An ageing and a shrinking labour force implies that the prevention of a premature exit from work due to poor health will become more relevant in the future. Medical rehabilitation is a health service that aims at active participation in working life. The provision of this service will be relevant for an increasing part of the ageing labour force, namely, employees with a migrant background and their different subgroups. Thus, this study examines whether first- and second-generation employees with migrant background differ from non-migrants in their utilisation of rehabilitation services and whether within the subsample of migrant employees, those persons with foreign nationality differ from those with German nationality.n=6303). Survey data of the first study wave were used to identify the dependent variable of the utilisation of rehabilitation (in- and outpatient), the independent variable of migrant status and the covariates of sociodemographic, work- and non-work-related factors. Applying bivariate statistics with tests of independence and block-wise logistic regressions, differences between the groups were investigated. Additionally, average marginal effects were computed to directly compare the adjusted models.Socially insured employees born in 1959 or 1965 were surveyed nationwide in 2011 as part of the lidA cohort study (n=1148).The study showed that first-generation migrants had a significantly lower likelihood of utilising outpatient rehabilitation than non-migrants  and that average marginal effects indicated higher differences in the full model than in the null model. No significant differences were found between the first- or second-generation migrants and non-migrants when comparing the utilisation of inpatient rehabilitation or any rehabilitation or when analysing German and foreign employees with migrant background . This detailed investigation shows the heterogeneity in the utilisation of health services such as medical rehabilitation, which is why service sensitive to diversity should be considered. Demographic change affects many domains in industrialised countries, including the ageing and shrinking labour force. In Germany, as a countermeasure, the statutory retirement age was raised leading to prolonged working lives and a higher proportion of older employees . Along wAn ageing labour force and an increasing number of employees with functional limitations imply that the prevention of premature exit from work due to poor health will become increasingly relevant in the future. Therefore, prevention, rehabilitation and reintegration will gain relevance in working life, especially medical rehabilitation aiming at continued work participation . When thIn this context, it is important to note that the older labour force in Germany is heterogeneous. For example, the proportion of employees with a migrant background (EMB) is continuously growing, e.g., from 16.2% in 2010 to 23.9% in 2018 , 12. ConPMB comprise persons born outside of Germany  and persons born in Germany, but with one or both parents born abroad  , 10, 14.It is known that EMB, especially those with foreign nationality, more frequently suffer from occupational accidents and diseases and that they retire earlier with a disability pension compared to employees with German nationality , 16. ThiHowever, current studies on migrants’ utilisation of rehabilitation services in Germany have several limitations. Quantitative studies are often based on secondary data, such as process data from rehabilitation providers . In most such data sets, the migrant background is solely indicated by ‘nationality”, thus not permitting a differentiation in migrant backgrounds and misclassifying a large proportion of people, up to 48%  .To our knowledge, representative studies in Germany investigating the utilisation of in- and outpatient rehabilitative care in older employees with distinct differentiation between migrant backgrounds are missing. Additionally, there are no investigations as yet that would compare groups within PMB or EMB to identify possible contrasting behaviours such as first- and second-generation behaviours or behaviours related to nationality. Obtaining German nationality is accompanied by considerable simplifications in one’s life and a higher willingness to integrate into German society , which mTherefore, the current study primarily investigates, whether first- and second-generation employees with migrant background differ from employees without migrant background in their utilisation of rehabilitation services. Second, the study investigates the subsample of migrant employees with foreign nationality as to whether they differ from those migrant employees with German nationality in their utilisation of these services. Moreover, the impact of different sociodemographic, work- and non-work-related factors is investigated to explain group differences.https://fdz.iab.de/en/FDZ_Individual_Data/lidA.aspx]  .For the present analysis, data from the first study wave in 2011 were used, where 6585 participants took part. At this point in time, the participants were 46 and 52 years old. Participants in full-time, part-time, irregular or marginally employed positions (at least 1h/week) in 2011 were included in the sample (n=6339). Due to the sampling specification, employees such as civil servants, self-employed persons and freelancers were excluded. As all interviews in the lidA study were performed in German, no interviews were realised with persons not able to communicate sufficiently in the German language. Further, 36 participants with undefined migrant status were excluded. As a result, the sample consists of 6303 individuals.The primary outcome was ‘utilised medical rehabilitation’, which was self-reported with the questionnaire. Participants were asked to report whether they had utilised an in- or outpatient rehabilitation service in the previous three years. All outcomes were generated as a binary variable indicating general, in- or outpatient rehabilitation vs. no utilisation of rehabilitation, respectively.The lidA cohort study allows distinguishing migrant groups by means of specific indicators, as recommended by Schenk et al. .Migrant background was operationalised based on the self-reported country of birth, nationality of the participants and the country of birth of each of their parents. Participants with place of birth in Germany, German nationality and with both parents born in Germany, were the reference group (non-EMB). The first migrant generation (G1 EMB) was defined according to the definition of the German Federal Statistical Office , 9 as peThe second migrant generation (G2 EMB) was classified as participants born in Germany with at least one parent born abroad. For the second group comparison, the subsample of employees with migrant background (EMB) was split into those employees with German/dual and foreign nationality (German and foreign EMB).Sociodemographic, work-related, and non-work-related factors were included as covariates in the analysis to describe group differences and to control potential confounders.As sociodemographic factors, the year of birth (1959/1965), sex  and occupational class were considered as covariates. As sex is an important determinant for health service utilisation, we tested for interaction effects between sex and migrant background, but this was neither significant for general, in- or outpatient rehabilitation, nor for sex and nationality in EMB.Occupational classes as classified by Blossfeld were used, which are based on the German Classification of Occupation of the Federal Employment Agency in the 1988 version . The occSpecific physical and psychosocial work exposure variables that are known to be associated with poor health were selected , 34. A rThe following psychosocial work factors were considered: quality of leadership, own influence at work and work-privacy conflict, all based on the Copenhagen Psychosocial Questionnaire  , 38. InfWork-related stress, another psychosocial work factor, was assessed and analysed with the long version of the effort-reward imbalance (ERI) questionnaire by Siegrist et al. , 41, whiOccupational physical load was measured with two variables. First, the physical environmental factors, meaning the combination of variables comprising exposure to cold, heat, humidity and noise, and second, physical burdensome factors, such as working while leaning over, working on the knees, working one-sided or doing heavy lifting and carrying . ParticiSelf-rated health in general was parametrised by the single item Short Form-12 Health Survey (SF-12) , containThe second non-work-related variable was the main language spoken at home, which was categorised into mostly German and mostly another language. Here, this variable was not used to identify third-generation migrants (the persons themselves and with parents born in Germany but whose mother tongue was not German) but to account for possible differences between these migrant groups.All mentioned items without any references were self-developed questionnaire items. The English translation of the items can be found in the attachment : the percentage of MD ranged from 0.05%  to 20.0% . Up to 1900 cases were lost, depending on the variables included in the regression models. Consequently, missing data were replaced by the fully conditional specification method, a multiple imputation approach, to increase the power of the regression analysis and to reduce bias [Descriptive and bivariate statistics including cross tables, Chiuce bias . Using t2- and Wilcoxon-Mann-Whitney-test), as well as block-wise logistic regression to investigate differences between these two groups with respect to the utilisation of general rehabilitation. Separated analyses for in- and outpatient rehabilitation were not possible due to the small number of events (utilisation of rehabilitation) in German and foreign EMB.To answer the second research question, the subsample of employees with migrant background were additionally separated into employees with German or foreign nationality. Subsequently, descriptive and bivariate analyses were performed to compare these two groups  were computed with SAS 9.4.AMEs allow us to compare the results of nested models that are otherwise possibly biased by unobserved heterogeneity. The latter represents influences on the dependent variable by unobserved or unconsidered variables that can cause false interpretation in e.g. logistic regression as odds ratios also demonstrate unobserved heterogeneity. Therefore, the interpretation of the regression coefficient in models with a non-linear transformation  is typically not as straightforwardly interpretable as in ordinary least-squares regression. The coefficient represents the influence of each variable on the linear scale of the outcome, not the probability scale of the observed outcome. AMEs are based on derivatives of the logistic probability distribution functions, which measure the average conditional effects. The AME shows for each variable in a regression model how much the event probability changes when the independent variable increases by one unit or rather when a binary independent variable changes its level , 47.2 is presented as a measure for comparing competing models. All statistical analyses  were performed using SPSS version 25.0 .In all statistical tests, p-values (two-tailed) < 0.05 were considered statistically significant. For the logistic regressions, Nagelkerke’s Pseudo-RThe baseline characteristics of the 6303 participants included in the analysis are given in Table Comparing the general utilisation of rehabilitation services in the logistic regression model, G1 EMB had a somewhat lower and G2 EMB had a slightly higher odds of utilisation than non-EMB, when considering all explanatory variables . Nevertheless, utilisation did not differ significantly from that among non-EMB, neither for G1 nor for G2 EMB . Average marginal effects showed the highest/lowest probability for inpatient rehabilitation in model 3 while the odds ratios did not indicate a large difference.Analysing the utilisation of outpatient rehabilitation, G1 EMB had significantly lower odds of receiving outpatient rehabilitation than non-EMB in the null model. When adding all explanatory covariates, the direction of the effect for G1 EMB remained the same . Throughout all models, G2 EMB had somewhat lower odds ratios of utilising outpatient rehabilitation. The average marginal effects showed the lowest probability for inpatient rehabilitation in model 3. The difference in the AMEs between the null and the final model indicated an increase of the effect by 60%.The analyses of the second research question were performed by separating EMB into those persons with German and foreign nationality. The results are shown in Tables Block-wise logistic regression modelling utilisation of rehabilitation in general was performed to investigate differences between these two groups, as shown in Table Secondary findings revealed that certain covariates had a significant association with the utilisation of rehabilitation. For all outcomes of rehabilitation, having poor health was associated with higher odds. Having a work-privacy conflict was associated with lower odds for the utilisation of outpatient rehabilitation while having low influence at work showed higher odds of using a rehabilitation in general. Further predictive factors with higher odds in several models were born in 1959, having medium work stress and having qualified or unskilled positions.In the present study, we analysed the utilisation of medical rehabilitation and its subtypes (in- and outpatient) for subgroups of employees in relation to their migrant background. In the following, the main findings will be summarised. Subsequently, the results for the first research question comparing G1 und G2 EMB with non-EMB concerning their utilisation of general, inpatient and outpatient rehabilitation respectively will be discussed in chronological order. A discussion about the second research question, contrasting persons with foreign and German nationality with migrant employees will follow, as well as aspects about associated covariates to complete with the strengths and limitations of the present study.Comparing G1 and G2 EMB with non-EMB, no significant group differences were found for the utilisation of general and inpatient rehabilitation. With respect to the utilisation of outpatient rehabilitation, however, G1 EMB had a 58% significantly lower chance than non-EMB when considering all explanatory covariates. The findings for G2 EMB were usually closer to those for non-EMB than to those for G1 EMB. Moreover, within EMB, foreign EMB showed a slightly lower but non-significant chance of using medical rehabilitation at all compared to German EMB.To date, there are no other German studies investigating the utilisation of medical rehabilitation and its subtypes while differentiating migrant background, as detailed as in the presented study. Therefore, the following comparison to other German studies is only possible to a certain degree.In other studies, where the differentiation in migrant background with large representative cohort data is not solely possible given the indicator of nationality but also other indicators, the results are as follows: Voigtländer et al.  analysedConcerning inpatient rehabilitation, the results of the lidA-study show that there are no significant group differences. However, we found 16% and 10% higher chances of using inpatient rehabilitation for G1 and G2 EMB, respectively, than for non-EMB. In the full model, the average marginal effects showed a larger difference in the probability of utilisation of inpatient rehabilitation between G1 EMB and non-EMB than between G2 EMB and non-EMBFindings of higher utilisation for rehabilitation in EMB than in non-EMB have only been found for psychosomatic rehabilitation, including depression and somatisation, where foreign nationals, especially Turkish nationals, had a higher utilisation rate of psychosomatic rehabilitation than Germans –51. HoweFocusing on outpatient rehabilitation, G2 resembled non-EMB rather than G1 EMB, which might indicate the successful integration of the second-‘children’-generation of migrant employees in Germany. Most importantly, a significantly lower chance for G1 EMB to utilise this type of rehabilitation than non-EMB, even in the fully adjusted model, was detected.The included covariates did not fully explain the differences in the model, while the difference in the AMEs between the null and the final model displayed an increase in the effect by 60%. Therefore, our findings indicate that these differences have to be attributable to factors other than sociodemographic, work- and non-work-related variables. These factors might be related to the rehabilitative care system and/or migrant-specific characteristics or understandings of health that go beyond differences in the considered patterns.Thus far, research on possible barriers to the utilisation of medical rehabilitation for EMB has addressed access to barriers and barriers within medical rehabilitation. In particular, the lack of knowledge about the rehabilitation system and its possibilities are the main barriers to access, not only for EMB but also for general practitioners who recommend rehabilitation. At the same time, diverse treatment concepts that are sensitive to religion, culture and gender are missing. Discrimination and miscommunication, due to language barriers and illiteracy, are also barriers to the utilisation of rehabilitation by EMB –24.No equivalent to the finding that G1 EMB have lower odds of using outpatient rehabilitation can be found in the existing studies. Only one review investigating inequalities in health care utilisation among migrants found that first-generation migrants have a lower utilisation of outpatient care, such as specialist consultations and physical therapy .Most studies do not consider both, in- and outpatient medical rehabilitation separately. In Germany, comparable research has mainly focused on medical rehabilitation in general, summarising all types of rehabilitation. This may be due to lacking information about the different rehabilitation types in the data sets or to the lower number of cases not allowing for stratification. The latter is the result of a generally lower utilisation of outpatient medical rehabilitation services by adults compared to the utilisation of inpatient medical rehabilitation (ca. 80%) , which dThe results concerning the second research question comparing German and foreign nationals within the subsample of migrant employees are partly comparable to other studies. The findings are in line with previous results showing that foreign nationals utilise rehabilitation less often than Germans , 55, 56.Secondary findings revealed that certain covariates had a positive association with the utilisation of rehabilitation. Having poor health was associated in all models, while having a work-privacy conflict was only associated with outpatient rehabilitation. Further predictive factors were being born in 1959, having medium work stress, low influence at work and holding qualified or unskilled positions. All of them seem plausible, as they are congruent with reported findings so far , 23, 33.representativeness for the population of socially insured employees of the considered two age cohorts [Furthermore, this study has several strengths. First, the use of a national sample presents high  cohorts . Second, cohorts . The ind cohorts , which a cohorts , 47. FinDespite these merits, there are some limitations of our study. The lidA cohort study uses two birth cohorts sampled within socially insured employees, which excludes civil servants, most self-employed persons as well as freelancers. As a result, the sample is limited regarding its representativeness of older employees in terms of age variety and occupational class. An additional restriction might have introduced a bias into participant selection, as the study was conducted in German and therefore EMB could be potentially excluded due to language problems. However, we assumed for these a certain knowledge of German when working in socially insured positions. Another possible weakness is the usage of the self-rated health status (SF-12) serviced after the potential rehabilitation, as health status prior to rehabilitation was unavailable to adjust as a covariate. Accordingly, the current health status was used as a proxy for the initial status, while assuming a similar health change for everyone who had used rehabilitation services so that the influence of the initial health status on rehabilitation utilisation would have been adequately adjusted for in the regression model. Last, the number of events (utilised rehabilitation) within the migrant groups included in the logistic regression analyses in relation to the number of events in the reference group was fairly low , which should be considered when regarding the results.Our study has found that migrant employees of the first-generation utilise outpatient rehabilitation significantly less often than non-migrant employees. These findings are partly attributable to differences in sociodemographic, work- and non-work-related factors between these population groups. Other factors may play a role, possibly related to the rehabilitative care system, migrant-specific characteristics or understandings of health. Additionally, no significant differences between migrant employees of the first- or second-generation and non-migrant employees when comparing the utilisation of inpatient rehabilitation or any rehabilitation in Germany have been detected. The same was observed when analysing differences between German and foreign nationals within migrant employees. However, the migrant employees of the second-generation rather resemble the Germans than their parent generation (first-generation), which is an important fact regarding integration. Our distinct investigation contributes to the knowledge on the heterogeneity and different behaviours in the utilisation of health services such as medical rehabilitation. These results highlight the growing need to consider diversity sensitive services that are important for social-political decision makers to ensure equal opportunities and work participation. Further research should also consider the actual need for rehabilitation in employees with migrant background, as this could influence the utilisation patterns of rehabilitation and provide insights into their perceptions and coping with diseases.Additional file 1. English version of self-developed questionnaire items used for analysis. The additional file contains the English translation of the self-developed questionnaire items used for analysis.


High-level evidence consistently indicates that resource-intensive facility-based rehabilitation does not provide better recovery compared to home programs for uncomplicated knee or hip arthroplasty patients and, therefore, could be reserved for those most impaired. This study aimed to determine if rehabilitation setting aligns with evidence regardless of insurance status.Sub-study within a national, prospective study involving 19 Australian high-volume public and private arthroplasty centres. Individuals undergoing primary arthroplasty for osteoarthritis participated. The main outcome was the proportion participating in each rehabilitation setting, obtained via chart review and participant telephone follow-up at 35 and 90 days post-surgery, categorised as ‘facility-based’  or ‘home-based’ . We compared characteristics of the study cohort and rehabilitation setting by insurance status (public or private) using parametric and non-parametric tests, analysing the knee and hip cohorts separately.n = 610, mean age 68.7 (8.5) yr., 51.1% female; Hip: n = 692, mean age 65.5 (10.4) yr., 48.9% female]; 26% (158/610) of knee and 61% (423/692) of hip participants participated predominantly in home-based programs. A greater proportion of public recipients were obese and had greater pre-operative joint impairment, but participated more commonly in home programs , less commonly in inpatient rehabilitation .After excluding ineligible participants , 1334 eligible participants remained. Complete data were available for 1302 (97%) [Knee: Facility-based programs remain the norm for most knee and many hip arthroplasty recipients with insurance status being a major determinant of care. Development and implementation of evidence-based guidelines may help resolve the evidence-practice gap, addressing unwarranted practice variation across the insurance sectors.The online version of this article (10.1186/s12891-019-2570-8) contains supplementary material, which is available to authorized users. The lifelong risks for total knee arthroplasty (TKA) and total hip arthroplasty (THA) are increasing in Australia and elswhere , 2. In AThe patient-reported joint-specific improvements following TKA or THA are typically large –13, and Facility-based supervised physical therapy-based rehabilitation commencing shortly after discharge from acute care has become the accepted standard of care following TKA or THA –25, perhWhilst a recent systematic review concluded that some form of physical therapy program is better than a minimal program (exercise instruction) or nothing following TKA , there iDespite the evidence base and despite considerable resources being used to identify, develop and assess recommendations or models of care at the state and national level in Australia –53, therThe absence of an evidence-based guideline can result in widespread practice variation, with many people not receiving the most appropriate care and limited healthcare resources being used sub-optimally. If the rehabilitation pathway provided following hip or knee arthroplasty was aligned with current evidence, patients would participate predominantly in a home-based therapy program, with intensely supervised facility-based programs reserved for people who require more assistance and support throughout the rehabilitation process , 55. ConThe primary aim of this study was to describe the most commonly utilized rehabilitation settings (facility- or home-based) by people who underwent elective TKA or THA secondary to osteoarthritis (OA). The secondary aims included to assess whether rehabilitation setting differed according to insurance status (public or private).https://clinicaltrials.gov/ct2/show/NCT01899443 (July 2013).This study was a planned sub-study of a large multi-centre, prospective observational cohort of people with knee or hip OA who underwent primary TKA or THA in 19 public and private Australian hospitals between August 2013 and January 2015. The study was prospectively registered in Results of the larger study and other sub-studies have been reported previously , 56–58 ITrained site coordinators screened and recruited study participants during their routine pre-operative assessment, typically within 6 weeks of surgery. The larger cohort included adults age ≥ 18 years) with a primary diagnosis of OA in the index joint, with willingness and capacity to be followed-up by telephone post-surgery, and capacity to comprehend the study protocol, presented in English. People were excluded from the larger cohort if they were undergoing revision, hemi-arthroplasty or resurfacing surgery or had surgery planned on another joint within 3 months of the first. For the current study, we further restricted entry to people who would be eligible to undergo rehabilitation in any of the settings under consideration , and therefore we excluded people who experienced a significant complication during the acute-care phase  , 13 and Site coordinators recorded acute-care outcomes, including discharge destination, reasons for referral to inpatient rehabilitation , and complications on a study proforma at the time of patient discharge.Post-discharge outcomes were collected via telephone follow-up at 35 and 90 days by trained research officers (RO). To assist recall, a study diary was provided to participants at the time of enrolment. Outcomes of interest included length of stay (LOS) in an inpatient rehabilitation unit (where applicable), number of visits to physiotherapy clinics or day hospitals or use of domiciliary services, whether supervised physiotherapy was ongoing at 90 days or whether only an unmonitored home program (defined below) was followed since discharge from acute-care. The ROs confirmed details of rehabilitation ascertained from the site, the medical record audit and/or the previous telephone call as part of the follow-up process. We considered participants lost to follow-up if their 90-day assessment was not completed within 2 weeks of the due date or after a minimum five attempts to contact them.For quality control, study investigators re-abstracted medical record data provided by the site coordinator. Study personnel double-entered baseline, complication and discharge destination data, and corrected any disparities using data from the original patient study file.The primary outcome, rehabilitation setting, was divided into two broad categories (facility-based or home-based) that we further split into five categories as follows:i)exclusively (any number of days), following discharge from acute care (‘Inpatient only’)Rehabilitation in an inpatient unit ii)Rehabilitation in an inpatient unit (any number of days) followed by outpatient therapy including public or private physiotherapy clinic visits, or day-hospital visits; (‘Inpatient and outpatient’)iii)exclusively, including public or private physiotherapy clinic visits or day-hospital visits (‘Outpatient’)Four or more treatments in an outpatient setting Facility-based:iv)participation in a home-based program with no monitoring or supervision at any time, following discharge from acute care (‘Unmonitored home program’)v)participation in a home-based program which included telerehabilitation or receipt of domiciliary visits up to the 90-day assessment, or attendance of up to three clinic-based (outpatient) sessions, (‘Monitored home program’). This threshold (up to three clinic sessions) was guided by published studies reporting the use of home programs following TKA or THA , 38, 42.Home-based rehabilitation:We also monitored participants’ use of community support packages, i.e., privately or publicly funded access to a limited number of services e.g. transport, meal provision, house cleaning, after discharge from the acute hospital as differences in access to such packages may explain differential reliance on inpatient rehabilitation between public and private sectors.As this was a subset of participants from a larger study, the sample size was dictated by the sample size of the larger study and then by the number of participants who fulfilled the secondary eligibility criteria.2 tests or Fisher’s exact tests, as appropriate. The knee and hip cohorts were analysed separately.Following assessment of distributional assumptions, we used descriptive statistics as appropriate to describe the cohort. We compared characteristics of the study cohort and rehabilitation setting by insurance status (public or private) using unpaired, two-sided t-tests or Wilcoxon rank-sum tests for continuous variables and χwww.stata.com; StataCorp., College Station, TX), and used p < 0.05 as the cut-off for statistical significance. We followed the STROBE guidelines for reporting.We completed all analyses using Stata Version 15.1 (n = 9 private) ; 1334 people (n = 621 TKA) were eligible for the sub-study after applying the additional exclusion criteria for the current study. We obtained complete data on rehabilitation to 90 days post-surgery on 1302 people  (97%) , were operated upon in the private sector. All publicly insured participants were operated upon in the public sector.For the larger study, 1905 had surgery within the study timeframe from one of 19 hospitals (Baseline characteristics of the cohort are shown in Table P < 0.001) (Table P < 0.001). Reasons for referral to inpatient rehabilitation varied by insurance status, with the predominant reason for referral for publicly insured participants being poor progress (8/18) whilst surgeon or patient choice  was the most common reason for privately insured participants  participated predominantly in home-based rehabilitation with greater participation observed amongst those publicly insured  (Table P = 0.019). Additional file Privately-insured participants who received outpatient therapy (outpatient only or inpatient followed by outpatient) had a greater number of sessions  sessions; public: 6 ; 1) Table . Private sessionsP = 0.72), and utilisation of community support packages was similar regardless of insurance status .At 90 days post-surgery, only 5% (12/240) of publicly-insured and 5.7% (21/370) of privately-insured patients were still receiving facility-based therapy (P < 0.001) (Table P < 0.001). The predominant reason for referral to inpatient rehabilitation for publicly insured participants was poor progress (5%), whilst surgeon or patient choice (71.4%) was the most common reason for privately insured participants .Following THA, 423 participants (61.1%) participated predominantly in a home-based program with greater participation observed amongst those publicly insured  (Table Privately-insured participants who received outpatient therapy (outpatient only or inpatient followed by outpatient) had a greater number of sessions  Table . As seenP = 0.020). Utilisation of community support packages was similar regardless of insurance status .A minority of THA recipients were still receiving facility-based therapy at 90 days post-surgery; the proportion was higher for privately insured recipients (Public 1.2% (3/248) vs Private 4.5% (20/444), In this nationally-representative cohort we found that only 26% of TKA and 61% THA patients received predominantly home-based rehabilitation. Greater facility-based utilisation was evident for privately insured patients, both in terms of rate of utilisation and number of treatment sessions. We also observed wide variation in the utilisation of inpatient rehabilitation and in the forms of outpatient-based programs , both within and between insurance sectors, regardless of the surgery type. These observations are more than academic; facility-based programs are provided at greater cost to the payer, whether it is a patient, a government, or a private insurer. Inpatient rehabilitation programs in particular add many thousands of dollars to the episode-of-care costs , 45, 50,n > 18,000) conducted in the Unites States revealing vast geographic variation in rehabilitation settings following TKA as well as variation in length of therapy episode ranging from an average of 33 (95% CI 28–41) days though to 42 (36–50) days [Our findings concur with a recent retrospective survey of arthroplasty recipients conducted in the Netherlands that concluded that facility-based therapy remained the norm after arthroplasty , and one50) days .The variation we observed in the utilization of inpatient rehabilitation corroborates the variation reported by Australia’s largest private healthcare insurer - that private hospital-level referral to inpatient rehabilitation varies from 0 to 100% . SimilarAs the number of arthroplasty surgeries grows, along with the associated costs, the alignment of rehabilitation setting with the evidence – particularly if led by a shift away from inpatient rehabilitation programs - offers an opportunity to improve the efficiency of TKA and THA surgeries. With this goal in mind, the development of evidence-based guidelines would be a reasonable place to start though we acknowledge that they alone will not likely remove the evidence-practice gap. Changes to reimbursement models between provider and insurer, and consumer and clinician education around the efficacy of the programs available so that evidence rather than preference predominantly drives what is received, will also be required. We note that guidelines are being developed in the United Kingdom , but couTo the best of our knowledge, this is the first large-scale, prospective review of what rehabilitation settings are commonly used by TKA and THA recipients. We report rehabilitation setting used across a large, clearly defined homogeneous cohort, followed prospectively with deliberate exclusion of those who were not equally eligible for home-based and facility-based rehabilitation. The characteristics of the cohort reflect those reported in previous Australian studies , 44, 46.A limitation of the study is the reliance on patient recall to describe rehabilitation received. Whilst we incorporated several mechanisms to reduce recall bias including questioning of rehabilitation received at both 35 and 90 days post-surgery, use of patient recall diaries, and hospital-level evidence of inpatient rehabilitation admission, it is possible that utilisation of outpatient-based therapy was mis-reported. Further, we provide a snapshot of rehabilitation received (setting and number of treatments) by individuals without regard for individual needs. Whilst we acknowledge there may be some patients who require more supervised therapy – and we excluded those for whom this may be most obvious - we believe that it is unlikely that variation in individual need explains much of the variation observed. This is most apparent when we consider the lower rates of participation in facility-based therapy (both in terms of proportion of recipients and number of treatment sessions) amongst the publicly insured recipients despite their greater pre-operative joint impairment, BMI and comorbid burden, and shorter acute hospital length of stay. Our utilisation rates may not be generalisable to remote locations; no participant hospital was located in a remote region and this may explain why no participant reported the use of telerehabilitation. Finally, as the focus of this paper is on the utilisation of different rehabilitation settings, we have purposely not reported outcomes including satisfaction with the program received. We have previously reported outcomes for this cohort between those who did and did not have inpatient rehabilitation and found no differences in patient-reported joint-specific and health-related quality of life scores at 35, 90 and 365 days post-surgery , 13. We Contrary to the body of evidence derived from randomised trials and prospective observational studies indicating home-based programs yield similar recovery profiles, the more intensely supervised facility-based rehabilitation remains the norm for most TKA and many THA recipients, and more so for those privately insured despite presenting with less joint-related impairment and obesity prior to surgery than those publicly insured.These observations suggest that current practice in Australia is not primarily guided by the available evidence or need and is likely provided at a far greater cost than it would be if the best available evidence were adopted. Resolving this evidence-practice gap should be a priority for all stakeholders. The development of evidence-based guidelines in this area is needed.Additional file 1:Acute complications that rendered a patient ineligible for the sub-study. List of complications. (PDF 16 kb)Additional file 2:Figure S1. Variation in rehabilitation setting by hospital: TKA. Figure S2. Variation in rehabilitation setting by hospital: THA. Table S1. Reasons for referral to inpatient rehabilitation as provided by the hospital. Table S2. Type of facility-based outpatient rehabilitation sessionsa by insurance status. (PDF 6967 kb)Additional detail about rehabilitation setting.


Understanding diverse labor market trajectories around vocational rehabilitation provides important insight into potential effectiveness of rehabilitation efforts. We examined factors associated with work participation trajectories before and after vocational rehabilitation.Using nationwide Finnish register data of 7180 vocational rehabilitees, we constructed latent trajectory groups of work participation two years before and two years after their rehabilitation episode starting in 2008–2010. We plotted changes in labor market statuses in these groups and examined other associated factors using multinomial logistic regression.We identified four trajectories based on work participation levels before and after vocational rehabilitation. The “High–Resumed” group (35.6%) typically returned to full duties. The “High–to–Negligible” group (20.7%) typically transitioned to full disability retirement or unemployment. Among the “Medium–Resumed” (25.5%) and “Longstanding Negligible” (18.3%) groups, work disability and unemployment were common before rehabilitation, but afterwards those assigned to the former group often returned to full or partial duties. Overall, older age, male gender, living in areas with lower employment rates, having lower education, being employed in the private sector, and having mental diagnoses were associated with the other three trajectories than the most favorable “High-Resumed” trajectory. Furthermore, certain industrial sectors, job exposures, and less common diagnoses further separated specific trajectories.Work participation trajectories around vocational rehabilitation are diverse, only partly dependent on initial levels of work participation, and determined by various individual and work-related factors. Future nationwide studies should assess the effectiveness of vocational rehabilitation taking into consideration both individual and work-related factors. Labor market outcomes after vocational rehabilitation may depend on various characteristics of the rehabilitee such as labor market history, the nature of work disability, and sociodemographic factors. More favorable employment outcomes have generally been reported for individuals who are younger, have a higher socioeconomic position, have more previous employment, and have shorter length of preceding disability, while variation by other factors such as gender and disease groups remains unclear –10.Assessment of labor market outcomes after vocational rehabilitation is complex, because return to work may be perceived as a multiphase and multifaceted process rather than a single event –13. TherInvestigating labor market trajectories over a lengthy period of time surrounding vocational rehabilitation provides important insight into the factors associated with potential effectiveness of rehabilitation efforts. While previous studies have examined changes between different labor market statuses after vocational or other work-related rehabilitation –18, lessWe used nationally representative Finnish register data to identify latent trajectory groups of work participation over a period of two years before and two years after an episode of vocational rehabilitation. In order to find out which statuses the individuals in question occupied while being out of work, we further examined changes in the receipt of different social security benefits among the different trajectory groups. In addition, we examined factors associated with being assigned to particular trajectory group of work participation around vocational rehabilitation. More specifically, we aimed to answer the following research questions:What kind of typical work participation patterns can be found around vocational rehabilitation?What kind of changes can be observed in statuses other than work, such as sickness absence, disability retirement, and unemployment, around vocational rehabilitation among groups following different work participation trajectories?Are sociodemographic factors, prior work-related exposures, and characteristics of the rehabilitation episode associated with particular work participation trajectories around vocational rehabilitation?We used a nationally representative 70% random sample of the working aged population living in Finland on the last day of year 2007. The register-based data include information on episodes of vocational rehabilitation, employment, unemployment, earnings-related retirement, and other benefit receipt from the Finnish Centre for Pensions, on episodes of compensated sickness absence and national pensions obtained from the Finnish Social Insurance Institution, and on sociodemographic and work-related factors obtained from the Finnish Longitudinal Employer‒Employee Data (FLEED). For the purposes of this study, we utilized information from calendar years 2006–2014.Since 2004, vocational rehabilitation has been a statutory right in Finland. Eligibility to vocational rehabilitation is based on evaluation of a threat of disability retirement within the next few years due to a diagnosed illness or an injury as well as of the expectation that work participation can be promoted and disability retirement postponed or prevented with vocational rehabilitation. The system emphasizes early onset of rehabilitation in order to reach these goals. Vocational rehabilitation in Finland is highly fragmented. Those who are attached to working life with a sufficient amount of recent employment (sum of earnings in the previous five years approximately 35000 euros at 2017 level) are eligible for vocational rehabilitation provided by the earnings-related pension scheme, while those who are outside working life may receive vocational rehabilitation from the Social Insurance Institution of Finland or other sources .We studied only vocational rehabilitation that was provided by the earnings-related pension scheme, the rehabilitees therefore being relatively well attached to the labor market. This does not mean that all rehabilitees came directly from employment. In 2016, 23% came to vocational rehabilitation from retirement, typically after having received a temporarily granted disability pension . Our datWe included individuals whose vocational rehabilitation episode began in 2008–2010 and who were aged 25–59 at that time. Daily changes in work participation and other labor market statuses were followed up over a period of two years before the begin date and two years after the end date of vocational rehabilitation. This four-year measurement period of labor market participation did not cover the time period in the middle that was spent in vocational rehabilitation. However, because our data on labor market participation was available until the end of October 2014, and because we wanted to follow-up each study person over a full two-year period after the termination of their rehabilitation episode, we could only examine rehabilitation episodes that ended by October 2012, i.e. 22 months after the last episodes of year 2010 had begun. We therefore excluded individuals whose vocational rehabilitation episode lasted more than 22 months (24.1%). The final study population consisted of 7180 individuals.Work participation trajectories was the outcome of main interest. We used information on episodes of employment and of receiving social security benefits to calculate the monthly proportion of time spent at work over the 24 months before and 24 months after vocational rehabilitation. We assumed that those who had an ongoing employment episode without receiving any benefits that compensated for being out of work, such as sickness allowance, worked 100% of the time; full-time work is very typical in Finland [We further examined changes in six mutually exclusive labor market statuses over the two years before and two years after vocational rehabilitation. By doing so, we could assess how overall work participation was divided into full and partial duties as well as what were the prevalent statuses while being fully out of work. The statuses were 1) work (with full work duties), 2) partial work disability , 3) full sickness absence, 4) unemployment, 5) full disability retirement (temporary or permanent), and 6) other .We included sociodemographic factors , prior work-related exposures , and characteristics of the vocational rehabilitation episode  as covariates. Age at the start of rehabilitation was examined in groups 25–39, 40–49, and 50–59 years. Region of residence and education were measured at the end of the year preceding the measurement period of labor market participation. Region of residence consisted of categories 1) Southern, 2) Western (including the Åland islands), 3) Eastern, and 4) Northern Finland. Education consisted of categories 1) tertiary, 2) secondary, and 3) primary.Industrial sector and occupational information for the job exposure matrices were also primarily measured at the end of the year preceding the measurement period of labor market participation. For those who were non-employed in that year, however, the information was derived from the end of other years, available for industrial sector over a five-year period and for occupation over a four-year period preceding the start year of vocational rehabilitation. Priority was nevertheless given to deriving the information from the years preceding the measurement period of labor market participation. Industrial sector and occupation could not be identified for 160 and 285 individuals, respectively, because they were constantly non-employed before rehabilitation. These individuals were excluded from the models including industrial sector or job exposures.Industrial sector was based on a classification by Statistics Finland. We examined the following categories as dummy variables: 1) manufacturing, 2) trade , 3) transportation and storage, 4) knowledge work , and 5) human health and social work activities.For occupation, we used a classification by Statistics Finland, based on the International Standard Classification of Occupations (ISCO-88). Job exposures were then estimated for each occupation with a gender-specific job exposure matrix (JEM), which was developed earlier in a large population survey and described with more detail elsewhere ,26. HeavEmployment sector that provided the vocational rehabilitation was classified as 1) private and 2) public. In the national vocational rehabilitation scheme, the provider is selected based on current or last employment.The primary medical reason for vocational rehabilitation was classified according to the tenth revision of the International Classification of Diseases (ICD-10). We examined the following disease groups as dummy variables: 1) musculoskeletal diseases (M00–M99), 2) mental disorders (F00–F99), 3) neoplasms (C00–D48), 4) nervous diseases (G00–G99), 5) circulatory diseases (I00–I99), and 6) injuries .Duration of vocational rehabilitation was based on the total continuous duration and could consist of various successive vocational rehabilitation efforts of different types. A large peak was observed at the duration corresponding to around three months, and smaller peaks at the duration corresponding to four, five, and six months. We categorized duration into 1) <3 months, 2) exactly 3 months , 3) >3 months, ≤6 months, and 4) >6 months.We constructed work participation trajectories based on monthly measured work participation over two years before and two years after the episode of vocational rehabilitation. The analysis time was assessed as a single four-year period, excluding the time spent in rehabilitation. The work participation trajectories were obtained using a semiparametric group-based modelling strategy by PROC TRAJ in SAS version 9.4 . This method was developed for analyzing longitudinal data, changes over time, and identifying distinct latent groups of subjects who tend to have a similar profile over time (trajectories) ,29. The After constructing the work participation trajectories, we plotted changes in the distribution of the six labor market statuses before and after vocational rehabilitation among the different trajectory groups of work participation.We then examined how the different covariates were associated with assignment to different trajectory groups of work participation around vocational rehabilitation using multinomial logistic regression analysis. We calculated relative risk ratios (RRR) and their 95% confidence intervals.The study was fully register-based and applied identification numbers pseudonymized by Statistics Finland. Research using such data does not need to undergo review by an ethics committee according to Finnish legislation. The researchers analyzed the data stored by Statistics Finland using a remote access system. All output extracted from the system was approved by Statistics Finland to ensure compliance with data protection regulations.Over 40% of the rehabilitees were aged 50 or above and over 60% were women. Close to half of the study population came to rehabilitation because of musculoskeletal diseases and over a fourth because of mental disorders. Further characteristics of the rehabilitees are presented in Four trajectory groups of work participation around vocational rehabilitation were identified . In the Among the High–Resumed trajectory group, the decrease in work participation before vocational rehabilitation was mainly replaced by a corresponding increase in full sickness absence . The resThe decrease in work participation before vocational rehabilitation among the High–to–Negligible group was also mainly replaced by an increase in full sickness absence, but also by small increases in unemployment and full disability retirement . After vAmong the Medium–Resumed group, full sickness absence was a common status particularly in the period 2–0.5 years before vocational rehabilitation . PartialThe Longstanding Negligible group was mainly on full disability retirement both before and after vocational rehabilitation . Also siFirst, we assessed age- and gender-adjusted predictors of being assigned to the High–to–Negligible, the Medium–Resumed, and the Longstanding Negligible trajectory groups of work participation around vocational rehabilitation, compared to being assigned to the most favorable group, i.e. the High–Resumed group . Male geWe then assessed mutually adjusted predictors of being assigned to the different trajectory groups . The anaUsing a nationally representative sample of vocational rehabilitees, we identified four typical work participation trajectories over a period of two years before and two years after their episode of vocational rehabilitation that started in 2008–2010. Over one third and around one fourth of the rehabilitees followed trajectories where initial high or initial medium level of work participation, respectively, was resumed after vocational rehabilitation. The remaining less than 40% of the rehabilitees followed trajectories where either an initial high level of work participation rapidly declined reaching a negligible level one year after vocational rehabilitation or where work participation was at a negligible level already more than one year before vocational rehabilitation and remained at that level. To our knowledge, this is the first study to provide information on latent trajectories of work participation around vocational rehabilitation.In our data, those who resumed their initial high level of work participation can be considered as the most favorable group with typical return to full duties after sickness absence and the rehabilitation episode. The three less favorable trajectory groups were generally associated with older age, male gender, living in Eastern or Northern Finland, having less than tertiary education, being rehabilitated in the private sector, being rehabilitated due to mental disorders, starting rehabilitation in 2008 instead of in the two later years, as well as being rehabilitated during shorter or longer periods than the typical three-month period.Those who resumed their initial medium level of work participation can also be considered as a relatively favorable group. This was the group for which partial work disability was most common both before and after vocational rehabilitation. Return to partial duties could have been an alternative to full disability retirement and therefore promoted overall work participation. Indeed, our earlier studies suggest that being on partial work disability prevents later full disability retirement ,31. FactAmong those who had a negligible level of work participation already before vocational rehabilitation, full disability retirement was very common, while the use of partial work disability benefits at any period was virtually non-existent. Factors associated with this trajectory in particular were prior employment in the health and social work sector as well as high prior exposure to job strain. Furthermore, lower education had a particularly strong association with this trajectory.Those whose initial high level of work participation rapidly declined and, despite vocational rehabilitation, reached a negligible level typically transitioned to full disability retirement or unemployment. This trajectory in particular was associated with prior employment in the manufacturing and trade sectors as well as with being rehabilitated due to nervous diseases.Previous studies have indicated that previous employment –5,7,9 anIn line with our findings, many previous studies also indicated that younger age –3,5,7–10Previous findings from Sweden indicated that work resumption after vocational rehabilitation was higher in the manufacturing industry than in other sectors . SomewhaPrevious studies have found either no effects ,2,7,9 orDifferences in employment outcomes after vocational rehabilitation by disease group have also been somewhat unclear. Many studies have focused on particular disease groups –3,8,9. SPrevailing economic conditions may influence labor market outcomes after vocational rehabilitation ,43. We fWe found that both shorter and longer than the typical three-month duration of vocational rehabilitation were associated with the two trajectories with negligible levels of work participation after rehabilitation. Duration may have been related to the type of vocational rehabilitation received, on which we did not have information. In the Finnish system, work try-outs typically last for a few months, while work counselling typically lasts for six months or more. The duration of training may vary considerably, the content ranging from short courses to training programs lasting for several years . In our Our study had various strengths. The study population consisted of individuals who were derived from a large nationally representative sample and who had participated in a statutory nationwide program of vocational rehabilitation. The register-based data did not have missing information or loss to follow-up. Moreover, the rich data comprised detailed longitudinal information on employment participation, vocational rehabilitation, other benefit receipt, various sociodemographic factors, industrial sector, and occupation. Using specific occupational codes, the data were further complemented with information on various job exposures based on previously developed job exposure matrices. Furthermore, by using a semiparametric group-based modelling strategy, we provided novel findings on latent trajectory groups of work participation around vocational rehabilitation. Including information on work participation both before and after vocational rehabilitation reduces some of the confounding effect of labor marker history on subsequent labor market outcomes .Our study also had limitations. The pension insurers conducting the vocational rehabilitation do not systematically collect data on the provided services. We therefore did not have information on the specific type of vocational rehabilitation or on characteristics of the provider. Neither did we have information on treatment history nor on potential receipt of medical rehabilitation. In Finland medical rehabilitation is conducted separately from vocational rehabilitation and it is therefore not a part of the vocational rehabilitation process. Labor market outcomes may depend on whether the provided services include e.g. educational, job-related, medical, or other rehabilitation ,19,44–46In addition, by using the job exposure matrices, we did not capture variation in the working conditions between individuals holding the same occupational title. The influence of job exposures on the work participation trajectories may therefore have been underestimated.It was beyond the scope of this study to assess the effectiveness of vocational rehabilitation on work participation. Favorable or unfavorable work participation trajectories do not necessarily mean that vocational rehabilitation was successful or unsuccessful, respectively. Some individuals may still have had good chances of return to work irrespective of whether or not they took part in vocational rehabilitation. Others may have been less responsive to vocational rehabilitation or, for one reason or another, may not have participated in vocational rehabilitation during an optimal time frame. In our data, full disability retirement and unemployment were relatively common already before vocational rehabilitation, suggesting that interventions were not always carried out at early stages of reduced work participation. Further nationwide studies are needed to assess the effectiveness of vocational rehabilitation on work participation outcomes, taking into consideration both individual and work-related factors.Work participation trajectories and associated changes in other labor market statuses before and after vocational rehabilitation appear to be diverse. Previous levels of work participation were commonly resumed after vocational rehabilitation, but at the same time work participation could decline to negligible levels despite high initial levels. Less favorable work participation trajectories appear to be generally associated with older age, male gender, living in areas with poorer employment opportunities, lower education, employment history in the private sector, and mental diagnoses.


Proponents of artificial reef (AR) deployment are often motivated by the usefulness of such structures. The usefulness of ARs is related to their capability of providing ecosystem services/additional functions. We present two distinct Portuguese AR case studies: (1) The Nazaré reef off the central coast of Portugal and (2) the Oura reef off the Algarve coast. Semi-structured interviews were conducted with local fishermen in the fishing towns of Nazaré and Quarteira pre-and post-AR deployment. The main focus of the interviews was to understand fishermen’s perception of AR usefulness (or lack thereof) in terms of nine ecosystem services/additional functions potentially provided by the ARs. We tested the null hypothesis that ARs do not provide additional ecosystem services/additional functions. When queried pre-AR deployment, fishermen indicated that ARs are most likely to provide three ecosystem services: “habitat and refuge,” “biodiversity preservation” and “food production.” Fishermen had similar perceptions post-deployment. For the Nazaré reef, fishermen tended to have a positive or neutral perception of ecosystem services/additional functions being provided by ARs. For the Oura reef, fishermen tended to have a mostly neutral perception of AR ecosystem services; however, there were also some positive and other negative perceptions. It was difficult for stakeholders to conceptualize some of the ecosystem services/additional functions provided by ARs prior to actively using them. As a result, some stakeholders changed their perception of the ecosystem services/additional functions after using the structures. These results indicate that stakeholders likely need to perceive ARs as useful in order for them to provide their support for AR installation. Likewise, their support is often needed to justify the use of public funds to install ARs, therefore making it imperative for resource managers to undertake similar interviews with fishermen when considering the use of ARs in other areas. Artificial reefs (ARs) have been used to mitigate coastal fishing pressure, enhance the potential of biodiversity, and enhance fisheries catch . ARs canHowever, in order to be successful, AR projects require many resources . First, Interest in the ecosystem services concept has been growing since the late 1990s . Many auThis paper investigates the varying perceptions of small-scale fishing communities on the usefulness and potential impacts of ARs in two coastal areas in Portugal. The principal research question we address is: How do fishermen perceive usefulness (or lack thereof) of ARs before and after AR deployment? This question is posed for nine ecosystem services and additional functions that were expected to be provided by the ARs. We first describe the ecosystem services and additional functions that ARs are known to provide in general, followed by a description of the AR study areas of interest here. We then present the methodology and questionnaire we used to capture stakeholder perceptions of AR usefulness in both locations, the hypotheses we tested with the questionnaire data, and a summary of the results of the interviews conducted for this study. Lastly, we provide a discussion of the ecosystem services and additional functions perceived by fishermen pre- and post-AR deployment in the two case studies, and justification for using public funds to deploy ARs. We also provide an assessment of the limitations of this study and areas of future research.Marine ecosystems provide a wide range of services that are fundamental to human well-being and livelihoods, from food production to water filtration, and storm protection . The totFood production is an extractive use associated with artisanal and commercial fishing activities that can be modified through AR deployment. For example, Artificial reefs can provide several opportunities for leisure activities, including surfing , diving Resource managers can introduce ARs to control undesired organisms through predation, herbivory, or any other natural process. In this way, ARs can act as artificial habitats that alter the distribution of species and local biodiversity . Some spArtificial reef infrastructure provides substrate that contributes to the production of flora and fauna due to high local availability of nutrients in the water column . Falcão Concrete ARs are increasingly being used as a shoreline protection measure . ARs canArtificial reefs can be deployed to create habitat and refuges for marine species if adequate depth, temperature, salinity, dissolved oxygen, and the type of materials used are appropriately considered in their construction . ARs alsArtificial reefs can be used to improve biodiversity in localized areas. For the purpose of this study, we consider two additional AR functions beyond ecosystem service provision, namely: reuse of obsolete structures and fishing effort diversion. Both of which have been shown to provide important benefits or impacts.Artificial reefs are generally made from structures that are no longer in use, such as scrap materials in combination with reinforced concrete . HoweverArtificial reefs can function as an effective resource management measure to reverse fisheries resources depletion by diverting fishing effort from overexploited fishing areas, or areas which are environmentally vulnerable, to those which are less heavily exploited or less vulnerable . ARs canThis study focuses on AR deployment case studies located off the coast of Nazaré . In bothThe two case study AR sites have very different geographic profiles , and can2.The water off Nazaré is home to a diverse assemblage of fish species, which benefits small-scale fishermen that are able to catch fish species that normally inhabit deep water closer to the coastline. The continental shelf extends out from the coast for approximately 2,000 m and then drops off sharply into a canyon  and 2B. 2  fishermen’s expectations for AR benefits pre-deployment and (2) fishermen’s perceptions of actual benefits obtained post-AR deployment. These data were then used to test the model’s hypotheses (see ‘Hypotheses’). Pre- and post-deployment primary data were collected through the implementation of semi-structured questionnaire-based interviews with fishermen in each case study location.t1) was implemented with the aim of better understanding what ecosystem services fishermen believe AR could provide (A pre-AR deployment questionnaire (Q provide . The queStakeholder viewpoints and preferences can provide important input into the management of marine resources . Having N = 17 in Nazaré and N = 26 in Quarteira). We interviewed a total of 58 skippers .t2) was implemented 5 years after AR deployment (May 2008 in Quarteira and September 2015 in Nazaré). The aim of this survey was to gather fishermen’s perceptions of the benefits they received from the AR so that the answers provided in the pre-deployment and post-deployment questionnaires could be compared. Our expectation was that respondents had learned from the experience of fishing in the vicinity of the AR. The post-deployment questionnaire included 5-point Likert scale questions similar to the pre-deployment questionnaire, with a focus on the ecosystem services that fishermen believe they have actually benefited from , against (2) the alternative hypothesis that each of the ecosystem service perception scores given by fishermen would differ between the pre- and post-deployment questionnaires (H1). We used R software version 3.1.3 , X is a set of seven ecosystem services and two additional functions potentially provided by AR and nx is a given ecosystem service or additional function from X.Since we used the 5-point Likert scale data to score the AR effect and the respondents to each questionnaire were not the same pre- and post-deployment, we cannot assume that the population of the ranking scores given by the respondents is normally distributed. Therefore, for each fishing community, we used the Mann–Whitney U-test  to test: (1) the null hypothesis that it was equally likely that each of the ecosystem service perception scores given by fishermen would be the same after reef deployment (Hon 3.1.3  to test n = 23) and non-normal data sets , we conducted a non-parametric Wilcoxon test for each case study site individually to compare respondents’ perceptions of ecosystem service provision pre- and post-AR deployment (p > 0.05). However, the median likert scores pre- and post-deployment for the additional AR function of “reuse of obsolete structures” was found to be significant for both locations (Oura: p < 0.0005 and Nazaré: p < 0.05).In general, for both case study sites and both time periods, respondents indicated that “habitat and refuge” was the most expected (pre-deployment question) or realized (post-deployment question) AR ecosystem service, followed closely by “biodiversity preservation” and “food production” . Given tployment . The WilIn comparing the pre- and post-deployment responses of Nazaré respondents , there ip-value < 0.05), for which median responses showed that respondents’ expectations pre-deployment for the ecosystem services that the AR would provide were not met.The Wilcoxon test shows that Nazaré respondents perceived fewer changes in ecosystem services when doing comparisons before and after reef deployment. Most of before and after data presented similar distributions. Significant differences between pre- and post-deployment responses were only found for “recreation,” “biological control” and “reuse of obsolete structures”  . A Wilcoxon test showed that the median score for five of the seven ecosystem services was not significantly different between pre- and post-deployment ( > 0.05) .By measuring differences in the median perception of ecosystem service and additional function provision pre- and post-AR deployment, we were able to make inferences about respondents’ perceived usefulness of the deployed ARs. It was also important to determine if, in general, fishermen perceived the ARs as useful or not.0) can be accepted regarding six of the ecosystem services and additional functions in the case of the Nazaré AR and five in the case of the Oura AR  that benefited from previous AR experience.The results indicate that the null hypothesis . A positive trend was only statistically corroborated for the third ecosystem service, thus found for Oura after AR deployment.Given that benefits of ARs are often only realized in the distant future, it is not easy for fishermen to conceptualize pre-deployment what ecosystem services an AR is likely to provide or increase unless they have previous experience realizing benefits from ARs or other knowledge of ecosystem service benefits associated with ARs. In order to believe in the potential of ARs to provide future benefits, stakeholders will likely need help understanding the benefits of ARs. By providing credible information in advance to support what ecosystem services they can expect from the deployment of an AR, stakeholders may be more likely to support AR deployment . AR propStakeholders may also have improved perceptions of AR usefulness if the benefits are well-explained pre-deployment; however, unless there are known benefits from an existing AR that can be used as an example, it may be difficult for stakeholders and potential funders to fully believe in the potential usefulness of ARs. On the contrary, if stakeholders’ expect that an AR will provide positive benefits and then start accruing benefits from the moment they are able to first use it, support for the AR will be high and can be used as an example in the future to advocate for additional AR deployment .However, even when ARs are already put in place and information is provided, additional support may be needed. For example, divers may easily see and attest to increased biodiversity at a dive site, but other stakeholders, such as fishermen, may not directly perceive that they are also benefiting. Ultimately, fishermen must develop some degree of belief that they have realized ecosystem service benefits in order to ultimately believe that the AR is worthwhile. This was exhibited by In the Nazaré AR case, fishermen had high expectations for what additional ecosystem services and functions the AR could provide from the beginning. However, after the AR was deployed, fishermen believed that they had realized very few ecosystem services and additional functions compared to their pre-deployment expectations. Overall, the results showed that although Nazaré fishermen were optimistic about the capacity of the AR to provide numerous ecosystem services and additional functions, ultimately the AR did not meet fishermen’s expectations. The presence of a canyon nearby may influence fishermen to have different views of AR practicality as fishermen will have better access to both shallow and deeper water fish species.In the Oura AR case, however, fishermen’s expectations before the AR was deployed were on average lower than the Nazaré fishermen expected. Fishermen on average had high expectations for a much smaller set of ecosystem services, namely “biodiversity preservation,” “food production” and as a “habitat and refuge.” Fishermen’s expectations for this smaller set of ecosystem services were ultimately realized in the post-deployment phase. The fishermen’s experience of utilizing other ARs nearby may be related to this sense of practicality.When public funds are invested in deploying ARs, the direct beneficiaries  create expectations for what benefits they will receive. If those expectations are met post-deployment, AR proponents can argue that deployment was a useful allocation of public money. However, negative experiences where high expectations are not fully met, like the experience of the Nazaré AR, can result in increased scrutiny and can result in reluctance to fund AR projects in the future .The provision of ecosystem services depends upon complex interactions between organisms and the environment. The need for and importance of individual ecosystem services will depend on the stakeholders that will ultimately be benefiting from them. These factors will therefore affect which ecosystem services are provided, as well as individual stakeholder perceptions of their usefulness. In addition, AR proponents can disseminate information about the likely ecosystem services an AR will provide to potential users. The use of scientific studies, such as the present study, can be used to inform and support future debates on AR usefulness and ultimately improve decision making . For exaIn the present study, fishermen did not assign high scores to the same AR ecosystem services and additional functions both before and after AR deployment. For the Nazaré AR, there were no nearby ARs that could be pointed to as examples. As a result stakeholder expectations were not based on previous experience. On the other hand, for the Oura AR, the pre-and post-deployment results regarding ecosystem service provision were similar. This was likely due to the fact that most fishermen already had experienced on the use of ARs pre-deployment, and already had a good idea of their usefulness .Although not tracked, there is a possibility that some of the respondents were queried both before and after deployment. However, since the interviews conducted for this study were anonymous, we cannot confirm which respondents were queried twice. Although this limits further statistical analysis, interviews with the same respondent pool in both the pre- and post-deployment data collections were not possible given the 14 years between studies. Despite this limitation, this study shows that, generally, fishermen across both case studies had a range of expectations of the ecosystem services and benefits that ARs will provide. Likewise, they reported having benefited to some extent from a range of ecosystem services post-deployment. We argue that even if fishermen scored each ecosystem service the same or less post-AR deployment, the ARs are not necessarily deficient in providing ecosystem services. This result likely only indicates that the initial expectations were not completely met and likely unrealistic.0); or if they actually are providing additional ecosystem services and functions (in case of different scores post-deployment compared to pre-deployment—H1). Ultimately, for the two cases presented here, it appears that respondents received positive benefits from ecosystem services provided by ARs in both study areas, but expectations were not met for most of the AR ecosystems services presented to respondents.A key objective of the present study was to determine if fishermen generally perceived that ARs do not provide additional ecosystem services and functions (in case of similar scores post-deployment compared to pre-deployment—HPromoters of AR deployment are often motivated by potential benefits of the structures to human activities. However, apart from a number of studies that have showed positive effects of reef structures in terms of species enhancement, few studies have documented additional ecosystem services that ARs can provide. Even fewer studies have compared pre-deployment perceptions of potential AR ecosystem services and additional functions with those that stakeholders ultimately realize post-deployment. The reason for this may be due to the relatively long delay between when ARs are deployed and when ecosystem services and benefits are realized.The present study aims to contribute to this knowledge gap by highlighting some of the ecosystem services and functions that ARs have provided to fisheries stakeholders in Portugal. Unless long-term scientific monitoring is planned in advance, it is very unlikely that funds will be available for a pre-deployment assessment and post-deployment monitoring and evaluation such as that presented here. We argue that funds and future research should focus on similar pre- and post-AR deployment case studies in order to continue adding to this body of knowledge. Similarly, AR monitoring and evaluation studies should evaluate potential negative impacts that may be related to AR deployment. Expanded documentation of the effects of AR deployment will provide valuable information that can be used to argue for or against AR deployment in the future.10.7717/peerj.6206/supp-1Supplemental Information 1Dataset of ecosystem services perceptions from fishermen at pre and post deployment phases for Nazare and Ouraartificial reefs.Click here for additional data file.


Oxidative stress, inflammation and androgen receptor (AR) signaling play a pivotal role in the initiation, development and progression of prostate cancer (PCa). Numerous papers in the literature have documented the interconnection between oxidative stress and inflammation; and how antioxidants can combat the inflammation. It has been shown in the literature that both oxidative stress and inflammation regulate AR, the key receptor involved in the transition of PCa to castration resistant prostate cancer (CRPC). In this review, we discuss about the importance of targeting Nrf-2-antioxidant signaling, NF-κB inflammatory response and AR signaling in PCa. Finally, we discuss about the crosstalk between these three critical pathways as well as how the anti-inflammatory antioxidant phytochemicals like sulforaphane (SFN) and curcumin (CUR), which can also target AR, can be ideal candidates in the chemoprevention of PCa. Prostate cancer (PCa) is the second major cause of cancer in men and fifth leading cause of cancer-associated deaths in men worldwide . NumerouIn response to oxidative stress, there is an activation of nuclear factor erythroid 2 -like 2 /Kelch-like erythroid cell-derived protein with CNC homology-associated protein 1, (Keap1)signaling pathway . Nrf-2 i4 dehydrogenase, aflatoxin B1 dehydrogenase, ferritin and UDP-glucuronosyltransferase (UGT) 1A1 [Electrophiles (under stress conditions) alter the cysteine residues of Keap1 resulting in the prevention of ubiquitination of Nrf-2 . Nrf-2 tUGT) 1A1 ,23,24 (TUGT) 1A1 ,27,28,29UGT) 1A1 ,31. The UGT) 1A1 . SeveralUGT) 1A1 ,34. DuriUGT) 1A1 . Nrf-2 hUGT) 1A1  and sensUGT) 1A1 . ChemoprUGT) 1A1 ,40,41,42UGT) 1A1 ,45,46,47It has been a well-studied fact that chronic inflammation leads to the initiation and advancement of PCa by modifying the tumor microenvironment altering the balance of chemokines, cytokines, ROS and other transcriptional factors ,49. The A multitude of inflammatory cytokines have been shown to actively mediate between prostate inflammation and PCa . The expNF-κB has emerged as a crucial link between inflammation and cancer . The dimIt has been reported that NF-κB mediated inflammation is even crucial in cancers whose growth is not linked with primary inflammatory condition ,69. In P (FGF8) [Androgen receptor (AR) signaling is indispensable for the development of prostate gland . It is n (FGF8) , cyclin  (FGF8) , prostat (FGF8) , transme (FGF8)  and FK50 (FGF8)  (Table 1 (FGF8) . The maj (FGF8) ,95,96 an (FGF8) ,98.The crosstalk between AR and other signaling pathways in PCa modulates the transactivational activity of AR. When AR function becomes dysregulated in PCa, it results in anomalous expression of AR-dependent genes including transcription factors, cell cycle regulators and proteins critical for cell survival, secretion and lipogenesis . RandomiAR-V7 has been reported to be an imperative prognostic biomarker in CRPC ,106. AR-Nrf-2, NF-κB and AR signaling have emerged as the most crucial signaling pathways in PCa. The interconnection between these three signaling pathways is involved in the initiation, development and progression of PCa.Nrf2 and NF-κB in addition to individually affecting several signaling pathways for maintaining a redox homeostasis also crosstalk with each other to further alter the levels of vital redox modulators in both normal and disease conditions . AntitumNF-κB activation induced by LPS may be mitigated by several Nrf-2 activators such as SFN, CUR and phenethyl isothiocyanate (PEITC) . AdditioTwo of the most critical pathways by which SFN displays its potent chemopreventive effect in PCa are Nrf-2 activation ,40,41,42SFN inhibits the translocation of NF-κB into the nucleus and stimulation of the expression of proinflammatory genes in PCa . SFN inhCrosstalk between androgen and pro-inflammatory signaling has been shown to remodel AR and NF-κB cistrome that reprograms transcriptome of PCa cell in a way that leads to the progression of PCa . There iNF-κB significantly upregulates the mRNA as well as protein levels of AR, transactivation of AR, cell proliferation as well as PSA levels in the serum by binding directly to the AR promoter and activating it . This waOxidative stress contributes to the initiation, progression and transition of PCa to CRPC by activating AR signaling . Thus reWe recently showed that bardoxolone methyl (BM) which is a potent Nrf-2 inducer can increase the efficacy of enzalutamide in an enzalutamide-resistant PCa cell line (CWR22Rv1) by degrading both AR-FL as well as AR-V7 further underscoring the AR suppressive function of Nrf-2 . This coOxidative stress and inflammation are the key players involved in the initiation and progression of PCa because of their potential to modulate AR signaling. Thus the integrated signaling network involving Nrf-2, NF-κB and AR plays a very critical role both in the development and therapy of PCa . TherefoNumerous studies have shown the anti-cancer efficacy of SFN, an isothiocyanate derived from broccoli in various different kinds of cancers ,146,147.


The astonishing variety of sounds that birds can produce has been the subject of many studies aiming to identify the underlying anatomical and physical mechanisms of sound production. An interesting feature of some bird vocalisations is the simultaneous production of two different frequencies. While most work has been focusing on songbirds, much less is known about dual-sound production in non-passerines, although their sound production organ, the syrinx, would technically allow many of them to produce “two voices”. Here, we focus on the king penguin, a colonial seabird whose calls consist of two fundamental frequency bands and their respective harmonics. The calls are produced during courtship and for partner and offspring reunions and encode the birds’ identity. We dissected, μCT-scanned and analysed the vocal tracts of six adult king penguins from Possession Island, Crozet Archipelago.King penguins possess a bronchial type syrinx that, similarly to the songbird’s tracheobronchial syrinx, has two sets of vibratory tissues, and thus two separate sound sources. Left and right medial labium differ consistently in diameter between 0.5 and 3.2%, with no laterality between left and right side. The trachea has a conical shape, increasing in diameter from caudal to cranial by 16%. About 80% of the king penguins’ trachea is medially divided by a septum consisting of soft elastic tissue .The king penguins’ vocal tract appears to be mainly adapted to the life in a noisy colony of a species that relies on individual vocal recognition. The extent between the two voices encoding for individuality seems morphologically dictated by the length difference between left and right medial labium. The septum trachealis medialis might support this extent and could therefore be an important anatomical feature that aids in the individual recognition process. Birds exhibit a huge variety of vocal sounds and have exploited the use of acoustic signals in many behavioural contexts, e.g. mate choice and territory defence (reviewed in –3). The Taeniopygia guttata and northern cardinals Cardinalis cardinalis and concluded that ML and LL are most likely responsible for sound production. In addition to the often highly specialized anatomy of the syrinx, the respiratory tract [Similar to the tissues present in the vocal apparatus of terrestrial mammals, the syrinx and trachea of birds mainly consist of four anatomical elements: bone, cartilage, muscle and vibratory soft tissue. The vibrating tissues of birds are analogous to the vocal folds of the larynx in mammals  and typiry tract , oropharry tract , larynx,ry tract , and beary tract .Sturnus vulgaris [Zonotrichia leucophrys and zebra finches [Aix sponsa [Centrocercus urophasianus [The detailed anatomy, i.e. the number and location of membranes, morphology of ossified elements as well as the number of muscles and their exact insertion sites on the syrinx differs immensely between species and adds to the intricacy of produced sounds vulgaris , white-c finches . Only fex sponsa  and the hasianus , that prhasianus –38.Aptenodytes patagonicus have been shown to be emitted during mate choice [The display calls of king penguins e choice  and sex-e choice . Furthere choice , 42. Thee choice .The king penguin display call consists of a succession of frequency modulated syllables with two simultaneous series of harmonically related bands of slightly different frequencies and their respective harmonics, a “two-voice signal” , 44, 45.Spheniscus demersus, reports a septum of the trachea that became caudally thicker and was strongest just before the bifurcation of the two bronchi. Watson [Procellariidea, but not in the Southern rockhopper penguin Eudyptes chrysocome or the Little penguin Eudyptula minor. Zeek [A. forsteri have been reported to “appear” to have no tracheal septum [Detailed knowledge about the vocal tract anatomy of penguins however is generally lacking. The first study conducted by Meckel  on the a. Watson  describeor. Zeek  investigl septum . Howeverl septum  also sugHere, we present the detailed anatomy of the entire vocal tract of king penguins, who have previously been reported to produce two-voiced sounds , 42. We We find no major differences in the gross anatomy of vocal tracts between male and female king penguins. Therefore, the anatomical features described subsequently are only shown exemplarily in the male.The king penguin has a bronchial syrinx Fig. a, with aThe trachea is separated by a septum: septum trachealis medialis,  muscle runs alongside the trachea Fig. a,b and aThe 3D reconstruction and analysis of the upper vocal tract, specifically of the head and throat Fig. , show noThe two male specimens have a shorter overall trachea length while the females have a smaller overall trachea width Table . For thet-test, P = 0.011; Table 1 and F02, to be consistently higher for female king penguins with 49.0 ± 12.9 Hz than for males with 40.3 ± 11.5 Hz. There are no sex differences between F01 and F02  in the king penguins’ call could be determined through the different sizes of the vibratory tissues on each side of the syrinx. Lateralization of the syrinx as the source of acoustic features has been proposed in numerous studies [The key feature that allows both male and female king penguins to produce two simultaneous fundamental frequencies is their bronchial syrinx type. Using a mechanical model of the avian syrinx, Elemans et al.  showed t studies , 58, 59. studies . Future  studies , 61 woul studies . Sound p studies . The upp studies , 64, 65)The size, location and type of tissue of the STM as part of that filter suggests influences on the vocal output as well. The STM could play an important role in the coupling of each sound source with either side of the vocal tract, and the resulting delayed acoustic feedback could influence the spectral characteristics of the king penguin call. Furthermore, as this coupling process happens for the two voices F01 and F02 on each side of the king penguin syrinx separately, the STM could function as a “barrier”, preventing F01 and F02 from mixing for most of the length of the trachea.Dugong dugon [Crex crex [Tracheal septa have been reported to be present in little penguins , Africanng dugon , and leang dugon ). Reportng dugon , 68, dugng dugon ). Convinng dugon , emperorng dugon  and Afring dugon . The STMng dugon  used comng dugon  nor in kng dugon  and in crex crex .Pygoscellis Adeliae, king and emperor penguins and concluded that diving penguins probably reduce the air volume of the parabronchial, tracheobronchial and lung air spaces to prevent pulmonary barotrauma. The STM could have a similar function as to prevent the collapse of the trachea. Another hypothesis is that the septum allows for simultaneous feeding and breathing in diving species as suggested by Davenport et al. [Dermochelys coriacea.. The tracheal septum might play a vital role in preventing the compression of the lower part of the trachea caused by the food-filled oesophagus and hence might facilitate breathing.Given that a tracheal septum has also been reported for other aquatic species , 49, 50,Aptenodytes. The STM separating the trachea into two lumina may further favour the production or psychoacoustic recognition of the two voices, while additionally aid in stabilizing the trachea during prey ingestion. The increased diameter from caudal to cranial in connection with the calling position adopted by king penguins during vocalising is likely an adaptation to improve the propagation of this important signal of individuality in the environment of a noisy seabird colony.Male and female king penguins do not differ substantially in basic anatomical features of the vocal tract. Both sexes possess a bronchial type syrinx allowing for the simultaneous production of the two voices featured in the king penguins characteristic display calls. The difference in size between left and right labia results in an offset between the two fundamental frequencies, i.e. the beat that encodes for individuality in To study the detailed anatomy of the king penguin vocal tract, six specimens were collected in the king penguin colony of “La Baie du Marin” at Possession Island, Crozet Archipelago , between November 2015 and April 2016. Vocal tracts were dissected from four males and two females that were found freshly dead at the periphery of the colony. While the exact age of the birds is unknown, plumage coloration indicates that all individuals were adults, i.e. at least four years or older. Sex was determined for all birds through macroscopic identification of the gonads during dissection, following Hocken . Vocal tTracheal diameter was measured at three different levels, (i) cranial just below the larynx, (ii) the middle of the trachea and (iii) caudal just above the bronchial bifurcation. Tracheal length was measured between the bronchial bifurcation and the last tracheal ring just below the larynx. Width measurements of medial labia were taken at the inside of bronchial bone B7. All measurements were performed ex situ on fixed vocal tracts.To visualize soft tissues , 74, theScans were performed using a Phoenix nanotom m cone beam μCT scanner . Scans for the entire vocal tracts were conducted using three slightly overlapping field of views (FOV), each acquiring 1600 projections during a 360° rotation at a voltage of 120 kV and 100 mA current. The female syrinx dataset was acquired as one individual FOV scan with the same settings. All scans were performed using a tungsten (“standard”) target with an additional 0.1 mm aluminium filter. Voxel size of the female syrinx was 0.04 μm and of the male syrinx 0.05 μm.Micro-CT raw data were reconstructed and filtered using the software phoenix datos|× 2 . Subsequently, they were cropped and converted to 8bit using VGStudio MAX 2.2 . Stitching of multiple data sets, threshold based plus additional manual segmentation, surface generation of the μCT data were performed with Amira 6.0.1 , following the protocol of Ruthensteiner .King penguin vocalisations were recorded also in the king penguin colony of “La Baie du Marin”  betweenWe measured the overall frequency of the two fundamentals and of their difference in frequency in syllables of males and females. As display calls of king penguins are highly redundant, consisting of successive syllables with a repetition of the same individual information many times (one syllable is sufficient to elicit recognition ), our fr1 and F02 were done on the spectrum (Fast Fourier Transform (FFT) length of 1024, Blackman window). In cases where we had recorded and measured the two voices of more than one call , the measurements were averaged for each individual. We analysed the two-voice frequencies for a total of N = 42 males and N = 19 females. To compare two-voice measurements between the sexes, we performed (1) Welch’s t-tests on the first (F01) and second (F02) voices and on the beats, i.e. 1/(F02- F01), and (2) a generalized linear model (family = gamma) on the non-normally distributed frequency extent, i.e. F02 - F01.Signals were analysed using Avisoft SASLab Pro  and dow