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Funding Information: The authors would like to thank everybody who contributed to the HBM4EU Aligned Studies: the participating children, teenagers, adults and their families, the fieldworkers that collected the samples and database managers that made the information available to HBM4EU, the HBM4EU project partners, especially those from WP7 for developing all materials supporting the fieldwork, WP9 for organizing the QA/QC scheme under HBM4EU and all laboratories who performed the analytical measurements. We would like to acknowledge Sun Kyoung Jung from the National Institute of Environmental Research of South-Korea for providing the KoNEHS Cycle III results (crt adjusted). HBM4EU is co-financed under Horizon 2020 (grant agreement No 733032). The authors thank all principal investigators of the contributing studies for their participation and contribution to the HBM4EU Aligned Studies and the national program owners for their financial support. Further details on funding for all the participating studies can be found in the Supplemental Material, Table S12. As one of the core elements of the European Human Biomonitoring Initiative (HBM4EU) a human biomonitoring (HBM) survey was conducted in 23 countries to generate EU-wide comparable HBM data. This survey has built on existing HBM capacity in Europe by aligning national or regional HBM studies, referred to as the HBM4EU Aligned Studies. The HBM4EU Aligned Studies included a total of 10,795 participants of three age groups: (i) 3,576 children aged 6–12 years, (ii) 3,117 teenagers aged 12–18 years and (iii) 4,102 young adults aged 20–39 years. The participants were recruited between 2014 and 2021 in 11–12 countries per age group, geographically distributed across Europe. Depending on the age group, internal exposure to phthalates and the substitute DINCH, halogenated and organophosphorus flame retardants, per- and polyfluoroalkyl substances (PFASs), cadmium, bisphenols, polycyclic aromatic hydrocarbons (PAHs), arsenic species, acrylamide, mycotoxins (deoxynivalenol (total DON)), benzophenones and selected pesticides was assessed by measuring substance specific biomarkers subjected to stringent quality control programs for chemical analysis. For substance groups analyzed in different age groups higher average exposure levels were observed in the youngest age group, i.e., phthalates/DINCH in children versus teenagers, acrylamide and pesticides in children versus adults, benzophenones in teenagers versus adults. Many biomarkers in teenagers and adults varied significantly according to educational attainment, with higher exposure levels of bisphenols, phthalates, benzophenones, PAHs and acrylamide in participants (from households) with lower educational attainment, while teenagers from households with higher educational attainment have higher exposure levels for PFASs and arsenic. In children, a social gradient was only observed for the non-specific pyrethroid metabolite 3-PBA and di-isodecyl phthalate (DiDP), with higher levels in children from households with higher educational attainment. Geographical variations were seen for all exposure biomarkers. For 15 biomarkers, the available health-based HBM guidance values were exceeded with highest exceedance rates for toxicologically relevant arsenic in teenagers (40%), 3-PBA in children (36%), and between 11 and 14% for total DON, Σ (PFOA + PFNA + PFHxS + PFOS), bisphenol S and cadmium. The infrastructure and harmonized approach succeeded in obtaining comparable European wide internal exposure data for a prioritized set of 11 chemical groups. These data serve as a reference for comparison at the global level, provide a baseline to compare the efficacy of the European Commission's chemical strategy for sustainability and will give leverage to national policy makers for the implementation of targeted measures. publishersversion published

Objectives Within the framework of the burden of disease (BoD) approach, disease and injury burden estimates attributable to risk factors are a useful guide for policy formulation and priority setting in disease prevention. Considering the important differences in methods, and their impact on burden estimates, we conducted a scoping literature review to: (1) map the BoD assessments including risk factors performed across Europe; and (2) identify the methodological choices in comparative risk assessment (CRA) and risk assessment methods. Methods We searched multiple literature databases, including grey literature websites and targeted public health agencies websites. Results A total of 113 studies were included in the synthesis and further divided into independent BoD assessments (54 studies) and studies linked to the Global Burden of Disease (59 papers). Our results showed that the methods used to perform CRA varied substantially across independent European BoD studies. While there were some methodological choices that were more common than others, we did not observe patterns in terms of country, year or risk factor. Each methodological choice can affect the comparability of estimates between and within countries and/or risk factors, since they might significantly influence the quantification of the attributable burden. From our analysis we observed that the use of CRA was less common for some types of risk factors and outcomes. These included environmental and occupational risk factors, which are more likely to use bottom-up approaches for health outcomes where disease envelopes may not be available. Conclusions Our review also highlighted misreporting, the lack of uncertainty analysis and the under-investigation of causal relationships in BoD studies. Development and use of guidelines for performing and reporting BoD studies will help understand differences, avoid misinterpretations thus improving comparability among estimates. Registration The study protocol has been registered on PROSPERO, CRD42020177477 (available at: https://www.crd.york.ac.uk/PROSPERO/).

O cádmio é um metal pesado tóxico e carcinogénico, que representa uma ameaça séria para a saúde humana. A população geral pode encontrar-se exposta ao cádmio por diversas vias e o estudo INSEF-ExpoQuim visou caracterizar a exposição da população portuguesa adulta (28-39 anos ) a este agente químico através de um estudo transversal. Este estudo incluiu 295 indivíduos, os quais reponderam a um questionário (dados sociodemográficos, de estilos de vida e possíveis vias de exposição ) e facultaram uma amostra de urina para quantificação de cádmio por espectrometria de massa com plasma indutivo acoplado ( ICP- -MS ). Observou-se uma média geométrica de 0,092 μg Cd/g creatinina [ IC ( 95%): 0,084-0,101 ], apresentando as mulheres valores mais elevados ( 0,103 vs 0,079 ), bem como os fumadores ( 0,135 vs 0,081). Cadmium is a toxic and carcinogenic heavy metal, that presents a serious threat to human health. The general population can be exposed through several pathways and the study INSEF-ExpoQuim aimed to characterise the exposure of the Portuguese adult population (28-29 years) to this chemical agent through the development of a cross-sectional study. This study has included 295 individuals, that have answered to a questionnaire (sociodemographic characteristics, lifestyle and possible exposure sources) and provided a urine sample for the quantification of cadmium by inductively coupled plasma mass spectrometry ( ICP-MS). A geometric mean of 0.092 μg Cd/g creatinine [ 95%CI: 0.084-0.101 μg Cd/g creatinine ] was observed, with females ( 0.103 vs 0.079) and smokers ( 0.135 vs 0.081) presenting higher values. O estudo INSEF-ExpoQuim foi cofinanciado no âmbito do projeto HBM4EU, que recebeu financiamento do programa de investigação e inovação Horizonte 2020 da União Europeia, ao abrigo da convenção de subvenção n.º 733032. O INSEF foi desenvolvido como parte integrante do projeto Improvement of epidemiological health information to support public health decision and management in Portugal Towards reduced inequalities, improved health, and bilateral cooperation, tendo beneficiado de um apoio financeiro de 1 500 000 euros concedido pela Islândia, Liechtenstein e Noruega, através das EEA Grants. info:eu-repo/semantics/publishedVersion

Baseado no artigo publicado: Alvito P, A ssunção RM, Bajard L, Mar tins C, Mengelers M, Hans Mol, Van den Brand A, Namorado S, Vasco E, Viegas S, Silva M. Current advances, research needs and gaps in Mycotoxins Biomonitoring under HBM4EU – lessons learned and future t rends. Toxins (Basel ). 2022;14(12):826. https://doi.org/10.3390/toxins14120826 Ficheiro substituído a 2023-02-27, retificação das referências bibliográficas. As micotoxinas são toxinas naturais produzidas por fungos, apresentando efeitos tóxicos para o homem e para os animais. Reconhece-se, atualmente, que as alterações climáticas terão impacto na distribuição geográfica de algumas espécies de fungos produtores de micotoxinas o que se traduzirá, previsivelmente, num aumento da exposição humana a estes compostos. Pelas razões descritas, urge conhecer a atual exposição a micotoxinas na Europa, com vista à sua futura monitorização e à prevenção/redução do seu impacto na saúde. No âmbito da Iniciativa Europeia em Biomonitorização Humana (HBM4EU) consideraram-se as micotoxinas desoxinivalenol (DON) e fumonisina B1 (FB1) como substâncias prioritárias, tendo sido abordadas várias questões relativas à avaliação da exposição humana e o potencial risco para a saúde. No presente artigo, apresentam-se as questões identificadas como mais importantes, respostas obtidas e perspetivas futuras. Os resultados confirmaram a exposição humana a DON, tendo sido obtidos, pela primeira vez, dados harmonizados de exposição ao nível europeu e derivado um valor de referência para essa exposição. Foi ainda proposto, pela primeira vez no HBM4EU, uma sucessão de eventos biológicos baseados no mecanismo de ação da FB1 que permitiu associar a exposição durante a gravidez ao desenvolvimento de defeitos do tubo neural no feto. Espera-se que estes resultados possam contribuir para uma futura monitorização da exposição a micotoxinas na Europa e para melhorar a avaliação de risco destas substâncias. Mycotoxins are natural low-molecular-weight toxins produced by fungal species that can be toxic for humans and animals. Under the climate change scenario, some fungal species might shift their geographical distribution in response to global warming, leading to changes in the pattern of mycotoxin occurrence and, thus, increasing the risk of human mycotoxin exposure. For this reason, it urges to assess the current human exposure to mycotoxins in Europe, to monitor internal exposure and prevent future health impact. The European Human Biomonitoring Initiative (HBM4EU), running from 2017 to 2022, was set to generate knowledge on internal exposure and their potential health impacts. Within this initiative, the mycotoxins deoxynivalenol (DON) and fumonisin B1 ( FB1) were considered as priority substances to be studied and several policy questions were addressed concerning their risk assessment. The present paper presents policy questions identified within HBM4EU for these mycotoxins, answers obtained and future perspectives. The exposure of the general European population to DON was confirmed using new harmonized data and a reference guidance value for human biomonitoring was set for the first time. Additionaly, an adverse outcome pathway for neural tube defects was proposed for FB1 for the first time. Hopefully these findings may contribute to a more accurate risk assessment of European population´s exposure to mycotoxins. O projeto HBM4EU recebeu financiamento do programa de investigação e inovação da União Europeia Horizonte 2020 sob o contrato de concessão n.º 733032 e das instituições em que os autores desenvolvem as suas atividades. Os autores agradecem à FCT/MCTES pelo financiamento com fundos nacionais relativos ao CESAM (UIDP/50017/2020+UIDB/ DB/50017/2020) e ToxOmics (UIDB/00009/2020; UIDP/00009/ 2020). info:eu-repo/semantics/publishedVersion

Funding Information: Thanks are due to CESAM (UIDP/50017/2020+UIDB/50017/2020+LA/P/0094/2020), and ToxOmics (UIDB/00009/2020; UIDP/00009/2020), through national funds. L.B. thanks Research Infrastructure RECETOX RI (No. LM2018121), financed by the Ministry of Education, Youth and Sports, and the project CETOCOEN EXCELLENCE (No. CZ.02.1.01/0.0/0.0/17_043/0009632) for a supportive background of the European Union’s Horizon 2020 research and innovation program under grant agreement No. 857560, and to the HBM4EU, under grant agreement No. 733032. This publication reflects only the authors’ view and the European Commission is not responsible for any use that may be made of the information it contains. Funding Information: This study was co-funded by the HBM4EU, which has received funding from the European Union’s research and innovation programme Horizon 2020 under grant agreement No. 733032, and from the authors’ institutions. Publisher Copyright: © 2022 by the authors. Mycotoxins are natural metabolites produced by fungi that contaminate food and feed worldwide. They can pose a threat to human and animal health, mainly causing chronic effects, e.g., immunotoxic and carcinogenic. Due to climate change, an increase in European population exposure to mycotoxins is expected to occur, raising public health concerns. This urges us to assess the current human exposure to mycotoxins in Europe to allow monitoring exposure and prevent future health impacts. The mycotoxins deoxynivalenol (DON) and fumonisin B1 (FB1) were considered as priority substances to be studied within the European Human Biomonitoring Initiative (HBM4EU) to generate knowledge on internal exposure and their potential health impacts. Several policy questions were addressed concerning hazard characterization, exposure and risk assessment. The present article presents the current advances attained under the HBM4EU, research needs and gaps. Overall, the knowledge on the European population risk from exposure to DON was improved by using new harmonised data and a newly derived reference value. In addition, mechanistic information on FB1 was, for the first time, organized into an adverse outcome pathway for a congenital anomaly. It is expected that this knowledge will support policy making and contribute to driving new Human Biomonitoring (HBM) studies on mycotoxin exposure in Europe. publishersversion published

No âmbito da Iniciativa Europeia em Biomonitorização Humana (HBM4EU) realizou-se um estudo ocupacional, envolvendo trabalhadores com potencial exposição a crómio hexavalente [Cr( VI)], um reconhecido agente carcinogénico. No presente estudo são apresentados os resultados de biomarcadores de genotoxicidade, incluindo a análise de lesão no DNA e de alterações cromossómicas em células sanguíneas. O estudo foi realizado em vários Países Europeus e abrangeu trabalhadores de diversos setores industriais e atividades, bem como um grupo de controlo constituído por trabalhadores administrativos das mesmas empresas (controlo interno) e de outras não relacionadas com produção/aplicação de Cr( VI) (controlo externo). Os resultados mostraram níveis de alterações cromossómicas (ensaio do micronúcleo) e de lesão no DNA (ensaio do cometa) significativamente aumentados nos trabalhadores expostos comparativamente aos controlos externos ( p=0,03; p

No âmbito da Iniciativa Europeia em Biomonitorização Humana (HBM4EU) foi realizado um inquérito dirigido aos cidadãos europeus que pretendia recolher informação acerca das suas opiniões e perceções sobre a exposição a substâncias químicas, bem como sobre o que é a biomonitorização humana (BMH), por que é que ela é importante e qual o seu papel na saúde. Em Portugal responderam ao inquérito 669 indivíduos, a maioria do sexo feminino, com ensino superior e empregados. A maioria dos participantes portugueses considera que a BMH é uma atividade que deve ser realizada regularmente e de forma coordenada. Os participantes também consideram que os estudos de BMH são muito relevantes para várias atividades, desde a avaliação do impacto da exposição às substâncias químicas, ao apoio de políticas de saúde ocupacional. As áreas indicadas como uma prioridade para os estudos de BMH revelaram uma maior preocupação com a exposição por via alimentar. In the scope of the European Human Biomonitoring Initiative, a survey directed to all the European citizens was launched to collect information on their opinions and perceptions on exposure to chemicals and human biomonitoring (HBM). In Portugal, 669 individuals have answered the survey, the majority being female, with high educational level and having a job. The majority of the Portuguese survey participants considers that HBM is an activity that should be performed regularly and in a coordinated way. The participants also consider that HBM surveys are relevant to several activities from the evaluation of the impact of exposure to chemicals to the support of occupational health policies. The areas indicated as a priority to the HBM surveys have revealed a bigger concern with exposure through food. O projeto HBM4EU foi cofinanciado pelo programa de investigação e inovação Horizonte 2020 da União Europeia, ao abrigo da convenção de subvenção n.º 733032, e pelas instituições nacionais parceiras do projeto info:eu-repo/semantics/publishedVersion

O arsénio é um elemento naturalmente presente no meio ambiente e que também pode ser libertado em resultado de atividades antropogénicas, podendo encontrar-se na forma de compostos orgânicos ou inorgânicos. O arsénio é considerado pela Organização Mundial de Saúde como um dos dez químicos de maior preocupação para a saúde pública, uma vez que o arsénio e os compostos inorgânicos de arsénio estão classificados como cancerígenos pela Agência Internacional para a Investigação do Cancro. A exposição a arsénio inorgânico ocorre principalmente por via alimentar, através do consumo de água e de alimentos contaminados. Em Portugal são escassos os dados sobre a exposição a arsénio na população geral, pelo que o objetivo do presente estudo é a caracterização da exposição da população adulta portuguesa a arsénio, utilizando amostras de urina colhidas num estudo populacional nacional ( INSEF-ExpoQuim). O presente trabalho incluiu 171 participantes no estudo INSEF-ExpoQuim que forneceram uma amostra de urina para análise da concentração de arsénio total por espectrometria de massa com plasma indutivo acoplado ( ICP-MS ). Observou-se uma média geométrica de 47,1 μg As/L [ IC95%: 41,4-53,5 ] e 8,8% dos indivíduos apresentavam valores de arsénio considerados elevados. Não se observaram diferenças nos níveis de arsénio por sexo, grupo etário, grau de urbanização da área de residência, nível de escolaridade e situação face ao trabalho. Os resultados preliminares obtidos apontam para a necessidade de monitorização dos níveis de arsénio na população portuguesa. Arsenic is an element naturally present in the environment, but it can also be released as a result of anthropogenic activities. In the environment, arsenic can be found in the form of organic compounds and in the form of inorganic compounds. Arsenic is considered by the World Health Organization as one of the ten chemicals of greatest concern for public health, since arsenic and inorganic arsenic compounds are classified as carcinogenic by the International Agency for Research on Cancer. Exposure to inorganic arsenic occurs mainly through food, through consumption of contaminated water and food. In Portugal, data on arsenic exposure in the general population are scarce, so the aim of the present study was to characterize the exposure of the Portuguese adult population to arsenic, using urine samples collected in a national population study ( INSEF-ExpoQuim). The present work included 171 participants in the INSEF-ExpoQuim study who provided a urine sample for analysis of total arsenic concentration by inductively coupled plasma mass spectrometry (ICP-MS). A geometric mean of 47.1 μg As/L [ 95% CI: 41.4-53.5 ] was observed and 8.8% of the individuals had arsenic levels considered high. No differences were observed in arsenic levels by sex, age group, degree of urbanization of the area of residence, educational level and employment situation. The obtained preliminary results point to the need to monitor the levels of arsenic in the Portuguese population. O estudo INSEF-ExpoQuim foi cofinanciado no âmbito do projeto HBM4EU, que recebeu financiamento do programa de investigação e inovação Horizonte 2020 da União Europeia, ao abrigo da convenção de subvenção n.º 733032. O INSEF foi desenvolvido como parte integrante do projeto Improvement of epidemiological health information to support public health decision and management in Portugal Towards reduced inequalities, improved health, and bilateral cooperation, tendo beneficiado de um apoio financeiro de 1 500 000 euros concedido pela Islândia, Liechtenstein e Noruega, através das EEA Grants. info:eu-repo/semantics/publishedVersion

Em epidemiologia ocupacional é importante conhecer e caracterizar a exposição aos fatores de risco e estabelecer o nexo de causalidade com as alterações na saúde. De entre as várias formas de avaliar a exposição no local de trabalho, contam-se as matrizes de exposição ocupacional (MEO). Uma MEO consiste num sistema de classificação da exposição, para uma ou mais substâncias ou agentes, em distintas ocupações e por ramos específicos de atividade. As MEO requerem estimativas qualificadas, sistemáticas e detalhadas das potenciais exposições e podem ser construídas com informação primária ou secundária. No essencial, trata- se de reconstruir, com o rigor possível, a exposição a que os trabalhadores estiveram sujeitos durante a sua vida profissional. Embora os dados da biomonitorização humana (BMH) sejam frequentemente usados para efeitos de validação de MEO, podem igualmente ser usados para o seu desenvolvimento. Este trabalho pretende descrever a abordagem baseada em matrizes de exposição ocupacional na avaliação da exposição ocupacional e o contributo dos dados de biomonitorização humana nessa avaliação. As MEO constituem, sem dúvida, um importante instrumento a ser utilizado quer em estudos populacionais, quer em Saúde Ocupacional, potenciando vários estudos e monitorizações, com destaque para a biomonitorização humana. In occupational epidemiology, it is important to know and characterize exposure to risk factors and establish the causal link with changes in health. Among the various ways of assessing exposure in the workplace are job exposure matrices (JEM). A JEM consists of an exposure classification system, for one or more substances or agents, in different occupations and by specific branches of activity. A JEM requires qualified, systematic and detailed estimates of potential exposures and can be constructed with primary or secondary information. Essentially, it is a question of reconstructing, as rigorously as possible, the exposure to which workers were subjected during their professional lives. Although human biomonitoring (HBM) data are often used for JEM validation purposes, they can also be used for the development of JEM. This work intends to describe the technical development of occupational exposure matrices, as an exposure assessment tool, and the role that human biomonitoring can play in this development. JEM are undoubtedly an important instrument to be used both in population studies and in occupational health, enhancing several studies and monitoring, especially human biomonitoring. info:eu-repo/semantics/publishedVersion

CoMix Europe Working Group: Daniela Paolotti, André Karch, Veronika Jäger, Joaquin Baruch, Tanya Melillo, Henrieta Hudeckova, Magdalena Rosinska, Marta Niedzwiedzka-Stadnik, Krista Fischer, Sigrid Vorobjov, Hanna Sõnajalg, Christian Althaus, Nicola Low, Martina Reichmuth, Kari Auranen, Markku Nurhonen, Goranka Petrović, Zvjezdana Lovric Makaric, Sónia Namorado, Constantino Caetano, Ana João Santos, Gergely Röst, Beatrix Oroszi, Márton Karsai, Mario Fafangel, Petra Klepac, Natalija Kranjec, Cristina Vilaplana, Jordi Casabona. CoMix Europe Working Group: Sónia Namorado, Constantino Caetano, and Ana João Santos (Department of Epidemiology, National Institute of Health Dr Ricardo Jorge, Portugal) Background: Evidence and advice for pregnant women evolved during the COVID-19 pandemic. We studied social contact behaviour and vaccine uptake in pregnant women between March 2020 and September 2021 in 19 European countries. Methods: In each country, repeated online survey data were collected from a panel of nationally-representative participants. We calculated the adjusted mean number of contacts reported with an individual-level generalized additive mixed model, modelled using the negative binomial distribution and a log link function. Mean proportion of people in isolation or quarantine, and vaccination coverage by pregnancy status and gender were calculated using a clustered bootstrap. Findings: We recorded 4,129 observations from 1,041 pregnant women, and 115,359 observations from 29,860 non-pregnant individuals aged 18-49. Pregnant women made slightly fewer contacts (3.6, 95%CI = 3.5-3.7) than non-pregnant women (4.0, 95%CI = 3.9-4.0), driven by fewer work contacts but marginally more contacts in non-essential social settings. Approximately 15-20% pregnant and 5% of non-pregnant individuals reported to be in isolation and quarantine for large parts of the study period. COVID-19 vaccine coverage was higher in pregnant women than in non-pregnant women between January and April 2021. Since May 2021, vaccination in non-pregnant women began to increase and surpassed that in pregnant women. Interpretation: Limited social contact to avoid pathogen exposure during the COVID-19 pandemic has been a challenge to many, especially women going through pregnancy. More recognition of maternal social support desire is needed in the ongoing pandemic. As COVID-19 vaccination continues to remain an important pillar of outbreak response, strategies to promote correct information can provide reassurance and facilitate informed pregnancy vaccine decisions in this vulnerable group. HPRU in Modelling & Health Economics,NIHR200908,European Union’s Horizon 2020 research and innovation programme,EpiPose 101003688,TransMID 682540,TransMID 682540,TransMID 682540,EpiPose 101003688,Wellcome Trust,213589/Z/18/Z,National Institute for Health Research,CV220-088—COMIX,CV220-088—COMIX,CV220-088— COMIX,Global Challenges Research Fund,ES/P010873/1,Medical Research Council,MC_PC_19065,NIHR,PR-OD-1017-20002 HPRU in Modelling & Health Economics (NIHR200908: KLMW); European Union Horizon 2020 research and innovation programme – (EpiPose 101,003,688: AG, WJE). Wellcome Trust (213,589/Z/18/Z: ESP). European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (TransMID 682,540: CF, PN, NH). This research was partly funded by the Global Challenges Research Fund (GCRF) project RECAP managed through RCUK and ESRC (ES/P010873/1: CIJ). NIHR (PR-OD-1017–20,002: WJE) UK MRC (MC_PC_19065—Covid 19: Understanding the dynamics and drivers of the COVID-19 epidemic using real-time outbreak analytics: WJE). info:eu-repo/semantics/publishedVersion

© 2022. The Author(s). BACKGROUND: Participation rates in health surveys, recognized as an important quality dimension, have been declining over the years, which may affect representativeness and confidence in results. The Portuguese national health examination survey INSEF (2015) achieved a participation rate of 43.9%, which is in line with participation rates from other similar health examination surveys. The objective of this article is to describe how local teams of survey personnel conducted the survey, describing strategies used to solve practical survey problems and to try to increase the participation rate. METHODS: After a literature search, informal interviews were conducted with 14 public health officials from local health examination teams, regional and central authorities. Forty-one of the local staff members (survey personnel) also filled in a short questionnaire anonymously. The interviews and self-administered questionnaires were analysed using mixed methods, informed by thematic analysis. RESULTS: The local teams believed that the detailed manual, described as a "cookbook for making a health examination survey", made it possible to maintain high scientific standards while allowing for improvising solutions to problems in the local context. The quality of the manual, supported by a series of training workshops with the central research and support team, gave the teams the confidence and knowledge to implement local solutions. Motivation and cohesion within the local teams were among the goals of the training process. Local teams felt empowered by being given large responsibilities and worked hard to incite people to attend the examination through a close and persuasive approach. Local teams praised their INSA contacts for being available for assistance throughout the survey, and said they were inspired to try harder to reach participants to please their contacts for interpersonal reasons. CONCLUSIONS: The theory of organizational improvisation or bricolage, which means using limited resources to solve problems, was useful to discuss and understand what took place during INSEF. A detailed manual covering standard procedures, continuous monitoring of the data collection and face-to-face workshops, including role-play, were vital to assure high scientific standards and high participation rates in this health examination survey. Close contacts between the central team and local focal points in all regions and all survey sites were key to accommodating unexpected challenges and innovative solutions. publishersversion published