriptions including antibiotics decreased from 60.26 to 58.48% (p < 0.01). Prescriptions for injections or adrenal corticosteroids also decreased, to 40.31 and 11.16% of all prescriptions, respectively. All these positive issues were also recorded in 2011. However, each of the above values remained higher than WHO standards. The percentage of drugs prescribed from the Essential Drug List increased after the implementation of the NEMS (p < 0.01). Where the available data allowed changes in costs to be assessed, the average expense per prescription increased significantly, from 25.77 to 27.09 yuan (p < 0.01).
The NEMS effectively improved rational medicine use in China. However, polypharmacy and the over-prescription of antibiotics and injections remain common. There is still a large unfinished agenda requiring policy improvements. Treatment guidelines, intensive support supervision, and continuing training for both professionals and consumers are the essential actions that need to be taken.
PMCID: PMC4213512  PMID: 25344413
Rational drug use; Prescribing behavior; Essential medicines policy; Primary health care; China
8.  A Multilevel Assessment of Barriers to Adoption of Dietary Approaches to Stop Hypertension (DASH) among African Americans of Low Socioeconomic Status 
We examined perceptions of Dietary Approaches to Stop Hypertension (DASH) and the food environment among African Americans (AA) with high blood pressure living in two low-income communities and objectively assessed local food outlets.
Focus groups were conducted with 30 AAs; participants discussed DASH and the availability of healthy foods in their community. Sessions were transcribed and themes identified. Fifty-four stores and 114 restaurants were assessed using the Nutrition Environment Measures Survey (NEMS).
Common themes included poor availability, quality, and cost of healthy foods; tension between following DASH and feeding other family members; and lack of congruity between their preferred foods and DASH. Food outlets in majority AA census tracts had lower NEMS scores (stores: −11.7, p=.01, restaurants: −8.3, p=.001) compared with majority White areas.
Interventions promoting DASH among lower income AAs should reflect the food customs, economic concerns, and food available in communities.
PMCID: PMC3769217  PMID: 22080704
Hypertension; diet; food deserts; African American
9.  Design and National Dissemination of the StrongWomen Community Strength Training Program 
Preventing Chronic Disease  2007;5(1):A25.
Physical activity is essential for maintaining health and function with age, especially among women. Strength training exercises combat weakness and frailty and mitigate the development of chronic disease. Community-based programs offer accessible opportunities for strength training.
Program Design
The StrongWomen Program is an evidence-informed, community-based strength training program developed and disseminated to enable women aged 40 or older to maintain their strength, function, and independence. The StrongWomen Workshop and StrongWomen Tool Kit are the training and implementation tools for the StrongWomen Program. Program leaders are trained at the StrongWomen Workshop. They receive the StrongWomen Tool Kit and subsequent support to implement the program in their communities.
Program dissemination began in May 2003 with a three-part approach: recruiting leaders and forming key partnerships, soliciting participant interest and supporting implementation, and promoting growth and sustainability.
We conducted site visits during the first year to assess curriculum adherence. We conducted a telephone survey to collect data on program leaders, participants, locations, and logistics. We used a database to track workshop locations and program leaders. As of July 2006, 881 leaders in 43 states were trained; leaders from 35 states had implemented programs.
Evidence-informed strength training programs can be successful when dissemination occurs at the community level using trained leaders. This research demonstrates that hands-on training, a written manual, partnerships with key organizations, and leader support contributed to the successful dissemination of the StrongWomen Program. Results presented provide a model that may aid the dissemination of other community-based exercise programs.
PMCID: PMC2248774  PMID: 18082014
10.  Changing Job Satisfaction, Absenteeism, and Healthcare Claims Costs In a Hospital Culture 
Global Advances in Health and Medicine  2014;3(Suppl 1):BPA01.
Fairfield Medical Center is a 222-bed community hospital located in Lancaster, Ohio. Organizational leadership chose to invest in the Transforming Stress Workshop, a 6-hour workshop with a 2-hour follow-up workshop, in order to improve the well-being of its staff and physicians.
Special thought and consideration were given to being able to sustain any benefits and/or improvements long-term. As a result, strategies were developed to integrate the program into our culture.
Four staff members from a variety of disciplines were selected and sent to HeartMath Train-the-Trainer to gain proficiency in HeartMath methodology and tools, expanding their duties to deliver the classes. Biweekly workshops were offered from August 2007 through December 2010, educating a total of 975 employees, or 48% of the staff.
Other tactics providing a sustainable program included senior leadership support and championing, management team training, positive employee comments published internally, use of tools in committee and department meetings, incorporation into orientation and on-boarding processes, part of major initiative roll-outs, element in clinical ladder, expansion to include Transforming Team Workshops, sharing of Participant and Organizational Quality Assessment-Revised data, a lead HeartMath instructor who provides consulting to other organizations, provision of classes to local educators, and open workshops for employee family members.
Three metrics were selected to measure the success of the program: employee satisfaction, absenteeism rates, and healthcare claims cost. Statistically significant cultural and financial return on investment were demonstrated. Employees who received HeartMath training experienced a 2:1 savings on healthcare claims as compared to employees who had not received training. Employee Opinion Survey results demonstrated that employees who had HeartMath training had higher overall satisfaction scores than those who had not received training (Table and Figure) HeartMath participants demonstrated a lower overall absenteeism rate (P = 0), resulting in a $94,794 savings over a 3-year period. Cultural and financial returns on investment were demonstrated using these indicators.
Healthcare Claims Costs
Abbreviations: PMPM, per member per month; PMPY, per member per year.
HeartMath claims expense excludes five outlier claims in excess of $20 000 for conditions that could not have been avoided using HeartMath.
Non-HeartMath participants’ total claims expenses excludes six outlier cases with payments > $125 000.
Employee opinion survey: Impact of HeartMath Training, over all scores.
Investing in HeartMath training and ongoing practice has proven to be a wise decision and continues to be valuable when initiating new concepts in a stressful, changing environment. Sustainability is key to long-term success and true cultural change. Continued employee training of the HeartMath tools and the continued use of the tools enriches the program planning and implementation of new initiatives at Fairfield Medical Center.
PMCID: PMC3923278
Job satisfaction; absenteeism; healthcare claims costs; stress; HeartMath; return on investment (ROI); biofeedback
11.  A self-evaluation tool for integrated care services: the Development Model for Integrated Care applied in practice 
The purpose of the workshop is to show the applications of the Development Model for Integrated Care (DMIC) in practice. This relatively new and validated model, can be used by integrated care practices to evaluate their integrated care, to assess their phase of development and reveal improvement areas. In the workshop the results of the use of the model in three types of integrated care settings in the Netherlands will be presented. Participants are offered practical instruments based on the validated DMIC to use in their own setting and will be introduced to the webbased tool.
To integrate care from multiple providers into a coherent and streamlined client-focused service, a large number of activities and agreements have to be implemented like streamlining information flows and adequate transfers of clients. In the large range of possible activities it is often not clear what essential activities are and where to start or continue. Also, knowledge about how to further develop integrated care services is needed. The Development Model for Integrated Care (DMIC), based on PhD research of Mirella Minkman, describes nine clusters containing in total 89 elements that contribute to the integration of care. The clusters are named: ‘client-centeredness’, ‘delivery system’, ‘performance management’, ‘quality of care’, ‘result-focused learning’, ‘interprofessional teamwork’, ‘roles and tasks’, ‘commitment’, and ‘transparant entrepreneurship’ [1–3]. In 2011 a new digital webbased self-evolution tool which contains the 89 elements grouped in nine clusters was developed. The DMIC also describes four phases of development [4]. The model is empirically validated in practice by assessing the relevance and implementation of the elements and development phases in 84 integrated care services in The Netherlands: in stroke, acute myocardial infarct (AMI), and dementia services. The validation studies are recently published [5, 6]. In 2011 also other integrated care services started using the model [7]. Vilans developed a digital web-based self-evaluation tool for integrated care services based on the DMIC. A palliative care network, four diabetes services, a youth care service and a network for autism used the self-evaluation tool to evaluate the development of their integrated care service. Because of its generic character, the model and tool are believed to be also interesting internationally.
Data sources
In the workshop we will present the results of three studies in integrated diabetes, youth and palliative care. The three projects consist of multiple steps, see below. Workshop participants could also work with the DMIC following these steps.
One: Preparation of the digital self-evolution tool for integrated care services
Although they are very different, the three integrated care services all wanted to gain insight in their development and improvement opportunities. We tailored the digital self-evaluation tool for each specific integrated care services, but for all the basis was the DMIC. Personal accounts for the digital DMIC self-evalution survey were sent to multiple partners working in each integrated care service (4–16 partners).
Two: Use of the online self-evaluation tool each partner of the local integrated care setting evaluated the integrated care by filling in the web-based questionnaire. The tool consists of three parts (A-C) named: general information about the integrated care practice (A); the clusters and elements of the DMIC (B); and the four phases of development (C). The respondents rated the relevance and presence of each element in their integrated care practice. Respondents were asked to estimate in which phase of development their thought their service was.
Three: Analysing the results
Advisers from Vilans, the Centre of excellence for long-term care in the Netherlands, analysed the self-evolution results in cooperation with the integrated care coordinators. The results show the total amount of implemented integrated care elements per cluster in spider graphs and the development phase as calculated by the DMIC model. Suggestions for further development of the integrated care services were analysed and reported.
Four: Discussing the implications for further development
In a workshop with the local integrated care partners the results of the self-evaluation were presented and discussed. We noticed remarkable results and highlight elements for further development. In addition, we gave advice for further development appropriate to the development phase of the integrated care service. Furthermore, the professionals prioritized the elements and decided which elements to start working on. This resulted in a (quality improvement) plan for the further development of the integrated care service.
Five: Reporting results
In a report all the results of the survey (including consensus scores) and the workshops came together. The integrated care coordinators stated that the reports really helped them to assess their improvement strategy. Also, there was insight in the development phase of their service which gave tools for further development.
Case description
The three cases presented are a palliative network, an integrated diabetes services and an integrated care network for youth in the Netherlands. The palliative care network wanted to reflect on their current development, to build a guiding framework for further development of the network. About sixteen professionals within the network worked with the digital self-evaluation tool and the DMIC: home care organisations, welfare organizations, hospice centres, health care organisations, community organizations.
For diabetes care, a Dutch health care insurance company wished to gain insight in the development of the contracted integrated care services to stimulate further development of the services. Professionals of three diabetes integrated care services were invited to fill in the digital self-evaluation tool. Of each integrated care service professionals like a general practitioner, a diabetes nurse, a medical specialist, a dietician and a podiatrist were invited. In youth care, a local health organisation wondered whether the DMIC could be helpful to visualize the results of youth integrated care services at process- and organisational level. The goal of the project was to define indicators at a process- and organisational level for youth care services based on the DMIC. In the future, these indicators might be used to evaluate youth care integrated care services and improve the quality of youth care within the Netherlands.
Conclusions and discussion
It is important for the quality of integrated care services that the involved coordinators, managers and professionals are aware of the development process of the integrated care service and that they focus on elements which can further develop and improve their integrated care. However, we noticed that integrated care services in the Netherlands experience difficulties in developing their integrated care service. It is often not clear what essential activities are to work on and how to further develop the integrated care service. A guiding framework for the development of integrated care was missing. The DMIC model has been developed for that reason and offers a useful tool for assessment, self-evaluation or improvement of integrated care services in practice. The model has been validated for AMI, dementia and stroke services. The latest new studies in diabetes, palliative care and youth care gave further insight in the generic character of the DMIC. Based on these studies it can be assumed that the DMIC can be used for multiple types of integrated care services. The model is assumed to be interesting for an international audience. Improving integrated care is a complex topic in a large number of countries; the DMIC is also based on the international literature. Dutch integrated care coordinators stated that the DMIC helped them to assess their integrated care development in practice and supported them in obtaining ideas for expanding and improving their integrated care activities.
The web-based self-evaluation tool focuses on a process- and organisational level of integrated care. Also, the self assessed development phase can be compared to the development phase as calculated by the DMIC tool. The cases showed this is fruitful input for discussions. When using the tool, the results can also be used in quality policy reports and improvement plans. The web-based tool is being tested at this moment in practice, but in San Marino we can present the latest webversion and demonstrate with a short video how to use the tool and model. During practical exercises in the workshop the participants will experience how the application of the DMIC can work for them in practice or in research. For integrated care researchers and policy makers, the DMIC questionnaire and tool is a promising method for further research and policy plans in integrated care.
PMCID: PMC3617779
development model for integrated care; development of integrated care services; implementation and improvement of integrated care; self evaluation
12.  Effect of Rater Training on Reliability and Accuracy of Mini-CEX Scores: A Randomized, Controlled Trial 
Mini-CEX scores assess resident competence. Rater training might improve mini-CEX score interrater reliability, but evidence is lacking.
Evaluate a rater training workshop using interrater reliability and accuracy.
Randomized trial (immediate versus delayed workshop) and single-group pre/post study (randomized groups combined).
Academic medical center.
Fifty-two internal medicine clinic preceptors (31 randomized and 21 additional workshop attendees).
The workshop included rater error training, performance dimension training, behavioral observation training, and frame of reference training using lecture, video, and facilitated discussion. Delayed group received no intervention until after posttest.
Mini-CEX ratings at baseline (just before workshop for workshop group), and four weeks later using videotaped resident–patient encounters; mini-CEX ratings of live resident–patient encounters one year preceding and one year following the workshop; rater confidence using mini-CEX.
Among 31 randomized participants, interrater reliabilities in the delayed group (baseline intraclass correlation coefficient [ICC] 0.43, follow-up 0.53) and workshop group (baseline 0.40, follow-up 0.43) were not significantly different ( = 0.19). Mean ratings were similar at baseline (delayed 4.9 [95% confidence interval 4.6–5.2], workshop 4.8 [4.5–5.1]) and follow-up (delayed 5.4 [5.0–5.7], workshop 5.3 [5.0–5.6];  = 0.88 for interaction). For the entire cohort, rater confidence (1 = not confident, 6 = very confident) improved from mean (SD) 3.8 (1.4) to 4.4 (1.0),  = 0.018. Interrater reliability for ratings of live encounters (entire cohort) was higher after the workshop (ICC 0.34) than before (ICC 0.18) but the standard error of measurement was similar for both periods.
Rater training did not improve interrater reliability or accuracy of mini-CEX scores.
Clinical trials registration identifier NCT00667940
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-008-0842-3) contains supplementary material, which is available to authorized users.
PMCID: PMC2607488  PMID: 19002533
medical education; faculty development; rater training; clinical competence; assessment; randomized trial
13.  Conflicting priorities: evaluation of an intervention to improve nurse-parent relationships on a Tanzanian paediatric ward 
Patient, or parent/guardian, satisfaction with health care provision is important to health outcomes. Poor relationships with health workers, particularly with nursing staff, have been reported to reduce satisfaction with care in Africa. Participatory research approaches such as the Health Workers for Change initiative have been successful in improving provider-client relationships in various developing country settings, but have not yet been reported in the complex environment of hospital wards. We evaluated the HWC approach for improving the relationship between nurses and parents on a paediatric ward in a busy regional hospital in Tanzania.
The intervention consisted of six workshops, attended by 29 of 31 trained nurses and nurse attendants working on the paediatric ward. Parental satisfaction with nursing care was measured with 288 parents before and six weeks after the workshops, by means of an adapted Picker questionnaire. Two focus-group discussions were held with the workshop participants six months after the intervention.
During the workshops, nurses demonstrated awareness of poor relationships between themselves and mothers. To tackle this, they proposed measures including weekly meetings to solve problems, maintain respect and increase cooperation, and representation to administrative forces to request better working conditions such as equipment, salaries and staff numbers. The results of the parent satisfaction questionnaire showed some improvement in responsiveness of nurses to client needs, but overall the mean percentage of parents reporting each of 20 problems was not statistically significantly different after the intervention, compared to before it (38.9% versus 41.2%). Post-workshop focus-group discussions with nursing staff suggested that nurses felt more empathic towards mothers and perceived an improvement in the relationship, but that this was hindered by persisting problems in their working environment, including poor relationships with other staff and a lack of response from hospital administration to their needs.
The intended outcome of the intervention was not met. The priorities of the intervention – to improve nurse-parent relationships – did not match the priorities of the nursing staff. Development of awareness and empathy was not enough to provide care that was satisfactory to clients in the context of working conditions that were unsatisfactory to nurses.
PMCID: PMC2706791  PMID: 19549319
14.  Neighborhood Impact on Healthy Food Availability and Pricing in Food Stores 
Journal of community health  2010;35(3):315-320.
Availability and price of healthy foods in food stores has the potential to influence purchasing patterns, dietary intake, and weight status of individuals. This study examined whether demographic factors of the store neighborhood or store size have an impact on the availability and price of healthy foods in sample of grocery stores and supermarkets. The Nutrition Environment Measures Study-Store (NEMS-S) instrument, a standardized observational survey, was utilized to evaluate food stores (N=42) in a multi-site (Vermont and Arkansas) study in 2008. Census data associated with store census tract (median household income and proportion African-American) were used to characterize store neighborhood and number of cash registers was used to quantify store size. Median household income was significantly associated with the NEMS healthy food availability score (r=0.36, p<0.05); neither racial composition (r=−0.23, p=0.14) nor store size (r=0.27, p=0.09) were significantly related to the Availability score. Larger store size (r=0.40, p<0.01) was significantly associated with the NEMS-S Price scores, indicating more favorable prices for healthier items; neither racial composition nor median household income were significantly related to the Price score (ps>0.05). Even among supermarkets, healthier foods are less available in certain neighborhoods, although, when available, the quality of healthier options did not differ, suggesting that targeting availability may offer promise for policy initiatives. Furthermore, increasing access to larger stores that can offer lower prices for healthier foods may provide another avenue for enhancing food environments to lower disease risk.
PMCID: PMC3071013  PMID: 20127506
diet; obesity; built environment; economics; race
15.  An Innovative Plant Genomics and Gene Annotation Program for High School, Community College, and University Faculty 
CBE Life Sciences Education  2008;7(3):310-316.
Today's biology educators face the challenge of training their students in modern molecular biology techniques including genomics and bioinformatics. The Dolan DNA Learning Center (DNALC) of Cold Spring Harbor Laboratory has developed and disseminated a bench- and computer-based plant genomics curriculum for biology faculty. In 2007, a five-day “Plant Genomics and Gene Annotation” workshop was held at Florida A&M University in Tallahassee, FL, to enhance participants' knowledge and understanding of plant molecular genetics and assist them in developing and honing their laboratory and computer skills. Florida A&M University is a historically black university with over 95% African-American student enrollment. Sixteen participants, including high school (56%) and community college faculty (25%), attended the workshop. Participants carried out in vitro and in silico experiments with maize, Arabidopsis, soybean, and food products to determine the genotype of the samples. Benefits of the workshop included increased awareness of plant biology research for high school and college level students. Participants completed pre- and postworkshop evaluations for the measurement of effectiveness. Participants demonstrated an overall improvement in their postworkshop evaluation scores. This article provides a detailed description of workshop activities, as well as assessment and long-term support for broad classroom implementation.
PMCID: PMC2527984  PMID: 18765753
16.  Food venue choice, consumer food environment, but not food venue availability within daily travel patterns are associated with dietary intake among adults, Lexington Kentucky 2011 
Nutrition Journal  2013;12:17.
The retail food environment may be one important determinant of dietary intake. However, limited research focuses on individuals’ food shopping behavior and activity within the retail food environment. This study’s aims were to determine the association between six various dietary indicators and 1) food venue availability; 2) food venue choice and frequency; and 3) availability of healthy food within food venue.
In Fall, 2011, a cross-sectional survey was conducted among adults (n=121) age 18 years and over in Lexington, Kentucky. Participants wore a global position system (GPS) data logger for 3-days (2 weekdays and 1 weekend day) to track their daily activity space, which was used to assess food activity space. They completed a survey to assess demographics, food shopping behaviors, and dietary outcomes. Food store audits were conducted using the Nutrition Environment Measurement Survey-Store Rudd (NEMS-S) in stores where respondents reported purchasing food (n=22). Multivariate logistic regression was used to examine associations between six dietary variables with food venue availability within activity space; food venue choice; frequency of shopping; and availability of food within food venue.
1) Food venue availability within activity space – no significant associations. 2) Food Venue Choice – Shopping at farmers’ markets or specialty grocery stores reported higher odds of consuming fruits and vegetables (OR 1.60 95% CI [1.21, 2.79]). Frequency of shopping - Shopping at a farmers’ markets and specialty stores at least once a week reported higher odds of consumption of fruits and vegetables (OR 1.55 95% CI [1.08, 2.23]). Yet, shopping frequently at a super market had higher odds of consuming sugar-sweetened beverages (OR 1.39 95% CI [1.03, 1.86]). 3) Availability of food within store – those who shop in supermarkets with high availability of healthy food has lower odds of consuming sugar-sweetened beverages (OR 0.65 95% CI [0.14, 0.83]).
Interventions aimed at improving fruit and vegetable intake need to consider where individuals’ purchase food and the availability within stores as a behavioral and environmental strategy.
PMCID: PMC3571876  PMID: 23360547
Food store availability; Food environment; Dietary habits
17.  Next-generation sequencing: a challenge to meet the increasing demand for training workshops in Australia 
Briefings in Bioinformatics  2013;14(5):563-574.
The widespread adoption of high-throughput next-generation sequencing (NGS) technology among the Australian life science research community is highlighting an urgent need to up-skill biologists in tools required for handling and analysing their NGS data. There is currently a shortage of cutting-edge bioinformatics training courses in Australia as a consequence of a scarcity of skilled trainers with time and funding to develop and deliver training courses. To address this, a consortium of Australian research organizations, including Bioplatforms Australia, the Commonwealth Scientific and Industrial Research Organisation and the Australian Bioinformatics Network, have been collaborating with EMBL-EBI training team. A group of Australian bioinformaticians attended the train-the-trainer workshop to improve training skills in developing and delivering bioinformatics workshop curriculum. A 2-day NGS workshop was jointly developed to provide hands-on knowledge and understanding of typical NGS data analysis workflows. The road show–style workshop was successfully delivered at five geographically distant venues in Australia using the newly established Australian NeCTAR Research Cloud. We highlight the challenges we had to overcome at different stages from design to delivery, including the establishment of an Australian bioinformatics training network and the computing infrastructure and resource development. A virtual machine image, workshop materials and scripts for configuring a machine with workshop contents have all been made available under a Creative Commons Attribution 3.0 Unported License. This means participants continue to have convenient access to an environment they had become familiar and bioinformatics trainers are able to access and reuse these resources.
PMCID: PMC3771231  PMID: 23543352
training; next-generation sequencing; NGS; cloud; workshop
18.  Train the Trainer for general practice trainer - a report of the pilot within the programme Verbundweiterbildungplus 
Background: Since 2008 the Verbundweiterbildungplus programme of the Competence Centre General Practice Baden-Wuerttemberg offers continual improvement with regards to content and structure of general practice training. The programme uses the didactical concept of the CanMEDs competencies, which were developed in Canada, as a postgraduate medical training framework. Train the trainer (TTT)-programmes are an additional important element of these contentual optimisations of postgraduate training. Within this article we describe the conception and evaluation of the first TTT-workshop within the programme Verbundweiterbildungplus.
Methods: The conception of the first TTT-workshop was influenced by results of a survey of general practitioner (GP) trainers and by experiences with teaching GP trainers involved in medical undergraduate teaching. A questionnaire was designed to get a self-assessment about organisational and didactic aspects oriented on the CanMEDs competencies of postgraduate medical training. In addition, the workshop was evaluated by the participants.
Results: The workshop lasted 12 teaching units and included the following elements: introduction into the CanMEDs competencies, feedback training, fault management, legal and organisational aspects of post graduate training. From the 29 participating trainers 76% were male and on average 57 years old. The evaluation showed a good to very good acceptance of the workshop. Initial self-rating showed the need of improving in the fields of determining learning objectives, providing formative feedback and incorporation of a trainee. Most trainers rated themselves as very good in procure CanMEDs competencies with the exclusion of the competencies “Manager“ and “Scholar“.
Conclusion: A TTT-programme is an important method to improve GP training which has not been used in Germany so far. Such a GP TTT-programme should highlight especially training in providing feedback and teaching in management aspects. Results of this article add information that can be used for developing TTT-programmes also in other specialties.
PMCID: PMC3374139  PMID: 22737198
General Practice; Train the Trainer; Feedback Training; Management; Postgraduate Medical Training
19.  “But there are no snakes in the wood”: risk mapping as an outcome measure in evaluating complex interventions 
Sexually Transmitted Infections  2007;83(3):232-236.
To complement biological and social behavioural markers in evaluating the complex intervention of sexual and reproductive health among adolescents in rural Zimbabwe, community‐derived markers of effectiveness were sought. Through a participatory workshop with adolescent boys and girls, an innovative “risk map research workshop” was developed to be conducted throughout the study sites.
78 gender‐specific standardised workshops were conducted among secondary school students. Participants drew risk maps of their community. Focus group discussions explored each risk area identified on the map. Grounded Theory was used to create “categories” and “subcategories.” Workshops continued to be held until “saturation”, whereby no new categories emerged. “Axial coding” identified the inter‐relationship between categories and subcategories according to their relevance to sexual and reproductive health risk.
Six “risk area” Grounded Theory categories emerged from the data: bush/rural terrain, commercial centres, homes, school environs, religious and spiritual venues, and roadsides. 17 subcategories emerged, grouped under each of the risk area categories, such as riverbeds, growth points, homesteads, classrooms, all‐night prayer meetings and truck stops. Risks and the consequences of risks included sexually transmitted infections (including HIV), violence, sexual abuse, expulsion from school and illegal abortion.
Risk maps provide unique data that can be used to measure more subtle changes that occur as a result of social behavioural interventions aimed at addressing reproductive and sexual health. Another round of risk map research workshops will be held towards the end of the study to explore changes in milieu, behaviour and experiences, and will complement and triangulate the biological and other social behavioural outcome measures.
PMCID: PMC2659103  PMID: 17344248
20.  The implementation of a participatory manuscript development process with Native American tribal awardees as part of the CDC Communities Putting Prevention to Work initiative: Challenges and opportunities 
Preventive medicine  2014;67(0 1):S51-S57.
In 2009, the Centers for Disease Control and Prevention funded 50 communities, including three tribal awardees, to implement environmental approaches to address obesity and smoking through the Communities Putting Prevention to Work initiative. The tribes were among the selected awardees offered training support for analyzing, writing, and publishing their findings. This article describes the process of translating the workshops, guided by a participatory framework, for implementation with the tribes.
Nine participants from three tribes attended the workshops in Decatur, Georgia, in August and October of 2012: 1) a one-day pre-conference workshop focused on integrating both Indigenous and academic evaluation methods; 2) a 4 day data analysis workshop; and 3) a 5 day scientific writing workshop. Participants were provided with technical assistance following the workshops.
Participants viewed the workshops positively and have continued to develop their manuscripts. To date one tribal awardee has submitted their manuscript for publication.
The participatory manuscript development process described here is the first of its kind outlining a pathway for tribal community health practitioners to translate and publish their work. Further development of this process could increase the number of community-developed manuscripts, thereby advancing the field of translational intervention science and leading to improved health equity.
PMCID: PMC4125542  PMID: 24513172
American Indian; Native American; Community-based participatory research; Participatory publication; Participatory evaluation
21.  Evaluation of an inter-professional workshop to develop a psychosocial assessment and child-centred communication training programme for paediatricians in training 
The quality of psychosocial assessment of children in consultations varies widely. One reason for this difference is the variability in effective mental health and communication training at undergraduate and post-qualification levels. In recognition of this problem, the Royal College of Paediatrics and Child Health in the United Kingdom have developed the Child in Mind Project that aims to meet this deficit in medical training. This paper describes the evaluation of a workshop that explored the experiences and expectations of health care professionals in the development of a training programme for doctors.
The one-day inter-professional workshop was attended by 63 participants who were invited to complete evaluation forms before and immediately after the workshop.
The results showed that the workshop was partially successful in providing an opportunity for an inter-professional group to exchange ideas and influence the development of a significant project. Exploring the content and process of the proposed training programme and the opportunity for participants to share experiences of effective practice were valued. Participants identified that the current culture within many health care settings would be an obstacle to successful implementation of a training programme. Working within existing training structures will be essential. Areas for improvement in the workshop included clearer statement of goals at the outset and a more suitable environment for the numbers of participants.
The participants made a valuable contribution to the development of the training programme identifying specific challenges. Inter-professional collaborations are likely to result in more deliverable and relevant training programmes. Continued consultation with potential users of the programme – both trainers and trainees will be essential.
PMCID: PMC535901  PMID: 15555066
22.  Using computerised decision support to improve compliance of cancer multidisciplinary meetings with evidence-based guidance 
BMJ Open  2012;2(3):e000439.
The cancer multidisciplinary team (MDT) meeting (MDM) is regarded as the best platform to reduce unwarranted variation in cancer care through evidence-compliant management. However, MDMs are often overburdened with many different agendas and hence struggle to achieve their full potential. The authors developed an interactive clinical decision support system called MATE (Multidisciplinary meeting Assistant and Treatment sElector) to facilitate explicit evidence-based decision making in the breast MDMs.
Audit study and a questionnaire survey.
Breast multidisciplinary unit in a large secondary care teaching hospital.
All members of the breast MDT at the Royal Free Hospital, London, were consulted during the process of MATE development and implementation. The emphasis was on acknowledging the clinical needs and practical constraints of the MDT and fitting the system around the team's workflow rather than the other way around. Delegates, who attended MATE workshop at the England Cancer Networks' Development Programme conference in March 2010, participated in the questionnaire survey.
Outcome measures
The measures included evidence-compliant care, measured by adherence to clinical practice guidelines, and promoting research, measured by the patient identification rate for ongoing clinical trials.
MATE identified 61% more patients who were potentially eligible for recruitment into clinical trials than the MDT, and MATE recommendations demonstrated better concordance with clinical practice guideline than MDT recommendations (97% of MATE vs 93.2% of MDT; N=984). MATE is in routine use in breast MDMs at the Royal Free Hospital, London, and wider evaluations are being considered.
Sophisticated decision support systems can enhance the conduct of MDMs in a way that is acceptable to and valued by the clinical team. Further rigorous evaluations are required to examine cost-effectiveness and measure the impact on patient outcomes. The decision support technology used in MATE is generic and if found useful can be applied across medicine.
Article summary
Article focus
How to improve the conduct of a cancer MDT and standardise decision making in accordance with best evidence.
Development and implementation of a novel clinical decision support (CDS) platform for breast cancer MDT.
This study evaluates (1) the concordance between the CDS suggestions and MDT recommendations and (2) the identification rate of potentially eligible patients for recruiting into the ongoing research trials, by the MDT and the CDS. A separate questionnaire survey was conducted at the national workshop at the Cancer Networks' Development Programme to get an estimate of acceptability of such MDT decision support systems by the cancer networks.
Key messages
An advanced CDS platform could significantly improve the conduct of cancer MDMs.
Further robust evaluations are necessary.
Strengths and limitations of this study
We share our experience of developing an advanced decision support system and implementing it in a complex clinical environment of cancer MDT, which was subsequently adopted as a breast MDMs management tool.
The results reported here, however encouraging, are at this point indicative of the potential benefits but not yet conclusive. They should be treated with caution until further rigorous evaluations confirm the effectiveness and generalisability of the CDS system.
PMCID: PMC3383983  PMID: 22734113
23.  Clinical instructors' perception of a faculty development programme promoting postgraduate year-1 (PGY1) residents' ACGME six core competencies: a 2-year study 
BMJ Open  2011;1(2):e000200.
The six core competencies designated by Accreditation Council for Graduate Medical Education (ACGME) are essential for establishing a patient centre holistic medical system. The authors developed a faculty programme to promote the postgraduate year 1 (PGY1) resident, ACGME six core competencies. The study aims to assess the clinical instructors' perception, attitudes and subjective impression towards the various sessions of the ‘faculty development programme for teaching ACGME competencies.’
During 2009 and 2010, 134 clinical instructors participated in the programme to establish their ability to teach and assess PGY1 residents about ACGME competencies.
The participants in the faculty development programme reported that the skills most often used while teaching were learnt during circuit and itinerant bedside, physical examination teaching, mini-clinical evaluation exercise (mini-CEX) evaluation demonstration, training workshop and videotapes of ‘how to teach ACGME competencies.’ Participants reported that circuit bedside teaching and mini-CEX evaluation demonstrations helped them in the interpersonal and communication skills domain, and that the itinerant teaching demonstrations helped them in the professionalism domain, while physical examination teaching and mini-CEX evaluation demonstrations helped them in the patients' care domain. Both the training workshop and videotape session increase familiarity with teaching and assessing skills. Participants who applied the skills learnt from the faculty development programme the most in their teaching and assessment came from internal medicine departments, were young attending physician and had experience as PGY1 clinical instructors.
According to the clinical instructors' response, our faculty development programme effectively increased their familiarity with various teaching and assessment skills needed to teach PGY1 residents and ACGME competencies, and these clinical instructors also then subsequently apply these skills.
Article summary
Article focus
In order to train PGY1 residents, we need to help clinical instructors to become familiar with the teaching and assessment skills that form the Accreditation Council for Graduate Medical Education six core-competencies.
Our study used a self-reported questionnaires based analysis to evaluate the clinical instructors' perception to our faculty development programme.
Key messages
Participants reported that their most commonly used skills were learnt from itinerant and circuit bedside teaching, and mini-clinical evaluation exercise evaluation demonstration in our programme.
Participants also reported that the 40 h basic training course improved their abilities to train and assess PGY1 residents in patient care, interpersonal and communication skills, and medical knowledge domains whereas postcourse training workshop and videotape session enhanced their ability in system-based practice, practice-based learning and improvement, and professionalism domains.
A serial follow-up questionnaire suggested that the degree of participant application of skills learnt from our programme increased progressively after finishing the 40 h basic training course, the postcourse training workshop and videotape session.
Strengths and limitations of this study
According to the clinical instructors' responses, our programme effectively increased their familiarity with teaching and assessment skills needed when teaching PGY1 residents' Accreditation Council for Graduate Medical Education competencies and that these skills were subsequently applies.
This study was limited by the fact that questionnaire used to track and assess the effectiveness of the training programme may have had information and recall bias. In addition, this study had a relatively small sample size and did not contain a control group. However, no controlled educational trials on this subject have been published as yet.
PMCID: PMC3225591  PMID: 22116089
24.  Assessing the Food Environment of a Rural Community: Baseline Findings From the Heart of New Ulm Project, Minnesota, 2010–2011 
Changes in the food environment in the United States during the past few decades have contributed to increased rates of obesity, diabetes, and heart disease. Improving the food environment may be an effective primary prevention strategy to address these rising disease rates. The purpose of this study was to assess the consumer food environment of a rural community with high rates of obesity and low levels of fruit and vegetable consumption. Findings were used to identify food environment intervention strategies to be implemented as part of a larger community-based heart disease prevention program.
We used the Nutrition Environment Measures Survey for Restaurants (NEMS-R) and Stores (NEMS-S) to assess 34 restaurants, 3 grocery stores, and 5 convenience stores in New Ulm, Minnesota.
At least half of the restaurants offered nonfried vegetables and 100% fruit juice. Only 32% had at least 1 entrée or 1 main dish salad that met standards for “healthy.” Fewer than half (41%) had fruit available and under one-third offered reduced-size portions (29%) or whole-grain bread (26%). Grocery stores had more healthful items available, but findings were mixed on whether these items were made available at a lower price than less healthful items. Convenience stores were less likely to have fruits and vegetables and less likely to carry more healthful products (except milk) than grocery stores.
Baseline findings indicated opportunities to improve availability, quality, and price of foods to support more healthful eating. A community-wide food environment assessment can be used to strategically plan targeted interventions.
PMCID: PMC3944948  PMID: 24602590
25.  Effectiveness of an evidence-based chiropractic continuing education workshop on participant knowledge of evidence-based health care 
Chiropractors must continue to learn, develop themselves professionally throughout their careers, and become self-directed and lifelong learners. Using an evidence-based approach increases the probability of optimal patient outcomes. But most chiropractors lack knowledge and interest in evidence-based approaches. The purpose of this study was to develop and measure the effectiveness of evidence-based training for chiropractic practitioners in a continuing education setting.
We developed and evaluated a continuing education workshop on evidence-based principles and methods for chiropractic practitioners. Forty-seven chiropractors participated in the training and testing. The course consisted of 12.5 hours of training in which practitioners learned to develop focused questions, search electronic data bases, critically review articles and apply information from the literature to specific clinical questions. Following the workshop, we assessed the program performance through the use of knowledge testing and anonymous presentation quality surveys.
Eighty-five percent of the participants completed all of the test, survey and data collection items. Pretest knowledge scores (15-item test) were low (47%). Post intervention scores (15-item test) improved with an effect size of 2.0. A 59-item knowledge posttest yielded very good results (mean score 88%). The quality of presentation was rated very good, and most participants (90%) would "definitely recommend" or "recommend" the workshop to a colleague.
The results of the study suggest that the continuing education course was effective in enhancing knowledge in the evidence-based approach and that the presentation was well accepted.
PMCID: PMC1560147  PMID: 16930482

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