Høgskulen i Sogn og Fjordane

Abstract Terrestrial hydrology is central to the Arctic system and its freshwater circulation. Water transport and water constituents vary, however, across a very diverse geography. In this paper, which is a component of the Arctic Freshwater Synthesis, we review the central freshwater processes in the terrestrial Arctic drainage and how they function and change across seven hydrophysiographical regions (Arctic tundra, boreal plains, shield, mountains, grasslands, glaciers/ice caps, and wetlands). We also highlight links between terrestrial hydrology and other components of the Arctic freshwater system. In terms of key processes, snow cover extent and duration is generally decreasing on a pan‐Arctic scale, but snow depth is likely to increase in the Arctic tundra. Evapotranspiration will likely increase overall, but as it is coupled to shifts in landscape characteristics, regional changes are uncertain and may vary over time. Streamflow will generally increase with increasing precipitation, but high and low flows may decrease in some regions. Continued permafrost thaw will trigger hydrological change in multiple ways, particularly through increasing connectivity between groundwater and surface water and changing water storage in lakes and soils, which will influence exchange of moisture with the atmosphere. Other effects of hydrological change include increased risks to infrastructure and water resource planning, ecosystem shifts, and growing flows of water, nutrients, sediment, and carbon to the ocean. Coordinated efforts in monitoring, modeling, and processing studies at various scales are required to improve the understanding of change, in particular at the interfaces between hydrology, atmosphere, ecology, resources, and oceans.

Abstract The United Nations sustainable development goals are under fire. By attempting to cover all that is good and desirable in society, these targets have ended up as vague, weak, or meaningless. We suggest a model for sustainable development based on three moral imperatives: satisfying human needs, ensuring social equity, and respecting environmental limits. The model reflectsOur Common Future'scentral message, moral imperatives laid out in philosophical texts on needs and equity, and recent scientific insights on environmental limits. The model is in conflict with the popular three‐pillar model of sustainable development, which seeks to balance social, environmental, and economic targets. Rather, we argue that sustainable development constitutes a set of constraints on human behaviour, including constraints on economic activity. By identifying indicators, and thresholds, we illustrate that different regions or groups of countries face different challenges. Copyright © 2016 John Wiley & Sons, Ltd and ERP Environment

BACKGROUND: Reliability of the Actigraph GT3X+ accelerometer has not been determined under normal wear time criteria in a large sample of subjects and accelerometer units. The aim of this study was to assess contralateral hip difference and inter-instrument reliability of the Actigraph GT3X+ monitor in adults under long-term free-living conditions. METHODS: Eighty-seven adult subjects (28 men; mean (standard deviation) age 31.3 (12.2) years; body mass index 23.7 (3.1) kg/m2) concurrently wore two GT3X+ accelerometers (174 units in total) attached to contralateral hips for 21 days. Reliability was assessed using Bland-Altman plots, mixed model regression analyses and absolute measures of agreement for different lengths of data accumulation (single-day-, 7-day- and 21-day periods). RESULTS: There were no significant differences between contralateral hips (effect size ≤0.042; p ≥.213). Inter-instrument reliability increased with increased length of data-accumulation. For a 7-day measurement period (n = 232 weeks), limits of agreement were ±68 cpm (vertical axis) and ±81.3 cpm (vector magnitude) for overall physical activity (PA) level, ±51 min for sedentary time, ±18.2 min for light PA, ±6.3 min for moderate PA, ±3.5 min for vigorous PA, and ±6.7 min for moderate-to-vigorous PA. CONCLUSIONS: The Actigraph GT3X+ accelerometer is a reliable tool for measuring PA in adults under free-living conditions using normal data-reduction criteria. Contralateral hip differences are very small. We suggest accelerometers be attached to the right hip and data to be accumulated over several days of measurement.

BACKGROUND: The objectives of this review were to examine the overall efficacy of music therapy for children and adolescents with psychopathology, and to examine how the size of the effect of music therapy is influenced by the type of pathology, client's age, music therapy approach, and type of outcome. METHOD: Eleven studies were included for analysis, which resulted in a total of 188 subjects for the meta-analysis. Effect sizes from these studies were combined, with weighting for sample size, and their distribution was examined. RESULTS: After exclusion of an extreme positive outlying value, the analysis revealed that music therapy has a medium to large positive effect (ES =.61) on clinically relevant outcomes that was statistically highly significant (p <.001) and statistically homogeneous. No evidence of a publication bias was identified. Effects tended to be greater for behavioural and developmental disorders than for emotional disorders; greater for eclectic, psychodynamic, and humanistic approaches than for behavioural models; and greater for behavioural and developmental outcomes than for social skills and self-concept. CONCLUSIONS: Implications for clinical practice and research are discussed.

Many global tourist destinations have experienced growth in arrivals. This has triggered various conflicts in destinations and sparked debates as to how to deal with what is increasingly referred to as ‘overtourism’. Most Destination Marketing Organisations (DMOs) pursue strategies to stimulate arrivals even further. Pro-growth discourses are reinforced by lead bodies such as the World Tourism Organisation (UNWTO). However, maximisation strategies based on higher numbers of tourists increasingly cause conflicts with local residents, whereas simultaneously undermining climate change mitigation pledges as negotiated in the Paris Agreement. New approaches to destination management based on optimisation are therefore warranted. Drawing on a survey of international tourists (n = 5,249) in south-western Norway, this article discusses whether ‘activities’, i.e. the development of local, small-scale and ideally more sustainable experiences, can contribute to economic growth without necessarily increasing numbers of arrivals. Results confirm that destinations should seek to better understand their markets, including length of stay, spending, and/or activity intention, to identify profitable markets. Ultimately, such knowledge may help addressing overtourism conflicts while building tourism systems that are more economically, socially, and environmentally resilient.

BACKGROUND: Poor cardiorespiratory fitness is associated with cardiovascular disease risk factors. AIM: To perform a systematic review and meta-analysis of the relationship between poor cardiorespiratory fitness and cardiovascular disease risk in children and adolescents. METHODS: Systematic literature search (1980 to 11 April 2015) for studies that determined a cardiorespiratory fitness cut point that predicted cardiovascular disease risk in children and adolescents. RESULTS: We identified 7 studies that included 9280 children and adolescents (49% girls) aged 8-19 years from 14 countries. Cardiovascular disease risk was already present in boys (6-39%) and girls (6-86%). Boys with low fitness (<41.8 mL/kg/min) had a 5.7 times greater likelihood of having cardiovascular disease risk (95% CI 4.8 to 6.7). The comparable diagnostic OR for girls with low fitness (<34.6 mL/kg/min) was 3.6 (95% CI 3.0 to 4.3). The 95% confidence region of cardiorespiratory fitness associated with low cardiovascular disease risk ranges, 41.8-47.0 mL/kg/min in boys (eg, stages 6-8 for a boy aged 15 years) and 34.6-39.5 mL/kg/min in girls (eg, stages 3-5 for a girl aged 15 years). The cardiorespiratory fitness cut point to avoid cardiovascular disease risk ranged 41.8 mL/kg/min in boys and was 34.6 mL/kg/min in girls. SUMMARY: Fitness levels below 42 and 35 mL/kg/min for boys and girls, respectively, should raise a red flag. These translate to 6 and 3 stages on the shuttle run test for a boy and a girl, both aged 15 years, respectively. These cut points identify children and adolescents who may benefit from primary and secondary cardiovascular prevention programming.

BACKGROUND: The central impairments of people with autistic spectrum disorder (ASD) include social interaction and communication. Music therapy uses music and its elements to enable communication and expression, thus attempting to address some of the core problems of people with ASD. OBJECTIVES: To review the effects of music therapy for individuals with autistic spectrum disorders. SEARCH STRATEGY: The following databases were searched: CENTRAL, 2005, (Issue 3); Medline, (1966 to July 2004); Embase, (1980 to July 2004); LILACS, (1982 to July 2004); PsycINFO, (1872 to July 2004); CINAHL, (1982 to July 2004); ERIC, (1966 to July 2004); ASSIA, (1987 to July 2004); Sociofile, (1963 to July 2004); Dissertation Abstracts International, (late 1960's to July 2004). These searches were supplemented by searching specific sources for music therapy literature and manual searches of reference lists. Personal contacts to some investigators were made. SELECTION CRITERIA: All randomised controlled trials or controlled clinical trials comparing music therapy or music therapy added to standard care to "placebo" therapy, no treatment or standard care. DATA COLLECTION AND ANALYSIS: Studies were independently selected, quality assessed and data extracted by two authors. Continuous outcomes were synthesised using a standardised mean difference (SMD) in order to enable a meta-analysis combining different scales, and to facilitate the interpretation of effect sizes. Heterogeneity was assessed using the I(2) statistic. MAIN RESULTS: Three small studies were included (total n = 24). These examined the short-term effect of brief music therapy interventions (daily sessions over one week) for autistic children. Music therapy was superior to "placebo" therapy with respect to verbal and gestural communicative skills (verbal: 2 RCTs, n = 20, SMD 0.36 CI 0.15 to 0.57; gestural: 2 RCTs, n = 20, SMD 0.50 CI 0.22 to 0.79). Effects on behavioural problems were not significant. AUTHORS' CONCLUSIONS: The included studies were of limited applicability to clinical practice. However, the findings indicate that music therapy may help children with autistic spectrum disorder to improve their communicative skills. More research is needed to examine whether the effects of music therapy are enduring, and to investigate the effects of music therapy in typical clinical practice.

Abstract The most recent Intergovernmental Panel on Climate Change assessment report concludes that the Atlantic Meridional Overturning Circulation (AMOC) could weaken substantially but is very unlikely to collapse in the 21st century. However, the assessment largely neglected Greenland Ice Sheet (GrIS) mass loss, lacked a comprehensive uncertainty analysis, and was limited to the 21st century. Here in a community effort, improved estimates of GrIS mass loss are included in multicentennial projections using eight state‐of‐the‐science climate models, and an AMOC emulator is used to provide a probabilistic uncertainty assessment. We find that GrIS melting affects AMOC projections, even though it is of secondary importance. By years 2090–2100, the AMOC weakens by 18% [−3%, −34%; 90% probability] in an intermediate greenhouse‐gas mitigation scenario and by 37% [−15%, −65%] under continued high emissions. Afterward, it stabilizes in the former but continues to decline in the latter to −74% [+4%, −100%] by 2290–2300, with a 44% likelihood of an AMOC collapse. This result suggests that an AMOC collapse can be avoided by CO2 mitigation.

The purpose was to study the effect of a sling exercise training (SET)-based core stability program on maximal throwing velocity among female handball players. Twenty-four female high-school handball players (16.6 ± 0.3 years, 63 ± 6 kg, and 169 ± 7 cm) participated and were initially divided into a SET training group (n = 14) and a control group (CON, n = 10). Both groups performed their regular handball training for 6 weeks. In addition, twice a week, the SET group performed a progressive core stability-training program consisting of 6 unstable closed kinetic chain exercises. Maximal throwing velocity was measured before and after the training period using photocells. Maximal throwing velocity significantly increased 4.9% from 17.9 ± 0.5 to 18.8 ± 0.4 m·s in the SET group after the training period (p < 0.01), but was unchanged in the control group (17.1 ± 0.4 vs. 16.9 ± 0.4 m·s). These results suggest that core stability training using unstable, closed kinetic chain movements can significantly improve maximal throwing velocity. A stronger and more stable lumbopelvic-hip complex may contribute to higher rotational velocity in multisegmental movements. Strength coaches can incorporate exercises exposing the joints for destabilization force during training in closed kinetic chain exercises. This may encourage an effective neuromuscular pattern and increase force production and can improve a highly specific performance task such as throwing.

BACKGROUND: Children and adolescents with autistic spectrum disorder (ASD) presenting with significant limitations in conventional forms of verbal and non-verbal communication are found to respond positively to music therapy intervention involving both active, improvizational methods and receptive music therapy approaches. Improvizational musical activity with therapeutic objectives and outcomes has been found to facilitate motivation, communication skills and social interaction, as well as sustaining and developing attention. The structure and predictability found in music assist in reciprocal interaction, from which tolerance, flexibility and social engagement to build relationships emerge, relying on a systematic approach to promote appropriate and meaningful interpersonal responses. RESULTS: Published reports of the value and effectiveness of music therapy as an intervention for children with ASD range from controlled studies to clinical case reports. Further documentation has emphasized the role music therapy plays in diagnostic and clinical assessment. Music therapy assessment can identify limitations and weaknesses in children, as well as strengths and potentials. Research evidence from a systematic review found two randomized controlled trials that examined short-term effects of structured music therapy intervention. Significant effects were found in these studies even with extremely small samples, and the findings are important because they demonstrate the potential of the medium of music for autistic children. Case series studies were identified that examined the effects of improvizational music therapy where communicative behaviour, language development, emotional responsiveness, attention span and behavioural control improved over the course of an intervention of improvizational music therapy.

Key points In this study we describe the time course of fatigue development during and after an intense bout of self‐paced, high‐intensity dynamic exercise using various electrical stimulation parameters to assess neuromuscular function (NMF) changes. Most of the decrease in muscle function occurs within the first 40% of the exercise bout, and substantial recovery in muscle function occurs within 1–2 min after exercise termination. Decreases in muscle function varied greatly with different methods of stimulation, suggesting that the extent to which muscle fatigue is documented during exercise depends upon NMF assessment methodology. Measurements of muscle function must be performed as soon as possible after exercise termination, and previous studies may have underestimated the extent to which muscle fatigue develops during exercise. Abstract The time course of muscular fatigue that develops during and after an intense bout of self‐paced dynamic exercise was characterized by using different forms of electrical stimulation (ES) of the exercising muscles. Ten active subjects performed a time trial (TT) involving repetitive concentric extension/flexion of the right knee using a Biodex dynamometer. Neuromuscular function (NMF), including ES and a 5 s maximal isometric voluntary contraction (MVC), was assessed before the start of the TT and immediately (<5 s) after each 20% of the TT had been completed, as well as 1, 2, 4 and 8 min after TT termination. The TT time was 347 ± 98 s. MVCs were 52% of baseline values at TT termination. Torque responses from ES were reduced to 33–68% of baseline using different methods of stimulation, suggesting that the extent to which peripheral fatigue is documented during exercise depends upon NMF assessment methodology. The major changes in muscle function occurred within the first 40% of exercise. Significant recovery in skeletal muscle function occurs within the first 1–2 min after exercise, showing that previous studies may have underestimated the extent to which peripheral fatigue develops during exercise.

ABSTRACT: Soil is an important compo-nent for monitoring of sustainability of land use in relation to both the conservation of natural resources and biodiversity of ecosystems. Re-cently research has focused on the role of mites (Acari) in biomonitoring and their importance as soil bioindicators. Mite communities are ex-tremely sensitive to all types of soil disturbance. This article presents a review of some studies on mite communities in order to discuss whether the diversity and numbers of mites present in the soil can reflect human impact on ecosystems and landscape, and whether mites can be used in monitoring systems. Limited data available about mite communities in agricultural ecosys-

OBJECTIVE: To investigate the effect of a seven-month, school-based cluster-randomized controlled trial on academic performance in 10-year-old children. METHODS: In total, 1129 fifth-grade children from 57 elementary schools in Sogn og Fjordane County, Norway, were cluster-randomized by school either to the intervention group or to the control group. The children in the 28 intervention schools participated in a physical activity intervention between November 2014 and June 2015 consisting of three components: 1) 90min/week of physically active educational lessons mainly carried out in the school playground; 2) 5min/day of physical activity breaks during classroom lessons; 3) 10min/day physical activity homework. Academic performance in numeracy, reading and English was measured using standardized Norwegian national tests. Physical activity was measured objectively by accelerometry. RESULTS: We found no effect of the intervention on academic performance in primary analyses (standardized difference 0.01-0.06, p>0.358). Subgroup analyses, however, revealed a favorable intervention effect for those who performed the poorest at baseline (lowest tertile) for numeracy (p=0.005 for the subgroup∗group interaction), compared to controls (standardized difference 0.62, 95% CI 0.19-1.07). CONCLUSIONS: This large, rigorously conducted cluster RCT in 10-year-old children supports the notion that there is still inadequate evidence to conclude that increased physical activity in school enhances academic achievement in all children. Still, combining physical activity and learning seems a viable model to stimulate learning in those academically weakest schoolchildren.

BACKGROUND: Music therapy is a psychotherapeutic method that uses musical interaction as a means of communication and expression. The aim of the therapy is to help people with serious mental illness to develop relationships and to address issues they may not be able to using words alone. OBJECTIVES: To review the effects of music therapy, or music therapy added to standard care, compared to placebo, standard care or no treatment for people with serious mental illnesses such as schizophrenia. SEARCH STRATEGY: The Cochrane Schizophrenia Group's Register (July 2002) was searched. This was supplemented by hand searching of music therapy journals, manual searches of reference lists, and contacting relevant authors. SELECTION CRITERIA: All randomised controlled trials that compared music therapy with standard care or other psychosocial interventions for schizophrenia. DATA COLLECTION AND ANALYSIS: Studies were reliably selected, quality assessed and data extracted. Data were excluded where more than 30% of participants in any group were lost to follow up. Non-skewed continuous endpoint data from valid scales were synthesised using a standardised mean difference (SMD). If statistical heterogeneity was found, treatment 'dosage' and treatment approach were examined as possible sources of heterogeneity. MAIN RESULTS: Four studies were included. These examined the effects of music therapy over the short to medium term (1 to 3 months), with treatment 'dosage' varying from 7 to 78 sessions. Music therapy added to standard care was superior to standard care alone for global state (medium term, 1 RCT, n = 72, RR 0.10 CI 0.03 to 0.31, NNT 2 CI 1.2 to 2.2). Continuous data suggested some positive effects on general mental state (1 RCT, n=69, SMD average endpoint PANSS -0.36 CI -0.85 to 0.12; 1 RCT, n=70, SMD average endpoint BPRS -1.25 CI -1.77 to -0.73),on negative symptoms (3 RCTs, n=180, SMD average endpoint SANS -0.86 CI -1.17 to -0.55) and social functioning (1 RCT, n=70, SMD average endpoint SDSI score -0.78 CI -1.27 to -0.28). However these latter effects were inconsistent across studies and depended on the number of music therapy sessions. All results were for the 1-3 month follow up. AUTHORS' CONCLUSIONS: Music therapy as an addition to standard care helps people with schizophrenia to improve their global state and may also improve mental state and functioning if a sufficient number of music therapy sessions are provided. Further research should address the dose-effect relationship and the long-term effects of music therapy.

Biotic interactions are often ignored in assessments of climate change impacts. However, climate-related changes in species interactions, often mediated through increased dominance of certain species or functional groups, may have important implications for how species respond to climate warming and altered precipitation patterns. We examined how a dominant plant functional group affected the population dynamics of four co-occurring forb species by experimentally removing graminoids in seminatural grasslands. Specifically, we explored how the interaction between dominants and subordinates varied with climate by replicating the removal experiment across a climate grid consisting of 12 field sites spanning broad-scale temperature and precipitation gradients in southern Norway. Biotic interactions affected population growth rates of all study species, and the net outcome of interactions between dominants and subordinates switched from facilitation to competition with increasing temperature along the temperature gradient. The impacts of competitive interactions on subordinates in the warmer sites could primarily be attributed to reduced plant survival. Whereas the response to dominant removal varied with temperature, there was no overall effect of precipitation on the balance between competition and facilitation. Our findings suggest that global warming may increase the relative importance of competitive interactions in seminatural grasslands across a wide range of precipitation levels, thereby favouring highly competitive dominant species over subordinate species. As a result, seminatural grasslands may become increasingly dependent on disturbance (i.e. traditional management such as grazing and mowing) to maintain viable populations of subordinate species and thereby biodiversity under future climates. Our study highlights the importance of population-level studies replicated under different climatic conditions for understanding the underlying mechanisms of climate change impacts on plants.

Abstract Silica is an essential element for marine life and plays a key role in the biogeochemistry of the ocean. Glacial activity stimulates rock weathering, generating dissolved silica that is exported to coastal areas along with meltwater. The magnitude of the dissolved silica export from large glacial areas such as the Greenland Ice Sheet is presently poorly quantified and not accounted for in global budgets. Here we present data from two fjord systems adjacent to the Greenland Ice Sheet which reveal a large export of dissolved silica by glacial meltwater relative to other macronutrients. Upscaled to the entire Greenland Ice Sheet, the export of dissolved silica equals 22 ± 10 Gmol Si yr −1 . When the silicate‐rich meltwater mixes with upwelled deep water, either inside or outside Greenland's fjords, primary production takes place at increased silicate to nitrate ratios. This likely stimulates the growth of diatoms relative to other phytoplankton groups.

BACKGROUND: Globally most children do not engage in enough physical activity. Day length and weather conditions have been identified as determinants of physical activity, although how they may be overcome as barriers is not clear. We aim to examine if and how relationships between children's physical activity and weather and day length vary between countries and identify settings in which children were better able to maintain activity levels given the weather conditions they experienced. METHODS: In this repeated measures study, we used data from 23,451 participants in the International Children's Accelerometry Database (ICAD). Daily accelerometer-measured physical activity (counts per minute; cpm) was matched to local weather conditions and the relationships assessed using multilevel regression models. Multilevel models accounted for clustering of days within occasions within children within study-cities, and allowed us to explore if and how the relationships between weather variables and physical activity differ by setting. RESULTS: Increased precipitation and wind speed were associated with decreased cpm while better visibility and more hours of daylight were associated with increased cpm. Models indicated that increases in these variables resulted in average changes in mean cpm of 7.6/h of day length, -13.2/cm precipitation, 10.3/10 km visibility and -10.3/10kph wind speed (all p < 0.01). Temperature showed a cubic relationship with cpm, although between 0 and 20 degrees C the relationship was broadly linear. Age showed interactions with temperature and precipitation, with the associations larger among younger children. In terms of geographic trends, participants from Northern European countries and Melbourne, Australia were the most active, and also better maintained their activity levels given the weather conditions they experienced compared to those in the US and Western Europe. CONCLUSIONS: We found variation in the relationship between weather conditions and physical activity between ICAD studies and settings. Children in Northern Europe and Melbourne, Australia were not only more active on average, but also more active given the weather conditions they experienced. Future work should consider strategies to mitigate the impacts of weather conditions, especially among young children, and interventions involving changes to the physical environment should consider how they will operate in different weather conditions.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a major health problem estimated to become the third leading cause of death and the fifth leading cause of disability by 2020. Tobacco control is the most effective protective intervention, and it serves as a key element in patient counselling. However, a focus on tobacco control may cause unintended and adverse effects to individuals who already suffer from the disease. AIM: The current study aims to understand how patients with COPD experience daily life in a society with heavy emphasis on tobacco control. METHOD: The design was longitudinal and descriptive. The sample included thirteen men and five women with COPD, recruited from pulmonary rehabilitation units. Data were collected by means of qualitative interviews and analysed using qualitative content analysis with search for meanings. FINDINGS: The main theme was a feeling of being exiled in the world of the healthy, because of self-blame and society's stigmatisation of COPD as a self-inflicted disease. The participants experienced feelings of disgrace through subtle blame and a lack of support from their social network, health care encounters and larger society. This seemed to increase illness-related strain and a need for defensive actions. LIMITATIONS: A small convenience sample, local cultural influence, the study's wide scope and lack of health professionals' views must be considered. CONCLUSION: This study illuminates the challenge of how to combine health advice on smoking cessation with nonblaming psycho-social support throughout the course of COPD. An awareness of the potential for stigma, the nature of nicotine dependence and broadened causal explanations for the disease may improve the ability of caregivers to address patient strain and its negative association with coping and well-being. Dilemmas in health communication concerning COPD patients' experience of stigma and negative emotional response should be further explored.

BACKGROUND: Patient involvement in health care decision making is part of a wider trend towards a more bottom-up approach to service planning and provision, and patient experience is increasingly conceptualized as a core dimension of health care quality.The aim of this multi-level study is two-fold: 1) to describe and analyze how governmental organizations expect acute hospitals to incorporate patient involvement and patient experiences into their quality improvement (QI) efforts and 2) to analyze how patient involvement and patient experiences are used by hospitals to try to improve the quality of care they provide. METHODS: This multi-level case study combines analysis of national policy documents and regulations at the macro level with semi-structured interviews and non-participant observation of key meetings and shadowing of staff at the meso and micro levels in two purposively sampled Norwegian hospitals. Fieldwork at the meso and micro levels was undertaken over a 12-month period (2011-2012). RESULTS: Governmental documents and regulations at the macro level demonstrated wide-ranging expectations for the integration of patient involvement and patient experiences in QI work in hospitals. The expectations span from systematic collection of patients' and family members' experiences for the purpose of improving service quality through establishing patient-oriented arenas for ongoing collaboration with staff to the support of individual involvement in decision making. However, the extent of involvement of patients and application of patient experiences in QI work was limited at both hospitals. Even though patient involvement was gaining prominence at the meso level - and to a lesser extent at the micro level - relevant tools for measuring and using patient experiences in QI work were lacking, and available measures of patient experience were not being used meaningfully or systematically. CONCLUSIONS: The relative lack of expertise in Norwegian hospitals of adapting and implementing tools and methods for improving patient involvement and patient experiences at the meso and micro levels mark a need for health care policymakers and hospital leaders to learn from experiences of other industries and countries that have successfully integrated user experiences into QI work. Hospital managers need to design and implement wider strategies to help their staff members recognize and value the contribution that patient involvement and patient experiences can make to the improvement of healthcare quality.

BACKGROUND: In adults, a minimum of 3-5 days of accelerometer monitoring is usually considered appropriate to obtain reliable estimates of physical activity (PA). However, a longer period of measurement might be needed to obtain reliable estimates of sedentary behavior (SED). The aim of this study was to determine the reliability of objectively assessed SED and PA in adults. METHODS: Eighty-seven adult subjects (28 men; mean (standard deviation) age 31.3 (12.2) years; body mass index 23.7 (3.1) kg/m2) wore the GT3X+ accelerometer for 21 subsequent days, for which the reliability of different wear time criteria (8 to 12 h/day and 3 to 5 d/week) was explored. Variance partitioning along with the Spearman-Brown prophecy formula was used as the basis for determining intraclass-correlation coefficients (ICC) and the number of monitoring days needed (N) to achieve an ICC = 0.80. Week-by-week reliability was reported using ICC, Bland-Altman plots and absolute measures of agreement. RESULTS: Seven-10 days of monitoring was needed to reliably assess overall- (axis 1 and vector magnitude (VM) counts per minute (CPM)) and moderate-to-vigorous PA (MVPA), 3-4 days was needed for light PA (LPA), whereas the number of days needed for SED depended on whether adjustments were made for wear time (6-8 days) or not (13-15 days). The week-by-week ICC was ≥0.70 for all variables, with limits of agreement being ±267.8 cpm for CPM, ±352.3 cpm for VM CPM, ±76.8 min/day for SED, ±57.8 min/day for LPA and ±43.8 min/day for MVPA, equal to 1.0-1.6 standard deviations, when adjustment was made for wear time. CONCLUSIONS: For most variables, more than one week of measurement was needed to achieve an ICC = 0.80. Correcting for wear time was crucial to reliably determine SED. Considerable week-by-week variability was found for all variables. Researchers need to be aware of substantial intra-individual variability in accelerometer-measurements.