Desiccation leads to structural changes of the inner pectic cell wall layers inUlva compressa. This contributes to protection against mechanical damage due to desiccation–rehydration cycles.Ulva compressa, characterized by rbcL phylogeny, is a common species in the Mediterranean Sea. Ulva as an intertidal species tolerates repeated desiccation–rehydration cycles in nature; the physiological and structural basis were investigated under experimental conditions here. Desiccation to 73 % relative water content (RWC) led to a significant decrease of the maximum quantum yield of photosystem II (Fv/Fm) to about half of the initial value. A reduction to 48 or 27 % RWC caused a more drastic effect and thalli were only able to recover fully from desiccation to 73 % RWC. Relative electron transport rates were stimulated at 73 % RWC, but decreased significantly at 48 and 27 % RWC, respectively. Imaging-PAM analysis demonstrated a homogenous desiccation process within individual thallus discs. The different cell wall layers of U. compressa were characterized by standard staining procedures, i.e. calcofluor white and aniline blue for structural components , ruthenium red for pectins and toluidine blue for acidic polysaccharides. Already a reduction to 73 % RWC caused severe changes of the cell walls. The inner pectin-rich layers followed the shrinkage process of the cytoplasm, while the outer denser fibrillar layers maintained their shape. In this way, the thalli were not plasmolyzed during water loss, and upon recovery not negatively influenced by any mechanical damage. Transmission electron microscopy corroborated the arrangement of the different layers clearly distinguishable by their texture and electron density. We suggest the flexibility of the pectin-rich cell wall layers as a major contribution to desiccation tolerance in Ulva.The online version of this article (doi:10.1007/s00425-015-2292-6) contains supplementary material, which is available to authorized users. Desiccation tolerance (DT) is a relatively rare yet phylogenetically widespread phenomenon in green algae; however, the strategies to achieve tolerance are only partly understood. Among green algae, DT occurs in the chlorophyte as well as in streptophyte lineages, the latter giving rise to land plants  is an emerging model organism for green macroalgae and much effort has been made to investigate physiological reactions involved in tolerance of the colonization of the intertidal zone , homogalacturonan, rhamnoxylogalacto-glucuronan and arabinogalactan proteins  as well as light microscopic techniques. Moreover, a detailed physiological description of desiccation effects in Ulva was performed. To estimate the effect of desiccation on a cellular level, a microscopic version of an Imaging PAM was used to answer the questions whether the thalli desiccated homogenously or an inhibition of photosynthesis first occurs in individual cells. Furthermore, we performed a profound physiological description of DT reactions in U. compressa, one of the most common Ulva species in Europe  of the cell wall by different staining procedures and follow their change during experimental desiccation. Furthermore, we characterized the fibrillar components of Ulva compressa was collected on April 8, 2012 at a beach near Sousse, Tunisia (35°51′34.9″N 10°37′02.9″E). Thalli were washed in sea water to remove sediment and transferred to the laboratory, where unialgal cultures were established. Algae were cultivated in 250–1000 mL Erlenmeyer flaks containing artificial seawater  according to the manufacturer’s protocol. Primers and PCR conditions used for PCR amplification and cycle sequencing of nd Lewis . Individ1 Posada  under th1 Posada , using a−2 s−1 PAR) at room temperature (22 ± 0.5 °C).Six discs were cut out with a punch (diameter = 6 mm) from mid-sized thalli, excess ASW was removed from the surface of the discs. The discs were placed in a desiccation chamber according to Karsten et al. ; the relU. compressa thallus discs were weighed after removal of surface water with a paper towel and subsequently placed in a desiccation chamber under the same conditions as described above. Discs were weighed again after 30, 60 and 90 min to determine the weight of the desiccated discs. Then, they were dried in the oven at 100 °C for 13 h and weighed again, allowing calculating the relative water content (RWC):W0 is the weight of the fully hydrated discs, Wt is the weight of discs at time t after desiccation and Wd is the weight of the oven-dried discs. 30 min of desiccation corresponded to a RWC of 73 ± 4 %. After 60 and 90 min, RWC was reduced to 48 ± 5 % or 27 ± 4 %, respectively .Six Macroscopic images were taken using a Nikon Coolpix 8400 camera  connected to a Nikon SMZ800 stereomicroscope. Furthermore, samples were investigated by a Zeiss Axiovert 200 M microscope, equipped with a 63 × 1.4 NA objective lens. Cellulose within the cell walls was stained with 1 % calcofluor white  was added to a fresh or desiccated thallus piece on a slide, respectively, and subsequently investigated by light microscope  and prepared according to Holzinger et al.  during standardized desiccation treatment and rehydration was measured with a pulse-amplitude modulated fluorimeter  equipped with a red LED (630 nm). For measuring Fv/Fm, the discs were placed in a KS-2500 suspension cuvette  to allow dark adaptation (10 min) and ensure a uniform distance between each sample and the PAM light probe. Fv/Fm was measured in control samples and after 30, 60 or 90 min of desiccation, respectively, followed by recovery in ASW for 2 h. After this time, the Fv/Fm value of the recovered samples was determined.The maximum photochemical quantum yield of photosystem (PS) II  and near infrared remission  for the first time on a cellular level in U. compressa. Therefore, control and thalli discs desiccated as described above  were dark adapted for 10 min on a slide, overlaid with two drops immersion oil and subsequently investigated under a modified Axio ScopeA.1 epifluorescence microscope equipped with a Zeiss Fluar 40 × 1.3 (∞/0.17) objective lens and a CCD Camera IMAG-K6 controlled with ImagingWinGigE (V2.45i) software. Measuring light for Fv/Fm determination was provided by a LED (620 nm). Images were further processed with Adobe Photoshop (CS5) software.The microscopy version of an Imaging PAM  was used to visualize −2 s−1 PAR, each 30 s) were recorded using a PAM 2500. This was always performed independently in six replicates for control and after 30, 60 or 90 min desiccation treatment, respectively, to avoid distortion of rETR values in response to desiccation treatment due to high measuring light. Furthermore, discs independently desiccated for 30, 60 or 90 min were placed in ASW 2 h to estimate rETR of recovered samples. All measurements were performed on U.compressa thalli discs which were placed in a KS-2500 suspension cuvette without prior dark adaptation. Desiccation was performed in a chamber under the same conditions as described above. The rETR curves were fitted by the model of Walsby (α positive slope at limiting photon fluence rates (electrons photon−1), Ik initial value of light-saturated photosynthesis (μmol photons m−2 s−1) and rETRmax maximum relative electron transport rate (μmol electrons m−2 s−1).Relative electron transport rates  were determined in a time series  and rETR values (n = 6) were always measured in independent samples . Chlorophyll a, b and carotenoid content (n = 4) were determined independently in control and after 30, 60 or 90 min desiccation. To analyse the influence of time on Fv/Fm values, a repeated-measure analysis of variance (ANOVA) was performed, followed by a Tukey’s post hoc test (P < 0.001) to find significant differences among control, desiccated and recovered samples. Comparison of photosynthetic parameters derived from rETR measurements and chlorophyll a, b or carotenoid content was performed by one-way ANOVA, followed by Tukey’s post hoc test (P < 0.001) to find homogeneous subgroups of significantly different means. All statistical analyses were carried out in Origin 8.5 .rbcL sequence obtained from the Ulva sample was 1197 nucleotides long. The alignment of the new sequence with 22 published Ulva sequences was a total length of 1355 nucleotides, with no excluded, 1250 constant, and 70 parsimony-informative sites. The ML analysis yielded 24 optimal trees (ln L = − 2718.913) that differed only in the relative placement among sequences in a large clade corresponding to U. compressa , which was sister to Ulva intestinalis. Several other well-supported clades, representing different Ulva species, were also highly supported, in agreement with the analysis of Wolf et al. . Chlorophyll b was decreased from 25.87 ± 1.43 mg m−2 to 20.59 ± 1.14 mg m−2 in all desiccated samples, whereas the values for carotenoids did not change significantly upon desiccation .The pigment content decreased slightly in desiccated samples. Chlorophyll At the TEM level, the cellular architecture of cultivated cells under control conditions is illustrated in Fig. Fv/Fm) was affected by experimental desiccation and showed significant differences depending on duration of desiccation , which did not recover upon rehydration  lower rETRmax values occurred in the control discs and discs with RWC 48 % and 27 %  increasing Ik value in discs with RWC 73, 48 and 27 %  was not reached again .Recent investigations have stressed the importance of connecting physiological and ecological studies of U. compressa, we never observed branching in our thalli. This is likely attributed to the constant salinity regime in the habitat and in culture . The fibrillar material, mainly containing cellulose and xyloglucans  mostly contain filamentous structural components involving unbranched linear polysaccharides, which was shown by CFW staining. We are aware that also callose could be stained by this component as well , ascorbate peroxidase (APX) and catalase (CAT). Hypersalinity and hydrogen peroxide lead to an up regulation of gene expression in antioxidative enzymes in Ulva fasciata . Moreover, this resolution of the Fv/Fm value demonstrates that within the thalli the desiccation-induced reduction of the Fv/Fm values was homogenous and we conclude from these observations that all of the examined cells were in a similar physiological state. Gao et al. , and did not recover which points towards an irreversible change of PS II. In contrast, the rETRmax values still tend to recover after 90 min desiccation. This might be explained by the different experimental setup for Fv/Fm and rETRmax measurements . Whereas the Fv/Fm was determined by repeated measurements of the same samples, the rETR curves were recorded independently in control, desiccated and rehydrated samples. Repeated saturation pulse analyses (for Fv/Fm determination) can be regarded as high light stress leading to full reduction of the plastoquinone pool . These investigations were beyond the scope of the present study, but will certainly elucidate the mechanical properties of the different cell wall layers. This will help us to get a deeper insight  into the role of the cell wall properties in DT of intertidal algae.We conclude that structural changes in the cell walls of A.H. planned experiments, performed experiments, wrote manuscript, K.H. performed experiments, wrote manuscript, F.K. performed experiments, L.A.L. performed experiments, wrote manuscript.Fig. S1 Experimental setup for controlled desiccation and rehydration of Ulva compressa thallus discs for microscopic and physiological investigations. After setting the RH to ~62 % inside the chamber the discs were desiccated for 30, 60 or 90 min. The Fv/Fm values were measured in three time series: control, desiccated  rehydrated discs. rETR values were determined independently for control, desiccated  and rehydrated discs (dashed line). The relative water content for each desiccation level is shown (TIFF 90 kb)Fig. S2 Aniline blue staining of Ulva compressa. a Surface view of a thallus segment (DIC). b Fluorescence image of the same area. Chloroplast autofluorescence is shown (red). The cell walls lack callose as they are not stained by aniline blue. Scale bars 10 µm (TIFF 2142 kb)Fig. S3 Chlorophyll a, b and carotenoids of control discs and discs desiccated for 30, 60 or 90 min (n = 4). Significances between the groups are indicated by small letters (chl. a), capital letters (chl. b) and underlined letters (carotenoids). They were determined by one-way ANOVA (P < 0.001) followed by Tukey’s post hoc test (TIFF 72 kb)


Ralstonia solanacearum based on sequence homology with the catalytic and C-terminal domains of human aSMase. A biochemical characterization of RsASML does not support a role in sphingomyelin hydrolysis but rather finds RsASML capable of acting as an ATP diphosphohydrolase, catalyzing the hydrolysis of ATP and ADP to AMP. In addition, RsASML displays a neutral, not acidic, pH optimum and prefers Ni2+ or Mn2+, not Zn2+, for catalysis. This alters the expectation that all aSMase-like proteins function as acid SMases and expands the substrate possibilities of this protein superfamily to include nucleotides. Overall, we conclude that sequence homology with human aSMase is not sufficient to predict substrate specificity, pH optimum for catalysis, or metal dependence. This may have implications to the biochemically uncharacterized human aSMase paralogs, aSMase-like 3a (aSML3a) and aSML3b, which have been implicated in cancer and kidney disease, respectively, and assumed to function as aSMases.Acid sphingomyelinase (aSMase) is a human enzyme that catalyzes the hydrolysis of sphingomyelin to generate the bioactive lipid ceramide and phosphocholine. ASMase deficiency is the underlying cause of the genetic diseases Niemann-Pick Type A and B and has been implicated in the onset and progression of a number of other human diseases including cancer, depression, liver, and cardiovascular disease. ASMase is the founding member of the aSMase protein superfamily, which is a subset of the metallophosphatase (MPP) superfamily. To date, MPPs that share sequence homology with aSMase, termed aSMase-like proteins, have been annotated and presumed to function as aSMases. However, none of these aSMase-like proteins have been biochemically characterized to verify this. Here we identify RsASML, previously annotated as RSp1609: acid sphingomyelinase-like phosphodiesterase, as the first bacterial aSMase-like protein from the deadly plant pathogen  Sphingomyelinases (SMases) are enzymes that catalyze the hydrolysis of sphingomyelin (SM) to generate ceramide (Cer) and phosphocholine The genetic and biochemical properties of aSMase have been well characterized Ralstonia solanacearum is a deadly plant pathogen that causes southern bacterial wilt, infects agriculturally important crops , and has a broad geographic distribution R. solanacearum is extremely lethal and expresses over a hundred different pathogenicity factors upon plant infection Bacillus cereus, Staphylococcus aureus, Clostridium perfringens, Listeria ivanovii and Streptomyces griseocarneusBacterial homologues of neutral SMases have been identified in many pathogens including R. solanacearum. We find that the RsASML protein, unlike aSMase, cannot hydrolyze SM to Cer but appears to be an ATP diphosphohydrolase, which catalyzes the hydrolysis of ATP and ADP to AMP. In addition, the biochemical properties of RsASML differ from aSMase, displaying a neutral pH optima and a Ni2+ metal dependence. Overall, this work broadens the substrates and pH optima of aSMase-like proteins and presents the possibility that R. solanacearum uses ATP hydrolysis to aid in plant pathogenicity. In addition, the identification of a bacterial aSMase-like protein suitable for X-ray crystallography studies may aid in future studies defining the structural features of the aSMase protein superfamily.Here we identify and biochemically characterize the gene RSp1609, herein referred to as RsASML, as the first bacterial aSMase-like protein from the deadly plant pathogen R. solanacearum GMI1000 was PCR amplified from a cosmid . The PCR product was cloned into the E. coli overexpression vector ppSUMO using BamHI and NotI restriction sites. The resulting translated protein contained a cleavable N-terminal HisTag/SUMO-RsASML peptide. The RsASML ppSUMO plasmid was transformed into Origami 2 (DE3) cells for protein expression.The RsASML gene, encompassing amino acids 30–476, which lacks a putative N-terminal secretory signal peptide (residues 1–29), from Cells harboring the RsASML ppSUMO plasmid were grown at 37°C in Terrific broth to an OD ∼2.0. The temperature was reduced to 15°C, and after one hour at 15°C protein production was induced with 30 mg IPTG per liter. Twenty hours after IPTG induction, cells were centrifuged and cell pellets were stored at −80°C.Cells were resuspended in Buffer A  and lysed by sonication. After centrifugation the supernatant was applied to a 5 mL HisTrap FF column , washed extensively with Buffer A, and eluted with Buffer B . Fractions containing the His/SUMO-RsASML protein were collected, and the His/SUMO-tag was removed by overnight incubation with the purified SUMO-protease, ULP-1. Digested protein was applied to a Hi-Load 26–60 Superdex 200 size-exclusion column equilibrated with 10 mM HEPES, pH 8.0, 50 mM NaCl. Fractions containing the RsASML protein were pooled and concentrated to 5–10 mg/mL, aliquoted, and flash frozen.nm over time using a BioTek Synergy HT microplate reader. The extinction coefficient for pNP at 405nm is 18,000 M−1cm−1. Km and Vmax values were determined by plotting the initial velocity (µM/min) of the reaction versus the concentration of substrate and using a non-linear regression analysis. kcat values (min−1) were determined by dividing the Vmax values (µM/min) by the concentration of the enzyme RsASML (µM). For pH screening, multiple endpoint assays were used to calculate the initial velocity, where the reaction was quenched by addition of 1 N NaOH and the absorbance was immediately measured.Purified RsASML protein was incubated with the pNP-based substrates: para-nitrophenol phosphate (pNPP), para-nitrophenol phosphocholine choline), and pNP-thymidine 5′-monophosphate  in a standard 96-well plate at 25°C. A temperature of 25°C was used for activity assays as incubation at 37°C resulted in a decrease of RsASML enzyme activity over time, presumably due to protein instability. pNP formation was followed by monitoring the change in absorbance at 40514C in the phosphocholine headgroup, was incorporated in Triton X-100 micelles by sonication and incubated with RsASML or Bc-nSMase (Bacillus cereus nSMase) proteins at room temperature in their respective optimal reaction buffers. Reactions were quenched by addition of 1.5 mL chloroform and 400 µL water. 14C labeled phosphocholine was extracted using a standard Folch extraction by collecting the aqueous layer and the radioactive products were quantified using a Beckman LS6500 Scintillation Counter as described previously Sphingomyelin, labeled with 2, 10 mM HEPES, pH 8.0 or Bc-nSMase: 10 mM MgCl2, 25 mM Tris, pH 7.5). The reaction was quenched by addition of 400 µL Chloroform/Methanol/HCl (100∶200∶1). An additional 120 µL Chloroform and 120 µL 2 M KCl were added to this solution, vortexed, and centrifuged at 3000 rpm for 10 min. 200 µL of the organic layer was removed, placed in a clean glass tube, and dried. The extracted lipids were resuspended in 50 µL of Chloroform/Methanol (1∶1) and 5 µL was spotted onto a clean TLC plate. The plate was placed in a TLC chamber equilibrated with Chloroform/Methanol/Water (65∶35∶8) to separate the reaction products. Plates were visualized using a Typhoon FLA 7000 with excitation and emission.0.4 mM Nitrobenzoxadiazol-lyso-sphingomyelin (NBD-lyso-SM) and Nitrobenzoxadiazol-lyso-phosphatidylcholine (NBD-lyso-PC) (Avanti Polar Lipids) stock solutions were prepared by first solubilizing in Methanol  and after addition of BSA (4 mg/mL). Stock solutions were stored at −20°C until use. Reactions were initiated by addition of RsASML or Bc-nSMase proteins to the NBD-lyso lipids  in their respective reaction buffers (RsASML: 1 mM NiCl2) for 1 hr at RT. Reactions were quenched by addition of 80 µL 1 M stock of Acetic Acid/Sodium Acetate (14.7/5.3), 560 µL water, and 30 µL of chloroacetaldehyde (50% solution). The reaction products were derivatized by incubation overnight at 60°C to form the fluorescent etheno-derivatived products.RsASML was incubated with adenosine-based nucleotides (1 mM) in reaction buffer  was performed using a Waters 1525 Binary HPLC Pump, Waters 717 plus autosampler, and Shimandzu RF-551 Spectrofluorometric detector. The derivatized reaction products were diluted 100 fold in Buffer A  and applied to a Luna 5u C18 (2) 100A column. Products were separated using a stepwise gradient against 50/50 mixture of Buffer A and Methanol. Emission and excitation values of 275 nm and 415 nm were used to detect the fluorescent products.Human aSMase is heavily glycosylated making it a difficult crystallization target R. solanacearum for further biochemical analysis  derive from pathogenic organisms analysis . The prianalysis . This inE. coli BL21 (DE3) cells failed. Human aSMase contains a number of intra-molecular disulfide bonds that are required for activity E. coli cytoplasm, did result in the generation of soluble protein that could be purified to >95% homogeneity using Nickel and size-exclusion columns  family. RsASML was able to catalyze the hydrolysis of phosphate from para-nitrophenol phosphate (pNPP) , as wellr metals . Signifi5 µM/min , Table 21 µM/min , Table 2s tested .cat and Km values found that RsASML had similar kcat values for pNPPC and pNP-TMP  , which r pNP-TMP , Table 3E. coli proteins, we generated RsASML H280R by substituting Histidine 280 to Arginine using site-directed mutagenesis. This mutation in RsASML corresponds to the H427R mutation in human aSMase found in a subset of Niemann-Pick Type A patients To ensure that the activity we were observing was due to RsASML and not any minor contaminating B. cereus (Bc-nSMase) as a positive control. RsASML lacks the SAP domain found in human aSMase that is thought to aid in SM extraction from the membrane and facilitate SM availability to the catalytic domain. To ensure the lack of SMase activity of RsASML was not due to the absence of a SAP domain and lack of SM access to the catalytic domain, we assessed the activity of RsASML in more soluble lipid systems. These systems utilized the fluorescently labeled lipids NBD-lyso-SM and NBD-lyso-phosphatidylcholine (NBD-lyso-PC) complexed with fatty acid-free BSA. RsASML did not hydrolyze NBD-lyso-SM and NBD-lyso-PC, while Bc-nSMase hydrolyzed both   , Table 4The potent inhibition of ATP, ADP, and AMP suggested that RsASML might be a nucleotide phosphodiesterase specific for adenosine-based nucleotides. The ability of RsASML to hydrolyze adenosine-based nucleotides was directly assessed. RsASML catalyzed the hydrolysis of both ATP and ADP to form AMP . AMP was2+ metal dependence is not likely to be biologically relevant as free Ni2+ concentrations are very low. It is more likely that Mn2+ is the physiological relevant metal for RsASML activity.Here we identify and biochemically characterize RsASML, the first bacterial aSMase-like protein, as well as the first aSMase-like protein to be biochemically characterized. Although RsASML shares significant sequence homology with the catalytic and C-terminal domains of human aSMase, the protein does not display SMase activity. Rather, our in vitro characterization suggests RsASML may function as an ATP diphosphohydrolase. In addition to broadening the potential substrates of the MPP_aSMase protein superfamily, we find that RsASML displays a different pH optima and metal dependence to human aSMase. We note that the NiThis work has a number of implications to the MPP_aSMase protein superfamily. To date, all aSMase-like proteins have been assumed to exhibit aSMase activity based simply on the substrate specificity of aSMase. This includes the uncharacterized human proteins aSML3a and aSML3b, which similar to RsASML also lack the SAP domain found in aSMase. This is important as aSML3a (gene name: SMPDL3A) and aSML3b (gene name: SMPDL3B) have recently been identified as necessary for cell division These results also raise the possibility that the substrates of S-SMase, the secreted form of aSMase, which is located in the neutral pH environment of the extracellular space and where Zinc concentrations are very low, may not be limited to SM. How S-SMase functions outside its normal acidic pH optimum is a major question that still needs to be addressed. An interesting study found that S-SMase was capable of hydrolyzing artherogenic, modified LDL-bound SM at neutral pH but not normal LDL-bound SM R. solanacearum in vivo. Recently, DORN1 was identified as the long sought after plant extracellular ATP receptor R. solanacearum.Furthermore, it would be interesting to evaluate the role of RsASML as a putative ATP diphosphohydrolase in the pathogenesis of


The vital role of evaluation as integral to program planning and program development is well supported in the literature, yet we find little evidence of this in health promotion practice. Evaluation is often a requirement for organisations supported by public funds, and is duly undertaken, however the quality, comprehensiveness and use of evaluation findings are lacking. Practitioner peer-reviewed publications presenting evaluation work are also limited. There are few published examples where evaluation is conducted as part of a comprehensive program planning process or where evaluation findings are used for program development in order to improve health promotion practice.For even the smallest of programs, there is a diverse array of evaluation that is possible before, during and after program implementation. Some types of evaluation are less prevalent than others. Data that are easy to collect or that are required for compliance purposes are common. Data related to how and why programs work which could be used to refine and improve programs are less commonly collected. This finding is evident despite numerous resources and frameworks for practitioners on how to conduct effective evaluation and increasing pressure from funders to provide evidence of program effectiveness. We identify several organisational, evaluation capacity and knowledge translation factors which contribute to the limited collection of some types of data. In addition, we offer strategies for improving health promotion program evaluation and we identify collaboration of a range of stakeholders as a critical enabler for improved program evaluation.Evaluation of health promotion programs does occur and resources for how to conduct evaluation are readily available to practitioners. For the purposes of program development, multi-level strategies involving multiple stakeholders are required to address the organisational, capacity and translational factors that affect practitioners’ ability to undertake adequate evaluation. Different types of evaluation  are required at different stages in planning and implementing a program. Evaluation activities are much broader than measuring before and after changes as a result of intervention. They include stakeholder consultation, needs assessment, prototype development and testing, measuring outputs, monitoring implementation activities, and assessing how a program works, its strengths and limitations . FollowiThis cyclical approach to planning and evaluation is not always evident in practice; many organisations appear to take a linear approach, often undertaking planning and evaluation activities independently, and commensurate with the funding available. Others see evaluation as a measure of compliance or proof that is more useful to those requesting or funding the program evaluation than to those implementing the program.In this discussion we will argue that, for even the smallest of programs, there is a diverse array of evaluation that is possible before, during and after program implementation. We suggest that some types of evaluation are less prevalent than others. We will examine three types of factors contributing to limited program evaluation and propose strategies to support practitioners to undertake evaluation that improves health promotion practice.Evaluation of health promotion programs does occur. However, the evaluation undertaken seems to be determined, at least in part, by data that is easy to collect, such as program costs, client satisfaction surveys, number of participants, number of education sessions, and costs per media target audience ratings points (TARPs). These data may be aggregated and reported on, however such cases seem to be fairly rare and restricted to evaluations that are undertaken as research or where compliance is required; for example, where program funding may not be approved without a clear evaluation plan.There is little evidence of evaluation being truly used for program development despite:“Effective evaluation is not an ‘event’ that occurs at the end of a project, but is an ongoing process which helps decision makers better understand the project; how it is impacting participants, partner agencies and the community; and how it is being influenced/impacted by both internal and external factors” .Extensive literature on the health promotion planning and evaluation process , 9–19;Evaluation identified as a core competency of health promotion practice –23; andPlanning and evaluation units as central components of public health and health promotion degrees , 25.Our experience as evaluators indicates that practitioners frequently regard evaluation as an add-on process when a program is finished, rather than an ongoing process. Evaluation measures which are focused on outputs do not usually reflect the totality of a program’s effects. As such, practitioners may not perceive the data to be useful and therefore may undertake data collection solely to be compliant with program reporting requirements, or to justify continued funding.Are resources being used well? Are services equitable and accessible? Are services acceptable to culturally and linguistically diverse populations? Could modifications to the program result in greater health gains?Evaluation that identifies what works well and why, where program improvements are needed and whether a program is making a difference to a health issue will provide more valuable data for service providers. It is acknowledged that these data are often harder to collect than measures of program activity. However, these types of evaluation are needed to avoid missed opportunities for service improvements . ImportaThe answers to these types of questions can inform more effective and sustainable health promotion programs, reduce the potential for iatrogenic effects (preventable harm), and justify the expenditure of public funds. To be an ethical and responsible service provider, this accountability is critical.Why does the planning and evaluation cycle break down for some organisations?We can identify a number of factors that contribute to limited program evaluation, many of which are generally well known to health promotion practitioners , 27, 28.Funding for preventive health programs is highly competitive , with imThese project-based funding models can damage the sustainability of good preventive health programs for a number of reasons, including that funding may end before the program is able to demonstrate evidence that it works. Instead of desirable longer-term emphasis on health change and program development, evaluation choices tend to be responsive to these short-term drivers. Consequently, the planning process for programs may be fast-tracked with the focus weighted heavily towards intervention, and the evaluation component can move towards one of two extremes – either research-oriented or managerial evaluations.Research-oriented evaluation projects, experimental in nature, include attempts to create a controlled research study, which may not be sustainable outside the funding period. There is good evidence of sound research-oriented evaluations , 32. HowManagerial evaluations are minimalist types of evaluation that are designed to meet auditing requirements. We suspect that understanding of program evaluation has become rather superficial, based more on recipe-style classification or naming conventions  and less on the underlying purpose.These categories may meet funder requirements as a recognisable model of types of evaluation. However, the purpose of the evaluation and its value are often lost. The capacity to inform both the current program and future iterations is also reduced. Furthermore, the usefulness of the evaluation data collected may be compromised if the program planning process has not considered evaluation in advance, in particular, objectives that are relevant to the project and that can be evaluated.Evaluation of health promotion programs is particularly important to prevent unintended effects. Yet the reality for agencies undertaking health promotion work is that evaluation may not be well understood by staff, even those with a health promotion or public health background. For example, health promotion practitioners intending to collect evaluation data that can be shared, disseminated or reported more widely may need to partner with a relevant organisation in order to access a Human Research Ethics Committee (HREC) to seek ethics approval. Evaluation can also be seen as difficult , 34, andAs a result, there may be inadequate consideration of evaluation or evaluation is not planned at all. Data are not always suitable to address desired evaluation questions, or are not collected well. Consider the use of surveys to obtain evaluation data. People creating surveys often have no training in good survey design. The resulting survey data are not always useful or very meaningful and these negative experiences may fuel service providers’ doubts about the value of evaluation surveys, and indeed evaluation in general.A number of circumstances can contribute further to limited evaluation. For example, when resources are scarce or there is instability in the workforce, or when a program receives recurrent funding with no requirement for evidence of program effectiveness, the perceived value of rigorous evaluation is low. Furthermore, in any funding round, the program may no longer be supported making any evaluative effort seem wasteful. Conversely, if the program was successful in previous funding rounds there is often little motivation to change other than a gradual creep in activity number and/or scope. Consequently, there appear to be few incentives for quality evaluation used to inform program improvements, to modify, expand or contract, or to change direction in programming.Political influence also plays a role. Being seen to be ‘doing something quickly’ to address a public health issue is a common reaction by politicians leading to hurriedly planned programs with few opportunities for evaluation. The difficulties of working with hard to reach and unengaged target groups may be ignored in the urgency to act quickly. As a result, getting buy-in from community groups may not be actively sought, or may be tokenistic at best, with the potential for exacerbating the social exclusion experienced by marginalised groups .There is also some reluctance by practitioners to evaluate due to potential risk of unfavourable findings. Yet, it is important to share both positive and negative outcomes so that others learn from and do not make similar mistakes. Confidence to publish lessons learned firstly requires developing the skills to be able to disseminate knowledge through peer-reviewed journals and other forums. Secondly, practitioners require reassurance from funding agencies that funds will not automatically be withdrawn without opportunity for practitioners to adjust programs to improve outcomes.Information about how to conduct evaluations for different types of programs is plentiful and readily available to practitioners in the public domain What is needed to support practitioners to undertake improved evaluation?We propose that multi-level strategies are needed to address the organisational, capacity and translational factors that contribute to the currently limited program evaluation focused on health promotion program development , 12, 14.We have questioned here the expectations of funding agencies in relation to evaluation. We concur with Smith  and quescould we be doing better? Asking this question in the context of raising the standards and quality of programs to benefit the target groups [Organisational leadership needs to place a high value on evaluation as a necessary tool for continuous program development and improvement. There should be greater focus on quantifying the extent of impact needed. Practitioners need to feel safe to ask: t groups  is recomEstablishing partnerships with researchers can add the necessary rigour and credibility to practitioners’ evaluation efforts and can facilitate dissemination of results in peer-reviewed journal articles and through conferences. Sharing both the processes and results of program evaluations in this way is especially important for the wider health practitioner community. Furthermore, identifying organisations that use evaluation well for program development may assist in understanding the features of organisations and the strategies and practices needed to overcome common barriers to evaluation.In some organisations, there is limited awareness of what constitutes evaluation beyond a survey, or collecting operational data. We would argue that with some modification, many existing program activities could be used for evaluation purposes to ensure systematic and rigorous collection of data. Examples include recording journal entries of program observations, and audio or video recording of data to better understand program processes and participant involvement.most significant change technique, a highly participatory story-based method for evaluating complex interventions [success case method for evaluating investments in workforce training [Specialist evaluation skills are not always required. Practitioners may wish to consider appreciative inquiry methods  which foventions  and the training . These mtraining . Boydelltraining .Such arts-based evaluation strategies may be particularly suited to programs that already include creative components. They may also be more culturally acceptable when used as community engagement tools for groups where English is not the native language or where literacy may be low. In our experience, funding agencies are increasingly open to the validity of these data and their potential for wider reach, particularly in vulnerable populations , 44. TheWe encourage practitioners to begin a dialogue with funders to identify relevant methods of evaluation and types of evidence that reflect what their programs are actually doing and that provide meaningful data for both reporting and program development purposes. Other authors have also recognised the paucity of useful evaluations and have developed a framework for negotiating meaningful evaluation in non-profit organisations .Workforce development strategies, including mentoring, training, and skills building programs, can assist in capacity building. There are several examples of centrally coordinated capacity building projects in Australia which aim to improve the quality of program planning and evaluation in different sectors through partnerships and collaborations between researchers, practitioners, funders and policymakers  for program development and not conducted simply to meet operational auditing requirements.Organisations need to create a learning environment that encourages and rewards reflective practice and evaluation for continuous program improvement. In addition, a significant evaluation component is required to ensure that reactive responses to major public health issues can be monitored, evaluated and modified as required.At a policy level, all programs should be monitored, evaluated and refined or discontinued if they do not contribute to intended outcomes. Seeking evidence that is appropriate to program type and stage of development is important; funders need to give consideration to a range of evaluation data. Adequate budget also needs to be available for and invested in program evaluation.Evaluation of health promotion programs does occur and resources for how to conduct evaluations are readily available to practitioners. Multi-level strategies involving a range of stakeholders are also required to address the organisational, capacity and translational factors that influence practitioners’ ability to undertake adequate evaluation. Establishing strong partnerships between key stakeholders who build evaluation capacity, fund or conduct evaluation activities will be critical to support health promotion practitioners undertake evaluation for program development.


There is a need for theoretically grounded and evidence-based interventions that enhance the use of research evidence in physical therapist practice. This paper and its companion paper introduce the Physical therapist-driven Education for Actionable Knowledge translation (PEAK) program, an educational program designed to promote physical therapists’ integration of research evidence into clinical decision-making. The pedagogical foundations for the PEAK educational program include Albert Bandura’s social cognitive theory and Malcolm Knowles’s adult learning theory. Additionally, two complementary frameworks of knowledge translation, the Promoting Action on Research Implementation in Health Services (PARiHS) and Knowledge to Action (KTA) Cycle, were used to inform the organizational elements of the program. Finally, the program design was influenced by evidence from previous attempts to facilitate the use of research in practice at the individual and organizational levels.The 6-month PEAK program consisted of four consecutive and interdependent components. First, leadership support was secured and electronic resources were acquired and distributed to participants. Next, a two-day training workshop consisting of didactic and small group activities was conducted that addressed the five steps of evidence based practice. For five months following the workshop, participants worked in small groups to review and synthesize literature around a group-selected area of common clinical interest. Each group contributed to the generation of a “Best Practices List” - a list of locally generated, evidence-based, actionable behaviors relevant to the groups’ clinical practice. Ultimately, participants agreed to implement the Best Practices List in their clinical practice.This, first of two companion papers, describes the underlying pedagogical theories, knowledge translation frameworks, and research evidence used to derive the PEAK program – an educational program designed to promote the use of research evidence to inform physical therapist practice. The four components of the program are described in detail. The companion paper reports the results of a mixed methods feasibility analysis of this complex educational intervention. A copy of the educational materials used for the 2-day workshop is available from the corresponding author.participants selected the clinical area that would be pursued for the rest of the program based on their common interests and a perceived opportunity for patient benefit. Further, participants identified five sub-topics of the clinical area and organized themselves into five corresponding small groups based on the sub-topic(s) of greatest interest to each participant.It is important to note that the For 5 months following the workshop, participants met regularly in small groups (three to seven therapists) to develop a list of locally relevant ‘best practices’ for their clinical sub-topic. A designated group leader accepted responsibility for organizing regular small group communication and monthly reporting to the larger group. Each small group worked through the five EBP steps to find, appraise, and synthesize the highest quality research evidence for their clinical sub-topic. More specifically, groups were tasked to use research evidence, their own expertise, and knowledge of patient perspectives to generate actionable, evidence-based behaviors that could be implemented in their own practice. Actionable, evidence-based behaviors submitted by each small group were compiled into a single, “Best Practices List” for all participants to implement.Small groups determined how often they met  and used the online collaboration tool to accomplish their work. Monthly lunchtime meetings were conducted using Skype™ video conference for all participants to report on and discuss their progress. Monthly meetings were facilitated by the study principal investigator (PI) and attended by the study librarian. The study principal investigator and librarian met individually with groups when requested.th month, each small group submitted between 7 and 15, actionable, evidence-based behaviors to the Best Practices List. The study PI compiled the behaviors and distributed them to all participants for review and comment. Two rounds of review and comment were conducted online. Next, the list was sent for external review by experts selected by participants. Expert feedback was incorporated into the Best Practices List and, at the end of the 6th month, participants attended a final two hour meeting to review and discuss each behavior. Edits were made until all participants were satisfied that they could adhere to the recommended practice. At the conclusion of this final meeting the study participants gave verbal affirmation that they agreed with and would follow the behaviors outlined in the Best Practices List. This final list  – a physical therapist with 10 years experience teaching EBP and promoting KT in clinical and classroom environments.et. al. emphasize the need to develop a coherent framework for developing multifaceted approaches to promoting the use of research in practice [Nutley practice . This paUpon developing a new educational program it is important to describe a coherent theoretical framework that explains why and how the program is expected to work. The framework can be then used in an analysis of change—to suggest explanations for why some components worked well together and to identify those components considered to be most important for achieving the program’s learning objectives. Two pedagogical theories have been identified to explain change associated with the PEAK program. The PEAK program highlights the importance of small group achievement of specific tasks  and of independent and experiential learning situated in clinical practice (adult learning theory).Further, two complementary and theoretically compatible KT frameworks were chosen to integrate contemporary understanding of research utilization at the organizational level into the PEAK program. Both frameworks emphasize that local culture and structures will impact the way in which knowledge is implemented. The KTA framework emphasises the importance of both securing leadership and resource support and adapting recommendations with consideration for the local context. The PARiHS framework suggests that successful implementation will only occur when the evidence is robust, when practitioners can access the evidence and agree with it, and when the intervention occurs within a context that is receptive. Additionally, careful planning of the facilitation process is required for participants to integrate the evidence in their local context . FinallyThe multifaceted and participant-driven nature of the PEAK program makes it an inherently complex intervention . Recent This first of two companion papers describes the underlying pedagogical theories, KT frameworks, and research evidence used to derive the PEAK program – an educational program designed to promote the use of research evidence to inform physical therapist practice. The four components of the program are described in detail to support future evaluation and replication of the program. A companion paper reports the result of a mixed methods feasibility analysis of this program.The authors declare that they have no competing interests.JKT and SM contributed equally to the writing of this manuscript. Both authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/14/125/prepubBest Practices List generated by PEAK participants: “University of Southern California Best Practices List: Physical Therapy for Lumbar Spine Conditions”.Click here for file


Moreover, growing evidence suggests a key role of intracellular CuAOs and PAOs in several facets of plant development. Here, we discuss recent advances in understanding the contribution of different CuAOs/PAOs, as well as their cross-talk with different intracellular and apoplastic metabolic pathways, in tissue differentiation and organ development.Plant polyamines are catabolized by two classes of amine oxidases, the copper amine oxidases (CuAOs) and the flavin adenine dinucleotide (FAD)-dependent polyamine oxidases (PAOs). These enzymes differ to each other in substrate specificity, catalytic mechanism and subcellular localization. CuAOs and PAOs contribute to several physiological processes both through the control of polyamine homeostasis and as sources of biologically-active reaction products. CuAOs and PAOs have been found at high level in the cell-wall of several species belonging to Fabaceae and Poaceae families, respectively, especially in tissues fated to undertake extensive wall loosening/stiffening events and/or in cells undergoing programmed cell death (PCD). Apoplastic CuAOs and PAOs have been shown to play a key role as a source of H In Arabidopsis thaliana 10 CuAO genes are present, among which only eight encode for putative functional CuAOs AtCuAOε1  and AtCuAOε2  are consecutive fragments of a copy of AtCuAOδ gene. Phylogenetic analysis evidenced that plant CuAOs form three clades (I-III), clade I being composed of three subgroups (Ia-Ic) and clade II of two  putrescine (Put), cadaverine (Cad), spermidine (Spd), spermine (Spm), and thermospermine (Therm-Spm) are involved in several physiological processes, such as cell proliferation, differentiation and defense responses  are localized in the apoplast  and the other members of clade III in peroxisomes , AtCuAOγ1 (clade IIa) as well as Nicotiana tabacum CuAO1 (NtDAO1), oxidize mainly Put, Cad, and Spd , which shows preference for N-methyl-Put and is involved in nicotine biosynthesis, although all three proteins are clustered together in clade III  was shown to produce Nor-Spd from Therm-Spm , which are localized intracellularly and show an -AtPAO5, 2O2; hydroxyl radical, •OH; singlet oxygen, 1O2) and nitric oxide (NO) in orchestrating developmental processes, as well as in being involved in signaling of both local and systemic defense responses in plants. The apoplast is a major “hub” for these chemical species. Their accumulation in large amounts and the complexity of the regulatory mechanisms involved in their biosynthesis reflect the peculiar role of this compartment in physiological events that depend on temporarily regulated and spatially restricted ROS and NO signatures , transition metal ions and H2O2 -mediated NO production  distribution  in plants , which is clustered together with AtCuAOδ in clade IIb, was attributed to the implication of PA metabolism in physiological processes taking place during fruit ripening , are controlled by Therm-Spm and Spm  and an AtPAO5-like (GhPAO4) PAO may play a crucial role in the generation and differentiation of embryogenic callus during somatic embryogenesis  have a role in shoot regeneration from root cultures (Lim et al., Some studies suggest that in CuAO and PAO gene families regarding catalytic activity, subcellular localization, expression pattern and physiological roles of the encoded proteins. Indeed, important links to developmental and stress-related events are emerging for CuAOs and PAOs through ROS/NO production and regulation of specific PA levels.Numerous recent studies have evidenced an extraordinary complexity in All authors listed, have made substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Research has documented severe mental health problems in female victims of intimate partner violence (IPV). Therefore, providing effective treatment is pivotal. Few studies have investigated the effects of intervention programs on reducing the harmful consequences of IPV.The present study examined the effects of a specific three-phase intervention program for female victims of IPV on psychological symptoms  and perceived social support. Given that many of the women dropped out before and during the intervention program, potential differences in initial levels of psychological symptoms, perceived social support, as well as descriptive variables were explored between the women who completed the whole program and the groups of women who dropped out prematurely.The initial sample consisted of 212 female victims of IPV. Symptoms of PTSD, depression, anxiety, and level of perceived social support were measured with validated scales before the start of the intervention and after completion of each treatment phase.Results showed a significant effect of the intervention program on reducing psychological symptoms and increasing levels of perceived social support. Effect sizes ranged from medium to very high. Significant positive effects were found for each of the treatment phases. There were no significant differences between the women who completed the whole program and those women who dropped out prematurely in terms of initial level of symptoms and perceived social support as well as descriptive characteristics.Specifically developed intervention programs for female victims of IPV are effective in reducing the harmful personal consequences of IPV. Future studies should consider employing controlled study designs and address the issue of high drop out rates found in intervention studies. Intimate partner violence (IPV) is a global problem of tremendous proportions. The World Health Organization (WHO) estimates that 10–50% of women experience physical or sexual abuse by their partner at some point in their lives. Estimations show that 28,000 Danish women between the ages of 16 and 64 years are exposed to IPV during the course of a year . We know of only a couple of studies that have investigated the effect of the TRG method on reducing psychological symptoms. In two quantitative studies, Mendelsohn et al. . The program initially included 212 female victims of IPV (and their children) who had left their violent partner. The program was based on the work of Mendelsohn et al.  who deven et al.  found thand its three individual phases on psychological symptoms  and perceived social support among female victims of IPV. Given that many of the women dropped out of the intervention program before (n=75) and during the treatment (n=67) course, the second aim of this study was to examine possible differences in the initial level of psychological symptoms, perceived social support, and descriptive variables (including demographic characteristics and exposure to violence) between those who dropped out prematurely and those who completed the whole intervention program.The intervention program in the present study consisted of three separate phases: a stabilization-, a treatment-, and a follow-up phase. The first aim of the study was to examine the effects of the overall intervention program The initial sample consisted of 212 female victims of IPV. Seventy-five women dropped out of the program before it started and another 67 women dropped out during the course of the treatment. All included women were in contact with the organization MA that helps vulnerable women and their children. They were referred to a special MA intervention program called “Out of the Shadows of Violence” (OSV), which was aimed at helping female victims of IPV and their children. The women were recruited for the program through the general support initiative of MA as well as information brochures distributed to crisis centers for women, emergency departments, and public support centers.IPV was defined in the present study as any abuse of power by one partner against the other partner in an intimate relationship. It referred to events where one partner dominated, controlled, violated, or victimized the other partner physically, emotionally, and/or sexually. In order to be considered eligible for the intervention program, the women had to have left their violent partner, expressed a desire to move on with their lives following the violent relationship, and have one or more children in the age group of 0–12 years and be able to speak Danish. Furthermore, they were not allowed to participate in any other treatment program throughout the duration of the project.The intervention program in the present study was based on the TRG method and the traumatic treatment approach presented by Mendelsohn et al.  and HermThe overall aim of this stabilization program was to provide the woman with a sense of control over her physical safety as well as her psychological and social situation. More specifically, this program aimed to stabilize the woman's psychological symptoms as well as her financial and economic situation and to provide her and her child/children with physical safety and legal aid. The length of the stabilization program varied from 1 to 12 individual sessions depending on the individual needs of the woman. All sessions were carried out by social workers.The stabilization program was created due to the fact that many of the women suffered from severe psychological symptoms that resulted in them being unable to profit from standard psychological intervention programs that focus on the processing of traumatic experiences and subsequent reactions. For example, many of the women engaged in self-harming behavior and many women were unable to protect themselves against their former partner's ongoing physical and psychological violence.An example of specific components of the stabilization program was psychoeducation about psychological reactions to trauma and the rebuilding of everyday routines. In cases where the women were still being exposed to abuse from their former partner, the focus of the stabilization program was to secure them a new place of residence and to help design a potential escape plan, if necessary. With regards to social problems, example of specific actions in the stabilization program was to help the women get to a new residence, to acquire control over her financial situation, and to gain custody of their child/children. Another aspect of the stabilization program was to determine whether the women needed individual- or group treatment.Upon completing the stabilization program, the women went on to participate in the treatment program, which consisted of either individual- or group therapy. Individual sessions (with a psychologist) were offered to those women who did not want to or who were deemed unsuitable to participate in group sessions. The aims of the individual sessions were to help the women process traumatic experiences, to reduce their psychological symptoms, to provide them with a better understanding of their child's (children) situation, and to enhance their ability to talk with the child (children) about the violence. The length of the individual treatment varied from 1 to 12 sessions depending on the needs of the woman. Sessions were generally scheduled to every 14th day, but were scheduled more frequently in special circumstances. Each session lasted between 1 and 1½ hours.Group sessions were offered to women who wanted and were deemed suitable to participate in group treatment. The aims of the group sessions were to help the women to process traumatic experiences, to reduce psychological symptoms as well as feelings of guilt, shame, loneliness, and alienation. The group treatment consisted of 14 3-hour sessions scheduled once a week. The sessions were carried out by a psychologist and a social worker. The sessions were clearly structured; they had defined purposes and specific working tasks. All group members were obliged to actively participate in each session. The psychologist and social worker were responsible for ensuring that every group member had their own time to speak. They were also responsible for promoting the exchange of experiences and reducing potential conflict among group members. Each session started with a summary of what happened in the previous session. Thereafter followed the specific topic of the day, and, at the end of each session, the group members were asked to write down what they had learned. The sessions consisted of the following topics: introduction (session 1); the violent experiences (sessions 1–4); mental and physical consequences of the violence (session 5–9); the children's situation (sessions 10–12); the future (session 13); termination (session 14).The follow-up program aimed to maintain the positive changes displayed by the women and to support them in their new lives without their abusive partner. The follow-up program consisted of 2–4 individual sessions for the women who had completed individual treatment and three group sessions for the women who had completed group treatment. The follow-up sessions took place during the first 6 months after the treatment had been completed. The follow-up sessions focused on the psychological well-being of the women as well as their relationships with their children and former abusive partners.Data on PTSD severity, depressive and anxiety symptoms, and perceived social support were gathered from all the women during the OSV project period. This data collection represented part of an effort to evaluate the effectiveness of the overall intervention program and its individual intervention phases. Psychological data was gathered at four different time points: T1) before entering the stabilization program, T2) after completion of the stabilization program, T3) after completion of the treatment program, and T4) after completion of the follow-up program. Overall, 212 women were included in project OSV (T1) but 75 women dropped out of the project before entering the stabilization program. Consequently, 137 women completed the stabilization program (T2), 87 women completed both the stabilization and the treatment programs, (T3) and 70 women completed the whole intervention program (T4).The study was carried out in accordance with the ethical principles of the Declaration of Helsinki and all data were treated anonymously.DSM-IV. The answers are scored on a 4-point Likert-type scale . The Danish version of the HTQ has shown good reliability and validity  on psychological symptoms and perceived social support. Effect sizes were calculated using Cohen's d.Paired sample In order to explore potential differences between the different attrition groups and the group completing the whole intervention, the study sample was divided into four groups. Group 1 consisted of women who dropped out of the intervention program before it started. Group 2 consisted of women who only completed the stabilization program. Group 3 consisted of women who completed the stabilization- and treatment programs. Group 4 consisted of women who completed the whole intervention program. A one-way between-groups analysis of variance was conducted to explore associations between baseline psychological symptoms, perceived social support, and level of treatment participation (groups 1–4). Due to groups having unequal sample sizes, Tukey HSD post-hoc comparisons were conducted to explore between group variations. Chi-square tests for independence were used to explore potential relationship between the descriptive variables represented in Descriptive characteristics and psychological symptoms before start of treatment of the whole study sample and the different treatment participation groups are presented in t-tests conducted on the data for the 70 women completing the whole treatment program revealed significant reductions in all psychological symptoms following the intervention program. Effects sizes were in the very high range, the highest being for anxiety symptoms. Paired samples t-test also revealed a significant increase in levels of perceived social support following the intervention program. The effect size was in the high range. Means (M), standard deviations (SD), t-values, and effect sizes are presented in Paired samples t-tests conducted on data for the women who completed the stabilization program revealed significant reductions in PTSD severity (t(103)=7.34; p<0.01, d=0.54), depressive symptoms (t(104)=6.29; p<0.01; d=0.56), and anxiety symptoms (t(109)=6.30; p<0.01; d=0.47) from before to after completion of the stabilization program. In addition, there was a significant increase in levels of perceived social support (t(113)=−9.18; p<0.01; d=0.82) from before to after completion of the stabilization program.Paired sample t-tests conducted on the data for the women who completed the treatment program revealed significant reductions in PTSD severity (t(78)=3.09; p<0.01; d=0.24), depressive symptoms (t(77)=5.16; p<0.01, d=0.56), and anxiety symptoms (t(76)=8.31; p<0.01; d=1.15) from before to after completion of the treatment program. There was no significant difference in levels of perceived social support.Paired sample t-tests conducted on data for all women who completed the follow-up program revealed significant reductions in PTSD severity (t(68)=2.31; p<0.05; d=0.26) and depressive symptoms (t(63)=2.93; p<0.01; d=0.37) from before to after completion of the follow-up program. There were no significant differences in anxiety symptoms and levels of perceived social support.Paired sample The development of psychological symptoms and levels of perceived social support throughout the individual intervention phases are illustrated in One-way ANOVA revealed no significant associations between levels of treatment participation and levels of psychological symptoms and perceived social support measured before the start of the intervention. Chi-square test of independence also indicated no significant associations between levels of participation and civil status, years of education, work status, violence frequency, and duration of violence exposure.d=0.88–2.16), and are similar to effect sizes in other treatment studies with female victims of IPV  and depression (d=1.59). However, the intervention program also had a high effect on symptoms of PTSD (d=1.19). These findings highlight the importance of not only focusing on PTSD symptomatology but also on levels of anxiety and depression when treating and investigating the harmful effects of IPV. One possible explanation for the very high effect sizes found in relation to anxiety and depression could be the frequency and duration of the IPV reported in this sample of women. In the present study, 95.4% of the women had lived with their violent partner for more than 1 year, and 75.3% of them had been exposed to violence on a daily or weekly basis. It is possible that PTSD symptomatology found in this sample of women was persistent rather than acute due to a prolonged period of trauma exposures, which is similar to situations known to trigger complex PTSD  in reducing psychological symptoms and in increasing levels of perceived social support among women formerly exposed to IPV. These results support findings from previous studies that report significant reductions in PTSD, depression, and anxiety in female victims of IPV following participation in intervention programs  and high for perceived social support (d=0.82). The stabilization program focused particularly on using ego-supportive techniques as opposed to the symptom specific treatment used in the treatment program, which may explain why a higher effect size was found for perceived social support than psychological symptoms. With regards to the treatment program, effect sizes ranged between low for PTSD (d=0.24) and high for anxiety (d=1.15) with depression situated in the medium range. With regards to the follow-up phase, the women reported further but smaller reductions in symptoms of PTSD (d=0.26) and depression (d=0.37). When comparing effect sizes across the three intervention phases, the lowest effect sizes were found for the follow-up phase. Even though the women received considerably less sessions in this part of the intervention program compared to the other phases, they still showed improvement on most of the outcomes measures. However, it is difficult to determine whether these improvements were due to the follow-up sessions or the result from the continuing effects of the earlier intervention phases. Furthermore, it is possible that time itself may have caused these positive outcomes given that this study had no control group to compare the results with.The present study also examined the effects of the individual treatment phases  of the intervention program on psychological symptoms and perceived social support. Aside from symptoms of anxiety, which did not reduce significantly after completion of the follow-up phase, the results revealed significant reduction in all other psychological symptoms following completion of each of the individual treatment phases. Levels of perceived social support only increased significantly following the completion of the stabilization program. With regards to the stabilization program, the effect sizes ranged between medium for PTSD severity (Many women dropped out of the intervention program both before and during the intervention program. Therefore, the present study explored whether there were any differences in the initial levels of psychological symptoms and perceived social support as well as descriptive characteristics between the women who completed the whole program and those who dropped out early. No statistically significant differences were found in the present study. Unfortunately, information on important variables such as age and the women's number of children were lacking in the present study. There appears to be a general problem with retaining victims of IPV in intervention programs given that other studies also report high drop-outs rates (Johnson et al., The results of the present study have to be interpreted in light of some limitations. Given that this study did not include a control group, it is difficult to determine whether the effects of the OSV program were due to the intervention itself or other factors such as the passing of time. However, assigning victims of IPV to a wait-list control group and denying them treatment poses serious ethical challenges, which must be taken into consideration when designing future intervention studies. A possible solution could be to use a “treatment as usual group” as a control group. This was unfortunately not an option in this study given that there are no standardized treatments for victims of IPV in Denmark at present.Another implication for future studies is that positive intervention effects have been found across different intervention methods. The treatment manual of the OSV program was founded in the theoretical and methodological reflections of Mendelsohn et al.  whereas Another limitation concerns the overall dropout rate of 33% of the participants in the present study, which limits the generalizability of the results. Thus, the results may not be representative for all of the women who were initially included in the program. However, no differences in initial levels of psychological symptoms and perceived social support as well as descriptive variables were identified between the groups of women with different dropout rates. This indicates that the final study sample was similar to the initially included sample in relation to these variables. Other intervention studies report similar or even higher dropout rates (Johnson et al., Specific intervention programs for female victims of IPV have shown to be effective in treating the harmful personal consequences following this trauma exposure. The current OSV program was found to significantly reduce the women's psychological symptoms across the intervention period. Furthermore, certain parts of the intervention program had a significant positive effect on the women's levels of perceived social support. The division of the intervention program into different phases proved successful given that positive effects were found for each treatment component in relation to the women's psychological symptoms. Future research needs to focus on investigating which types of intervention programs are most successful in reducing the harmful effects of IPV as well as the question on how to reduce dropout rates in intervention programs.


The impact of efforts by healthcare organizations to enhance the use of evidence to improve organizational processes through training programs has seldom been assessed. We therefore endeavored to assess whether and how the training of mid- and senior-level healthcare managers could lead to organizational change.We conducted a theory-driven evaluation of the organizational impact of healthcare leaders’ participation in two training programs using a logic model based on Nonaka’s theory of knowledge conversion. We analyzed six case studies nested within the two programs using three embedded units of analysis . Interviews were conducted during intensive one-week data collection site visits. A total of 84 people were interviewed.We found that the impact of training could primarily be felt in trainees’ immediate work environments. The conversion of attitudes was found to be easier to achieve than the conversion of skills. Our results show that, although socialization and externalization were common in all cases, a lack of combination impeded the conversion of skills. We also identified several individual, organizational and program design factors that facilitated and/or impeded the dissemination of the attitudes and skills gained by trainees to other organizational members.Our theory-driven evaluation showed that factors before, during and after training can influence the extent of skills and knowledge transfer. Our evaluation went further than previous research by revealing the influence—both positive and negative—of specific organizational factors on extending the impact of training programs. In healMany theorists have emphasized the need for increased attention to and mobilization of evidence-informed decision making (EIDM) to support management practices in healthcare organizations ,5. The uIn Canada, two national organizations—the Canadian Health Services Research Foundation (CHSRF) and SEARCH Canada—developed health service executive training programs focused on helping managers develop the skills needed to acquire, appraise, adapt and apply research results. On 5 November 2012 (after we had concluded our research), the Canadian for Health Services Research Foundation changed its name to the Canadian Foundation for Healthcare Improvement (CFHI). SEARCH Canada ceased operation on 30 September 2009, after we had begun our research. We decided, however, to pursue our SEARCH-related inquiries because the end of the program did not undermine the relevance of evaluating its organizational impact up to that terminus.The CHSRF’s Executive Training for Research Application (EXTRA) program, which is still ongoing, aims ‘to facilitate the spread of evidence-informed health system management throughout senior levels until a critical mass is achieved in the system’ . SEARCH We therefore conducted a theory-driven evaluation focused on understanding the organizational impact of having healthcare leaders take part in either EXTRA or SEARCH Classic. In our work, we interpreted those programs as novel knowledge conversion strategies that emphasize the reinforcement of organizational culture and knowledge use processes through the training of decision makers.In this article, we first describe the context of the two programs and the methods we used to evaluate their organizational impact. We then present our findings of their impact and assess the processes through which it occurred. Next, we discuss the contextual conditions that facilitated or impeded the use of new knowledge, and our final section summarizes the main points and principal lessons for organizational capacity building.Many resources have been allocated to enhance the use of EIDM in healthcare organizations. In 2004, the CHSRF developed the EXTRA program for senior managers in Canada. While it has evolved since then, it had two objectives at the time of our research in 2008: to increase the skills of health service professionals selected as EXTRA fellows in using research to manage Canada’s healthcare system more effectively; and to encourage health service professionals selected as EXTRA fellows to collaborate in the management of healthcare delivery.Designed to be a long-term initiative, EXTRA was expected to produce a significant number of motivated health service professionals who would be equipped with the skills required to use research in order to improve the quality and effectiveness of Canada’s healthcare system. EXTRA’s underlying—and still current—assumption is that the actions of and interactions among a substantial number of mid- and senior-level managers who have the skills, knowledge and desire to build organizational capacity for using evidence-informed knowledge should lead to a more systematic use of evidence in organizational decision making. This assumption likewise maintains that decision makers should also act as important agents of change within their organizations.The EXTRA program had, at the time of our research, five core components:1. Four away-from-home residency sessions.2. One or more intervention projects at a fellow’s home organization, proposed when he/she applied to the program (intervention projects were presented to expert panels and organizations’ chief executive officers (CEOs) during the final session).3. Educational activities between residency sessions.4. Network-building opportunities among faculty and other fellows during the program .5. Post-program support and activities aimed at building an EIDM community of practice.Self-directed learning was facilitated through the EXTRA Desktop. This was a customized internet-based learning platform that provided participants with an electronic classroom; a virtual library of online course software, databases, search engines, journals, and other resources, as well as a variety of Internet technologies; and a virtual environment for collaboration and dialogue with other participants, faculty and mentors. A post-program community of practice for fellows and organizations enabled EXTRA alumni to continue their professional development and to build networks of pan-Canadian decision makers and healthcare organizations with whom and through which to share knowledge and experiences in health services management and delivery.Until its termination in 2009, SEARCH Canada helped healthcare organization leaders apply new knowledge in an effort to make sound decisions. It did so by building strong collaborative relationships, sharing information and developing people. SEARCH Canada was committed to four main goals and practices: enhancing the growth of practicing professionals and applied researchers; collaborating with academic, service and government partners across the health system; working with both organizations and individuals; and working in ways that integrated capacity into the core business and activities of healthcare organizations.SEARCH Classic was an intense, two-year experience that combined learning opportunities through face-to-face modules, inter-module work and the application of knowledge to practice-based projects. The three pillars of the SEARCH curriculum were choosing evidence, creating evidence and using evidence.SEARCH Classic participants—called SEARCHers—came from across the Province of Alberta, and they had access to extensive knowledge management resources and tools. SEARCHers also relied on the support of a vibrant Alberta-wide network of talented individuals who championed the cause of applied research  and its application in healthcare organizations, and who remained connected to the program participants and continued to collaborate with them following the conclusion of their formal involvement with the program.Despite their local differences, the overarching aims of EXTRA and SEARCH Classic were the same: to enhance organizational capacity to use EIDM. Their main operating hypotheses were also similar: in the context of strong organizational commitment, individual training should lead to organizational use of evidence. Table Both EXTRA and SEARCH Classic were designed to influence participants’ skills and knowledge. However, the programs also were intended to have a wider impact, and were founded on the assumption that the diffusion of knowledge would occur within trainees’ organizations. In order to gauge the extent to which the latter came to fruition, we sought to answer three questions:1. What was the nature and extent of the impact on the organizations of having a number of mid- and senior-level managers trained through EXTRA or SEARCH Classic?2. What were the organizational processes through which the programs’ impact occurred?3. What were the contextual conditions that facilitated or impeded the programs’ impact?et al.’s Framework of Evaluative Inquiry as an Organizational Learning System , ‘What are some of the key issues we’re facing? What research would you like to see? What might be of interest? What are we already started on and could we finish with?”In addition, our analysis showed that the following conditions appear to affect socialization:An individual’s leadership skills: These refer to an individual’s ability to motivate people to use EIDM. For example, one person talking about his EXTRA-fellow colleague said, ‘I'll give him credit, he will put pen to paper and get things out and publish something. … He brings that passion that just gets me fired up.’An individual’s role (mid- or senior-level manager): Trainees’ managerial roles seemed to affect the intensity of the socialization process. Some trainees had central roles in their organization, while others were not perceived as change agents. For example, one trainee did not hold a senior administrative position; instead, he came from the medical sector, and we can assume he had fewer opportunities to socialize with other colleagues and administrators. He reported, ‘I thought it would be fairly easy, but it was actually quite difficult. It was seen as an imposition.’Training program structure: Program structure includes delivery mode, instructional style and content. According to many trainees, program structure had an effect on the socialization process. More specifically, some perceived that management and leadership training helped them engage with other colleagues; for example, one person said, ‘I think the skills I learned were more the administrative people management. The change management stuff was just great! … That’s probably been my biggest benefit from the EXTRA program.’Existence of a collaborative network: In some organizations, people had robust collaborative networks. The programs also enhanced collaboration between colleagues and helped foster new networks. One person noted, ‘We had [a] network … within our small group. … So that you do feel like you can ask someone, you don’t feel like you’re lost or you can’t go ahead. I think that’s part of that confidence.’e.g., literature review for SEARCH) was seen by several participants to contribute to the opportunities to externalize their skills and knowledge:As evidence of externalization, we looked to see whether EXTRA fellows and SEARCHers found formal opportunities—vehicles that would enable fellows and SEARCHers to voice their engagement with EIDM and to demonstrate their skills—to communicate with their colleagues about their attitudes and skills. Those formal opportunities could include meetings, seminars, presentations and publications. Externalization would also, we believed, be useful for transferring attitudes; in that light, intervention projects would provide good externalization opportunities. All the EXTRA fellows and SEARCHers made presentations about their individual or group projects; however, we observed that the externalization process was stronger with EXTRA projects. The nature of a particular project : decentralization of the decision-making process, which ensures more people are able to use EIDM.As evidence of internalization, we looked for changes in the practice of EIDM in organizations, whereby individuals other than the EXTRA fellows and SEARCHers employed EIDM. While we found changes in attitudes toward EIDM in the organizations we studied, it was much harder to detect evidence of skill conversion. Based on our findings, we conclude that the following conditions affect internalization: learning processes and practices; an organization’s skills and knowledge resources; and CEO leadership in promoting EIDM.In our research, we sought first to determine the nature and extent of the impact on an organization of having a number of mid- and senior-level managers trained through the EXTRA and SEARCH Classic programs. We hypothesized that individual learning could spread within an organization through the interaction of tacit and explicit knowledge via four modes of knowledge conversion. We found that the impact could primarily be felt in close circles; that is, in trainees’ immediate work environments. Our results showed a change in the language used by colleagues and a new awareness and sensitivity about the use of evidence in decision making. The conversion of attitudes was found to be easier to achieve than the conversion of skills.et al.’s [Our project also analyzed—again through the four modes of knowledge conversion—the organizational processes by which a training program’s impact occurs. Our results show that, although socialization and externalization were common in all cases, a lack of combination impeded the conversion of skills. However, some degree of combination did occur in cases where the trainees were able actively to involve others in the process of using EIDM. This finding is compatible with Nonaka et al.’s  view of We also identified several individual, organizational and program design factors that facilitated and/or impeded the dissemination of the attitudes and skills gained by trainees to other organizational members Table . Among te.g., skills, leadership, centrality in their organizations, personal networks) affected their capacity to drive the four modes of knowledge conversion and to transfer attitudes and skills to others.1. The individual characteristics of EXTRA fellows and SEARCHers . Our results show that the number of people trained is not a sufficient condition to assure organizational dissemination of knowledge. We also revealed several limitations of the EXTRA and SEARCH Classic program assumptions. To begin with, the transfer of attitudes was achieved when EXTRA fellows and SEARCHers held central and/or leadership positions in their organizations. In addition, on the rare occasions it occurred, skills transfer was limited to the close circle around a fellow or SEARCHer. Extrapolating from this finding, we conclude that a high number of program participants may be required to achieve an organization-wide transfer of EIDM skills, but will in and of itself not be a sufficient condition for success. Involvement of other people in an organization, as well as high quality, active communication, seems to be essential for organizational changes to occur.Our research did not show a distinction in knowledge conversion between mid- and senior-level managers. The main determinant affecting knowledge conversion seemed to be the centrality of the trainees’ positions within their organizations. For knowledge conversion to occur, a trainee had to be in a role that involved a high degree of social interactions, to be directly involved in decision making and to be exercising leadership.We also uncovered the critical role played by organizational resources. According to our findings, rural organizations benefited the most from having managers enrolled in training programs. That was because those programs provided continuing education opportunities in regions that had no other such opportunities (which is not the case in larger urban centers). As well the programs drove the development of research projects specific to rural regions.The EXTRA program enrolled both individuals and teams. In this respect, our comparative analysis showed that simultaneously training multiple individuals from the same organization and having them work together on a project focused on achieving a common goal seems to provide more opportunities to socialize, externalize and combine knowledge.Knowledge Creation in Healthcare Organizations as a Result of Individuals’ Participation in the EXTRA and SEARCH Programs. Ottawa: Canadian Foundation for Healthcare Improvement; 2011.The data sets supporting the results of this article are available in the following report: Champagne F, Lemieux-Charles L, MacKean G, Reay T, Suarez-Herrea JC, Dubois N, Duranceau MF: CEO: Chief executive officer; CFHI: Canadian foundation for healthcare improvement; CHSRF: Canadian health services research foundation; EIDM: Evidence-informed decision making; EXTRA: Executive training for research application; SEARCH: Swift, efficient application of research in community health.The authors declare that they have no competing interests.FC, LLC, GMK, and TR were responsible for the conception of the study and, together with MFD, planned the process analysis. FC, LLC, and MFD formulated and composed the questionnaires. MFD performed the daily work associated with study inclusion and data collection. All authors were involved in writing the manuscript and all authors read and approved the final version.


The Weight Disorder Unit at Flinders Medical Centre was established in 1977 and in June 2014, the service was expanded under a rebranded name, the South Australian Statewide Eating Disorder Service (SEDS). Now, besides its inpatient unit, SEDS also has outpatient services and an eating disorder Day Program. This is the first Day Program in South Australia and besides providing nutritional support, the Day Program also focuses on helping participants to challenge disordered eating behaviours and thought patterns through group-based therapeutic interventions. To be admitted into the SEDS Day Program, clients need to be at least 15 years of age, have a Body Mass Index (BMI) of 15 and above and be medically stable. In order to gain a better understanding of the profile of clients that get admitted to day programs and the effectiveness of the Day Program, we plan to present the clinical profile of the participants and information collected from the SEDS Day Program. Information presented will include sociodemographic and medical information, information collected from clients' psychological assessments pre, post and 3 months follow-up after completion of the Day Program, and the retention rate of the Day Program participants.