Originating from the interdisciplinary collaboration between public health and the transportation field a workplace intervention to promote commuter cycling, ‘Bike to Work: cyclists are rewarded’, was implemented. The intervention consisted of two cycling contests, an online loyalty program based on earning ‘cycling points’ and the dissemination of information through folders, newsletters, posters and a website. The study purpose was to evaluate the dissemination efforts of the program and to gain insights in whether free participation could persuade small and middle-sized companies to sign up.The RE-AIM framework was used to guide the evaluation. Two months after the start of the intervention a questionnaire was send to 4880 employees. At the end of the intervention each company contact person (n = 12) was interviewed to obtain information on adoption, implementation and maintenance.Comparison analyses between employees aware and unaware of the program were conducted using independent-samples t-tests for quantitative data and chi-square tests for qualitative data. Difference in commuter cycling frequency was assessed using an ANOVA test. Non-parametric tests were used for the comparison analyses between the adopting and non-adopting companies.p = 0.15) or in the type of business sector (p = 0.92) between adopting and non-adopting companies. Five out of seven companies had the intention to continue the program. At the individual level, a project awareness of 65% was found. Employees aware of the program had a significantly more positive attitude towards cycling and reported significantly more commuter cycling than those unaware of the program (both p < 0.001). Participation was mainly because of health and environmental considerations.In total seven of the twelve participating companies adopted the program and all adopting companies implemented all intervention components. No significant differences were found in the mean number of employees (The results of the dissemination study are promising. The adoption and implementation rates indicate that the ‘Bike to Work: cyclists are rewarded’ program seems to be a feasible workplace intervention. At the individual level, a higher score of commuter cycling was found among the employees aware of the program. Nevertheless, more evidence regarding long term effectiveness and sustainability of the intervention is needed. The importance of regular physical activity (PA) in the maintenance of good health and the primary prevention of chronic diseases has been well documented -5. CurreBesides the health-related benefits, commuter cycling is also beneficial to our environment and it contributes to the reduction of mobility problems -25. DespA Flemish cycling organization, promoting cycling as a key element of sustainable mobility , implemeThe workplace setting was chosen as it allows reaching a substantial proportion of the adult population and it is believed to provide good opportunities to influence employee behavior -35. AfteThe RE-AIM framework was used to guide the evaluation. This model has shown to be very useful for evaluating dissemination efforts and provides information on five intervention related factors: reach, effectiveness, adoption, implementation and maintenance ,37.The workplace intervention ‘Bike to Work: cyclists are rewarded’ was implemented in Flanders between May 2011 and March 2012 by the Flemish Cycling Union. This cyclist organization consists of volunteers and staff members who lobby for cycling policies at different policy levels. The intervention was implemented in twelve small and middle-sized companies  who receive a program. Efficacy or effectiveness, depending on the study, concerns the impact of an intervention on important outcomes [Adoption is the percentage and representativeness of settings that are willing to implement a health promotion program. Implementation deals with the extent to which various elements of a program are delivered as intended. The final dimension, maintenance, operates at both the individual and the organizational level. At the individual level, maintenance refers to the extent to which effects are stable long after an intervention is delivered. At the organizational level maintenance covers the extent to which a program becomes institutionalized or part of the routine practices of an organization.Two dimensions operate at the individual level: reach and efficacy or effectiveness. outcomes . The dimData were collected at the individual (i.e. employees) and the organizational (companies) level. To obtain data at the individual level the contact person of each company was asked to distribute an e-mail containing a link to a questionnaire among all employees. The first e-mail was sent during the month of June 2011, two months after the official start of the project (May 2011), followed by a reminder e-mail one month later. If respondents were unable to fill out the questionnaire online, a paper form was provided. The questionnaire was based on the survey of the Dutch intervention to promote commuter cycling  and consData at the organizational level were obtained at the end of the program by conducting a telephone-administered survey  were considered aware of the program. Representativeness was estimated by comparing differences in age, gender, body mass index (BMI) and perceived health between those aware versus those not aware of the program.Project awareness was assessed using the question Employees aware of the program and being registered, were asked about the main motivators for participation. Employees that indicate knowing the intervention but who did not register were asked about the main barriers to participation.The intervention was based on effective interventions to promote commuter cycling. Therefore the effectiveness of the evidence-based program was assessed, in line with the study of Van Acker et al.  by compaTo establish adoption of the program, all contact persons were asked if their company implemented the program. The main reason for non-adopting was asked if the program was not implemented. Representativeness of the settings was assessed by comparing the type of business sector and the number of employees between the adopting and non-adopting companies.To gain insights in the implementation of the program, each contact person was asked about the different program components that were carried out. Furthermore, employees were asked to evaluate the different program components.Maintenance was assessed at both the individual as the organizational level. At organizational level, the companies were asked about their intention to continue the program. Employees aware and registered to the program were asked about their intention to commuter cycle during the next six months to establish maintenance at individual level. Employees aware and unaware of the program were asked for suggestions on how their company could continue to promote commuter cycling.U test for quantitative data (number of employees) and a chi-square test for qualitative data (type of business sector). All data were analyzed using SPSS 20.0 for Windows and an α level of p < 0.05 was used to decide upon statistical significance.Independent samples t-tests and chi square tests were used to compare demographic characteristics  between employees aware and unaware of the program. As the travel distance to work was skewed, comparison analyses between employees aware and unaware of the program were conducted by using an independent samples median test. Difference in the attitude towards cycling and the frequency of commuter cycling among employees who were aware of the program and those who were not aware of the program was assessed using an ANOVA test. To establish representativeness of the companies, comparison analyses between the adopting and non-adopting companies were conducted using a Mann- Whitney All companies, except one, distributed the questionnaire to all employees (n = 4880). After two mailings a total of 1116 respondents (23%) completed the questionnaire. All contact persons of the twelve companies agreed to participate in the telephone-administered interview.The main results for all the RE-AIM dimensions are presented in Figure p = 0.15) or in the type of business sector between adopting and non-adopting companies (p = 0.92).Seven of the twelve companies adopted the intervention. The remaining five companies who did not adopt the ‘Bike to Work: cyclists are rewarded’ program were asked about the reason for not participating. The main reported reasons were a lack of time and a shortage of staff resulting in a lack of monitoring and managing of the program. To establish representativeness, comparative analyses between adopting and non-adopting companies were conducted. No significant differences were found in the mean number of employees (All adopting companies (n = 7) reported having implemented all ‘Bike to Work: cyclists are rewarded’ program components . Additionally, employees who were aware and registered on the program were asked to evaluate the different program components (n = 110).In general the dissemination of information was evaluated relatively positively. More than half of the employees was positive about the website and the folder. Meanwhile a substantial proportion (15%) of the employees reported not knowing the newsletter. The contest as well as the online application where cycling points could be exchanged for gift vouchers and coupons were evaluated positively by slightly more than one third of the employees. No strong opinion on the contest and online application was noted as about half of the employees remained indecisive (See Table p = 0.7). The median travel distance to work differed between employees being aware of the program and being registered (8 km) and employees being aware but not being registered .Of all 1116 employees who filled out the questionnaire, 649 received the intervention (employees of the adopting companies) and were thereby eligible (58%). Of all 649 eligible employees, 65% was aware of the ‘Bike to Work: cyclists are rewarded’ program (n = 422). Of those employees aware of the program, 26% (n = 110) was registered on the online application. The median travel distance to work was comparable for employees aware (12.5 km) and unaware (13.5 km) of the program  and ‘I want to contribute to a better environment’ (97% agreed). The least of the employees agreed with the statements ‘The idea of cycling together appealed to me’ and ‘A colleague convinced me’ as motivators for participation (See Table p < 0.001) of the program, but groups did not differ in gender, BMI or perceived health. Therefore further analyses on attitude towards cycling and commuter cycling frequency were controlled for age.Results regarding the representativeness revealed that those aware of the project were significantly older  than those unaware  more positive among employees aware of the project than those unaware (respectively mean positive attitude of 3.8 ±0.52 and 3.6 ±0.56). Analyses revealed that employees aware of the project – next to having a more positive attitude towards cycling – also reported significantly more commuter cycling per week than those not aware .Results showed that the general attitude towards cycling was significantly  and a higher bicycle compensation. Furthermore, employees being aware and registered on the program also reported that participation in commuter cycling projects should be promoted more actively and accompanied by regular communication. In addition flexible working hours and a bicycle repair service were two suggestions made by employees being aware but not registered on the program.Within the field of health promotion several effective workplace interventions to promote PA in general have been developed , howeverThe current study used the RE-AIM framework to assess individual and organizational factors associated with a workplace intervention to promote commuter cycling. In general, the intervention ‘Bike to Work: cyclists are rewarded’ was well received by the different companies and employees. Similar to the Dutch intervention to promote commuter cycling the online application, the website and folders were assessed positively. Also, the main reported reasons for participation i.e. health and environmental concerns, were confirmed in the present study . The finThe positive results on the attitude towards cycling and the difference in commuter cycling frequency are a conservative indication of the intervention effectiveness. The results on commuter cycling are in line with other cycling interventions -31. NoteLimitations of the current results are noted. Firstly, this study evaluated a workplace intervention to promote commuter cycling within a real world setting, which is both a strength as a limitation. The absence of a non-intervention group of companies is a methodological weakness, so employees results concerning effectiveness need to be interpreted with caution. Also, the cross-sectional nature of the data makes it difficult to adequately address the maintenance dimension. Another limitation is the low response rate of the employees. Although a reminder e-mail was sent, a high percentage of non-response remained, resulting in a negative impact on the representativeness of the sample. At the same time the lack of information on non-participating employees is a weakness of the present study. Furthermore, self-reported data can lead to social desirable answers. For respondents aware of the program, questions concerning cycling frequency may have been answered in line with the social tendency. In line with the abovementioned limitation, the implementation of the program was not assessed objectively. The contact person of each organization was interviewed by telephone and asked to which degree all program components were carried out. Combining this telephone-administered survey with an ‘on site’ observation could contribute to a more comprehensive view of the program implementation.The use of the RE-AIM model to guide the evaluation is a strength, as it ensures a more comprehensive evaluation of the intervention. Next to the effectiveness of the program, insights were also gained into the reach, adoption and maintenance of the intervention. This is valuable information considering that the benefit of any public health intervention is not only determined by its efficacy or effectiveness, but also by the extent to which it is appropriately adopted and implemented . The evaFurthermore this study contributes to the limited body of dissemination literature . AlthougFuture dissemination of the intervention needs to take into consideration the main reported barrier to adoption, being a lack of time to monitor the program. The practical implementation of the intervention should not be additional to one’s current job responsibilities, but extra time for monitoring of the program should be provided. Furthermore for small and middle-sized companies, it seems that providing these companies the opportunity of initially signing in for free does not encourage future paid participation. Also, companies need to consider the main barriers to participation, being the distance to work and the work schedule of the employee, when deciding to implement the intervention.In conclusion, the results of this dissemination study are promising. The adoption and implementation rates indicate that the ‘Bike to Work: cyclist are rewarded’ program seems to be a feasible workplace intervention. At the individual level, a higher score of commuter cycling was found among the employees aware of the program In addition, the employees gave a positive evaluation of the intervention. Nevertheless more evidence regarding long term effectiveness and sustainability of the intervention is needed.PA: Physical activity; BMI: Body mass index.The authors declare they have no competing interests.VD contributed to the design of the study (in consultation with De Fietsersbond), analyzed the data, led the writing of the paper and wrote the manuscript. IDB, LM, GC and KDC participated in the design of the study, helped to interpret the data and to draft the manuscript. KDM, JS and JL provided feedback on the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/587/prepub


NOD-like receptors (NLRs) are a class of cytoplasmic pattern-recognition receptors. Although most NLRs play some role in immunity, their functions range from regulating antigen presentation  to pathogen/damage sensing  to suppression or modulation of inflammation . However, NLRP2, NLRP5, and NLRP7 are also involved in non-immune pathways such as embryonic development. In this review, we highlight some of the least well-understood aspects of NLRs, including the mechanisms by which they sense pathogens or damage. NLRP3 recognizes a diverse range of stimuli and numerous publications have presented potential unifying models for NLRP3 activation, but no single mechanism proposed thus far appears to account for all possible NLRP3 activators. Additionally, NLRC3, NLRP6, and NLRP12 inhibit NF-κB activation, but whether direct ligand sensing is a requirement for this function is not known. Herein, we review the various mechanisms of sensing and activation proposed for NLRP3 and other inflammasome activators. We also discuss the role of NLRC3, NLRP6, NLRP12, and NLRX1 as inhibitors and how they are activated and function in their roles to limit inflammation. Finally, we present an overview of the emerging roles that NLRP2, NLRP5, and NLRP7 play during embryonic development and postulate on the potential pathways involved. Innate immunity is initiated by germline-encoded pattern-recognition receptors (PRRs). Among these, the nucleotide oligomerization and binding domain (NOD)-like receptors (NLRs) comprise a large receptor family of more than 20 members –4. Only One set of NLRs that regulates NF-κB and MAPK are NLRC1 (NOD1 or CARD4) and NLRC2 (NOD2 or CARD15). NLRC1 recognizes iE-DAP, a subunit of peptidoglycan found in some bacterial cell walls –19. NLRCIn the case of NLRC4, it is activated by bacterial flagellin , 27 or tDistinct NLRs recognize microbial or viral components such as peptidoglycan, flagellin, or viral RNA. These pathogen specific molecules are known as pathogen-associated molecular patterns (PAMPs). Alternatively, some NLRs, like NLRP3, detect damage associated molecular patterns (DAMPs). DAMPs consist of byproducts of pathogen invasion or sterile cellular damage such as uric acid crystals, reactive oxygen species (ROS), or extracellular ATP release –42. SensThe ability of NLRP3 to respond to multiple PAMPs or DAMPs from such a broad range of pathogens strongly indicates the presence of upstream adaptors, as is the case for NLRC4, or common danger signals which funnel into one pathway. In the case of NLRC2, the different signaling pathways activated by MDP or viral RNA would suggest that different modes of NLRC2 activation lead to different protein conformations or other alterations in NLRC2 activity. This is subsequently responsible for activation of NF-κB, autophagy, or antiviral signaling. Indeed, these are some of the great-unsolved mysteries of NLR biology. In addition, other NLRs, like NLRC3, NLRP6, NLRP12, and NLRX1, play inhibitory roles during inflammation. Yet how these proteins are activated or perform their inhibitory functions is not well understood. Finally, there are numerous NLRs for which there are different reports indicating a multiplicity of potential functions. In this review, we discuss several of these unsolved mysteries and potential future directions in the field of NLR biology.NLRP3 was initially described as an activator of caspase-1 in 2002 and was subsequently associated with autoinflammatory periodic fevers like Muckle–Wells syndrome or bacterial infection , 46. SinProteomic studies directed at understanding the NLRP3 interactome using different activators of NLRP3 may also provide further insight into potential upstream regulators such as NAIPs or ion/ROS sensors. A recent paper by Mitoma et al.  found inSalmonella typhimurium infection in macrophages  , 77 or tCurrently, it is unclear how the inhibitory function of NLRP12 is regulated Figure  but the Nlrc3-deficient mice were generated and inflammation examined in response to LPS treatment  both resulted in increased NF-κB activation in Nlrp12−/− macrophages (As discussed above, the rophages , suggestin vitro (As discussed in the last section, NLRP12 and NLRP6 have roles in inhibiting inflammation by modulating NF-κB activation –79, 83. in vitro . The abiin vitro .The role of NLRs in tissue repair or MSC differentiation may be a logical progression following inflammation but several additional NLRs have been reported to regulate seemingly disparate functions. NLRP2 is reported to inhibit NF-κB activation , 97 and in vitro with IL-1β also arrests developing embryos (Other NLRs have also been proposed to regulate inflammasome activation and development. NLRP7 regulates inflammasome activation in response to acylated lipopeptides like FSL-1 or triacylated Pam3CSK4 . In addi embryos . However embryos . TherefoThe role of NLRs in immune function is unequivocal. However, there is much molecular, biochemical and structural research which remains to be done to better understand how NLRs are activated and regulated. Due to the diversity of functions among NLRs, understanding their activation and regulation should provide a cornucopia of new opportunities to modulate the immune system. The activation of proinflammatory NLRs has already been demonstrated to be important for the function of many adjuvants used in research or in the clinic , 112. TaCandida albicans infection (Several unstudied NLRs have recently been assigned some putative functions. NLRP10 has been reported to play a critical role in the induction of Th1 and Th17 mediated T cell responses through a defect in dendritic cells migration during nfection , 122. Asnfection . The facnfection –125. WitThe 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.


Few studies have explored the experiences of low income mothers participating in nurse home visiting programs. Our study explores and describes mothers' experiences participating in the Nurse-Family Partnership (NFP) Program, an intensive home visiting program with demonstrated effectiveness, from the time of program entry before 29 weeks gestation until their infant's first birthday.A qualitative case study approach was implemented. A purposeful sample of 18 low income, young first time mothers participating in a pilot study of the NFP program in Hamilton, Ontario, Canada partook in one to two face to face in-depth interviews exploring their experiences in the program. All interviews were digitally recorded and transcribed verbatim. Conventional content analysis procedures were used to analyze all interviews. Data collection and initial analysis were implemented concurrently.The mothers participating in the NFP program were very positive about their experiences in the program. Three overarching themes emerged from the data: 1. Getting into the NFP program; 2. The NFP nurse is an expert, but also like a friend providing support; and 3. Participating in the NFP program is making me a better parent.Our findings provide vital information to home visiting nurses and to planners of home visiting programs about mothers' perspectives on what is important to them in their relationships with their nurses, how nurses and women are able to develop positive therapeutic relationships, and how nurses respond to mothers' unique life situations while home visiting within the NFP Program. In addition our findings offer insights into why and under what circumstances low income mothers will engage in nurse home visiting and how they expect to benefit from their participation. The Nurse-Family Partnership (NFP) is a targeted home visiting program provided by nurses to young, low-income, first-time mothers during pregnancy and through the first two years of the child’s life. The effectiveness of the NFP program has been rigorously evaluated in three US randomized controlled trials -4. The gth week of pregnancy and extending to the child’s second birthday. NFP nurses visit biweekly except during the first month of the intervention and the first postpartum month, when nurses visit weekly. The nurses focus on six domains: personal health, environmental health, friends and family, the maternal role, use of health care and human services, and maternal life course development . During pregnancy, the focus is on fetal growth; attachment; changes in the mother’s body and life; changes in relationships with her partner, family, and friends; and questions about her labor and delivery and how to integrate motherhood into responsibilities with school and work. After the birth, the focus broadens to encompass infant growth and development, educational play, bonding and communicating with her child, and the mother’s life-course planning. The mother’s participation in the program is voluntary.The NFP program follows set guidelines and commences with visits beginning before the 29Researchers studying the effectiveness of home visiting programs in general have hypothesized that positive maternal and child outcomes are related to the development of trusting relationships between the professional and the mother ,12-15. TFew studies have examined mothers’ experiences and perceptions of home visiting by nurses. Jack and colleagues examined how socially disadvantaged mothers engage with public health nurses and home visitors . They reAlthough several studies have examined and demonstrated the effectiveness of the NFP program, no published research was found that specifically examined the experiences of mothers participating in this nurse home visiting program. Knowledge of women’s experiences within and perceptions of the NFP program is important as it will provide insights into what women like and value about the program and factors that influence their continued participation in the program. In addition, the findings may provide some insight into the mechanisms, including how the relationship between the mothers and their NFP nurses improves maternal, child and family outcomes. The aim of this study was to explore and describe the experiences of mothers participating in the NFP program from the time of program entry before 29 weeks gestation until their infant’s first birthday. The results presented in this paper are part of a larger mixed methods study examining the feasibility and acceptability of the NFP in a Canadian setting.The Prevention Research Centre (University of Colorado) Nurse Family Partnership International Program identified the McMaster University-Hamilton Public Health Services collaboration as the team to lead all future evaluations of the NFP in Canada. To retain fidelity to the program model evaluated in the original trials, international sites are required to complete a four-step process prior to full implementation of the program: 1) adapt the NFP curriculum to meet local standards and needs; 2) complete a small scale pilot study to assess for acceptability and feasibility; 3) conduct an RCT to evaluate the effectiveness of the program in the new context; and 4) expand implementation of the program. In 2008, a feasibility study was initiated in Hamilton, Ontario to evaluate procedures for recruitment, retention and collection of clinical data. Concurrently, a qualitative acceptability study was conducted to explore NFP clients’ and their families’, public health nurses’ (PHNs), and stakeholders’ perceptions of and experiences with this specific home visitation intervention.Six PHNs and one nurse manager completed the intensive nurse and nurse manager NFP training. In order to ensure fidelity to the NFP program, all NFP nurses and their nurse supervisors receive training from the Nursing Practice Team at Nurse-Family Partnership National Service Office in Denver, Colorado, USA. The comprehensive training includes a theoretical review of the NFP program elements, an overview of NFP program elements and application of the curriculum, and advanced skill development in nursing assessment and intervention. Prior to implementing the program in Hamilton, the PHNs had an opportunity to job-shadow a team of NFP nurse home visitors located in Pennsylvania.In 2008, the pilot study to assess feasibility and acceptability was initiated in Hamilton, Ontario, Canada. Hamilton has approximately 6,000 births per year . Twenty A total of 108 pregnant women were recruited into the pilot study to receive the full NFP intervention until their child’s second birthday. The women were recruited through prenatal referrals from primary care and community services to the Healthy Babies, Healthy Children (HBHC) Program administered by Hamilton Public Health Services. The HBHC program is a maternal child health program mandated by the provincial government providing home visiting to mothers at risk of poor pregnancy outcomes during pregnancy. In addition, under the HBHC program all new mothers are assessed during the postpartum period and families identified as at risk are eligible to participate in a long-term, mixed model  HBHC home visiting program. Eligibility criteria for the pilot study included: 1) being a first-time mother; 2) referral into the program before the end of the 28th week of gestation; 3) ≤ 21 years of age; and 4) assessed to be low-income based on low-income cut-off tables , receiptWe used a single case study approach to move beyond the feasibility study to examine whether the NFP intervention is acceptable to a broad range of stakeholders within the current health care system in Ontario, Canada . In doinIn order to develop a comprehensive understanding of the mothers’ experiences of participating in the home visiting program, a purposeful sub-sample of women were recruited from among the 108 women in the pilot study. Maximum variation sampling was used to recruit a diverse group of pregnant women and mothers with infants ≤ 12 months, and who were single or partnered, ranged in age from 16 to 21 and at various time points receiving the NFP curriculum. It was estimated that a sample of 15 to 20 women would be needed to reach saturation. The research assistant collecting data for the pilot study approached a purposeful sample of participants in the NFP pilot study, explained the purpose of this portion of the study and obtained written informed consent to participate. Women who agreed to participate received a telephone call to arrange a time and place for an interview. In-depth, semi-structured face-to-face interviews were conducted to explore the women’s perceptions about the NFP program and their experiences within the program. At the end of the interviews, women were asked for permission to be contacted for a follow-up interview within four months to explore their ongoing experiences with the NFP program. One of the researchers  and two trained research assistants carried out the in-depth interviews. The in-depth interviews were undertaken at a location convenient for the mothers; usually in the participant’s home. Both the first and follow-up interviews were guided by a semi-structured interview schedule. Examples of interview questions included: What has life been like since you got pregnant/had the baby? What has it been like having a NFP nurse visiting you? And What have you liked/disliked about the NFP program? The interviews lasted 30 to 60 minutes. The participants received a $25.00 gift card to thank them for their participation in the interviews. With the permission of the mothers, the in-depth interviews were digitally recorded. Participants completed a short demographic questionnaire. Observations and a description of the interview context were documented in field notes maintained by the interviewers. An audit trail of decisions made regarding methods, sampling, data collection and analysis procedures was also maintained to support confirmability of the findings.Data collection and initial analysis were undertaken concurrently. The interviews were transcribed verbatim and each transcript was compared to the recording for accuracy. Conventional content analysis was used to analyze all interviews and field notes ,28. TranInitially 22 mothers participating in the NFP feasibility study were approached and agreed to participate in the acceptability study. However only 18 of these mothers were subsequently located and completed the first interview between February 2009 and January, 2010. While all of these mothers consented to complete the second interview, only seven of the original 18 mothers were interviewed with four refusing because they were too busy; two mothers no longer had custody of their infants and did not want to be interviewed, one moved and four were lost to follow-up at the time of the second interview. However of the 18 women who participated in the initial interview 10 completed the NFP program. Of the participants who did not complete the NFP program, one moved, two lost custody of their infants and the remaining 5 left the NFP program after their infants turned one year of age. At the time of the initial interview six of the women were pregnant and the remaining 12 had infants < 12 months of age. The average age of the infants at the time of the first interview was four months. Thirteen of the women identified that they were single, and the remaining five were in common-law relationships. All but one of the women reported a total annual income less than $24,000 and 13 of the women identified their main source of income to be from social assistance or another government program. On average the participants had completed a grade 11 education.Getting into the NFP program; 2. The NFP nurse is an expert, but also like a friend providing support; and 3. Participating in the NFP program is making me a better parent. Although the themes are thickly interwoven, we will present each of them separately for ease of discussion.The mothers participating in the NFP program were very positive about their experiences in the program. Much of their discussion focused on their experiences with their NFP nurses. Three overarching themes, with subthemes, emerged describing the women’s experiences with and perceptions of the NFP nurses and program. These include: 1. Many of the women explained that they were offered the NFP program because they were young, needed support and as first-time mothers, wanted information about pregnancy and parenting. From maternal descriptions of the referral process, it was evident that a wide range of community services were aware of and referring to the NFP program, including: physician or midwifery services, community-based prenatal classes, local Children’s Aid Societies, and their social workers. One woman explained why her doctor referred her to the program, “She just thought it was a good thing for any …young mother …to have the right support and [to answer] any questions I had that she [her doctor] could not answer.” Another woman stated, “I was a patient of the Maternity Centre and the social worker there set me up with the Nurse-Family Partnership program.”Many of the women shared that they accepted the program because they felt they needed support and had a lot to learn as this was their first pregnancy. One mother explained:Knowing that there is always someone that you can call if there is anything wrong, and I have like a thousand questions about being pregnant and it’s good to have someone that will be there to answer them.Another mother stated she accepted the program because she needed support as her boyfriend had left her. She explained that she entered the program, “because I was clearly struggling with the pregnancy thing and being alone in the pregnancy and had asked for support.”A small number of women indicated that they accepted the program because it was “something to do” while waiting to have the baby. Several were initially ambivalent about participating in the program because of previous experience with other community programs that they felt were “useless.” One mother stated, “I was honestly a little sceptical about it at first…I did not think it would really help, but it’s actually been a really big help.” Another mother shared, “ I thought, ‘Oh it’s just going to be somebody coming to talk to you, check up on you, not really help you.’ I thought it was going to be kind of intrusive at first. But I really enjoyed it”.In discussion with the mothers about their experiences in the NFP program most mothers focused primarily on the positive relationships they had developed with their NFP nurses. The positive relationships described by the mothers had multiple dimensions which are captured under the following six subthemes: (1) the nurse’s personality; (2) The NFP nurse is “like a friend” who supports you; (3) the NFP nurse is respectful and trusting; (4) the NFP nurse is empowering and an advocate; (5) the NFP nurse is an honest expert; and (6) the NFP nurse is easy to access when you need her help.Most of the mothers when describing their NFP nurses identified that they had many positive personality attributes that facilitated their ability to engage with and develop a working relationship with the nurse. The personality attributes highly valued by the mothers included: a good sense of humour, being friendly, honest, non-judgmental and reliable, coming to the visit in a good mood and having an “easy going” nature. Many of the mothers also emphasized that as the therapeutic relationship with the nurse home visitor became established, they understood and appreciated how much the nurse truly cared about them and their child.Within this purposeful sample, only a single mother held a negative perspective about the characteristics of her nurse home visitor in commenting that she was “outdated” and further explaining, “She’s a nice lady….fairly easy going most of the time …she’s got the old way of doing things that she likes to go by.” Her viewpoint appeared rooted in contradictory information about infant feeding from her physician and NFP nurse. Despite this opinion, this mother planned to continue to have the nurse visit until her son turned two.The NFP nurse for many participants was someone they could consistently rely on to provide emotional and informational support. Many of the mothers shared that they experienced precarious social support and relationships with family, friends and their baby’s fathers throughout their pregnancy and beyond. Repeatedly we heard examples of mothers feeling isolated or abandoned during pregnancy by the very individuals they were counting on for social support. One mother explained, “He [the baby’s father] wanted me to get pregnant and then found out I wasn’t having a boy, I was having a girl, and he didn’t want to be there anymore.”Another mother shared “I lost a lot of my friends during my pregnancy”. Several of the young mothers also described growing up in less than stable environments and as a consequence lacked the support of extended family members. One pregnant woman who had lived in foster care during her childhood because of exposure to maltreatment experienced great sadness that, during this pregnancy and then into the postpartum period, she would not have any support from her mother who ”isn’t as stable as she should have been”.Many of the mothers identified the NFP nurse home visitor as providing a primary source of social support, particularly emotional support. Several of the mothers used the word “friend” to describe how they perceived the nurse. In her narrative, a young mother shared:I said, ‘make yourself at home’ and she did. …It didn’t seem like I was sitting there with a nurse, it felt like I was just sitting there with like a friend and so she made me really comfortable and like I could talk to her about anything.The mothers perceived the nurses as friends because the nurses were easy to talk to and the nurses focused on listening and learning about the mother’s life. The mothers explained that the work of home visiting did not seem “like a job” for the nurses and they perceived that the nurses equally enjoyed the home visiting process. One mother emphasized that she and her nurse, “talked more about my life than I would with other professionals and she knows a bit more about me, so I feel comfortable talking to her about most things.”“The relationship is a bonus because when I joined the program I wasn’t expecting to actually make a relationship with the nurse you know.” Another mother who had problems with addiction and depression, and who had temporarily lost custody of her baby continued to see her nurse on a regular basis. She lacked a support system in Hamilton and had developed good rapport with her nurse who she was continuing to work with her to deal with her issues. She simply expressed, “I feel kind of close to her.” In comparison to other professionals that the mothers had worked with, they perceived that the NFP nurses were consistently more accessible and that they could call and ask for advice and support when they were struggling with issues, not only regarding their pregnancy and baby, but also personal issues such as relationship problems.Mothers confirmed that they were able to further trust the nurse and open up during the home visits when the nurses were willing to share some of their own personal experiences related to such topics as parenting or healthy relationships. The nature of the conversations during the home visits sometimes included some level of personal sharing and one mother explained, “We talk about life. You know what I mean? We share stories. I know a bit about her husband. She knows a bit about my boyfriend.” As a result, the relationship that developed with the NFP nurse became a highly valued outcome related to program involvement for many of the mothers. One mother shared, A small number of the mothers also disclosed that to them, their nurse idealized their expectations of what a supportive family member, especially their mothers, should provide to them. One mother who had lived in multiple foster homes throughout her childhood and had very minimal contact with her mother, described her relationship with her nurse like the one she thought mothers and daughters should have when the daughter has a baby.taught me. I wouldn’t, I wouldn’t have known. Like I don’t have … my mother …[I don’t have contact with her] So like all the stuff I would have called her [my mother] up to ask her, I get from my nurse.Because of everything that she’s [NFP nurse] All the mothers expressed the importance of having the same nurse visit them throughout their time in the program. They perceived that the quality of their relationship with their nurse would have been threatened had they been visited by multiple nurses. One woman commented:[Having the same nurse every visit is important] because they know you. They know how you are…It’s not a different person every day so you have to make that first initial impression every single time. It’s very important that it’s the same person.Several mothers liked the feeling that their nurses trusted them. This allowed the mothers, in turn, to trust their nurses. For these mothers being trusted was empowering and very important in the relationship. The mothers’ trust in their nurses is a measure of their level of engagement in the therapeutic relationship as many discussed having difficulty trusting people. A mother shared:She trusts me and I trust her. It’s just like that. It’s really hard for me to trust people sometimes because I’ve been put down before with friends… but I trust her [NFP nurse] a lot… [I can talk to her] yes about anything.“insulted by” some of the questions about drugs and alcohol in the NFP program questionnaires. She felt that because of the relationship she had developed with her nurse, the nurse should have trusted her not to do drugs because her nurse knows that was “ not who I am”. At the same time the mother was comfortable enough to discuss this issue with her nurse and accepted the nurse’s explanation that the questions were a standard part of the curriculum. She felt that it was the nurse’s personality that kept her participating in the NFP program.The importance of being trusted by the nurse was made very clear by a mother who was Several mothers spoke about how the nurses empowered them. They felt they were in control of the activities they did with their nurses. They liked the fact that they set the learning agendas with their nurses based on their own needs instead of the nurses deciding for them.She asks me what I want her to bring in [to the home visit] so that’s kind of nice. She suggests things she could bring….and asks me if I want to see any of that?…she says she will bring it if I want her too.In addition mothers were pleasantly surprised that they had control over scheduling home visits. They shared: “They are willing to go around your schedule and set up days that are good for you and not just like convenient for them.” Most important, the mothers in this study appreciated that the structure of the program allowed for their nurses to be accessible and flexible in changing or scheduling new home visit appointments..” Another mother stated: “She makes me feel really good. She doesn’t make me feel like I did anything wrong, like I raised her wrong. She kind of makes it like it’s not your fault, it’s your first time, you’re learning.”Many of the mothers discussed how good it felt when their nurses gave them positive reinforcement related to their self-care and parenting. As one mother said: “She’s very encouraging and sometimes just hearing that you’re doing a good job makes the biggest difference in the world, especially with being such a young parentSome of the women shared that their nurses advocated for them when dealing with community agencies. One mother who was being monitored by the Children’s Aid Society (CAS) discussed how her nurse helped her deal with CAS and supported her when the agency child welfare worker visited. “The NFP [nurse] gives me good tips on stuff like how to deal with them [CAS]…. [my NFP nurse] comes to my meetings [with CAS] too…. [that] shows CAS like [I] do what I need to do with my son.”The NFP nurse is an accessible honest expert who gives advice and answers questions. The mothers valued the fact the nurses were knowledgeable health care professionals. They described the nurses as credible and honest experts they could rely on. Most of the mothers felt they could ask the nurses about anything. Furthermore, the information provided by the nurses was perceived as helpful. The mothers expressed that the nurses were skilled in assessing their information needs and providing education they could understand.For the new mothers, they particularly valued the nurse’s expert opinion about their infant’s health and development. Nurses were also recognized for their skills in conducting physical assessments of the mothers’ infants. Many of the mothers found the information provided by the nurses comforting, as the nurses were able to normalize and explain new situations the mothers were experiencing. As one mother explained:check it to make sure it looked right because I didn’t think it did but it was perfectly fine. So that was good. She’s really, she’s really cool.And then every time I had to ask her a question about anything like when his umbilical started to fall off, I needed her to For many mothers knowing they had easy access to expert information from their nurse was reassuring. One mother shared:Knowing that there’s always someone that you can call if there’s anything wrong, and I have like a thousand questions about being pregnant and it’s good to have someone that will be there to answer them. Because I ask everyone and they obviously don’t know accurate answers, they just tell me what they think. But a public health nurse they know the actual answer, so I like to know.Although the mothers saw their nurses as professionals, the mutual respect and trust that had become part of their relationships empowered them to see themselves on the same level as their nurses, i.e. person to person. This allowed them to ask their nurses health questions they did not feel comfortable asking other health care professionals. One mother stated:She’s more to me a person on the street that I can go and meet, not just like a professional. I know she’s a professional but it’s just easier on me knowing that she’s not I’d say uptight as what a doctor would be or something.transportation is really difficult…with a baby.”Most of the mothers did not have access to cars, nor could they afford regular use of taxis. Use of public transportation became more difficult once their infants were born. The mothers felt that the home visits made it much easier for them to engage with their NFP nurses on a regular basis. One mother stated, “That she comes to me so I don’t have to try and get out my door and go see her like at an office that I’d probably have to take a bus to…because [public] Access to the nurses by telephone was also very important to the mothers. All the mothers shared that they could contact their nurses by telephone if they had questions or needed their help. In addition they knew that they could rely on the nurses getting back to them in a timely manner when they called them. One mother said:She’ll answer her phone or she’ll call me back. After leaving a message she’ll call me back right away….[She will call back] sometimes same day, sometimes the next morning depending on what time it is throughout the day.The quick access to their nurses by telephone was extremely important to many of the women if they were worried about themselves or their infants. As one mother shared:stress off my chest [if I can call my nurse] because sometimes I think that something’s wrong when it’s not. Sometimes I’m just panicking because it’s the first time and never had this happen before, right? So I’m just learning.It’s a lot of Several mothers felt that after their infants were born the home visits with their NFP nurses sometimes became too long. They explained that since their baby was born they were much busier than when they were pregnant. Many had returned to school and found attending school and looking after their infants overwhelming and exhausting. The home visits were one more activity to fit into their hectic schedules. This is reflected in the following comment:I know that the visits were getting like very long but that was like the only thing, like we’d talk for so long. That was the only thing that the visits got like up to like maybe an hour and a half, 2 hours at a time….We kind of cut it down probably like a half an hour every time. She [nurse] would probably have liked an hour a visit.Most of the mothers shared the view that by participating in the NFP program they were becoming better parents. They identified that they had learned a lot from their nurses regarding self care, healthy living during pregnancy, breastfeeding, interpreting infant behaviour, infant developmental milestones, parenting, basic physical care of their infants, healthy relationships with partners and family members and available community resources. They shared that with each visit from their nurses they were learning new “stuff” that they wanted to know to make them good mothers. For example women interviewed during pregnancy shared that they learned important information to help them have a healthy baby. A mother commented:Like she brings in things  and … like what to look out for when you’re pregnant and after… I never knew half of those things. So she’s already helped me a lot.In the early weeks after their babies were born mothers shared that their nurses not only helped them learn the skills needed to physically care for their babies, but also helped them understand their babies’ behaviour and how to relate to their babies. One mother whose baby was 3 weeks old explained:love through trust and security. I thought that was cool. I never knew a baby could like take in love like we can because they don’t really know. But I thought that was pretty cool that they learn to trust you [when you respond to their needs]… that’s how they learn how to love.Now she’s [NFP nurse] starting to teach me some lessons. Yesterday we did a thing on how a baby learns about Another mother when asked what she felt she was getting from participating in the program stated:It’s made me learn a lot more to make myself a better mother than if I didn’t know anything at all and I’m just winging it …taking care of him.…It’s going to probably help me learn to make sure that as he’s growing up. I’m going to teach him different things…the proper way. He’s learning exactly what he’s supposed to be by this age and all that.Several women in the study who had partners felt that participation in the NFP program was helping them and their partners become good parents. One mother explained:I think he [partner] likes it because in a way it’s helping us build up our skills for parenting as well as build up our skills for making sure the baby’s healthy and ourselves are healthy…I think …she’ll [NFP nurse] help me because she’ll help me raise a healthy family and she talks about like healthy relationships with your family and with your boyfriend and everything. So it’s not just about like me and the baby, it’s about the whole thing.Knowledge of mothers’ experiences participating in the NFP program is extremely important for the development of a comprehensive understanding of critical aspects of the program that make it effective in improving health and social outcomes for mothers, their children and families in general. This study is one of the first to examine the NFP program from the perspective of clients participating in the program. Our findings contribute valuable new insights and start to address the paucity of information about the therapeutic relationships between ‘at risk’ mothers and NFP nurses that have been hypothesized to play a key role in the effectiveness of the NFP program . OverallMany of the women in our study were surprised by the positive relationships they developed with their nurses. Some even considered their nurses to be ‘friends’ they could confide in and trust.  Our findings support the theory postulated by Falk Rafael that good therapeutic relationships are developed between home visiting nurses and mothers when the nurses are non-judgemental and help mothers to become empowered to increase control over their lives and health . HoweverFor many young, low income, pregnant women a major motivator to participate in nurse home visiting programs may be a lack of adequate social support. Participants in our study shared that they entered the NFP program in order to obtain needed support. Consistent with the findings of previous studies on low-income mothers, most of the participants in our study experienced precarious social support ,41-43. TAs such, the support provided by NFP nurses may be a key critical factor, foundational to the effectiveness of the NFP program, enabling young mothers to engage in activities that will move them forward to employ healthy parenting and healthy self- development. Young, expectant and/or parenting, low income mothers often struggle with the responsibility of motherhood, material deprivation, and are at high risk for psychological distress -47. Low All the women interviewed felt their participation in the program was helping them to become good mothers. They identified they had learning needs about pregnancy, infant care and parenting before entering the program. This was one of the reasons they gave for agreeing to participate in the program. Similar to findings in previous research , mothersOur exploration of mothers’ perceptions of and experiences in the NFP program provides valuable insights into some of the factors that make the NFP program acceptable to mothers and effective in improving maternal and child health and social outcomes. As reported earlier, several of our findings have been reported in previous studies of mothers’ experiences in other nurse and non nurse led home visiting programs yet many of these programs do not have demonstrated effectiveness ,23,31-36This study has both strengths and limitations. Our study focused on the experiences of mothers in the NFP program from the time of entry into the program until the child’s first birthday. More insights into the experiences of mothers in the NFP program may emerge if we interview mothers within the second year of their child’s life and after completion of the NFP program. Although our second interview with participants indicated that they continued to have positive experiences within the NFP program we were only able to re-interview 7 of the 18 participants. It is possible that women who did not participate in the second interview were unhappy with the program; however this may not be the case. Three participants had exited the NFP program at the time of the second interview for the following reasons; one had moved out of the region and two had lost custody of their infants and no longer wanted to participate. Five of the participants who did not partake in the second interview graduated from the NFP program when their children turned 2 years of age, and the remaining 3 participants who did not participate in the second interview exited the program after their infants turned one year of age (after the time of the second interview). Our difficulty locating some of the participants for the second interview was likely due to factors related to poverty in this population which can lead to multiple household moves and an inability at times to afford a telephone. These factors make it challenging for researchers to follow-up with participants . AnotherExamining women’s experiences in the NFP program is an important step in uncovering the ‘active ingredients’ in effective home visiting. To date the NFP program is one of only a few home visiting programs to demonstrate effectiveness in improving health and social outcomes in both vulnerable mothers and their children ,18. Our As our study was limited to the examination of the mothers’ experiences until their child’s first birthday, further research is required to explore the experiences of women in the second year of the NFP program. Retention of families at risk in home visiting programs is often very challenging . Given oThis study should be replicated in other locations to develop a comprehensive understanding of the spectrum of mothers’ experiences in the program across multiple sites and different contexts . Finally research is needed to demonstrate the effectiveness of the NFP program in meeting the multifaceted needs of at risk mothers and their children within the Canadian context.NFP: Nurse-Family Partnership; HBHC: Healthy Babies Healthy Children; PHN: Public Health Nurse.The authors declare that they have no competing interests.CKL conceived of and designed the mothers’ experiences component of the larger study, collected, analyzed and interpreted the data and drafted the manuscript. SMJ conceived of and participated in the design of this study, data interpretation, and revisions to the design of the study and revisions to the manuscript. HM conceived of and designed the larger NFP pilot study and contributed to revisions to this manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6955/11/15/prepub


Running is associated with desirable lifestyle changes. Therefore several initiatives have been undertaken to promote running. Exact data on the health effects as a result of participating in a short-term running promotion program, however, is scarce. One important reason for dropout from a running program is a running-related injury (RRI). The incidence of RRIs is high, especially in novice runners. Several studies examined potential risk factors for RRIs, however, due to the often underpowered studies it is not possible to reveal the complex mechanism leading to an RRI yet.The primary objectives are to determine short- and long-term health effects of a nationwide “Start to Run” program and to identify determinants for RRIs in novice runners. Secondary objectives include examining reasons and determinants for dropout, medical consumption and economical consequences of RRIs as a result of a running promotion program.The NLstart2run study is a multi-center prospective cohort study with a follow-up at 6, 12, 24 and 52 weeks. All participants that sign up for the Start to Run program in 2013, which is offered by the Dutch Athletics Federation, will be asked to participate in the study.During the running program a digital running log will be completed by the participants every week to administer exposure and running related pain. After the running program the log will be completed every second week. An RRI is defined as any musculoskeletal ailment of the lower extremity or back that the participant attributed to running and hampers running ability for at least one week.The NLstart2run study will provide insight into the short- and long-term health effects as a result of a short-term running promotion program. Reasons and determinants for dropout from a running promotion program will be examined as well. The study will result in several leads for future RRI prevention and as a result minimize dropout due to injury. This information may increase the effectiveness of future running promotion programs and will thereby contribute positively to public health.NTR3676. The NTR is part of the WHO Primary Registries.The Netherlands National Trial Register  Several initiatives have been undertaken to encourage people to start running. In the Netherlands a nationwide supervised running promotion program called Start to Run is offered by the Dutch Athletics Federation, which attracts over 8,000 novice runners annually. So far, the exact health benefits of a 6-week running promotion program and reasons for dropout have barely been examined ; 6 weeks and 6 months follow-up, submitted).Running is associated with desirable lifestyle changes such as weight loss, smoking cessation and improvement in cardio respiratory fitness and mental health -3.The hePreliminary dropout from a running promotion program hinders a shift from extrinsic motivation to intrinsic motivation, which is important in becoming a regular exerciser . An impoSeveral studies tried to identify determinants for RRIs. One of the reasons that the most important risk factors for RRIs have not yet been identified might be related to the often-underpowered studies performed. Since the development of an RRI results from a complex interaction between both intrinsic and extrinsic risk factors, a multivariate analysis is essential for identifying risk factors for RRIs ,11. MultThe primary objectives of the NLstart2run study are therefore to determine short- and long-term health effects of a nationwide “Start to Run” program and to identify determinants for RRIs in novice runners. This information is important for developing successful running promotion programs in the future . SecondaNTR3676).The NLstart2run study is a multi-center prospective cohort study with a follow-up at 6, 12, 24 and 52 weeks, as can be seen in Figure All participants that sign up for the 6-week Start to Run (STR) program of the Dutch Athletics Federation in 2013 will be asked to participate in the NLstart2run study. The STR course is organized twice a year and starts in March and September. The STR participants will be recruited by the Dutch Athletics Federation via national and local media. Additional information about the study and procedures is sent to all STR participants. Participants can register for the study after signing a digital informed consent.Participants of the STR program who are aged between 18 and 65 are eligible for inclusion. Participants will be excluded if there are absolute contraindications for vigorous physical activities according to the American College of Sports Medicine ACSM) guidelines , or in cThe STR training program consists of three training sessions per week, one group training session supervised by a licensed athletic trainer and two individual training sessions. Each training session begins with a 15-minute warm-up and finishes with a 15-minute cool-down that consist of walking, stretching and relaxation exercises. The core of the training includes running program in which both running duration and intensity will be gradually increased. The STR program aims to prepare participants in 6 weeks for a 20-minute run without breaks. After the 6-week STR program, participants can choose to continue running in a way they prefer.In the current study a running-related injury (RRI) is defined as any musculoskeletal ailment of the lower extremity or back that the participant attributed to running and hampers running ability for at least one week ,18. HampBased on previous studies on RRIs among novice runners, an injury incidence of 20% is expected ,14,18. T2 (m)).The five-part baseline questionnaire will be administered online after participants give informed consent. Demographics, anthropometrics, and other personal characteristics are covered in part 1. Self-reported body height and weight will be used to calculate BMI (weight (kg) / heightPart 2 covers information on previous running and sports participation ,22. AlsoPhysical activity during daily life is assessed in part 3 with the Short Questionnaire to Assess Health-enhancing physical activity (SQUASH). The SQUASH was designed to give an indication of habitual activity level during an ordinary week. The SQUASH has been tested for validity and reliability with an accelerometer as a criterion measure in a general adult population and has turned out to be reliable and valid ,24.In part 4, the Behavioral Regulation in Exercise Questionnaire-2 (BREQ-2) is used to measure motivation toward exercise in general. The BREQ-2 assesses a motivation and external, identified, interjected and intrinsic regulations, and showed sufficient validity in adults .In the final part physical, mental and social health is measured. Perceived health is assessed with the Dutch version of the RAND-36 Health Survey (RAND-36), which was translated from the standardized SF-36 Health Survey ,27. The The runners starting with the STR program in March 2013 will receive four follow-up questionnaires at 6, 12, 26 and 52 weeks after beginning with the program. The group of runners who start in September will only receive three follow-up questionnaires at 6, 12 and 26 weeks. In the follow-up questionnaires continuation and reasons for discontinuation of running will be monitored. Participation in other sports will also be monitored in the follow-up questionnaires. Besides questions about continuation of running or other sport activities, all follow-up questionnaires also measure physical activity (SQUASH), motivation toward exercise (BREQ-2), and physical and mental health .During the 6-week STR program a weekly training log is sent to the participants. For each training session, data on running exposure (frequency and duration), running surface, perceived exertion and pain is registered. Weekly information on other sports activities (type of sports and exposure that week) is obtained from the training log. When participants do not enter their digital training log after five days, an e-mail reminder is sent automatically.Perceived exertion will be assessed using Borg’s Ratings of Perceived Exertion (RPE) scale. The RPE scale is widely used in exercise science and sports medicine to monitor or prescribe levels of exercise intensity. Borg’s RPE scale has shown to be a valid measure of exercise intensity .Pain will be measured by registering anatomical site of the body and severity of pain for each training session. A mannequin will be shown to identify the anatomical site of the running-related pain. By clicking on the anatomical site, the same spot will be pointed red. Severity of pain is additionally subdivided into pain without limitations, pain that causes a restriction in running, and pain which makes running impossible. To classify the severity of pain, a Visual Analog Scale (VAS) is used. When a training session is skipped, the reason for it will be asked . When running-related pain is the reason, anatomical site and severity of pain will be obtained.In addition to the pain registration obtained for each training session, the development and progression of overuse injuries is also monitored with a new method as proposed by Clarsen et al. . This meAfter the 6-week STR program, a digital training log is sent to the participants every two weeks. This training log is a simplified version of the log that was used during the first six weeks. Information on running exposure, running surface, running-related pain and other sports activities is registered per week instead of at each training session. In this simplified training log, pain registration and monitoring of overuse injuries is similar to the methods used in the first six weeks. Participants who quit running after the STR program can indicate so, and only have to complete the information on other sports activities.When an RRI is registered in the web-based training log, a questionnaire will be automatically sent to the participant after two weeks. This questionnaire is used to specify medical/paramedical treatment, the order of treatments, type and frequency of the treatment, medical aids, and absence from work, school or training due to the RRI. Injured runners are asked to specify the injury location, if the injury is new or recurrent, what structure is injured , and the injury mechanism . When the runner is seen by a professional, a diagnosis will be asked. Until recovery from the RRI, every four weeks a follow-up questionnaire on medical/paramedical consumption and absence from work, school or training is sent to the injured runner.To validate the RRI registration method that is used in this study, approximately 10% of the subjects who sustain an RRI will be contacted by a sports physician. The sports physician will perform a standard physical examination and will then complete the abovementioned RRI questionnaire regarding location, structure, and mechanism of the injury.From the data derived from the RRI questionnaire and subsequent follow-up questionnaires, direct and indirect costs will be calculated. Costs will also be calculated from a societal perspective. Direct healthcare costs will include costs resulting from medical/paramedical treatment and/or medical aids. Indirect costs will include costs resulting from absence from paid work or unpaid work, as well as leisure time lost. Dutch guideline prices will be used to value resource use . Direct Incidence of RRIs will be calculated for all participants and for male and female participants separately as the number of new injuries reported per 1000 hours of running exposure. Exposure time (in hours of running exposure) will be calculated from the time the participant started the running program until an RRI is reported (injured runners) or until the end of the program (non-injured runners).Descriptive data will be presented as means (± s.d.) and frequency distributions.For identification of risk factors for RRIs only data from the baseline questionnaire and the running log will be used. Data of the follow-up questionnaires will not be used for this purpose, because these data do not contribute to a pre-running risk-profile. It is possible for a single subject to sustain multiple RRIs during the study period. In this case only the occurrence of the first RRI will be used for analysis. Potential risk factors for RRI will be entered into a multivariate Cox regression prediction model. Hazard ratios and the corresponding 95% confidence intervals will be calculated for the factors associated with RRI.Data of the baseline and follow-up questionnaires will be compared with a repeated-measures ANOVA to examine the health effects of participating in a supervised running program. Reasons for dropout from the start-to-run program will be described and determinants for dropout will be analyzed by multivariate logistic regression models. Course and medical consumption and the associated direct and indirect costs will be described for injured runners.Missing data will be completed by multiple imputation using the Multiple Imputation by Chained Equations (MICE) procedure, a technique in which missing values are replaced based on estimated relations in the dataset . Ten mulThe extensive baseline questionnaire and follow-up questionnaires will provide insight into the short- and long-term health effects of participation in a 6-week running promotion program. Perceived health, physical activity in daily life and motivation to exercise will be monitored over time and thereby describe the effects of a running program for novice runners. Sports participation during and after the 6-week STR course will be monitored. Reasons and determinants for discontinuation for both running and sports will be examined as well. These findings may reduce dropout rates from future running or sports promotion programs and increase adherence to sports during and after a program.The NLstart2run study will result in several leads for future RRI prevention programs. The large sample size and the extensive baseline measurements will result in ample information on determinants for RRIs in novice runners. As a result of the large group of participants, it will be possible to study risk factors for specific RRIs or in specific subgroups. These findings will result in new information regarding modifiable risk factors that can be applied in future running promotion programs to minimize dropout due to injury.As a result of the NLstart2run study, valuable information on health effects and RRI prevention for novice runners will be gained. Moreover, medical consumption and consequences of an RRI, as well as reasons and determinants for discontinuation and dropout from a running promotion program will be examined. This information can be used for the implementation of more effective running promotion programs, thus making a positive contribution to public health.The authors declare that they have no competing interests.IB, MM, RD conceived of the idea and obtained funding for the study. BK is the study investigator, wrote the article and will be responsible for data acquisition. FH, EV, DWS, HW provided advice on the study design and contributed to the content of the article. RD, MM and HW coordinate the trial. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/685/prepub


Publicly-funded drug plans often use prior authorization policies to limit drug prescribing. To guide physician prescribing of a class of antibiotics with broad antimicrobial activity (quinolone antibiotics) in accordance with new prescribing guidelines, Alberta’s provincial health ministry implemented a new mechanism for formulary restriction entitled the optional special authorization (OSA) program. We conducted an observational study to determine the impact of this new formulary restriction policy on antimicrobial prescription rates as well as any clinical consequences.Quinolone antibiotic use, and adherence with quinolone prescribing guidelines, was assessed before and after implementation of the OSA program in patients with common outpatient infections using an administrative data cohort and a chart review cohort, respectively. At the same time this policy was implemented to limit quinolone prescribing, two new quinolone antibiotics were added to the formulary. Using administrative data, we analysed a total of 397,534 unique index visits with regard to overall antibiotic utilization, and through chart review, we analysed 1681 charts of patients with infections of interest to determine the indications for quinolone usage.Using segmented regression models adjusting for age, sex and physician enrollment in the OSA program, there was no statistically significant change in the monthly rate of all quinolone use  prescriptions per 1000 index visits) following implementation of the OSA program (p = 0.74). There was a significant level change in the rate of quinolone antibiotic use for urinary tract infection  prescriptions and upper respiratory tract infection  prescriptions per 1000 index visits. Among quinolone prescriptions identified on chart review, 42.5% and 58.5% were consistent with formulary guidelines before and after the implementation of the OSA program, respectively (p = 0.002). There was no change in hospitalization, mortality or use of physician services after implementation of the OSA program.Despite the addition of two new quinolone antibiotics to the formulary, we found that there was no change in the use of quinolones after implementation of a new formulary restriction policy for outpatients with common outpatient infections. Spending for prescription drugs represents nearly 17% of Canada’s health care expenditures and is the fastest-growing component of the health care budget ,3, respiIncreases in drug expenditures have been particularly pronounced for antimicrobial agents, and concerns also exist that their misuse and overuse may lead to antimicrobial resistance -11. To lA provincial strategy to improve outpatient antibiotic prescribing and reduce antimicrobial resistance was recently implemented in Alberta, Canada, and specifically recommended quinolone antibiotics , particularly second and third generation agents, as second line treatment for patients with community acquired pneumonia, acute exacerbation of chronic obstructive pulmonary disease (COPD), and acute sinusitis. Acknowledging that traditional prior authorization was likely infeasible, a new formulary restriction was developed ) in conjunction with changes to prescribing restrictions for quinolone antibiotics. We conducted an observational study to determine the impact of this new formulary restriction policy on antimicrobial prescription rates as well as any clinical and economic consequences.Our primary objective was to measure the impact of a new reimbursement policy aimed at restricting the use of quinolones to defined subgroups of patients with common outpatient infections including urinary tract infection (UTI), upper respiratory tract infection (URTI), acute exacerbation of chronic bronchitis (AECB) and community acquired pneumonia. The secondary objective was to compare the proportion of quinolone prescriptions which were consistent with the restricted reimbursement prescribing criteria, before and after institution of the restricted reimbursement program.https://www.ab.bluecross.ca/ ). Prior to November 15, 2005, four quinolones  were a general benefit on the Alberta Blue Cross formulary (meaning that they would be reimbursed without restriction). On November 15, 2005, AHW established a new formulary restriction policy for quinolones   provides drug coverage for a defined formulary to all residents of Alberta Canada over age 65 through Alberta Blue Cross, the details of which can be found elsewhere (th version [ICD-9] diagnosis codes used to define the infectious conditions). The study period included the two year period preceding, and one year after implementation of the restricted reimbursement program (effective November 15 2005).Given that coverage of pharmaceuticals is provided to all Albertans ≥ age 65 (and thus complete data on prescribing is available only for this cohort), our study was restricted to Albertans aged ≥ 65. Patients were included in the cohort if they had an outpatient visit to a primary care physician for acute exacerbation of chronic bronchitis, community acquired pneumonia, upper respiratory tract infection or urinary tract infection, common out-patient infections for which quinolones may be indicated  was the use of a quinolone in the 30 day period following a unique index visit for a urinary tract infection, upper respiratory tract infection, acute exacerbation of chronic bronchitis and community acquired pneumonia. We also assessed the use of an antibiotic that was not restricted within the restricted reimbursement program in this 30 day period.consistent  with the restricted reimbursement prescribing criteria.For patients noted on chart review to have a physician visit for one of the infections of interest, the secondary outcome measure included the proportion of visits that were associated with prescription for a fluroquinolone For the primary objective (to measure the impact of a restricted reimbursement program for quinolones on the use of quinolones for patients with common outpatient infections) the unit of analysis was the unique index visit for any of the four common infections. In an initial exploratory analysis we compared the rate of quinolone antibiotic use, other antibiotic use and no antibiotic use for the infectious conditions of interest, for the pre and post OSA time periods. We further stratified this by prescriber designation (enrolled and not-enrolled in the OSA program), and by infection of interest.The impact of the restricted reimbursement program on the outcome of quinolone use was examined using segmented linear regression analysis of interrupted time series data. Broadly speaking, the goal of this type of analysis is to examine for a level change (i.e. an abrupt change in quinolone prescribing) or a slope change (i.e. a change in the rate at which prescriptions of quinolones are changing) ,16. ThisFor the secondary objective (examining the use of quinolones consistent with the restricted reimbursement prescribing criteria), we performed descriptive analyses using chi-square tests to assess differences between proportions for the pre and post program periods.Ethics approval was obtained from the Conjoint Health Research Ethics Board in Calgary, and all physicians who participated in the chart review provided informed consent. The study funders had no role in study design or the collection, analysis, and interpretation of data or the writing of the article, nor any role in the decision to submit it for publication. The researchers acted independently from study funders, and the researchers had access to all of the data and performed all analyses independently.The study population consisted of 170,247 individuals who were seen at least once during the three year period for one of the infections of interest (Table The rates and proportion of visits for each infection were stable over the three year period. The majority of unique index visits were for acute exacerbation of chronic bronchitis or for upper respiratory tract infection (76.8%) Table . AntibioThe rate of quinolone use, other antibiotic use and no antibiotic use post index visit for the infectious conditions of interest was similar for physicians enrolled and those not enrolled in the optional special authorization program . Although statistically significant, this change is small.Using segmented regression models adjusting for age, sex and physician enrollment in the OSA program, there was no statistically significant change in the rate of quinolone use  prescriptions per 1000 index visits; p = 0.74)), and there was no change in the slope of quinolone use (p = 0.95), following implementation of the OSA program Figure . Of noteIn addition to implementing the OSA program on Nov 15, 2005, two new quinolone antibiotics (both brand name products) were also added to the Alberta Blue Cross formulary on the same date. Therefore it may be expected that quinolone use would increase (irrespective of the OSA program), and that this might influence the trends in quinolone use over time. To examine the implications of the simultaneous addition of these new agents, we repeated analyses before and after implementation of the OSA program using alternate definitions of quinolone antibiotics – specifically considering the impact on the use of levofloxacin for respiratory diagnoses and ciprofloxacin for urinary tract infection.Given that ciprofloxacin is the predominant quinolone used for urinary tract infections, we examined the use of ciprofloxacin after implementation of the OSA program. Among antibiotic users, there was a level change in the rate of ciprofloxacin use for urinary tract infections of −69.1  prescriptions per 1000 unique index visits after implementation of the OSA program (p < 0.001)). Similarly, as levofloxacin is the predominant quinolone used for AECB, URTI and pneumonia, we examined the use of levofloxacin before and after implementation of the OSA program. Among antibiotic users, there was a level change in the rate of levofloxacin use of −74.2  prescriptions per 1000 index visits for AECB  and after (0.3%) implementation of the optional special authorization program (p = 0.54). After implementation of the OSA program, there was a very small increase in the proportion of patients requiring hospitalization  within 30 days of an outpatient infection claim , though there were no differences in the proportion of patients admitted for one of the four infections of interest . The proportion of patients with any of the four infections used to define unique index visits who had a subsequent outpatient physician claim in the next 30 days increased from 55.6% to 56.5% (p < 0.001) after implementation of the optional special authorization program, though this change is unlikely to be of clinical significance.Chart reviews were conducted in a convenience sample of 60 consenting physician practices (127 primary care physicians were approached), corresponding to 3846 patient visits. On average, 64 patient visits were reviewed in each primary care physician’s office. However, upon review of the chart, it was determined that only 1681 (43.7%) of patient visits with a billing claim for an infection of interest in fact had one of the four infections of interest. A total of 804 (47.8%) of patient visits were before and 877 (52.7%) were after implementation of the OSA program. On average, 15 patient visits with infections of interest per primary care physician were reviewed before, and 15 patient visits were reviewed after implementation of the OSA program  after OSA implementation, for both OSA enrolled and non-enrolled physicians. Among visits for infection treated with an antibiotic, there was no change in quinolone antibiotic use after implementation of OSA program. Among quinolone prescriptions, 42.5% and 58.5% were consistent with formulary guidelines before and after the implementation of OSA, respectively (p = 0.002). This change was stable over time, with 58.6% of quinolone prescriptions being guideline compliant in the last six months of the year after OSA implementation, and seasonal variation in appropriateness of prescribing was small.In this large community-based cohort, we found no change in prescription of the overall quinolone class of antibiotics for four common infections after implementation of a new restricted reimbursement policy for quinolones. However, stabilization in the use of quinolones could be construed as encouraging, given that two new quinolones were added to the formulary at the same time as the restricted reimbursement policy was implemented. Moreover, we observed a significant reduction in the use of levofloxacin for AECB and URTI, and in the use of ciprofloxacin for urinary tract infection, conditions in which quinolones are frequently overused. While the lack of difference observed between OSA and non-OSA enrolled physicians might mean that the program had minimal impact on prescribing, primary care physicians who were not enrolled in the OSA program were also subject to greater quinolone prescribing restrictions since they were required to apply for traditional prior authorization before prescribing quinolones. It is possible that any changes observed were due to the receipt of educational materials on the appropriate use of quinolones, since both groups of physicians received educational materials.As noted, this analysis was confounded by the addition of two new quinolones to the Alberta Blue Cross formulary in conjunction with the OSA program. When we considered only quinolones that were on the formulary prior to the OSA program, quinolone use decreased by 6-10% for the different infections. The results of our chart review were consistent with those observed in our cohort derived from administrative data. In addition, the chart review demonstrated a >15% increase in the proportion of quinolone prescribing that was consistent with formulary guidelines. Finally, the implementation of this program did not appear to have a significant adverse impact on hospitalization, death, or use of physician services in the subsequent 30 days.The new restricted reimbursement policy may have been more effective at guiding physician prescribing if it included repeated physician education or ongoing feedback to physicians on their antimicrobial prescribing , since smight receive antibiotic therapy and it is unlikely that potential misclassification would differ before or after institution of the restricted reimbursement program, or by physician enrollment status. Another limitation is the potential for selection bias in that the primary care physicians who consented to participate in the chart review portion of the study might be different than the broader primary care physician population. It is reassuring that the observed lack of change in quinolone prescribing was consistent in both the chart review and the administrative cohort and physicians were unaware that their prescribing would be audited in the year following OSA implementation. Our analysis is limited by its observational design, and changes observed might be due to factors other than the optional special authorization program. However, a previous study examining the impact of a change in drug policy found similar results in both a cluster randomized trial and a simultaneously conducted observational analysis [A limitation of our study, which was confirmed in our chart review, is that the diagnostic information obtained from physician claims was often inaccurate. However, these codes were intentionally selected to define a broad cohort of patients who analysis  which , with no difference before or after OSA implementation.We found that a new restricted reimbursement policy was associated with stabilization in the use of quinolones in patients with common outpatient infections despite the inclusion of two new quinolone antibiotics on the provincial formulary, and was associated with an improvement in the appropriateness of quinolone antibiotic prescribing in the short-term. Future prescribing initiatives should assess whether ongoing provision of educational materials over time can enhance prescribing in accordance with formulary guidelines.All of the authors declare that they have no relevant competing interests.Dr M, L, T, and H made substantial contributions to study conception and design, drafting and critical revision. Dr M, H and G have all been involved with data analysis, and interpretation of data, and Dr G drafted the methods and results sections. All authors have approved the final version.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/12/290/prepubBlue cross.Click here for fileICD-9 Diagnosis Codes for Outpatient Infections of Interest.Click here for file


US teaching hospitals orient interns each year, usually in the summer months (June–July). These new physicians have usually just finished with their medical school training and do not have any other clinical experience outside of medical school . They are asked to begin seeing patients on day 1 of their internship without having formed relationships with other clinical staff such as nursing and without knowing the hospital system. It is also commonly believed that the ‘quality of health care decreases during trainee academic year-end changeovers’  concerns echoed what the nurses had noted. Responses included simple concerns such as where the bathrooms were located, to the complex early signs of sepsis for the neutropenic patient. Based on findings from the survey, we launched a new collaborative interdisciplinary orientation program in 2010 to assimilate interns into the hospital culture. Each year improvements have been made to the orientation program.Faced with consistent concerns that arise every July, a survey was formulated and distributed to the 2009 interns, approximately 8 months into their first year of internship to query ‘what they wish they had known the first week of their clinical rotation at their hospital facility’. The interns’  worked with internal medicine leadership to improve the intern orientation program. During the first year the nurses adopted an intern buddy, gave them a pocket sized welcome resource booklet , and touIn 2011, the orientation program grew with more collaborative efforts including the addition of ancillary departments and the inclusion of more simulation cases with nurse buddies during the orientation and collaborative simulations throughout the year. Computer order entry education was also added with nurses acting as proctors.We continue to expand upon the program every year due to positive feedback. In 2012, the nurse–buddy program was extended. The interns were matched with a ‘buddy–nurse’ with similar personal interests and with a nurse who would be on a unit/time that they would frequent during the first month. Further simulation experiences were also added.Orientation week included a nursing unit tour, ancillary fair, and three afternoons in simulation and computer labs with nurse–buddies. Attending physicians sponsored a luncheon, which featured a collaborative doctor/nurse bingo. Following lunch, the afternoons consisted of collaborative simulation sessions that included a procedures lab, an atrial fibrillation case, a women's health workshop, a breaking bad news case, an agitated and/or angry patient case, and a case on doing a correct hand-off and calling in a consult. The ancillary fair introduced the intern to other members of the health care team and informed them of the hospital's goals, initiatives, and culture. The intern visited booths with groups such as the safety team discussing high reliability training and patient representatives discussing the language of caring. The intern met case managers, social workers, rehabilitation services, the infection control nurse, and others in small groups with their nurse–buddy who provided information about their department and how they could help the intern provide the best care for their patients.This program received exemption status from the hospital's institutional review board.The initial collaborative orientation in 2010 set the tone for more positive relationships throughout the year. This first attempt received positive results from interns and nurses, and requests from ancillary personnel to be included next year. Findings (case reports), similar to Ushiro's criteria , showed n=21). It was rated very highly , and the interns reported that they found the orientation very/extremely helpful to interact with their nursing colleagues during orientation. They were also interested in spending more time in the simulation center. They rated the ancillary fair very highly as well. There have been case reports of interns connecting with their nurse buddies to discuss issues on the wards. Three month evaluations from interns, nurses, and faculty suggest that this program was extremely helpful in orienting the interns to the program and hospital, in helping them develop better relationships with nursing and ancillary staff, and possibly helping them feel less anxious about starting an internship.All of the interns completed an anonymous, online survey at the end of the orientation program in 2011 , we hope to continue to share our innovative program with others around the country so that other programs can hopefully develop and implement similar inter-disciplinary intern orientations in their hospitals.In the end, everyone, especially patients, benefit from improved collegiality and relationships that are developed through this type of program. We also believe that patient safety and quality of care could improve with these inter-disciplinary programs. Further studies would be needed to determine if these programs improve patient outcomes.This program received the support of the Chief Operating Officer, Chief Medical Officer, and the Chief Nursing Officer at University Medical Center Brackenridge who encouraged department directors to allow staff to participate. Many who participated were salaried employees who arranged their schedules to participate. Staff nurses used education delivery hours that were included in the yearly budget. On-going simulations hours were transferred to the IM program budget. IM faculty used educational value units (EVUs) that were also included in the yearly budget for their time during the simulation cases.