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1.  Barriers and facilitators to implementing Decision Boxes in primary healthcare teams to facilitate shared decisionmaking: a study protocol 
Decision Boxes are summaries of the most important benefits and harms of health interventions provided to clinicians before they meet the patient, to prepare them to help patients make informed and value-based decisions. Our objective is to explore the barriers and facilitators to using Decision Boxes in clinical practice, more precisely factors stemming from (1) the Decision Boxes themselves, (2) the primary healthcare team (PHT), and (3) the primary care practice environment.
A two-phase mixed methods study will be conducted. Eight Decision Boxes relevant to primary care, and written in both English and in French, will be hosted on a website together with a tutorial to introduce the Decision Box. The Decision Boxes will be delivered as weekly emails over a span of eight weeks to clinicians of PHTs (family physicians, residents and nurses) in five primary care clinics located across two Canadian provinces. Using a web-questionnaire, clinicians will rate each Decision Box with the Information Assessment Method (cognitive impacts, relevance, usefulness, expected benefits) and with a questionnaire based on the Theory of Planned Behavior to study the determinants of clinicians’ intention to use what they learned from that Decision Box in their patient encounter (attitude, social norm, perceived behavioral control). Web-log data will be used to monitor clinicians’ access to the website. Following the 8-week intervention, we will conduct semi-structured group interviews with clinicians and individual interviews with clinic administrators to explore contextual factors influencing the use of the Decision Boxes. Data collected from questionnaires, focus groups and individual interviews will be combined to identify factors potentially influencing implementation of Decision Boxes in clinical practice by clinicians of PHTs.
This project will allow tailoring of Decision Boxes and their delivery to overcome the specific barriers identified by clinicians of PHTs to improve the implementation of shared decision making in this setting.
PMCID: PMC3472191  PMID: 22867107
(3–10); Evidence-based practice; Continuing professional education; Risk communication; Patient-centered care; Counselling; Clinical topic summary; Decision support; Knowledge translation; Implementation science
2.  Lead, cadmium and aluminum in Canadian infant formulae, oral electrolytes and glucose solutions 
Lead (Pb), cadmium (Cd) and aluminum (Al) were determined in 437 individual samples of infant formulae, oral electrolytes and 5% glucose solutions available in Canada. In the electrolytes, Cd and Pb concentrations were all below 0.01 and 0.041 ng g−1, respectively. In the 5% glucose solutions, Pb and Cd levels averaged 0.01 and 0.09 ng g−1, respectively. Reported on an as-consumed basis, Pb levels in milk- and soya-based formulae averaged 0.90 and 1.45 ng g−1, respectively, while Cd levels averaged 0.23 and 1.18 ng g−1, respectively Average Al levels on an as-consumed basis were 440 ng g−1 (range 10–3400 ng g−1) in milk-based formulae and 730 ng g−1 (range 230–1100 ng g−1) in soy-based formulae. Al concentrations increased in the following order: plain formula < low-iron formula < iron-supplemented formula < casein hydrolysate formula ≈ premature formula ≤ soy formula. For example, in the powdered formulae, average Al concentrations were 18 ng g−1 for plain milk-based, 37 ng g−1 for low-iron, 128 ng g−1 for iron supplemented, 462 ng g−1 for lactose-free, 518 ng g−1 for hypoallergenic and 619 ng g−1 for soy-based formula. Al concentrations, as-consumed, increased with decreasing levels of concentration: powder < concentrated liquid < ready-to-use. Formulae stored in glass bottles contained between 100 and 300 ng g−1 more Al than the same formulae stored in cans. The source of the increased Al did not appear to be the glass itself, because most electrolytes and glucose solutions, also stored in glass, contained less than 8 ng g−1 Al. Corresponding differences in Pb and Cd levels were not observed. Al concentrations varied substantially among manufacturers; however, all manufacturers were able to produce plain milk-based formulae containing less than 50 ng g−1 Al, i.e. within the range of Al concentrations found in human milk. Next to soya-based and hypoallergenic formulae, premature formulae contained among the highest concentrations of Al, ranging 851–909 ng g−1 from one manufacturer and 365–461 ng g−1 from another.
PMCID: PMC3118527  PMID: 21623498
infant formulae; aluminium; lead; heavy metals, cadmium

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