Social marketing integrates communication campaigns with behavioural and environmental change strategies. Childhood obesity programs could benefit significantly from social marketing but communication campaigns on this issue tend to be stand-alone.A large-scale multi-setting child obesity prevention program was implemented in the Hunter New England (HNE) region of New South Wales (NSW), Australia from 2005–2010. The program included a series of communication campaigns promoting the program and its key messages: drinking water; getting physically active and; eating more vegetables and fruit. Pre-post telephone surveys (n = 9) were undertaken to evaluate awareness of the campaigns among parents of children aged 2–15 years using repeat cross-sections of randomly selected cohorts. A total of 1,367 parents  participated.At each survey post baseline, HNE parents were significantly more likely to have seen, read or heard about the program and its messages in the media than parents in the remainder of the state (p < 0.001). Further, there was a significant increase in awareness of the program and each of its messages over time in HNE compared to no change over time in NSW (p < 0.001). Awareness was significantly higher (p < 0.05) in HNE compared to NSW after each specific campaign (except the vegetable one) and significantly higher awareness levels were sustained for each campaign until the end of the program. At the end of the program participants without a tertiary education were significantly more likely (p = 0.04) to be aware of the brand campaign (31%) than those with (20%) but there were no other statistically significant socio-demographic differences in awareness.The Good for Kids communication campaigns increased and maintained awareness of childhood obesity prevention messages. Moreover, messages were delivered equitably to diverse socio-demographic groups within the region. Television advertising is a powerful medium, able to influence behaviour change by providing information in a relevant and engaging way . It has Given international concerns about obesity prevalence,  communicThe Good for Kids program was one of several concurrent child obesity prevention strategies implemented in NSW following a 2002 Obesity Summit that set the state agenda for obesity prevention efforts. At the time of its initiation, the program represented Australia’s largest ever community based child obesity prevention program. Following a competitive NSW Government selection process, core funding of $1.5 million per annum (2006–2010) was provided to the Hunter New England Area Health Service (HNEAHS) to conduct a dissemination program that addressed child overweight and obesity and contributed to evidence for policy and practice in the HNE region of NSW, Australia. The multi-setting program was implemented in partnership with a broad range of government, non-government and private organisations. To increase effectiveness, the program linked setting-based policy and practice change with awareness raising. Given the complexity of the intervention design, it was not possible to attribute the behavioural changes observed in Good for Kids directly to the social marketing components. However, we were able to make a direct link between the communication campaign and awareness. The objective of this study was to describe the effectiveness of the Good for Kids communication campaign in raising awareness of child obesity prevention messages among parents and carers of children and to describe demographic associations with awareness.A controlled pre-post study was undertaken to evaluate awareness of the child obesity prevention program and its communication campaigns and messages using repeat cross-sections of an existing cohort of parents. Written informed consent was obtained from all parents and the program and its evaluation were approved by the Aboriginal Health and Medical Research Council (637/08) and the HNE Human Research Ethics Committee (HNEHREC 06/07/26/4.04).The study was set in the Hunter New England region of New South Wales, Australia. The region is geographically large with a diverse population of approximately 180,000 children aged up to 15 years. Its population resides in metropolitan, urban and suburban areas, regional centres, and rural and remote communities . The regParents of children aged 2–15 years across NSW who had participated in a baseline random digit telephone survey for the program and who agreed to be followed up at a later date were eligible to participate in the study . Parents in this cohort were randomly selected for a series of repeat cross-sectional telephone surveys conducted before and after each of the communication campaigns. There were nine surveys in all corresponding to five mass media campaigns that were implemented during the program. The cohort was recycled from survey five onwards  and the remainder were in the comparison group (those who resided in NSW but outside of the HNE region).The Good for Kids program targeted children 2 to 12 years of age and was implemented in partnership with a broad range of government, non-government and private settings including child care services, schools, health services, sporting organisations and Aboriginal organisations. The program supported policy and practice changes conducive to healthy eating and physical activity among children. Five years after its commencement, and compared to the remainder of the state, the program was associated with: a significantly greater adoption of such policies and practices by settings in the HNE region and a significant reduction in girls 5–10 years who were overweight/obese.The Good for Kids social marketing strategy was built around key behaviour change messages that were consumer tested and aired via TV, radio, print and other media such as childcare and school newsletters. The key messages and the timing of their delivery coincided with the long term behaviour change objectives of the program: drinking water instead of sweetened drinks; increasing physical activity; reducing sedentary behaviour; and increasing vegetable and fruit consumption. These messages were summarised in an initial branding campaign and promoted more extensively in separate campaigns for each message. The messages and their delivery were developed and planned using social marketing theory and focus group testing -22.In September 2006, a social marketing workshop was held to establish the fundamental features of the Good for Kids strategy including program name, brand, messages and imagery. During the workshop, key stakeholders reviewed issues relating to childhood obesity, healthy eating and physical activity as well as existing social marketing strategies focused on similar subjects. Stakeholders considered the goals and objectives of the Good for Kids program, discussed key messages which had the potential to counter possible barriers to change, identified target audience segments and identified the most suitable channels for the implementation of the strategy. Information from the workshop became the basis of a product description brief that was sent to three commercial creative agencies. Agencies were invited to submit proposals to create the name, brand, messages and imagery for Good for Kids. The proposals received were tested in target audience focus groups including Aboriginal communities. A panel of program staff and stakeholders selected the successful proposal based on how well it captured the intent of the program. In the focus group testing conducted by a market research agency, the proposal that presented the “Good for Kids” concept was found to the most convincing and motivating for both parents/ carers and children aged 12–15 years.The target audience was segmented into children up to 12 years of age ; Aboriginal children up to 12 years of age and; parents and carers (grocery buyers aged 25 to 54 years) in the Hunter New England region of NSW. Grandparents, childcare workers, school teachers, sports coaches and health professionals and community members whose actions and advice influence children’s choices were a secondary target audience and were also considered in the development of the social marketing strategy.Good for Kids branding and messages were delivered to the target audience via five campaigns from 2007 to 2010  which doubled the program’s television advertising placements;. The peak to off-peak split for Good for Kids TVCs was 70:30 and 60:40 for the rerun campaign. Similar deals and coverage arrangements were sought, and in most cases achieved, with radio and print media outlets across the region. Table In addition to advertising activity, the program also benefited from branded promotional items such as water bottles; magnets; stickers; temporary tattoos; tennis balls; healthy shopping list templates; and various forms of physical activity equipment. These items were devised to encourage and support positive behaviour change. Good for Kids also gained regular editorial coverage throughout the regions many media outlets and had a presence at various community events in the Hunter New England region.In 2009, towards the end of Good for Kids, a culturally appropriate communication campaign targeting Aboriginal audiences was developed. This campaign relied on direct communication activity, as well as a series of radio advertisements covering Good for Kids program messages. The radio campaign was aired through stations and programming for Aboriginal audiences. Due to the costs associated with finding a sufficiently large sample of people in this niche market using computer-assisted telephone interviews, the campaign was not formally evaluated.Other communication campaigns promoting healthy eating and physical activity and sponsored by government were running during the intervention period in both the intervention and comparison areas and may have also played a role in raising awareness of physical activity and nutrition issues in the Hunter New England region. This included the ‘Get Moving’ campaign 2006) funded by the Federal Government, which sought to encourage children to be more active and NSW Health ran campaigns promoting fruit and vegetable consumption 2007) and water consumption (2008) [ funded b and wateQuestions were developed by Good for Kids staff to evaluate the communication campaigns using computer-assisted telephone interviews. They included measures of socio-demographics, program awareness, campaign awareness, and awareness of campaign messages. Program awareness was assessed using a prompted recall question that asked participants if they had ‘…recently seen, read or heard anything about the Good for Kids program in the media?’ (yes/no). The question covered all forms of media implemented. Campaign awareness was assessed using questions that drew on the content of the advertisement to prompt recall. For example, the TV awareness question for the water campaign was, ‘Do you remember recently seeing a television advert with up beat music and lyrics with images of glasses being filled with juice and water?’ (yes/no). For campaign awareness, only TV is reported. To assess awareness of specific campaign messages, a range of potential messages were read out and participants were asked to select the correct one. Correct messages were that children should: drink water instead of sweetened drinks; be more active in play and sport and cut down on small screen recreation and; eat more vegetables and fruit.Analyses were performed using SAS software Version 9.2 . Logistic regression within a generalised estimating equation framework was used to assess change in program, campaign and message awareness over time in HNE compared to NSW. For each region, a model was run to assess change from pre- to immediately post-campaign and from pre-campaign to the end of the program. Models had terms for time, region and the interaction of time and region. The p-value from the interaction term was used to determine if there was a statistically significant change in awareness between regions over time. The regression models adjusted for differences in socio-demographic characteristics , educational attainment and rural living) between the regions. Data from the final telephone survey was used to assess bivariate associations between program awareness and awareness of each of the campaigns with the socio-demographic characteristics of gender, age (<40 years cf. >40 years), locality, , education (tertiary cf. secondary or lower) and ethnicity  using chi square. All statistical tests were 2-tailed with an alpha of 0.05.Of the 1,595 parents or carers who agreed to be called back at the initial survey , 1367  participated in the surveys, giving an overall response rate of 86%. The majority of participants in the telephone surveys were female (80%-87%). For most surveys, HNE participants were significantly (p < 0.05) more likely to have been born in Australia, to be living in a rural area and to have lower levels of educational attainment than their NSW counterparts .The brand, water, physical activity and vegetable campaigns achieved 41%, 37%, 60% and 32% post-campaign awareness respectively in HNE compared to 14%, 10%, 21% and 22% in NSW  to the end of the program (survey nine) were significantly greater in HNE compared to NSW (p for interaction terms < 0.05). In HNE, awareness of the water campaign decreased over time.The proportion of participants who correctly identified the main message of the water, physical activity and vegetable campaign is shown in Figure HNE participants were significantly (p < 0.001) more likely to identify the main water and physical activity messages, but not the vegetable message, immediately post-campaign compared to the rest of NSW participants. By the end of the program however, HNE participants were significantly more likely to identify all three key messages (p < 0.001). In spite of higher message identification in HNE, based on the time by region interaction terms, there were no significant differences in change over time in message awareness between the regions.The findings show that the Good for Kids communication campaign effectively raised program awareness in the Hunter New England region. By the end of the program the brand, water, physical activity and vegetable campaigns were all effective and, after each campaign, parents in HNE were more likely than parents in NSW to identify the campaign messages that: children should drink water instead of sweetened drinks; be more active in play and sport, and cut down on small screen recreation and; eat more vegetables and fruit. There was also evidence that awareness of the program and campaigns reached all socio-demographic groups.The awareness levels achieved in this study were similar to or higher than those achieved by other Australian government campaigns. For example, unprompted recall of the Get Moving campaign increased from 10% to 43%,  and recaOther programs targeting obesity have also used mass media to raise awareness, achieving similar or higher levels of awareness than observed in Good for Kids. The United States Centres for Disease Control used a multi-setting social marketing campaign called VERB to promote physical activity among youths (aged 9 to 13 years) nationally . Campaighttp://www.parentsjury.org.au) award for the best marketing campaign to promote healthy eating or physical activity to children. In addition, all program communication included an action point for the audience to visit the program website for further resources and information. The website http://www.goodforkids.nsw.gov.au played a crucial role as a platform for the many program audiences and stakeholders to interact with the program. The program website was also linked to and from other relevant stakeholder sites to gain further exposure for the program.To achieve high levels of community awareness, Hornik and Kelly emphasize the importance of obtaining high levels of exposure for messages . They noBy using a mix of media  as well as donated (CSAs) and earned exposure , Good for Kids partly overcame the limitation of having its television advertisements aired on only one station. Based on an independent assessment of the campaigns by Mediacom (a Sydney based media company) the target audience rating points (TARPS) for each of the campaigns achieved or exceeded (by 45-50%) what was planned for based on that anticipated by the media expenditure (data not shown). This meant that, due to CSAs, more of the target group of grocery buyers aged 25–54 years were exposed to the television advertisements than was paid for by the program. In accord with communication  the GoodThere are several limitations that should be kept in mind when considering these findings. Firstly, the campaigns were not controlled over time (i.e. one campaign may have influenced awareness of another). This may explain the high baseline awareness of the water campaign in Hunter New England region Figures  and 4. TThrough the Good for Kids communication campaign, high levels of awareness were achieved and maintained and parents of all socio-demographic groups picked up the main messages. For future population-based childhood obesity prevention programs these finding suggest that media can be harnessed to increase awareness of healthy eating and physical activity messages, that media may assist in raising awareness among hard-to-reach groups, that a series of related campaigns can build program awareness and that despite their limitations, panel methods are a viable and cost-effective tool for campaign evaluation.The authors declare that they have no competing interests.ACB contributed to the design of the study, study implementation and coordination and drafted the manuscript. LW, RS, LC, KY, RH and NO contributed to the implementation and coordination of the study and helped to draft the manuscript. MF performed the statistical analysis. AJM contributed to the development of the survey instruments and helped draft the manuscript. JW contributed to the design of the study, its implementation and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.


SweTree Technologies is a plant and forest biotechnology company providing products and technologies to improve the productivity and performance properties of plants, wood and fiber for forestry and fiber related industries.Eucalyptus and Populus elite clones. Another crucial part of a practical tree biotechnology program is to test the GM trees with commercially interesting genes under field conditions. We have initiated field trials and plan to have over 35 different types of transgenic trees in field trials by the end of this year. These field experiments are performed by SweTree or in collaboration with academic partners. The importance and requirements for elite clone transformation and field trials will be discussed in the presentation.In the area of Biotech Trees, we have been testing and developing genes and biotech trees. Since 2002 we have successfully screened well over one thousand genes in our gene testing program. The program has been mainly directed towards increased growth, improved wood properties and stress tolerance. The current outcome of this program will be presented. The primary gene developing program is performed in hybrid aspen for which we have a very efficient transformation protocol. However for practical tree biotechnology the genes and DNA constructs have to be transformed into the best commercial clones. Therefore we have been setting up efficient transformation protocols for both


Sustained employability and health are generating awareness of employers in an aging and more complex work force. To meet these needs, employers may offer their employees health surveillance programs, to increase opportunities to work on health and sustained employability. However, evidence for these health surveillance programs is lacking. The FLESH study  was developed to evaluate a comprehensive workers’ health promotion program on its effectiveness, cost-benefit, and process of the intervention.The study is designed as a cluster randomised stepped wedge trial with randomisation at company plant level and is carried out in a large meat processing company. Every contracted employee is offered the opportunity to participate in the POSE program (Promotion Of Sustained Employability). The main goals of the POSE program are 1) providing employee’s insight into their current employability and health status, 2) offering opportunities to improve employability and decrease health risks and 3) improving employability and health sustainably in order to keep them healthy at work. The program consists of a broad assessment followed by a counselling session and, if needed, a tailored intervention. Measurements will be performed at baseline and will be followed up at 20, 40, 60, 80, 106 and 132 weeks. The primary outcome measures are work ability, productivity and absenteeism. Secondary outcomes include health status, vitality, and psychosocial workload. A cost-benefit study will be conducted from the employers’ perspective. A process evaluation will be conducted and the satisfaction of employer and employees with the program will be assessed.This study provides information on the effectiveness of the POSE program on sustained employment. When the program proves to be effective, employees benefit by improved work ability, and health. Employers benefit from healthier employees, reduced sick leave (costs) and higher productivity. The study can expose key elements for a successful implementation and execution of the POSE program and may serve as an example to other companies inside and outside the industry.http://www.trialregister.nl): NTR3445The trial is registered at the Dutch Trial Register ( Sustained health takes a prominent place in daily life and work. (Temporary) inability to work optimally due to health problems causes high productivity loss, and poses a great burden on individuals and society ,2. This The growing proportion of older people in the labour force stresses the need for new policies and programs to assure sustainable employability and to decrease the financial burden. Sustainable employability is defined as employees having the opportunity to perform work with preservation of health and wellbeing during their working life, now and in the future . It is cTo prevent long term sickness and work disability, risk inventory and evaluations (RI&E) have been introduced at the workplace. One of the outcomes of a RI&E is a plan to minimize potential risks for both employee and employer. In 2009 and 2010, the Dutch Labour Inspectorate performed nationwide inquiries at multiple meat processing companies. The main risk factors identified for sustained employability were related to job demands and job design , and contextual factors  ,16. PersTo promote sustained employability, workers’ health surveillances (WHS) have been developed with the aim of promoting sustained employability and health, and of reducing medical costs . A WHS pThe POSE program (Promotion Of Sustained Employability) was developed using elements from occupational and rehabilitation medicine. Elements from occupational medicine are e.g. WHSs, and interventions aimed at a healthy lifestyle. Elements from rehabilitation medicine are e.g. FCE, and interventions aimed at improved physical capacity. The POSE program offers employees a custom-made risk profile and, if necessary, an intervention plan using an integral approach . The goaThe purpose of the FLESH study is to evaluate the effectiveness and cost-benefit of the POSE program on work ability, productivity, and sickness absence among employees in the meat processing industry, compared to care as usual (CAU). The secondary aims are to improve perceived psychosocial and physical workload, health status, and vitality. Along with these evaluations a process evaluation will be conducted among employees and other stakeholders. The objective of this paper is to present the study protocol used in the FLESH study in which the following research questions will be addressed:1) Does the POSE program improve the primary outcome measures work ability, absenteeism and productivity compared to CAU?2) Does the POSE program improve the secondary outcome measures psychosocial workload, physical workload, subjective health status and vitality compared to CAU?3) Is the effectiveness of the POSE program influenced by age, program adherence, risk category, or motivation of management?4) To what extent do the applied methods appeal to the needs of the involved stakeholders (intervention acceptability)?5) Is the implementation of the POSE program cost beneficial from the employers’ perspective?The CONSORT statement was used in order to describe the design of this study ,23.This study is designed as a stepped wedge trial with a follow-up of one year. The design is presented in Figure Out of the 15 potentially available plants in The Netherlands, five plants fulfilled the inclusion criteria for the FLESH study. Inclusion criteria were having sufficient employees (n) and having budget for POSE program implementation. The order of inclusion in the study was randomly assigned.All contracted personnel (n ≈ 1000) are invited by letter to participate in the POSE program at their plant. Personnel is divided into: 1) production personnel and technical services; 2) facility services; 3) staff and office personnel.Employees are eligible for the FLESH study when they:– are contracted personnel.– perform paid labour for at least 12 hours per week at the meat processing company .– agree to participate in the POSE program.– provide informed consent to participate in the study.0, the employees at all five plants receive a baseline questionnaire. At T1, the POSE program is implemented at Plant A, the employees at the other plants serve as a control group and receive a follow-up questionnaire. At T2, the POSE program is implemented at Plant B, the program continues at Plant A, and Plant C, D and E serve as the control group, etc. T0 until T5 are separated by 20 weeks each. T6 and T7 serve as 6 months and 12 months follow-up measurements, respectively. At every time point, all employees receive a questionnaire consisting of items on the primary and secondary outcomes, as well as covariates .Before the start of the FCE, employees fill out the Physical Activity Readiness Questionnaire (PAR-Q) . If at lThe employee receives feedback on his/her results from the assessments by a consultant (in most cases the physiotherapist) and advice on whether or not to take consecutive actions. When an employee is advised to take consecutive actions he/she is encouraged to enrol in one of the pre-specified interventions. Depending on the outcome of the assessments, employees are categorised into three different risk profiles threatening sustainable employability: 1) no or very low risk, 2) low to medium risk, and 3) high risk. These risk profiles are based on guidelines by the Netherlands Society of Occupational Medicine (NVAB) -32 and g1) For persons with no or very low risk, meetings focussing on primary prevention are organised where general health principles are presented. The meetings are organised at the company’s plants. During these meetings, several topics are addressed, such as lifestyle (change), workload, work capacity and adjustment latitude. Employees are pointed to organisational activities such as company fitness and canteen policy.2) Persons with low to medium risk are either offered a monodisciplinary intervention or referred to their general practitioner (GP). The intervention can be deployed by a physiotherapist, a psychologist or a dietician. The choice of discipline and the contents of the intervention depend on the outcomes of the assessments, e.g. physiotherapy in case of MSDs. Basically, the interventions are aimed at preserving or restoring functional capacity of the employee, but they can also be aimed at the (work) environment, i.e. at creating and utilizing adjustment latitude. In the present study three ‘physical’ interventions and two ‘non-physical’ interventions are offered: improving personal work capacity, reducing and preventing back complaints, reducing and preventing neck and shoulder complaints, guidance by a dietician in case of substantial overweight of an employee, and stress reduction. These interventions were based on evidence described in several reviews -37.3) Employees with more complex or multiple complaints, who are absent from work regularly or continuously, are offered a multidisciplinary intervention. These multidisciplinary rehabilitation (MR) programs are conducted by professionals from several disciplines, such as a rehabilitation physician, physiotherapists, occupational therapists, and psychologists. Disciplines are deployed on indication. MR is deemed the most preferred evidence-based intervention for chronic complaints of the musculoskeletal system . MR alsoRegular healthcare, unrelated to the WHS program, is considered care as usual. Programs already running within the company are also considered CAU.The primary outcomes in this study are work ability, productivity and absenteeism.– Work ability is measured with the Work Ability Index (WAI) . The WAI– Productivity at the individual level is measured by self-report using the Quality and Quantity (QQ) questionnaire . The QQ – Absenteeism data are provided by the occupational health service (OHS).The secondary outcomes are psychosocial and physical workload, health status, and vitality.– Several aspects of the psychosocial workload are measured by the second version of the Copenhagen Psychosocial Questionnaire (COPSOQ II) . These a– Self-reported health status is evaluated by the Dutch version of the EuroQol-5D . It cons– Self-reported vitality is assessed by a subscale of the RAND-36 questionnaire . This scPersonal and work characteristics are assessed as covariate in this study.– Most personal and work characteristics  are obtained through the questionnaire. Additional personal and work characteristics  are retrieved from the company headquarters.– To assess physical workload, movement, and posture during work, a short version of the Dutch Musculoskeletal Questionnaire (DMQ) is administered . The 21 The cost-benefit of the POSE program will be evaluated from the employers’ perspective. The cost-benefit analysis will evaluate the total costs of the POSE program for the company and will compare absenteeism costs before and after the POSE program. Costs (in Euros) include:– Costs of the POSE program, which are the costs of the program itself and the sequential costs of company interventions (excluding insured interventions).– Costs due to time spent by employees on the different elements of the POSE program , which results in lost productivity.– Absenteeism costs. These data are obtained from the OHS’s registry system. The number of absence days will be expressed in monetary terms.– Productivity loss at work which will be assessed using the quantity scale of the QQ questionnaire , ranging– Replacement costs associated with employee turnover will be calculated as the sum of the costs for hiring and training a new employee.A process evaluation will be conducted to evaluate the preparation, implementation, execution, and follow-up of the POSE program according to a number of key components ,47. ContFor the sample size calculation, we used the formula proposed by Hussey and Hughes for stepped wedge cluster randomised trials . A pilotParticipants, care providers, and researchers are not blinded for the group assignment.The effect of the trial on the primary and secondary outcomes will be analysed using linear (for the continuous outcomes) and logistic (for the binary outcomes) multi-level analyses including a random coefficient for plant and a fixed effect for time. The latter parameter is included to adjust for any potential time effects . All tesThe effect of the trial on the costs will also be analyzed using linear multi-level analyses including a random coefficient for plant and a fixed effect for time. Bootstrapping will be used in case the costs will turn out to follow a positively skewed distribution.This paper presents the design of a stepped wedge trial to evaluate the effectiveness of a comprehensive workers’ health surveillance program in a meat production environment. The POSE program aims to balance the functional capacities of employees with work demands. Detecting and restoring imbalances between capacities and demands in an early stage may contribute to sustained employability.The current state of WHS programs and the use of FCEs in employment examinations have recently been reviewed ,21. The To our knowledge this is the first study that evaluates a WHS consisting of multiple assessments, i.e. a questionnaire, biometric assessments, and FCE, and that also deploys tailor-made interventions.The design of our study has some benefits over a parallel arm randomised controlled trial. The design allows to perform a within group and between group analysis, i.e. each plant serves as its own control, but also serves as control for the other plants. This limits the risk of confounding and increases statistical power.A strength of this study is the expected high participation rate of the POSE program. During a pilot study at two locations (not included in this study), the participation rate was 80-90%. We expect the same participation rates within our study. We strive to reach this participation throughout the entire study period. During the follow-up measurements we expect this rate to decrease over time. A careful distribution process and clear communication about the follow-up questionnaires might mitigate this decrease.When the POSE program proves to be effective within the company, we expect that the results of this trial can be used by other companies in the sector, which employ approximately 20,000 people in The Netherlands. Especially, since multiple plants are included in this study, this provides more generalisable results for all production workers. This WHS program was job-specific, so perhaps results cannot be generalised directly to other sectors. However, it is reasonable to presume that a custom-made WHS program can be adapted to other related sectors with similar results.We have not included translations of our questionnaire for foreign employees, whose Dutch language skills may be insufficient to complete the questionnaire. In the Dutch meat processing industry, about 25% of the employees is born outside The Netherlands . We striThe company has already been working on absenteeism reduction for a few years before implementing the POSE program. In these years, sickness absence has dropped from 7.0% to 4.5%. It is unknown whether this may lead to floor effects. Possible effects of the POSE program might therefore go unnoticed. Perhaps it is not realistic to expect absenteeism rates to drop even further, due to the type of work.Plants where the POSE program has not yet been implemented could already perform health related activities prior to implementation of the POSE program. Such activities might influence the results of the POSE program and therefore influence possible effects of the POSE program. We emphasized that the company should not start health-related activities prior to POSE program implementation, other than care as usual activities.Within our study an integrated approach is deployed. The study will yield valuable information on the effectiveness of this approach on work related outcomes. Combining the results of the process evaluation and the intervention effects will hopefully provide insight into the effectiveness of separate aspects, and perhaps underlying reasons for the effectiveness.The results of this study will provide information on the effectiveness of the POSE program on sustained employment. When the program proves to be effective, employees will benefit from this by an improved health and perhaps a healthier working environment. Employers might benefit from healthier employees, and in the case the intervention proves to be cost-beneficial, reduced costs and higher productivity. Furthermore it will expose key elements for a successful implementation and execution of the POSE program and may serve as an example to other companies inside and outside the industry.nd version; CSQ-8: Client satisfaction questionnaire; DMQ: Dutch musculoskeletal questionnaire; FCE: Functional capacity evaluation; FLESH: Functional labour evaluation for sustained health and employment; GP: General practitioner; ICC: Intraclass correlation coefficient; MR: Multidisciplinary rehabilitation; MSD(s): Musculo skeletal disorder(s); NVAB: Netherlands society of occupational medicine (nederlandse vereniging voor arbeids- en bedrijfsgeneeskunde); OHS: Occupational health service; PAR-Q: Physical activity readiness questionnaire; POSE: Promotion of sustained employability; QQ: Quality and quantity questionnaire; RI&E: Risk Inventory and Evaluation; WAI: Work ability index; WHS: Workers’ health surveillance; WIA: Dutch law for work and income according to work ability.CAU: Care as usual; CONSORT: CONsolidated standards of reporting trials; COPSOQ II: Copenhagen psychosocial questionnaire 2All authors declared that they have no competing interest.RS, MR and SB developed the initial study protocol and acquired funding for the FLESH study. They also provided valuable input to this design paper, which was drafted by BvH, MdB, and RS. All authors commented on the draft versions. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/12/1003/prepub


Funding should read "This study was supported by Program from the National Basic Research Program (973) of China (2012CB518804), the National Natural Science Foundation of China (31172319), the key Technology R?D Program of Jiangsu (BE2009388), the Fundamental Research Funds for the Central Universities (KYT 201003), and the Project Funded by the Priority Academic Program Development of Jiangsu Higher Education Institutions. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."


There is now substantial evidence that Web-based interventions can be effective at changing behavior and successfully treating psychological disorders. However, interest in the impact of usage on intervention outcomes has only been developed recently. To date, persistence with or completion of the intervention has been the most commonly reported metric of use, but this does not adequately describe user behavior online. Analysis of alternative measures of usage and their relationship to outcome may help to understand how much of the intervention users may need to obtain a clinically significant benefit from the program.The objective of this study was to determine which usage metrics, if any, are associated with outcome in an online depression treatment trial.Cardiovascular Risk E-couch Depression Outcome (CREDO) is a randomized controlled trial evaluating an unguided Web-based program (E-couch) based on cognitive behavioral therapy and interpersonal therapy for people with depression and cardiovascular disease. In all, 280 participants in the active arm of the trial commenced the program, delivered in 12 modules containing pages of text and activities. Usage data  were captured automatically by the program interface. We estimated the association of these and composite metrics with the outcome of a clinically significant improvement in depression score on the Patient Health Questionnaire (PHQ-9) of ≥5 points.P=.009) and linear (P=.002) relationships existed between activities completed per log-in and clinically significant change.In all, 214/280 (76.4%) participants provided outcome data at the end of the 12-week period and were included in the analysis. Of these, 94 (43.9%) participants obtained clinically significant improvement. Participants logged into the program an average of 18.7 times (SD 8.3) with most  completing all 12 modules. Average time spent online per log-in was 17.3 minutes (SD 10.5). Participants completed an average of 9 of 18 activities available within the program. In a multivariate regression model, only the number of activities completed per log-in was associated with a clinically significant outcome . The final model predicted 7.4% of variance in outcome. Curve estimates indicated that significant logarithmic : ACTRN12610000085077; http://www.anzctr.org.au/ACTRN12610000085077.aspx (Archived by WebCite at http://www.webcitation.org/6K9FQtKBn). Web-based interventions for psychological conditions have been found to have a moderate to large effect size ,2 that iTo date, much of the reporting of engagement is of dropout attrition   were not consistently associated with outcome for Web-based intervention for psychological disorders . Only thThe inability to consistently detect a dose-response relationship may be influenced by the usage metric utilized. Because most studies only report 1 or 2 such usage metrics and rarely examine the relationship between these metrics, little is known about the relative contribution of the different metrics or the relationship of these to outcomes. Previous attempts have been made to define the measurement of usage, most often in the form of adherence ,21, by pCardiovascular Risk E-couch Depression Outcome (CREDO) is a randomized, double-blind, parallel, attention-controlled, Internet-delivered trial targeting depressive symptoms in those with risk factors for or diagnosis of cardiovascular disease (CVD). The method and primary results of CREDO have been published elsewhere ,25. ThisTrial participants were recruited from the 45 and Up Study , a longiE-couch is an iCBT program containing psychoeducation about depression with components of CBT, interpersonal psychotherapy (IPT), applied relaxation, and physical activity. In its open access format , E-couchActivities were spread throughout E-couch. The CBT component had 12 activities, IPT had 4 activities, and the exercise component had 2 activities. The relaxation component contained a recording of relaxation exercises, but because this did not require participants to enter anything into the program, it was not included as an activity in this analysis. See The primary outcome measure of the study was the 9-item Primary Health Questionnaire (PHQ-9) , a widelA number of measures were used to assess usage of the intervention as recorded objectively by the program and did not rely on participant self-report.The proportion of the 12 possible E-couch modules that the individual completed was recorded. A complete module consisted of the user clicking through each page of the module until they had viewed all pages. No time limit or activity level was required to complete the module other than what was required to click through the module’s pages.Data were captured for each type of activity section  and overall activity completion. A total of 18 different activities were available for completion in the program and were spread throughout the modules. To complete more activities, users needed to complete more modules. In order for an activity to be counted as completed, the individual had to have engaged with the task in some way .The number of times the participant logged into the program over the course of the 12-week period was recorded. Participants were expected to complete 1 log-in per week; therefore, they were expected to have logged into the program on 12 occasions. All modules could theoretically be completed in 1 log-in at week 12 (a module being made available each week for 12 weeks). Participants were able to log in as many times as they wished per module, allowing this metric to range from 1 to an unknown limit imposed by the study duration and participants’ availability.Users were able to complete each activity as many times as they wanted and were not limited to 18 activities. Given this, the total number of activities completed was collected.The total time spent logged into the program each week was recorded. The program continued to keep time if the user did not log out; therefore, the time spent on the final page for each log-in was excluded in case of failure to log out. Average time spent online per log-in and total time in the program were used in this analysis. Average time spent online per log-in was capped at 60 minutes to reduce the impact of outliers. This impacted 1 participant; average time spent online per log-in was limited to 60 minutes from 83 minutes. No minimum average time requirement was defined for the program.This was calculated by dividing the total number of activities completed by the total number of log-ins to the program.This was calculated by dividing the total time in minutes spent in the program by the total number of log-ins to the program.This was calculated by dividing the number of modules completed by number of times that they logged in to the program.An aggregated measure was calculated by adding the number of modules completed (range 0-12) with the number of compulsory activities completed (range 0-18) to give a total range of 0 to 30.2), independent samples t tests, and Mann-Whitney U tests were used to determine if there were any differences between those who persisted with the study  and those who did not. Univariate associations of demographic variables with outcome and usage were evaluated using Spearman rank correlation (ρ) and chi-square tests. Similarly, Spearman rank correlations, independent samples t tests, Mann-Whitney U tests, and chi-square tests were used to examine the relationship between usage variables and clinically significant improvement.Data analyses were completed using SPSS version 20.0 . Data were examined for normality and where the assumptions of normality were not met, nonparametric tests were utilized. Chi-square , the variables were identified as a priori  and were entered into the model.A binary logistic regression model using the enter method was then completed to assess the ability of the usage variables to predict clinically significant improvement. Demographic and usage variables were included in the regression model if there was Written informed consent was obtained from all the participants and ethics approval for the 45 and Up Study was provided by the University of New South Wales Human Research Ethics Committee. Ethics approval for the CREDO trial was obtained from the University of Sydney Human Research Ethics Committee.Of the 562 participants who provided consent and met trial criteria, 280 (49.8%) were randomized into the E-couch iCBT program. Of these, 214 (76.4%) persisted with the study and provided postintervention outcome data. There were no significant differences between persisters and those who did not provide outcome data in age, sex, country of birth, marital status, or baseline depression severity . HoweverOf the 214 participants, 62.1% (133/214) completed all 12 modules and 79% (169/214) completed 10 modules or more. In all, 2 participants (1%) did not complete any modules, but did complete the assessments. Participants completed 9 of 18 (50%) available activities in the program on average; the number of activities completed ranged from 0 to 18. Several participants completed the same activity on multiple occasions, as allowed by the program, with the total number of activities completed ranging from 0 to 44 . Participants logged into the program an average of 18.7 times . The mean total time spent in the program was 318.3 minutes .On average, participants completed 0.5 activities per log-in (range 0-7.57) and 0.6 modules (range 0-2.0) per each log-in. The average amount of time spent online per log-in was 17.3 minutes (SD 10.5), whereas the average time to complete a module was 33.19 minutes (SD 23.18). For the combined usage measure of activities and modules, the mean score was 19.47 (SD 7.49).In all, 94 (43.9%) of participants obtained clinically significant improvement during the study. There was no difference between those who obtained clinically significant improvement and those who did not in age, level of education, country of birth, language spoken at home, marital status, or baseline depression score.P<.001), more log-ins , and total number of activities completed . Men completed more modules  than women did. There were no sex differences in the other basic usage measures or obtaining a clinically significant outcome . A significant correlation was found between baseline depression severity and number of modules completed  with people who were more depressed completing fewer modules. However, there was no significant association between baseline depression severity and other usage metrics. No relationships were found between the interactions of age, sex, and baseline depression severity with usage on outcome.Older age was associated with greater time spent online . Likewise, a significant difference was found in the number of activities completed between those who obtained change  and those who did not .Associations between basic and composite usage measures and clinically significant improvement were examined . Of the t212=3.02, P=.01) and average time spent online per log-in . No other composite usage metrics were associated with significant outcomes.Of the composite measures, a significant difference was found between those who obtained clinically significant change and those who did not in average number of activities completed per log-in  were entered into the model with sex and age. In the parsimonious model, total time spent online in the program, time spent online per log-in, activities completed per log-in, and the combined modules-activities measure remained in the model. Of these, only the number of activities completed per log-in was statistically associated with a clinically significant improvement see ..R2 statistic, the variance in the outcome predicted by this model was 7.4%. The likelihood of the model predicting whether or not the individual would obtain clinically significant change or not was 61.2%. A further regression was modeled using the variables excluded based on autocorrelations as sensitivity analysis. This yielded similar results with only activities completed per log-in being found to contribute significantly to the final model.According to the Nagelkerke To examine the linearity of the relationship between usage and outcome, the linear model of clinically significant change and significant usage metrics included in the linear regression were compared with logarithmic and quadratic curve estimation. Significant curve estimations were found for the 4 usage variables included in the final step of the analysis, except for the combined activities-modules metric see , althoug22 =6.6, P=.04), time spent online per log-in , and activities completed per log-in . In the time spent online variable, significantly more high users obtained clinically significant change than low users , in time spent online per log-in, more high users obtained change than medium users , and in activities completed per log-in, significantly more high users obtained change than low users  or medium users . See Patterns of usage were also explored by trichotomizing usage metrics using tertiles of low, medium, and high users. When exploring this categorization against obtaining clinically significant change, significant relationships were found between outcome and time spent online  and time spent online per log-in (logarithmic: P=.09). Similar to clinically significant change, tertile splits found a significant difference between high and low/medium level users for time spent online per log-in and for activities completed per log-in.A sensitivity analysis was completed using the continuous variable of PHQ-9 change score. This allowed for slightly increased power and the inclusion of more variables into the analysis. However, when a regression analysis was completed, activities completed per log-in remained the only significant predictor of outcome. Curve estimation did not meet significance for activities completed per log-in  were most likely to benefit from the program. These findings are not dissimilar to face-to-face CBT, in which it is the ongoing completion of homework activities across therapy sessions that best predicts outcome . Thus, tThe activities completed per log-in metric accounted for very little of the variance in the outcome. The inability of some other metrics to predict outcome may reflect limited variability, particularly concerning modules completed, a metric that has been associated with outcome previously . Within As expected, participants who did not persist with the trial provided outcome data with lower levels of usage. This is likely to reflect early dropout and not being exposed to the content; therefore, they were unable to be more adherent to the program overall. People who were older appeared to adhere more, consistent with other studies . HoweverThe lack of any strong predictive relationship between the usage metrics identified here and outcome may challenge the traditional view of a dose-response relationship relating to outcome. The high rates of usage in this study may have meant that many participants reached a dose-response plateau where they had been exposed to an appropriate level of the program and were unlikely to obtain further benefits from additional exposure. This model indicates that patients may reach therapy saturation at certain levels of use and would likely obtain the effects of the program early on. If this were the case, we would expect that outcome gains would be obtained with medium usage and then be maintained as patients persisted with the intervention. Such an effect has been seen in longer Web-based interventions ; for exaThe high rates of use may reflect this analysis only selecting participants that persisted with the study, whereas other usage-outcome association studies have utilized the last observation carried forward (LOCF) technique. Although retaining only those who had persisted may have biased the analysis to more adherent people, using the LOCF technique conflates the measurement of persistence (the number of people who complete the program) which, in turn, leads to these participants also appearing to have poor usage . Additionally, LOCF may also underestimate the overall effectiveness of the intervention because some studies have reported that people who notice an improvement in their symptoms drop out ,40, but The univariate associations between usage and outcome found in this analysis are consistent with our recent review which indicated that, of the online intervention studies which reported usage, most (31/33 studies) found a positive relationship between usage variables (34/37 variables) and outcome . HoweverA number of recommendations based on these findings can be made. The finding that those who completed a high number of activities per log-in achieved a greater benefit than those who undertook few, and that a medium activity per log-in count conferred no more benefit than a low activity per log-in count indicates that maximizing usage behavior online may improve outcomes. One way of doing this is ensuring that more activities are included with each module, thereby encouraging users to be more engaged with their treatment. These activities could include the use of activities related to the therapeutic modality of the program or multiple choice quizzes to assess learning with reference back to sections containing material related to incorrect answers.Programs that limit program exposure at each log-in to allow adequate time for learning, the completion of activities, and skills implementation to occur may also be beneficial as well as incorporating a “hook” to encourage users to return the following week . This diProviding education and setting early expectations about what users need to do to achieve benefit from the program  may be a helpful approach to improving program outcomes. This would include emphasizing that users are more likely to obtain benefit if they are more active and complete activities when they become available. Likewise, encouraging users to complete the activities on multiple occasions, particularly when waiting for the next module to become available, may also improve outcomes. However, definitive conclusion about the usefulness of these strategies is beyond the scope of this analysis and would benefit from further research.A further opportunity is to measure usage and program benefits throughout the course of the intervention to determine at what point users reach their therapy saturation and obtain little if any program gains after this time point. Conversely, such monitoring may indicate that a certain level of usage is required to obtain a benefit. Ensuring users are actively engaging in the program is likely to require frequent monitoring, which in itself can influence the outcome of the intervention, and the use of measures with good test-retest properties. Future programs utilizing this design will also need to consider the burden of intensive monitoring on users and the potential for this to increase the propensity to drop out from the study. Electronic measurement automation may provide a way to reduce monitoring burden.Previous research has found that although usage of program components was related to early improvements, it was the completion of homework exercises that was correlated with long-term improvements . Given tAs mentioned previously, the inclusion of only those participants who provided outcome data is likely to have limited the generalizability of the results. However, it is unclear what effect that this may have had on the analysis and how to best manage this. Using the LOCF may actually fail to give an accurate picture of the progress of these participants. This is largely because the LOCF method assumes no progress in this group. Although research has indicated that obtaining benefits may be key in helping people to persist with an intervention , it may In addition, the specific inclusion criteria of this trial and the unique nature of each intervention likely limits the generalizability of the results of this analysis to other populations. However, recent findings have indicated that this may be less of a factor than initially thought, and that the sampling bias related to trials may not actually limit the ability of trial results to be generalized based on demographic factors .Finally, despite that the data were drawn from a RCT, this substudy was observational in nature and no manipulation of variables related to usage occurred. Given this, the ability to imply causation is limited. Future research needs to explore the manipulation of these variables, such as controlling number of log-ins to determine if unlimited access affects outcomes, exploring usage and outcome in single log-in sites, or limiting the amount of activities or modules that can be completed per log-in to future test the hypotheses drawn from the findings of this study.Future research would benefit from exploration of the relationship between usage metrics and outcome to further investigate the nature of this relationship. Although this analysis found only 1 metric was predictive of outcome, this finding is limited by the context of this study. Future research needs to continue to explore this research in trials and naturalistic implementation of Web-based interventions to determine if this is the case.


Objective. To report an incidence of reflux in the deep venous system reversed by ablation of a popliteal fossa vein (PFV). Method. A 40-year-old man with pain and swelling in the medial upper calf was found to have an incompetent PFV. Results. Reflux in the femoral and popliteal veins was reversed utilizing endovenous laser ablation and foam sclerotherapy, documented on Duplex studies before and after the intervention. There was also resolution of symptoms. Conclusion. A PFV can be associated with deep venous reflux. Correction of this reflux with ablation of the PFV suggests that his type of reflux is secondary to volume effects of the incompetent popliteal vein. The popliteal fossa vein (PFV) has been described as a tributary of the popliteal vein found in the popliteal fossa, which is anatomically distinct from the great and small saphenous veins , 2. ClasA 40-year-old man presented to the Vascular Center Clinic with symptomatic chronic venous insufficiency (CVI). The patient began experiencing cramping and swelling in his right leg seven years prior, with worsening symptoms over the past two years. Upon initial physical exam, the patient was noted to have 1+ edema, hyperpigmentation in the “gaiter zone” distribution, and varicosities on the posterior and medial aspect of the right knee (C4a)  (VCSS: sPFV reflux has been previously demonstrated to be associated with higher rates of proximal, distal, superficial, perforator, and complex pattern reflux as compared to limbs without PFV; however, the prevalence of deep reflux was not statistically different between the two groups . TreatmeIn this case, an incompetent popliteal fossa vein led to a large complex of pressurized subdermal veins as well as reflux in the femoral and popliteal veins. It is likely that a proximal calf perforating vein such as a popliteal fossa vein would produce more pressure in the subdermal calf veins than similar sized more distal veins . It is u


BCR-ABL1 transcripts, a significant minority expresses variant transcripts, of which e19a2 is the most common. Although considered to have a relatively favourable outcome, reported responses to tyrosine kinase inhibitor (TKI) therapy are variable with molecular monitoring in CML patients with e19a2 BCR-ABL1 transcripts rarely reported. A case of e19a2 BCR-ABL1 CML with marked thrombocytosis is described in which the value of molecular monitoring is emphasised during treatment interruptions, dose reductions, and changes. This case serves to demonstrate the requirement for prospective real-time quantitative PCR (RQ-PCR) assays for patients with variant BCR-ABL1 transcript types and standardisation of such assays to enable modern patient management.While most patients with chronic myeloid leukemia (CML) express either e13a2 or e14a2  BCR-ABL1 fusion gene is the molecular hallmark and causative event of CML. Most CML patients express either e13a2 or e14a2 BCR-ABL1 fusion transcripts but approximately 5% of patients express variant transcripts that may involve fusion of alternative exons, insertions, or breakpoints within exons. Of these variant BCR-ABL1 fusions, the e19a2 is the most common with approximately 50 cases reported to date. CML with e19a2 BCR-ABL1, that encodes a 230 kDa protein [BCR-ABL1 CML [9/L) is uncommon and often associated with the e19a2 BCR-ABL1 transcript type [BCR-ABL1 CML who presented with a marked thrombocytosis is described.The ABL1 CML , althougABL1 CML , 13, sug9/L, WBC 31.7 × 109/L which comprised neutrophils 25.2 × 109/L, lymphocytes 2.1 × 109/L, monocytes 0.94 × 109/L, eosinophils 1.75 × 109/L, basophils 0.85 × 109/L, and blasts 0.1 × 109/L. The blood film showed thrombocytosis, marked platelet anisocytosis, neutrophilia with left shift, and rouleaux with the patient having an elevated lactate dehydrogenase of 554 IU/L. The bone marrow aspirate was hypercellular with particles present and showed significant myeloid hyperplasia and plentiful megakaryocytes, often present in groups with polymorphic morphology including hypolobulated and mononuclear forms. Cytogenetic studies were not performed but a standard reverse-transcriptase polymerase chain reaction methodology for detection of BCR-ABL1 transcripts [BCR-ABL1 transcripts. Direct sequencing demonstrated the presence of an e19a2 BCR-ABL1 fusion with a final diagnosis of chronic phase CML with a high-risk Sokal score of 3.15.An eighty-year-old male with a history of Duke's C colon carcinoma in remission presented with an abnormal full blood count: Hb 9.9 g/dL, PLT 1401 × 10nscripts  showed a9/L, a deep vein thrombosis (DVT) of the left popliteal vein extending into the common femoral vein was diagnosed prompting treatment with low molecular weight heparin. Complete cytogenetic remission was achieved (0/50 Ph+ metaphases) after three months of imatinib therapy with RQ-PCR for e19a2 BCR-ABL1 transcripts performed as previously described [BCR-ABL1 transcript level (BCR-ABL1/ABL1 3.8%, BCR-ABL1 transcripts to high levels (BCR-ABL1/ABL1 100%.The patient commenced on imatinib 400 mg od with aspirin 75 mg once daily. After three weeks of therapy, when the platelet count was still greater than 1000 × 10escribed  demonstrh levels . Treatmeh levels . He rema9/L are rare. An association with e19a2 BCR-ABL1 transcripts in CML patients and marked thrombocytosis has previously been documented [Thrombocytosis is a relatively common presenting feature of CML but platelet counts >1000 × 10cumented , corrobocumented , and supBCR-ABL1 is the most common variant transcript type in CML, yet molecular responses to TKI have rarely been evaluated, most likely to the unavailability of commercial plasmids necessary for construction of standard curves. While efforts to harmonise molecular methodologies that quantify e13a2 and e14a2 BCR-ABL1 transcripts are underway [E19a2 underway , attainmunderway  or complBCR-ABL1 transcript types during TKI dose reductions, interruptions, or changes in conjunction with conventional cytogenetic analysis.This case serves to highlight the requirement for RQ-PCR monitoring, an essential component of modern disease management, for the less common