The need for long-term care (LTC) represents a "new social risk," one that overlaps with and complements systems of care that pre-date such programs, complicating LTC program design. This commentary expands on Ikegami’s discussion of how these structural factors must be accommodated, as well as historical and cultural factors that influence public expectations of such a program. The commentary specifically focuses on the role of cash payments, caregiver benefits, and the sometimes indistinct line between LTC and health systems. The experiences of countries operating LTC program in a wide range of contexts can illuminate common challenges, as well as some potential solutions to these vexing design and operational issues. Long-term care (LTC) is a relatively new public and health policy concern, one that results from successes in improving population health as well as declines in fertility across industrialized nations. Because of its relative newness, government efforts to respond to the growing demand for LTC must necessarily build on existing systems, fundamentally shaping the issues that arise.1 The adoption of Germany’s program was due, in part, to cost pressures on the social assistance program financed by regional government, which funds nursing home stays for the poor.3 While any public program must build on and co-exist with established systems, LTC is particularly tricky because it overlaps with so many other policy areas: most obviously, a country’s healthcare system, but also with housing, labor, retirement, and family policy, so that boundaries between programs differ from country to country. Moreover, because so many of these areas are influenced by contentious and shifting societal norms – particularly around the role of the family generally and women specifically – the design of LTC programs can be difficult to negotiate.Indeed, in many cases, a government’s need to act is based on pressures that the demand for LTC care places on existing public programs: Ikegami notes how overutilization of Japan’s hospitals by older people  was a key factor behind the introduction of its LTC insurance (LTCI) program.This unavoidable variation across countries – in how a society sets goals for its LTC program and how it delineates LTC – reinforces Ikegami’s point about the difficulty of comparing programs. For example, a key difference lies in the role of family caregivers, and the extent to which cash payments are intended to pay for their work. Ikegami includes allowances to family caregivers as a LTC expense, reasoning that they are equivalent to cash payments. While care allowances are certainly meant to compensate carers for their work, it not clear that cash payments are primarily meant to benefit family caregivers.4), only indirectly benefitting family caregivers, or whether they act as family income supplements, meant to compensate carers for the work they do .Indeed, the goal of cash payments differs across countries. For example, in the US’s Medicaid program , most states’ cash for care programs ban payments to spouses, and often ban payments to family members living with the care recipient. Even where permitted, not all care recipients choose to use cash payments to hire relatives. In other countries as well, cash payments are used to hire independent workers. Indeed, in some cases the political rationale for cash payments is to help develop and recruit a professional workforce. In contrast, feminists in Japan campaigned against including a cash benefit in the Japanese program, on the grounds that it would consolidate the role of women in providing LTC  – clearly assuming that a cash payment would be used to compensate family caregivers. These differences reflect the varying meanings of cash payments: whether they aim to benefit care recipients, enabling them to operationalize choice in who provides care  While benefits such as respite fall clearly into the LTC bucket, other caregiver benefits are harder to classify. For example, some US states have introduced paid family leave (which provides income to those caring for disabled or elderly persons as well as for children), typically financed out of payroll taxes. In Germany, however, the public LTCI program finances unemployment, health insurance, and LTCI contributions for carers as well as contributions to Germany’s statutory pension fund, and paid leave is taken as a personal loan. If, however, a carer leaves employment, the LTCI program’s cash benefit can become a family income supplement, underlining how a cash benefit is fungible in some countries, but not where there are strict controls over their use.7The case of caregiver benefits highlights the difficulty of distinguishing LTC from other services and programs. Ikegami notes another example: nursing homes, an issue that arises due to the increasingly severe health status of nursing home residents. Worldwide, countries are striving to limit nursing home admission to people with more serious health conditions, and to provide most LTC in community-based settings – ideally, in people’s own homes. Rising acuity levels among nursing home residents have raised the cost of nursing homes and, in turn, created incentives to limit access. More importantly, they have blurred the distinction between the types of care delivered in nursing homes and in other settings that traditionally fall in the health sector, such as post-acute/rehabilitative and long-term chronic care. Concurrently, such shifts have created a need to find ways of serving significantly disabled individuals in community-based settings; delivering health-related services in those settings; and ensuring quality and coordination for those services. One of the Dutch program’s recent reforms was to acknowledge this distinction, formally shifting the costs of home nursing out of the LTC program and into the health sector. However, this shift, along with other changes that split responsibility for LTC, has created its own problems: namely, poor coordination across entities and the creation of incentives to cost-shift.8 This can be attributed to their early adoption of social insurance for LTC, back in 1968,9 with an initial, problematic design: the program covered a broad range of risks; utilized nursing homes heavily; had porous boundaries with other programs; and had high premiums from the very start. The program’s name – the Exceptional Medical Expenses Act (AWBZ), now the Long-term care Act (Wlz) – hints at how broad its initial goals were: in addition to explicitly covering LTC, it covered rehabilitation, hospital stays of over a year, and mental health care. The program also covered people of all ages. Thus, a major cause of budget pressures resulted from demand from children with learning disabilities, autistic spectrum diagnoses, and intellectual disabilities who otherwise lacked services. To solve these problems, a 2015 reform re-allocated program responsibilities among several different programs, leading to the aforementioned concerns about increasing fragmentation and cost-shifting.The Dutch program illustrates some issues that can arise out of a poorly-defined program, leading to high costs: the Dutch spent roughly 3.7 % of gross domestic products on LTC in 2015, compared to the Organisation for Economic Co-operation and Development average of 1.7%.10 The German program, in contrast, covers people of all ages, and recently revised its eligibility assessment to more explicitly cover people with dementia.11 Indeed, many LTC programs cover people of all ages. The downside of a unified program is that it can create a large political constituency supporting expanded benefits (leading to expanded costs); the differing political constituencies may also have significantly different goals. On the other hand, separate programs can create discontinuities and inequalities across populations. For example, Australia operates a generous LTC program for younger people with disabilities and a less generous aged care program, creating problems as people transition from one to the other. However, other political issues can arise if it is perceived that benefits received by older people are at the expense of younger or future generations, an issue that Japan has addressed by limiting the contribution base for its LTCI program to people 40 or older.This potted history of the Dutch program aims to highlight the importance of defining the core constituency of a LTC program and the needs that a program is aiming to address – as well as the influence that other areas of health and social policy can have on LTC programs. A key cost-control component of the Japanese program is that is it limited to older people and those with specified “geriatric diseases,” an approach that South Korea has copied.12 is complicated by its need to complement existing systems, the field has benefitted considerably from cross-national learning. Germany purposefully incorporated cost control mechanisms into its design. Japan built on the German program, while South Korea, in turn, learned from Japan’s experience; notably, it intentionally started small,13 as Ikegami recommends, with strict eligibility criteria and comparatively low contribution levels. Taiwan, too, has carefully studied other countries’ design in developing its yet-to-be-launched program, although, interestingly, it has seen a backlash against the social insurance model recommended by its policy experts,15 – a development that should remind the reader that local politics and history will nearly always trump careful planning. History also affects what citizens feel is owed them, which in turn influences how a program evolves. Although social insurance models are critiqued for creating a sense of entitlement among citizens, entitlement can arise from historical or social factors, as the evolution of Japan’s program demonstrates.Although LTC’s emergence as a “new social risk”Ikegami concludes by advising countries to start early in developing their LTC programs, so they can start small and constrain expectations – good advice, certainly. However, things rarely goes as planned: gestation periods for LTC programs can be extremely long. While researchers and policy experts—not to mention ordinary people—understand the critical and pressing need for LTC programs, politicians often see this as a low priority in the face of conflicting demands on the public purse. In both the case of Germany and Japan, a political catalyst was needed to induce the birth of the programs; many countries, including Taiwan and the United States, await their catalysts. Meanwhile, countries developing and adapting programs can learn from LTC programs worldwide.Not applicable.Author declares that she has no competing interests.PN is the single author of the paper.


WHO has recently published program reporting standards to guide the type of information that reproductive, maternal, newborn, child, and related health programs should document to promote cross-program learning. We strongly encourage our partners and key stakeholders to make use of the new standards as part of their routine program reporting. WHO has recently published program reporting standards to guide the type of information that reproductive, maternal, newborn, child, and related health programs should document to promote cross-program learning. We strongly encourage our partners and key stakeholders to make use of the new standards as part of their routine program reporting. The world's 2030 Sustainable Development Goals (SDGs) put forth a broad, visionary, and ambitious agenda, including targets that require efficient, effective programs in communities and populations implemented at scale. Collectively, our organizations invest significantly in global health science and practice.We all emphasize evidence-based learning, design, and implementation to improve the programs we support. There are several paths to improving the efficiency, effectiveness, and sustainability of programs; one path to improvement is cross-program learning. We often find, however, that program reports, when accessible, lack critical information necessary for reproducibility and adaptation to context. They also often lack information on key insights generated in the field that could be invaluable to other programs struggling with similar issues or seeking to implement similar interventions in a different context. Having accessible, systematic, comprehensive, and easily comparable data on program implementation—the how, why, who, and what—would facilitate learning, replication, validation, and scale up of interventions for different populations and environments.Program reports often lack critical information necessary for reproducibility and adaptation to context.For these reasons, we welcome the World Health Organization's (WHO's) recent publication on Program Reporting Standards (PRS) for sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH) programs.BOXRationale and objectivesStart and end dateSetting and contextStakeholdersFunding source(s)Theory of change and/or logic modelHuman rights perspectivesProgram overviewProgram planningPilotingComponents/activitiesQuality assurance mechanismsProgram components and implementationMonitoring mechanismsCoverage/reach and drop-out rateAdaptationsAcceptabilityFeasibilityFactors affecting implementationMonitoring of implementationEvaluationResultsCostsEvaluation and resultsLessons learnedSustainabilityScalabilityPossibilities for implementation in other settingsSynthesisWHO's Program Reporting Standards provide guidance for complete and accurate reporting on the design, implementation, monitoring, and evaluation process of reproductive, maternal, newborn, child, and related health programs.4 in other program areas have reached similar conclusions. The United Nations Population Fund (UNFPA) also learned this through its efforts to review the availability and quality of emergency obstetric and newborn care and to determine the drivers for successful implementation of policies and programs.Gaps identified in program reporting between “what is learned in the field and what is communicated in scientific publications”WHO's extensive and collaborative process to develop these PRS originated in a shared understanding of the need for more “action-oriented” information in the peer-reviewed and gray literature. Kågesten et al.The new PRS place emphasis on context, which is needed to understand how programs are delivered, key factors accounting for observed performance, and issues that may be important in its potential replication and/or scale up, including factors that can vary over the program's planned timeframe. Currently, contextual factors such as norms, behaviors, social networks, existing policies, and health system capacity are not included in routine reporting, though implementation success often depends on such factors. With organizations supporting and implementing programs across a wide range of different contexts, this information is critical to better understand both successful and failed programming; replicate and/or adapt programs as needed; and scale up effective interventions. Reporting items on sustainability and scalability can help ensure that these aspects are considered, as appropriate, from the beginning of implementation and are continually reflected upon throughout implementation. The process of stakeholder involvement and local ownership of programs needed for sustainability is considered vital by donors and United Nations (UN) agencies supporting governments; however, very little is reported on the success or failure of these processes. Use of PRS would allow for a consistent documentation of these experiences.From an implementation perspective, these standards are practical and easily applicable, though some adaptation may be required for larger programs.WHO's PRS ensure a comprehensive approach to documentation of the program development cycle, from design to evaluation and results. The ability to find all the needed information in a single document—and to be able to compare or collate this information across programs—represents a relatively modest change in existing processes that could, nevertheless, result in significant benefits, not only for program managers and implementers but also for program participants/beneficiaries and the larger global health research, policy, and practice communities.One key consideration that Kågesten et al. highlight in their article is the importance of uptake and use of the PRS. Given that the PRS are intended for use by any implementing partner, dissemination will be important through a range of channels and through different partners such as donors, UN, international NGOs, and the private sector, among others. Agencies and organizations could help in its uptake by incorporating PRS as a strong recommendation or as a standard element of contractual agreements and programming guidance provided to partners, country offices, and other stakeholders. A second but no less important piece will be ensuring the availability of the reports so the information can be widely accessed and shared. Many agencies and organizations already do this.Agencies and organizations can help with uptake of the Program Reporting Standards by incorporating them into contractual agreements and programming guidance provided to partners and country offices.Global Health: Science and Practice is an important venue for sharing programmatic experiences with sufficient space for discussion of context, implementation, and experiences. A key consideration moving forward is how to make sure that this tool for improving the way we report on and communicate about programs—for providing more thorough and accurate information on program successes and failures—is widely available, shared in other publications, and, ultimately, used. Progress in global public health depends on the ability of the field to share, learn from, and build on each other's programs, including understanding what did or did not work as well as why and in what contexts. Accurate, complete, and comparable reporting will help make this possible.We are pleased that WHO is taking concrete steps to address these gaps and to harmonize and strengthen reporting across the broad field of SRMNCAH programming. The new standards apply beyond the field of SRMNCAH and are an important contribution to document progress and achievements toward the SDGs. We strongly recommend our partners and key stakeholders in the field of global health and development take ownership and systematically make use of the new reporting standards as part of their routine program reporting.


Retirement preparation program: evaluation of resultsPsychology: Research and ReviewIncorrect version:Retirement preparation program: evaluation of resultsIt should read:The original publication (Psicologia: Reflexão e CríticaPsychology: Research and Review,


The 28th December 1908 Messina earthquake (Mw 7.1), Italy, caused >80,000 deaths and transformed earthquake science by triggering the study of earthquake environmental effects worldwide, yet its source is still a matter of debate. To constrain the geometry and kinematics of the earthquake we use elastic half-space modelling on non-planar faults, constrained by the geology and geomorphology of the Messina Strait, to replicate levelling data from 1907–1909. The novelty of our approach is that we (a) recognise the similarity between the pattern of vertical motions and that of other normal faulting earthquakes, and (b) for the first time model the levelling data using the location and geometry of a well-known offshore capable fault. Our results indicate slip on the capable fault with a dip to the east of 70° and 5 m dip-slip at depth, with slip propagating to the surface on the sea bed. Our work emphasises that geological and geomorphological observations supporting maps of capable non-planar faults should not be ignored when attempting to identify the sources of major earthquakes. It was one of the first earthquakes in Europe in the instrumental period, transforming the study of seismicity by triggering interest in earthquake environmental effects (EEE) that we now know are crucial for understanding the geometry and kinematics of a seismic source3. The epicentre was located in the Messina Strait graben, consistent with mapped environmental effects, and deformed Quaternary and Holocene geology10 31  affected the area, including the cities of Messina and Reggio Calabria, with devastating MCS intensities up to XI36. Eleven historic seismograms are available, but the spatial distribution and azimuthal coverage limit the seismological information that can be derived38. Investigations on earthquake environmental effects (EEE) have been carried out3; these included searches for ground ruptures, ground shaking, liquefaction, coastal retreat, gas emissions, slope movements both on land and submarine, acoustic and light effects and hydrological anomalies; although many environmental effects were noted, no clear surface ruptures were identified.The 283. We note that it has been suggested that many of the levelling benchmarks were reached by the tsunami25, raising concerns that some may have been disturbed. For example, contemporary coastal slumping is reported in the port of Messina . Also, the mountains along the Sicilian coast were affected by landsliding40  the offshore Messina-Taormina Fault (MTF) that is suggested to be an active normal fault as it is thought to deform Late Quaternary marine terraces and Holocene coastal notches33. There is no field evidence of recent co-seismic displacement on the onshore fault scarp of the east-dipping “Messina Fault” . Therefore, we found that including dextral slip does not significantly improve our solution. It may be possible to improve our dip-slip model by using a more sophisticated slip-distribution , already considered to be an active normal fault18. We have identified a known east-dipping fault33 in an offshore location as the likely seismic source, with a 70° dip, and 5 m slip with slip reaching the surface on the sea bed. 21, the 2006 Mozambique Earthquake (Mw 7)44, the 2008 Dangxiong Earthquake in the southern Tibetan Plateau (Mw 6.3)45, the 2008 Nima Earthquake in Tibet (Mw 6.4)46 and the 2009 L’Aquila Earthquake in Italy (Mw 6.3)47. Indeed, it is arguably a simpler scientific scenario to propose known mapped capable faults as potential earthquake sources than proposing previously-unknown and unmapped seismogenic sources. In this case, it was simply a matter of re-plotting the data to show variation in vertical motions with distance across the strike of the mapped Quaternary active and capable faults that produced the new insight  projected onto an E-W line, quasi perpendicular to the ~NNE-SSW strike of the Quaternary normal faults around the Messina Straits. We chose an E-W transect because the Quaternary faults have curvilinear traces and we have no a priori knowledge of which one or which part of them ruptured. Thus, an E-W transect was chosen to study the simplest question of whether the fault dips generally to the east or west. Figure 52. For this reason, we have questioned whether benchmarks located on the Sicilian side could have been affected by secondary processes. Indeed, previous studies39 including work by ISPRA  show that the entire Sicilian side, where the highly-fractured and deformed Palaeozoic bedrock outcrops39, is affected by landslide processes of rock fall, and in places rotational/translational rock slides40. The footwall sites mentioned above are either affected by coastal slumps . Our work should re-invigorate the drive to link mapped capable faults with historical earthquakes rather than ignoring the valuable insights that the geology and geomorphology can bring.Re-examination of levelling data from 1907–1909 reveals that the Mw 7.1 1908 Messina earthquake ruptured a 70Supplementary InformationESM1ESM2 and 3


Efficacy evaluation was analyzed using Latent Change Score Models and showed that the program did not impact on physical, psychological or online aggression and victimization, nor did it modify couple quality. It was, however, effective at modifying myths about romantic love, improving self-esteem, and improving anger regulation, as a trend. These initial results are promising and represent one of the first prevention programs evaluated in this country. Future follow-up will allow us to verify whether these results remain stable in the medium term.This study presents the first evaluation of Dat-e Adolescence, a dating violence prevention program aimed at adolescents in Spain. A cluster randomized control trial was used involving two groups  and two waves (pre-test and post-test six months apart). 1,764 students from across seven state high schools in Andalucía (southern Spain) participated in the study ; 52.3% were boys ( Dating violence, considered a subtype of intimate partner violence, has shown itself to be a construct that poses scientific challenges, its analysis encompassing biological, social, cultural and ideological factors . When weSafe Dates  –67 64–67 program , would n program , this ouOn the other hand, “floor effects” of behavioral outcomes could explain why no differences among groups were found, either for aggression or for victimization outcomes. This "floor effect" has been reported in community samples studies about interpersonal aggression, concluding that this effect attenuates the detection of intervention effects of universal programs , 18. In Positive outcomes were not found for couple quality. The program failed to improve positive quality, nor did it reduce negative interactions in the experimental group compared to the control group. These findings are consistent with previous studies regarding the non-decrease in negative interactions among couples , althougThe fact that no statistical differences were found in the control and experimental groups either for behavioral outcomes or for couple quality measures could also been explained in terms of the sample size. Our sample was estimated to find effect sizes of around .35 with an 80% of chance of rejecting the hypothesis that both groups were equal. Although the sample estimation was acceptable, the size meant that it was not possible to find small effects, as those found for behavioral outcomes at post-test in previous works ,14,15. IDat-e Adolescence program did, however, have a clear effect on beliefs and myths about romantic love, and self-esteem. The results showed that the experimental group participants significantly reduced their degree of agreement with the jealousy, omnipotence, better half and eternal passion myths, reflecting a more accurate and less mythicized view of love following intervention. Although we know of no prevention programs that have directly addressed myths about romantic love, previous studies have associated these myths with the origin and maintenance of dating violence [The violence ,71. ModiRegarding anger regulation and self-esteem, the program had a clear impact on self-esteem and showed a trend for anger regulation. Specifically, better anger regulation and decreased self-deprecation were observed in the experimental group participants following intervention. Although these results should be taken with caution, the findings are particularly noteworthy; they confirm that the program impacts positively on adolescents’ emotional competence, given that the negative views they hold of themselves decrease after intervention and their capacity to regulate their negative emotional states increases. Both anger regulation , 73 and Lastly, the fidelity analysis yielded reasonably positive results owing to the fact that, as the lessons progressed, the implementers worked toward complying with 100% of the content. Because fidelity was not 100% in the first lessons, this could indicate the need to adapt the content for these earlier sessions to ensure that all planned activities are fully implemented; it could also be indicative of the program implementers’ lack of knowledge about the group and how to handle it, meaning that they would end up spending more time on management tasks and class dynamic organization and less time on program activities. Fidelity to the program and to the implementation conditions at all development stages of an evidence-based intervention is essential , especiaDat-e Adolescence program showed that while it was effective at reducing factors directly related to violence, it did not directly impact on violence reduction. These results, although promising, should be interpreted with caution given that the program has only undergone one trial and no follow-up measures have been taken as yet. Future waves will allow us to evaluate whether the impact holds in the studied variables. Furthermore, the fact that the program has proved effective in terms of the predictors of dating violence considered in the program in accordance with the Dynamic Developmental Systems Model [To summarize, the evaluation of the first edition of the ms Model , suggestms Model  have empms Model  within iDat-e Adolescence program has some limitations worth noting. The first lies in the intervention’s design. Although the schools were randomly assigned to the control and experimental groups, it was the school staff who decided which classes would take part. Future editions benefiting from completely randomized trials would enable us to confirm whether the program’s efficacy is maintained. In the same vein, the program was implemented by researchers during this initial trial in line with recommendations made by Flay et al. [Despite yielding promising results, this first edition of the y et al.  and Gotty et al. . These sAnother important limitation has to do with experimental mortality. Participant attrition was reported at around 25%, the main cause of experimental mortality being the students’ absence at the time of data collection. In this regard, and as noted in literature , it is eWith regard to generalizing the results, this research was carried out in two cities in the Andalucía region and at state high schools with a medium economic, social and cultural level, meaning that the results are generalizable to a population bearing similar characteristics. Future trials should be conducted among populations with different economic, social and cultural characteristics in order to test the program’s efficacy in other groups and sociocultural contexts.Lastly, intervention fidelity was reported solely by the implementer. Future studies would benefit from including more than one trained observer and reporting interrater agreement. Similarly, it would be interesting to incorporate a student satisfaction measure and to analyze it complementary to the implementer’s observations with the aim of being able to change and improve the program content.Dat-e Adolescence, a dating violence prevention program implemented in state high schools in the autonomous region of Andalucía, Spain. Given that programs developed in the country to date have been scare and are of low methodological quality, this program, albeit with some limitations, represents one of the first efficacy evaluations in line with standards of evidence carried out in Spain. The outcomes showed significant changes in beliefs about romantic love, self-esteem and the expected trend in emotion regulation, but there was no impact on modifying aggressive behavior, victimization and couple quality. While the results are promising, they do demand follow-up measures and new trials.This research presents the first evaluation of


Since Taiwan’s age-friendly city (AFC) program was launched in 2012, the central government has provided various resources to the country’s 22 local authorities, including budgetary support, policy advocacy, and consultation from a team of experts. This study examines stakeholder perspectives on the process, performance, and outcome of the AFC program. A 53-item questionnaire was developed based on the World Health Organization (WHO) guideline, including mechanisms and processes (20 items), outcome evaluations (23 items), and resource integration (10 items). There was a “great difference” found among scores between facilitators and experts for “inter-exchange experience with local and international cities” (40%) and “monitor and revise indicators” (37%) in mechanisms and processes, “evaluate performance of indicators and action plans” (37%) in outcome evaluations, and “interaction between government and community” (46%) and “interaction between civil organization and senior society” (39%) in resource integration. Clearly, facilitators showed overly optimistic assessments in AFC mechanisms and processes, outcome evaluation, and resource integration. The results showed disconnect between experts’ expectations versus actual practice conducted by facilitators. Implications of these findings are to integrate top down expectations with the realities of bottom up practice to design more realistic evaluations; continue to educate stakeholders about design, implementation and evaluation; and further integrate resources from government, civil organizations, and community. Echoing the global trend of rapid elderly population growth, Taiwan’s 65-and-older population is expected to surpass 14% by 2018, officially making Taiwan an “aged society”  for implThe AFC program built upon the success of Taiwan’s healthy city (HC) program, employing a health in-all-policies (HiAP) approach in policy-making. HiAP is an approach on health-related rights and obligations. It improves accountability of policymakers for health impacts at all levels of policy-making and includes an emphasis on the consequences of public policies on health systems, determinants of health, and well-being . In 2010To overcome these limitations, Taiwan’s Department of Health Promotion (DHP) sponsored a Taiwan Alliance for Healthy Cities (TAHC) to assist local authorities in implementing the AFC program. A team of expert consultants, consisting primarily of academic scholars and specialists in the AFC program, was charged with providing counseling and guidance to facilitators in all 22 local authorities regarding community health building. TAHC periodically organized meetings or seminars to exchange experiences and provided evidence needed to implement the AFC program . FurtherTwenty-two facilitators from the local government in Taiwan were invited to participate in regular group meetings for the AFC program, sponsored by the HPA and TAHC. Over 80% of facilitators represented public health agencies from the local government, and the rest represented the administrative or planning agencies. The responsibility of facilitators included the following: organizing all program schedules, conducting need assessments for seniors, integrating and collaborating with other public and private sectors, encouraging community participation and stakeholder involvement, creating indicators and action plans, and conducting outcome evaluations. They played a key role as city project leaders or promoters for implementing the AFC program, and they determined whether or not the program was successful in the local governments. In addition, twenty inter-disciplinary scholars from the community health, public health, urban planning, gerontological nursing and architecture fields were invited for long-term collaboration with local authorities to counsel, guide, and assess the AFC program. TAHC and HPA organized expert team based on experiences of building community health and evaluating the quality of the program. Prior to implementing the AFC program, most of the experts had already established good partnerships with the local governments through various meetings and training programs, convening to periodically discuss the process of the AFC program. Meanwhile, the HPA and principal investigator (PI) of the AFC program usually held discussions with the experts to understand the progress and the level of performance in each local government. The well-organized commitment of the AFC program by the expert team was established incrementally through education and training using case studies, as well as during various meetings during the five-year period. The study was not submitted to the institutional review board due to low concern of harm to participants and the information being used to strengthen the implementation of the AFC program in the local government. All participants were still requested to sign the informed consent and anomalously completed the questionnaire.α level of <0.05.Our instrument included three parts and was based on the WHO Ageing and Life Course Department, which provided the institutional leadership for the WHO Global AFC Network. It comprised of 20 items on the mechanism and process of the AFC program (including PDCA process), 23 items on outcome evaluations  and 10 items on the integration of resources. These items were built on the initial work described by the implementation guidelines and from the minimum set of standards for communities that wish to participate in the WHO Global Age-Friendly Cities Network [Seven domains, based on the WHO guideline, had key indicators in implementing the AFC program. Findings were shown in Integration of resources from the public and private sectors as well as stakeholder involvement in developing the age-friendly community are needed in the “plan stage” for effective implementation of the AFC program. This is the first article on elaborating the difference of implementing AFC program between two stakeholders. Three parts including mechanism and process, outcome evaluation, and integration of resources in Taiwan are completely consistent with the criteria from the WHO Global Network of Age-Friendly Cities and Communities program model and consists of other potential contributions to city age friendliness. In practice, different checklist approaches have been adopted or recommended . Our fraInstead of just an assessment of the facilitators from the local government, Taiwan has provided a multi-way assessment for implementing the AFC program. Need assessments of the life and health status for Taiwanese seniors from their perspectives has been periodically conducted by the central government and academia ,15,16. AFor the sake of fulfilling the vision of adopting “active ageing” and “age in place”, the AFC program in Taiwan should sustainably promote and broadly spread from the local government to various communities. The program should not only concentrate on the needs of the elderly population, but the program’s facilitators or promoters should also be periodically monitored by the central government on providing person-environment fit with high quality, accessible and available facilities in the community. Using a “strictly bottom-up” alternative approach in Taiwan may empower older persons to bargain for actual opportunities in cities to maintain their quality of life . HoweverTo date, political leaders in local governments have always had power to decide the design and progress of all policies and the allocation of budget and resources in Taiwan. However, our findings indicate a significant difference between the two stakeholders pertaining to “organize education/training program” (29%) and “establish commitment for officers” (29%) in the “planning stage.” Furthermore, there were also differences between the two stakeholders in “involve and support by experts and specialist” 21%) in the “do stage,” and “participate award competition” (26%), “assess impact and outcomes” (29%) and “upgrade efficiency in local authorities” (23%) in the “check and action stages.” These facts obviously indicated lack of time is well-prepared good commitment in teamwork and an accurate assessment of the outcomes and impacts of the local governments during the short-term period. If facilitators implement an AFC program that is not fully supported by leaders or does not negotiate with public or private sectors, then the promotion of the AFC program is unrealistic and at times redundant with other similar urban initiatives. Regrettably, political leaders in local governments are constantly changing in Taiwan, which can result in changes in policy interests and challenges or uncertainties to focusing on implementing the age-friendly plan . As seen% in the The possible reasons for the great difference between two stakeholders are indicated as follows: (1). the different recognition of the AFC program existing; (2). most of facilitators had overly optimistic thinking in implementing the program; (3). the experts’ requirement of the facilitators meeting high standards and quality for the AFC program; (4). the need for facilitators need to do AFC work with multidisciplinary cooperation with other sectors; the work cannot be done independently; (5). because the outcome of the AFC program was difficult to be accurately evaluated by other sectors, experts were usually involved to guide the facilitators. We believe the experts provided objective assessments that can be used by local authorities; (6). outcomes of the AFC program are needed to be regularly evaluated by different stakeholders to improve quality, including older adults, delegates in the community, expert consultants, other institutions, or mass media, etc.; (7). The facilitators’ scores might be more subjective, because they might want a higher score in order to impress political leaders. However, the study found the less than 10% difference and more than 30% difference between the facilitators in local governments and scholars in the expert team, our findings can act as a reference for implementing the AFC program globally. It was based on the logic model, which is a suitable tool for program planning and evaluation purposes. Using a logic model like PDCA with the iterative process, facilitators in local governments may modify indicators in their logic models as often as necessary to implement the AFC program thoughtfully and sustainably. In the current study, items in Facilitators’ ratings of performance were consistently lower than experts’ ratings across all three domains of the questionnaire. Twenty-three out of 53 items showed a high level of difference, and the factors influencing the differences should be explored to determine how to minimize the discrepancies to enhance performance in the future. It is important to strengthen the leadership of political leaders, provide sufficient education/training program for facilitators, empower community participation and stakeholder involvement, and involve support from experts and specialists. Sustainable development of performance and accountability when implementing an AFC program is vital to fulfill the vision of “active ageing” and “ageing in place.”


In Ontario Canada, the Healthy Kids Community Challenge (HKCC) is a program intended to reduce the prevalence and prevent childhood overweight and obesity through community-based initiatives to improve health behaviours. Guided by the RE-AIM framework and Durlak and DuPre’s Ecological Framework for Understanding Effective Implementation, the evaluation focused on two objectives: 1) to describe the organization of the program at the community level; and, 2) to identify opportunities for improvement through an early assessment of factors contributing to implementation.n = 320) – members of the HKCC local steering committee, including the local project manager – completed a cross-sectional survey using SurveyMonkey and descriptive statistics were calculated. A sample (20%) of qualitative open-ended responses was thematically analyzed.Participants  and messaging regarding healthy behaviours for healthy kids, with less for its effectiveness in reducing weight (53.1%). There was a high-level of adherence to HKCC social marketing messages and overall program structure, with few Local Project Manager reports of adaptations to theme one (9.2%) and theme two messages (15.4%). Fewer Local Project Managers (50%) reported the existence of private partnerships. While most respondents agreed they had the appropriate information to complete mandatory reporting, the usefulness of the HKCC online networking platform was in question . Results reveal sufficient funding from the province to support program implementation, with a moderate level of local political commitment (63% of respondents).Results indicate that the HKCC was considered beneficial for enhancing access to health promoting programs, could be feasibly implemented with adherence to centrally-developed social marketing messages, and was amendable to local adaptation. Despite this, few private partnerships were reported. Going forward, there is opportunity to further evaluate factors contributing to HKCC program implementation, particularly as it relates to buy-in from intervention providers, and strategies for forming private sector partnerships to support long-term program sustainability. In Canada, rates of overweight and obesity represent a significant public health challenge, having risen substantially since the 1980s . PrevaleTogether Let’s Prevent Childhood Obesity) model [Drawing on the Ensemble Prévenons l’Obésité Des Enfants’  model , the Onty) model . The objMOHLTC supports HKCC communities  through the provision of funding, social marketing themes, training and tools, and other resources. A Scientific Reference Committee and Healthy Kids Resource Centres provide evidence-based advice and training, respectively. The HKCC has been designed to be consistent with the EPODE model, which includes social marketing, political commitment, sustainable resources, support services, and evidence  see: Pr.EPODE was developed based on a successful model of community programming to address risk factors for childhood obesity in northern France . EPODE pResults from a study measuring rates of childhood aged 5–12 years) obesity and overweight in two French towns  found a  years obSince the HKCC is a large, complex intervention, it requires an equivalently large and complex evaluation plan . The MOHGuided by Durlak and DuPre’s Ecological Framework for Understanding Effective Implementation , and conI.Community level factors: HKCC community context in which the program is implemented II.Provider characteristics: characteristics of the Local Project Managers and local steering committee members administering the program III.Characteristics of the innovation: features that describe the HKCC program IV.Factors relevant to the prevention delivery system – organizational capacity: extent to which the local steering committee and partner organizations can deliver the program V.Factors relevant to the prevention delivery system – training and technical assistance: training  to effectively prepare providers  to complete HKCC tasksDurlak and DuPre’s framework allowed for the assessment of HKCC program implementation relative to the levels and constructs of the framework to identify opportunities for improvement. The framework consists of five categories in which variables impacting implementation of community-based interventions are present , and is In addition to assessing participant perspectives on factors associated with implementation, we sought to collect information to describe the implementation of the HKCC as baseline for subsequent evaluation.Within Ontario, a standardized local delivery model, prescribed social marketing themes, and detailed planning and reporting requirements help to ensure consistent implementation of the HKCC across communities, while allowing for local adaptation. The model requires that each community hire a Local Project Manager to lead partnership development, planning and program implementation, and MOHLTC reporting . In the Run. Jump. Play. Every Day. , followed by Water Does Wonders , Choose to Boost Veggies and Fruit , and Power Off and Play!  [A centrally developed social marketing campaign was designed to motivate communities to organize interventions around pre-defined themes. Every 9 months, a new theme was announced to address factors associated with childhood overweight and obesity . The firActivities included central coordination and assistance to establish local steering committees, identification of community champions,MOHLTC provided resources to support the development of interventions and local program implementation to Local Project Managers. MOHLTC provided communities with: funding, training and capacity building, evidence-based advice, Local Project Manager and community toolkits  to support a single health promotion theme . ProvincData for this analysis were obtained from the first cycle of the local steering committee survey  received the survey through a snowball sampling method, participation was voluntary, and participants could stop their participation at any time. Of the 785 local steering committee members who received the survey, 40% (n = 320) completed some component of the online survey.HKCC communities  and external stakeholders (n = 7) from three communities selected purposively based on the fact that the research team had been in communication with them, and that there was a high likelihood that they would provide a response. Upon completion of the pilot, the survey was minimally adapted to improve clarity and the ease with which respondents could read and understand the survey questions.The survey was pilot tested to test study procedures and validity of the survey tool with a small number of internal staff participants  and if responses to the general questions matched other records. Results include descriptive statistics of quantitative measures, analyzed using SAS EG 7.1. Due to the high frequency of positive responses, data were grouped into two binary categories, “Strongly Agree/Agree” and “Other.” The “Other” category includes “Neither agree nor disagree,” “Disagree/Strongly Disagree,” and “Don’t know” results.n = 50) of qualitative responses to open-ended questions was undertaken to provide context and credibility to the quantitative data [n = 50; 20%) using NVivo to organize and code data. Third, thematic analysis of coded data was undertaken [Thematic analyses of a random sample  of participants completed the entire survey, while most  participants started it, completing at least 25% of the survey, including demographics. Given attrition as participants advanced through the survey, and that missing responses thereby constituted between 2.5 and 21.7% of the total responses depending on the item, percentage excluding missing is reported throughout.Participants were required to provide a response (each question included a “prefer not to answer” option) in order to advance through the online survey. Thus, missing data on closed-ended questions represents the end of participation. 82.8% (n = 39) reported the number of individuals to whom they distributed the survey link.To identify the number of eligible participants and to identify the denominator for categorical responses, Local Project Managers from every municipal HKCC community (n = 83) self-identified as Local Project Managers, while 74.1% (n = 237) identified as non-Local Project Manager local steering committee members. Since the survey was conducted one-year after program launch, and 2 years after funding applications were submitted, communities may have hired more than one Local Project Manager over this time period or had multiple individuals fulfilling these responsibilities. All items asked of both Local Project Managers and non-Local Project Manager local steering committee members are grouped together . Survey questions that were unique to the roles are summarized separately. Thirty-nine per cent of participants represented an HKCC community champion.Of the participants who completed the survey, 25.9% (n = 83) were hosted by: a local municipality (n = 27); the recreation sector (n = 20); the non-profit sector (n = 19); and/or a public health unit (n = 16). Local steering committee members (n = 237) were represented by: the non-profit sector (n = 50); a local municipality (n = 49); as being a local community member (n = 45), and/or a local public health unit (n = 40).All 39 municipal HKCC communities were represented; and, communities had between 1 and 24 individuals participate in the survey. Most Local Project Managers (LPM) and Local Steering Committee (LSC) members had been in their role for between 13 and 24 months  or less than 1 year . Local Project Managers (n = 166); b) sharing knowledge and expertise  (n = 164); c) mobilizing and encouraging your community to be involved in the HKCC (n = 154); and, d) developing theme-based action plans (n = 143).Nearly half (45.6%) of non-Local Project Manager local steering committee members were actively involved in the functioning of the HKCC partnership, while 24.5% provided some form of specific support to the project. Table The remainder of results have been organized and mapped onto the five categories outlined by Durlak and DuPre’s Framework .n = 79 mentions: in-kind, funding for programming, activities, sustainability, evaluation). For example, this support included “Free use of municipal grounds, storage space and community centre, free printing and supplies, volunteer hours for equipment assembly and installation, staff time for equipment purchasing and lending hub set up”.82.4% of participants agreed that there was strong support from local community partners for HKCC implementation, while 63.7% agreed there was sufficient funding from the province to support program implementation. In addition to fairly strong local political commitment (63%), half (51%) of respondents reported that there were sufficient existing policies to support implementation. Only 24.2% of Local Project Managers indicated that their community had received extra financial support for HKCC implementation (see Table Most participants 93%) agreed that the program was beneficial to their community, while 88.3% reported that it enhanced individuals’ access to community programs and activities   were confident that they: had the skills needed to engage with community partners (93.5%); could achieve the goals of the HKCC in their community (85.5%); and, could implement the HKCC in the community (81.4%). Some (59.7%) were less confident and found it challenging to engage community partners to participate in the HKCC. As one participant articulated in the qualitative data: “n = 277) of participants agreed that the HKCC could be adapted to fit local needs, while 86.8% agreed that initiatives were feasible to deliver. A majority (79.4%) of respondents perceived that there was general public support for the HKCC, while 71.4% perceived that social marketing campaigns were well-received. Although respondents indicated that the program was compatible with and adaptable to their communities, few  Local Project Managers reported that the actual HKCC brand had been adapted. While 9.2% of participants reported that messaging adaptations had occurred for theme one (Run. Jump. Play. Every Day.), 15.4% indicated that their community had adapted the messaging for theme two (Water Does Wonders). These findings are noteworthy in that adherence to specific HKCC brand and theme messaging may be important to implementation fidelity. A majority of respondents provided qualitative data (n = 61) data related to the adaptability of the HKCC   of participants  agreed that theme two “Water Does Wonders” was based on sound scientific evidence, while the same was true (86.0% agreement) for theme one “Run. Jump. Play. Every Day.” There was a high level of agreement (86.3%) for a strong evidence base supporting the provincial HKCC program. Further, nearly 70% of respondents agreed that systematic methods had been used to search for evidence to inform local HKCC activities and programs.Participants were asked to report on the use of evidence to inform the development of the HKCC program. As such, 86.6%  reported that they have developed informal private partners (without a partnership charter) on the HKCC, while fewer  have formal private partnerships. More than 32% (n = 22) of respondents reported that their HKCC community did not have any private HKCC-related partners.Results indicate that a high proportion (89.2%) of participants believed that local steering committee collaborations helped to facilitate program implementation, while 86.3% recognized strong leadership for the local steering committee . Most (91.5%) respondents agreed that their local steering committee had developed links with pre-existing community structures, while 81.9% agreed their local steering committee is or had networked with diverse sectors to gain support for the HKCC program.Results reveal fairly strong respondent agreement that there are sufficient resources and support to implement the program (80.6%), and that resources and supports offered by the Healthy Kids Resource Centres are useful (71.6%). More than half of respondents indicated that 1:1 support from MOHLTC helped to address specific questions or concerns (58.1%), and that Local Project Manager in-person training was useful.Guided by Durlak and DuPre’s Ecological Framework for Understanding Effective Implementation  and consPerceived program need and benefit are provider-level factors that contribute to implementation success . While rFeasibility to implement with fidelity is essential to achieve program outcomes . HKCC prThe presence of a shared vision and goals, and strong communication channels among partners within HKCC communities, are critical attributes of successful program planning and implementation . SustainCommunity partnerships are integral to spreading key messages about the program, and for leveraging resources – in-kind , material , and financial, and have been identified as a key success factor of EPODE-modelled interventions world-wide . Partnerhttp://www.mindingourbodies.ca/sites/default/files/partnershipprotocol_english_final.pdf).Mobilizing stakeholders at all levels to shape and change obesogenic environments requires the active support of program developers, implementers, evaluators, and policymakers . PrivateFunding and political support are deemed essential for effective implementation . ResultsBrownson  reiteratComparing our results with other programs, Pettigrew et al.  identifiPlanning for future HKCC evaluation activities might include an in-depth assessment of the role of external stakeholders, including individuals from the private sector, who are actively supporting program implementation. These partners may have a less formal – but equally important – role in the functioning of the program, particularly in the context of long-term program sustainability. For example, strong partnership functioning with stakeholders from public-and private-sectors can facilitate effective and efficient program development, delivery, and maintenance . EvaluatImplications for future research include the need to further explore functioning of the local steering committee through case study methodology. As per recommendations provided by Moore and others , case stOur study contributes a case to the growing literature on implementation of community-based initiatives. Our evaluation used a framework to assess early implementation that was deemed relevant to the HKCC program as it includes multi-level factors impacting implementation of community-based interventions, and included community factors as key constructs . Other fIt is important to consider some limitations of this study. First, recruitment through snowball sampling was used to increase the potential participation rates. Although Local Project Managers were provided with clear instructions to forward the survey link to their entire local steering committee based on this method, we are not certain if there was equal distribution of the survey link across local steering committees or equal participation rates across the communities, and therefore results may not be representative of all local steering committee members or communities. This is not too problematic, since we do not claim that our results are generalizable to all communities or across all LSC members . Also, although Local Project Managers indicated that they had successfully distributed the survey link to their local steering committee members, it is possible that the link was sent beyond the local steering committee, or that local steering committee members chose not to participate. It is also possible that not all members of the LSC received the survey, either because they were no longer involved in the HKCC at the time of the survey, or because they had missed the email invitation. Because of this method of recruitment, we could not track the number of times the survey link was distributed, and there was potential for respondents to participate in the survey more than once. Extensive efforts were made to identify and remove duplicates, but some may not have been detected and therefore their opinions may have been counted twice.Second, this study may have experienced some selection bias, with more polarized Local Project Manager and local steering committee members more likely to participate in order to share their opinions. We did note, for example, that most responses were skewed positively, and will address this by combining response options for subsequent surveys. Also, we could not be entirely sure if Local Project Managers or local steering committee members reported their roles accurately, as evidenced by the number of survey respondents that self-identified as Local Project Managers. This point is further complicated by the fact that communities had between one and 24 individuals participate in the survey. Finally, as noted throughout the manuscript, the proportion of missing data increased as the survey progressed, which may be attributable to survey fatigue. This can be remedied in future iterations of the survey with a function added whereby participants can exit and return to the survey where they left off.Given our selection and use of Durlak and DuPre’s  frameworResults indicate that the HKCC was considered beneficial for enhancing access to health promoting programs, could be feasibly implemented with adherence to centrally-developed social marketing messages, and was amendable to local adaptation. Despite this, few private partnerships were reported, and there was less agreement that the program could be beneficial in reducing or preventing childhood overweight and obesity over a 3 year period. Durlak and DuPre’s Ecological Framework for Understanding Effective Implementation  was showAdditional file 1. Ontario’s Healthy Kids Community Challenge Program Logic Model.Additional file 2. HKCC Local Steering Committee Survey.Additional file 3. Summary of qualitative results, including themes, number of mentions and selected quotations.


Pay-for-performance programs to incentivize quality are on the rise nationally . Kansas initiated a Medicaid P4P program to incentivize person-centered care (PCC) beginning in 2012 called PEAK 2.0. This program created an operationalized definition of PCC through stakeholder collaboration and research outcomes . Homes enrolled in the program undergo both self-evaluation and objective external evaluation based on the operationalized definition. These key features inherent in the PEAK 2.0 program make up has aided homes to implement PCC as well as, the ability to research homes that have implemented PCC in a new a different way than ever before.