Substance abuse has been considered as a growing challenge in Georgia that is closely linked with human immune deficiency virus (HIV) and hepatitis C transmission due to unsafe injection and other uncontrolled behaviors. Methadone maintenance therapy is one of the major treatment options for opioid-dependent individuals. It has proven efficacy in decreasing illegal opioid consumption and criminal behavior as well as reducing the level of HIV infection, mortality, HCV infection, and increasing social functioning.The data was initially extracted from the electronic database, as of October 30, 2015, for the patients undergoing methadone maintenance therapy in 2014 and 2015. We used two types of statistical analysis: binary regression and time-to-event analysis (Kaplan-Meier). For binary regression analysis, patients who initiated the treatment 12, 9, 6, and 3 months prior to October 30, 2015, respectively, were eligible for >12-, >9-, >6-, and >3-month retention analysis. We identified two types of the retention periods: (I) “the program specific retention period” (the time spent (uninterruptedly) in the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria (GFATM) opioid substitution treatment (OST) program after the clients’ last entry) and (II) “being on OST retention period” (the time spent (uninterruptedly) on OST since the clients’ last entry).For time-to-event analysis, the two different endpoints were investigated: (i) dropouts and (ii) being detained.p values decrease from 0.07 for >3- and >6-month retention to 0.01 for >9- and >12-month retention. The younger age group was more likely to get dropouts and be detained. HIV status and social status did not show statistically significant association with retention.The analysis showed that at each time point, “being on OST retention” rates are slightly higher than “program specific retention” rates. The percentages of patients retained in OST treatment after 3, 6, 9, and 12 months from the initiation of the treatment, respectively, were 89, 86, 85, and 83% and the percentages of patients retained in the GFATM program at the same time points were 88, 83, 82, and 80%. Patients older than 40 years are twice as likely to stay in the program compared to younger individuals. Gender is only associated with >9 and >12 months retention with approximately three times the odds for men compared to women. The strength of the association between hepatitis C status and “program specific” retention increases with time spent in the program as These findings identify the need for more support for younger patients as they are more vulnerable to dropouts and detention compared to the older age group, especially during the early stage of treatment. Substance abuse has been considered a growing challenge in Georgia that is closely linked with human immune deficiency virus (HIV) and hepatitis C transmission due to unsafe injection and other uncontrolled behaviors. According to studies conducted in 2009, 2012, and 2015, the number of people who inject drugs has increased from 40,000 to 45,000 and then to 49,700 .The estimated HIV prevalence in Georgia is 0.3% 0.2–0.4%) among the adult population (15–49 years of age). Injecting drug use was considered the leading route of HIV transmission in the early stages of the HIV epidemic in Georgia. Since 2012, however, heterosexual intercourse has become the major route of transmission  [% among tWorldwide, there are 12 million people who inject drugs (PWID), of whom 14.0% are living with HIV .The comparative analysis of Bio-Behavioral Surveillance Survey (BBS) results conducted in the last 5 years 2009–2014) showed significant changes in the injecting drug scene 009–2014 , 8. HeroIn 2014, the opiates affected some 17 million people in the world. The decline of opium production in 2015 is unlikely to lead to shortages in the global heroin market given the high opium production levels of previous years .Methadone maintenance therapy is one of the major treatment options for opioid-dependent individuals. It has proven efficacy in decreasing illegal opioid consumption and criminal behavior as well as reducing the level of HIV infection, mortality, hepatitis C virus (HCV) infection, and social functioning. There are studies reporting a positive impact of retention in opioid substitution treatment (OST) on HIV outcomes: the longer the duration of retention in OST, the higher the likelihood of long-term virological success , 10.OST was introduced in Georgia in 2005. Nowadays, OST is functional through three sources: (I) the donor: The Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria (GFATM), (II) the state program, and (III) the private sector. There are two different OST programs available: (1) methadone maintenance program and (2) the program using combined preparation with buprenorphine and naloxone.The state program is based on the co-payment principle: the cost of the methadone is covered by the State, while services  are self-paid (out-of-pocket) by patients at GEL 110 a month. The co-payment does not apply to HIV-positive individuals and those under the poverty line. In total, there are 15 sites operated by the State throughout the country. In 2015, the country’s total capacity for OST was 2750 (the state program had 2000 patients and the GFATM 750 patients) patients.The National Center for Disease Control and Public Health (NCDC) of Georgia through the GFATM-funded HIV prevention program provides treatment at six OST sites. There are four sites in Tbilisi , one in Gori (east Georgia), and one in Batumi (southwest Georgia). Additionally, two sites are running in the penitentiary institutions—one in Tbilisi and another in Kutaisi (west Georgia), providing long-term detoxification of methadone. Figure We conducted the operational study to investigate retention in OST and associated factors.GFATM OST program uses an electronic web-based real-time data collection tool in which the data is entered on a daily basis.The clients’ information which are routinely collected are (1) client’s ID, (2) residency address, (3) date of birth, (4) gender, (5) date of program entry, (6) date of program cessation, (7) reason of cessation, (8) OST program provider name and address, (9) hepatitis C status, (10) acquired immune deficiency syndrome (AIDS) status, and (11) social status.The data was initially extracted from the electronic database as of October 30, 2015, for the patients undergoing methadone maintenance therapy in 2014 and 2015. All duplicates as well as observations for which the program entry date was missing were excluded. The final data set included 1051 individuals out of an initial 1249.“The program specific retention period” was defined as the time spent (uninterruptedly) in the GFATM OST program after the clients’ last entry.“Being on OST retention period” was defined as the time spent (uninterruptedly) in OST since the clients’ last entry.For those patients which only had GF OST program experience “the program specific retention period” and “being on OST retention period” coincided with each other.“Dropout” was defined as a failure to adhere to the regimen  or abandoning the program with or without notification.The database consisted of patients (i) transferred from other OST programs into the GFATM OST program and (ii) those originally entered in the GFATM OST program. For this reason, we identified two types of the retention periods: (I) “the program specific retention period” and (II) “being on OST retention period.”Patients who initiated the treatment 12, 9, 6, and 3 months prior to October 30 were, respectively, eligible for >12-, >9-, >6-, and >3-month retention analysis  at different time points was calculated as follows: (I) more than 3-month retention ≥90 days stay, (II) more than 6-month retention ≥181 days stay, (III) more than 9-month retention ≥270 days stay, and (IV) more than 12-month retention ≥365 days stay , hepatitis C status, HIV status, gender, and being socially vulnerable. The latter was defined as a patient who applied to the Social Service Agency (SSA) in order to receive social assistance. The database automatically captures the information about the obtained social scores of the patient (at the moment of the patient’s registration), if this patient has applied for the social assistance and therefore is registered into the SSA database.p value of <0.05 and showed statistically significant association with the outcome as well as with other exposure variables. In the final model, variables were selected based on a significance threshold of p < 0.05. Separate multivariable modes were built for “program specific” and “OST specific” retention periods.First, univariate analyses were performed to assess the strength of the association between each independent variable and the outcome. Other variables were then included in an initial multivariable model if they had a univariate p values. All p values are two-sided and reported to three decimal places with those less than 0.001 reported as p < 0.001.Results are presented as estimated odds ratios (OR) with corresponding 95% confidence intervals (CI) and Factors that showed statistically significant association with retention in OST were further studied in relation to two different endpoints (failure events): (I) dropouts and (II) being detained, by contracting Kaplan-Meier survival curves. Patient’s death or retention in the program until the end of the study period as well as residential address or clinic change was treated as censored data.Due to the huge inequality in gender distribution within the cohort , we did not put gender as an exposure variable for time-to-event analysis.Analyses were performed using STATA version 11.Table The analysis showed that at each time point, “being on OST retention” rates are slightly higher than “program specific retention” rates. The percentages of patients retained in OST treatment after 3 months, 6, 9, and 12 months from the initiation of the treatment, respectively, were 89, 86, 85, and 83% and the percentages of patients retained in the GFATM program at the same time points were 88, 83, 82, and 80%.In univariate analysis, age showed a strong statistical association with both “program specific” and “being on OST specific” retention periods. Generally, at each time point, patients older than 40 years have almost two times the odds of staying in the program compared to younger individuals. Per each year increase in age, the odds of retention increases ~7%. Gender was associated with only >9- and >12-month retention with about three times the odds for men compared to women. Positive hepatitis C status was only associated with “program specific” retention periods at >9-month (1.73 95% CI (1.15–2.63) and >12-month (1.76 95% CI (1.15–2.67) time points. HIV status and social status did not show a statistically significant association with retention , showed some statistically significant association with retention Table .Table 3Mp = 0.014 significant level.From the total cohort, 32% (341) left the program, 2.3% died (10), 14.1% (48) was detained, 19% (65) left the program after the detoxification , 35% (120) ceased the treatment voluntarily (with or without any notification or due to failure to keep the regimen), 16.4% (56) changed to another clinic, and 12.3% (42) changed the residential address. For each reason of cessation, younger age group patients (<40) were proportionally more compared to older age group patients, at For the patients who left the OST program, the median duration of stay in the OST program was 140 days (interquartile (IQR) 31–558). The longest median duration of stay  was observed among patients who left the program after the detoxification course, followed by detainees with 140 days  and dropouts with 56 days .p < 0.001). For the younger age group patients, the probability of experiencing the dropouts some time after the end of the observation period was about 0.73 (95% CI 0.66–0.81), and for the old age group, it was 0.88 (95% CI 0.84–0.91). The younger age group was also less likely to be detained sometime after the observation period compared to the old age group (0.67 (95% CI 0.36–0.86) vs. 0.95 (95% CI 0.93–0.98)) . There was no statistically significant difference in Kaplan-Meier detention probability estimates (0.80(95% CI 0.53–0.92) vs. 0.92 (95% CI (0.78–0.96), transferred vs. not transferred, log rank test p = 0.059)  for the transferred patients and 0.79 (95% CI 0.74–0.83) for not transferred patients .The occurrences of the endpoints between the groups of hepatitis C-positive and -negative patients were not statistically significant . Patients who came from the paid program to the free-of-charge program have a higher probability of experiencing dropouts or being detained at some point after the end of the observation period.The strength of the study is that the data was extracted from a real-time web-based electronic system which captures and registers the basic characteristics of the patients. The accuracy of the data is monitored on a quarterly basis.The results of association between gender and retention were not conclusive as females represent only 2.8% of the cohort (29/1051).Due to different settings and definitions used in other studies, the comparability of our findings is also limited. Our study presents relatively high retention rates on OST >80% even after 12 months of treatment, compared to other studies’ findings. In a Ukrainian study, retention rate was 67% at 12 months of treatment . Our finAge, gender, and hepatitis C status were not associated with retention at 6 or 12 months in a Ukrainian study . Soyka MBeing transferred from the paid program to the free-of-charge program shows a positive association with retention. These findings are consistent with Australian study findings, conducted in 2013, which suggest that dispensing fees have a negative impact on OST retention as well as lifestyle and treatment. They also suggest that sponsorship “… would potentially increase the retention rate of income-poor OST program participants” .In Georgia, individuals can apply for the social benefit at the SSA. The authorized person of the SSA  visits the family. During the visit, a “family declaration” is filled in about the social-economic state of the family on the basis of the information delivered by the authorized person of the family. After allocation of the information provided in the declaration in the unified database and processing by established methodology, a rating score is assigned to the family, which amount defines the right of the family on any benefit  . IndividBeing socially vulnerable does not appear to be the driving force for transferring; as in our cohort, socially vulnerable people are equally distributed among those transferred and not transferred from the paid OST program. Among those who came from the other OST program, 77% were not socially vulnerable. Their transfer might indicate that, despite their social status, people find it difficult to pay the OST fee. Our findings might also suggest that being transferred from the paid program to the unpaid program could be a motivator for better retention rates. As it is noted in the World Drug Report, 2016: “higher social-economic groups have a greater propensity to initiate drug use than lower social-economic groups, but it is the lower social-economic groups that pay the higher price as they are more likely to become drug dependents” [These findings identify the need for more support for younger patients as they are more vulnerable to dropouts and detention compared to the older age group, especially at the early stage of treatment. More analysis enabling a direct comparison between paid and free-of-charge programs is needed to assess the retention and associated factors.


In July 2014, US residency programs fully implemented the Next Accreditation System including the use of milestone evaluation and reporting. Currently, there has been little investigation into the result of implementation of this new system. Therefore, this study sought to evaluate perceptions of Obstetrics and Gynecology residents and program directors regarding the use of milestone-based feedback and identify areas of deficiency.A Web-based survey was sent to US-based Obstetrics and Gynecology residents and program directors regarding milestone-based assessment implementation.Out of 245 program directors, 84 responded to our survey (34.3% response rate). Of responding program directors, most reported that milestone-based feedback was useful (74.7%), fair (83.0%), and accurate (76.5%); however, they found it administratively burdensome (78.1%). Residents felt that milestone-based feedback was useful (62.7%) and fair (70.0%). About 64.3% of residents and 74.7% of program directors stated that milestone-based feedback is an effective tool to track resident progression; however, a sizable minority of both groups believe that it does not capture surgical aptitude. Qualitative analysis of free response comments was largely negative and highlighted the administrative burden and lack of accuracy of milestone-based feedback.Overall, both Obstetrics and Gynecology program directors and residents report that milestone-based feedback is useful and fair. Issues of administrative burden, timeliness, evaluation of surgical aptitude, and ability to act on assigned milestone levels were identified. Although this study is limited to one specialty, such issues are likely important to all residents, faculty, and program directors who have implemented the Next Accreditation System requirements. Benefits cited are early recognition of struggling residents and identification of curriculum gaps in residency programs and additional opportunities for feedback to residents. Reported barriers included increased administrative work, difficulty adopting a “developmental progression model” in the context of distinct clinical rotations, and issues with organizing effective clinical competency committees.57In July 2014, all residency programs in the United States including Obstetrics and Gynecology implemented the NAS, incorporating the use of milestone evaluation and reporting.8 Our study seeks to evaluate resident and program director perceptions of milestone-based feedback.To our knowledge, there have been no prior studies to assess how the adoption of the milestone reporting has affected Obstetrics and Gynecology residency programs or what perceptions and attitudes residents have toward this system. This is especially important, as the Obstetrics and Gynecology curriculum must evaluate both medical and surgical proficiency, posing the unique challenge of using this feedback system to evaluate trainees on 2 very different competencies.www.surveymonkey.com).As we were not able to find previously published questionnaires that evaluated milestone-based feedback, we created 2 distinct surveys for Obstetrics and Gynecology: 1 for program directors and 1 for residents. Surveys were developed by a team of 5 Ob-Gyn residents and a program director. The surveys were trialed by different residents and academic faculty at our institution and revised as needed for content and clarity. The program director survey consisted of 12 questions aimed at assessing their perceptions and attitudes regarding the usefulness, accuracy, and ease of implementation of milestone-based feedback as compared with traditional feedback methods. The resident survey consisted of 11 questions aimed at assessing perceptions and attitudes regarding the usefulness and accuracy of milestone-based feedback. These attributes were chosen because they were felt to be the main barriers to nationwide adoption and implementation of milestone-based feedback and as such, identifying and correcting any inadequacies in one of these characteristics would likely increase adoption. Both surveys had 5-level Likert scale questions as well as a free response section where program directors and residents were invited to provide additional comments. All questions were optional and could be skipped. The surveys were created for distribution by email for data collection via SurveyMonkey . National demographic data among Obstetrics and Gynecology residency programs were compiled using the program self-reported information on the American Medical Association FREIDA online database.11 Proportion analysis was performed in Stata 10.0  to compare program director and resident responses for overlapping survey questions. Free responses were analyzed using qualitative content analysis, in which consensus codes were reached by 3 of the authors through an iterative process with preliminary and secondary coding. From this analysis, themes emerged into which responses could be categorized.An email list of all program directors and program coordinators at ACGME-accredited Obstetrics and Gynecology residency programs was created using information available on the ACOG and APGO Web sites.This survey study was reviewed and approved for exemption by the Partners HealthCare Institutional Review Board.Of the 261 Obstetrics and Gynecology US residency program directors, we obtained reliable contact information for 245 program directors and could contact 240 residency coordinators to forward our survey to the residents in their program. Out of 245 program directors, 84 responded to our survey (34.3% response rate). A total of 631 residents responded to our survey. An exact response rate for residents could not be calculated due to inability to accurately track how many residents received our survey via the resident coordinators and program directors; however, there were 5005 US Obstetrics and Gynecology residents at the time of the survey indicating that we received data from 12.6% of eligible residents.Resident respondents were distributed among all 4 postgraduate year (PGY) classes and all 5 ACOG regions, with no class or region representing more than 30% or less than 10% of respondents . About 7Program director respondents represented all 5 ACOG regions, with region 4 representing the most respondents (31.0%) and region 3 representing the fewest 10.7% . Most prAbout 87% of residents were familiar with milestone-based feedback . Most ofAlthough 78.1% of program directors believed that milestone-based feedback is more administratively burdensome compared with traditional feedback systems, they had a more favorable perspective regarding the new system than residents. Of program directors surveyed, most believed that milestone-based feedback is useful (74.7%), fair (83.0%), accurate (76.5%), timely (57.3%), and actionable (59%).In terms of tracking performance over time, 64.3% of residents and 74.7% of program directors believed that milestone-based feedback is an effective tool to track resident progression. However, 16.4% of residents and 36.6% of program directors believed that milestone-based feedback does not capture surgical aptitude and performance.In all, 34 of 84 program directors (40.5%) and 92 of 631 residents (14.6%) who completed the survey left additional comments see . Of thesOur study demonstrates that milestone-based feedback has been widely integrated into Obstetrics and Gynecology residency programs nationwide. As seen in 12 Integrating milestones with innovative programs such as CORE may help improve the surgical aspect of resident evaluations.Only half of the residents and about a third of program directors believed that milestone-based feedback captures surgical aptitude and performance appropriately, suggesting that an additional system is needed to document proficiency in these areas. In 2013, the Johns Hopkins University Plastic Surgery residency program implemented the Comprehensive Observations of Resident Evolution (CORE) program in an effort to capture resident-specific operative strengths and weaknesses. They found that this tool increases immediate attending/trainee feedback and assessment transparency, enables trainee self-monitoring, and informs end-of-rotation reviews, program-wide assessments, and tailoring of training to address specific needs.57 This is in direct contrast to the stated goals of the NAS. In our study, 75% of program directors reported that milestone-based feedback is more time-consuming than prior feedback systems. This could in part represent an early time investment in setting up evaluations to capture information for milestone assignment, but further evaluation over time is necessary to understand whether this administrative burden persists even when systems are in place.As with previous studies, our study demonstrates that residency program directors feel that milestone evaluation and reporting has increased administrative burden.Other concerns raised by this study include that milestone-based feedback is not actionable, as milestones are “more evaluative than meant to provide feedback.” Both residents and program directors noted that when residents are not performing at the expected level, there are not enough specific details on the shortcomings; hence, it is challenging to define a plan to address deficiencies. Furthermore, 20% of residents felt that milestone-based feedback was not timely and that it should be given at more frequent intervals for residents to be able to make timely changes and improvements. Comments from program directors highlight that spontaneous faculty comments have decreased on evaluation forms due to the increased time necessary to gather milestone-oriented information. This sentiment is highlighted several times in the resident comments as well. In addition, although milestone-based feedback is not meant to replace informal or verbal feedback, comments suggest that the administrative burden associated with milestone-based evaluation may also have taken away from real-time feedback. As the milestones are further developed, focusing on both streamlining the feedback submission process as to capture specific feedback in a timely manner without excessively burdening the submitter, as well as making sure that there are actionable plans to correct deficiencies once these are identified, may help to improve the acceptability and applicability of this system.There are several limitations to our study. First, as with any survey study, there is a possibility of bias, as program directors and residents who chose to respond to the survey may differ from those who did not respond. We were unable to calculate an exact resident response rate given our inability to determine how many residents received the survey, although 12.6% of eligible residents did respond. Nonetheless, we believe that with greater than 600 residents who are well distributed by PGY class, region, and program size, we could sample a reasonable range of opinions. Similarly, there is potential for sampling bias among program directors, as evidenced by the fact that a slightly higher percentage of program directors in our sample work at academic hospitals than the national average. Furthermore, 40% of program directors have only been in their role for 0 to 3, so they may not have had much experience with the traditional milestone system as program directors. In addition, this study is confined to Obstetrics and Gynecology and has some shared findings with previous studies in other specialties but likely some results may be specific to Obstetrics and Gynecology as there are different milestones for each specialty. We also recognize that for our free response portion, it is likely those who feel strongly positively or negatively that will likely comment. Hence, we expected and received polarized answers. Finally, “milestone-based feedback” was not specifically defined on the survey which could lead to misunderstanding of this term by the respondents.To our knowledge, our study is the first to assess residents and program director’s perceptions of milestone-based feedback in Obstetrics and Gynecology. Our study highlights the need for programs to continue to develop tools that capture and deliver milestone-based feedback more effectively with the goal of enhancing resident development. In addition, because milestones do not encompass the totality of the breadth of training needed to be a competent Obstetrician/Gynecologist, continuing other forms of evaluation and feedback is essential. Although this is certainly a challenging task, we believe that our findings will help guide program directors and residencies to further develop feedback tools that work optimally for residents and faculty in both surgical and nonsurgical specialties. As each specialty determines the optimal methods for measuring milestones, it is crucial to continue to evaluate and understand how residents and program directors experience milestone implementation.


The last great megathrust earthquake here, in 1877 of Mw ~8.8 opened a seismic gap, which was only partly closed by the 2014 earthquake. Prior to the earthquake in 2013, and shortly after it we compared data from leveled benchmarks, deployed campaign GPS instruments, continuous GPS stations and estimated sea levels using the upper vertical level of rocky shore benthic organisms including algae, barnacles, and mussels. Land-level changes estimated from mean elevations of benchmarks indicate subsidence along a ~100-km stretch of coast, ranging from 3 to 9 cm at Corazones (18°30’S) to between 30 and 50 cm at Pisagua (19°30’S). About 15 cm of uplift was measured along the southern part of the rupture at Chanabaya (20°50’S). Land-level changes obtained from benchmarks and campaign GPS were similar at most sites (mean difference 3.7±3.2 cm). Higher differences however, were found between benchmarks and continuous GPS (mean difference 8.5±3.6 cm), possibly because sites were not collocated and separated by several kilometers. Subsidence estimated from the upper limits of intertidal fauna at Pisagua ranged between 40 to 60 cm, in general agreement with benchmarks and GPS. At Chanavaya, the magnitude and sense of displacement of the upper marine limit was variable across species, possibly due to species—dependent differences in ecology. Among the studied species, measurements on lithothamnioid calcareous algae most closely matched those made with benchmarks and GPS. When properly calibrated, rocky shore benthic species may be used to accurately measure land-level changes along coasts affected by subduction earthquakes. Our calibration of those methods will improve their accuracy when applied to coasts lacking pre-earthquake data and in estimating deformation during pre–instrumental earthquakes.The April 1 Rapid large-scale, natural disturbances are a key factor in shaping the environment e.g. –4) and a and a4])Mw 8.8 and 9,1, respectively) [Understanding the consequences of natural disturbances is critical, not only to inform resource managers about present-day natural communities, but also to predict the effects of future disturbances and their consequences on the environment. Understanding disturbances requires study of damage, patterns of recolonization, resilience and reaccommodation of affected organisms and communities ; howeverctively) , are exactively) , 15. Duectively) . Intertictively) . In turnMw>8.5) earthquakes on average every 150–200 years [Mw 7–8) earthquakes that occur at greater depths (> 35 km) reaching below the coastline [Mw 8), 2007 Tocopilla (Mw 7.7) and 2012 Constitución (Mw 7) earthquakes.The Chilean coast runs along the subduction zone formed by convergence of the Nazca oceanic plate beneath the South American continent that commonly generates great megathrust earthquakes and accompanying tsunamis –18. Plat00 years , which r00 years ,20. The oastline , such asMw >8.8) earthquake of 1877 and triggered a transpacific tsunami with causalities in Hawaii and Japan [Mw >8.8–9 earthquake. The 2014 Iquique earthquake filled only a fraction of this seismic gap, leaving a ~300-km-long unruptured segment capable of producing an Mw ~8.5 event [Mw 6.9 earthquake, 11 days after the 2010 Maule earthquake [The northern segment of the subduction plate boundary, nearly 500 km ,22 betwend Japan . Given t.5 event –25 locatrthquake . Space grthquake . The intrthquake .The intertidal biota of rocky shores along the world coastlines, are characteristically zoned in biotic belts –31 usualCoastal land-level changes estimated from rocky-shore biota have been measured after several great earthquakes and used to provide a rapid assessment of the rupture length ,34,38,39We started surveying the coast of northern Chile eight months before the 2014 Iquique earthquake, and conducted the first post-earthquake survey ten days after to measure land-level changes. We hypothesize that such land-level changes are the most important exogenous disturbance to the ecology of sessile benthic invertebrates and macroalgae as measured by changes in vertical distribution (zonation). We tested this hypothesis by comparing: i) pre- and post- earthquake measurements collected at stationary benchmarks installed on upper shore levels, and ii) upper levels of vertical distribution of intertidal rocky shore biota. We compare these different types of measurements among sites along the Iquique rupture zone and beyond  and propet al. [The study sites  are locaet al. ), where et al. –43. Suchet al. ,44–46. Tet al. ,47 and ret al. ,48–52).Echinolittorina peruviana and the barnacle Jehlius cirratus; (b) a middle zone where mussels (Perumytilus purpuratus), barnacles  and leshy-encrusting and frondose algae such as the red algae Hildenbrandia lecanellieri, the green algae Ulva rigida and Pseudoulvella sp., and the brown algae Colpomenia spp. and Ralfsia spp., are the most common taxa; (c) a lower zone dominated by the brown kelp Lessonia berteroana, and a guild of encrusting coralline algae  and erect coralline algae .Big North coastal communities remain poorly known compared to those south of 27°S . Rarity No specific permits were required for the described intertidal field studies. The rocky shores we studied in Chile are unrestricted to public access and use, and are not privately owned or designated as protected areas (reserves or parks). No protected or endangered species were involved in this study.ca. 20 km south).Benchmarks consisting of 4 cm length stainless steel bolts were installed in August 2013 on the upper rocky shore levels at six sites . We measDaily solutions of additional five continuous GPS stations were processed, using the same constraints and used to estimate corresponding land-level changes at selected observation periods coincident with the benchmark leveling and campaign GPS. The processing strategy included a dense network of reference stations located in the southern part of South America and processed with Bernese 5.0 Software –59.d ≤ 10mag– 0.8), annual and semi-annual seasonal periodic variations, the secular pre-earthquake linear inter seismic trend, and a transient logarithmic post-seismic trend ) and an encrusting calcareous lithothamnioid algae). Differences in height between the upper limits of rocky shore biota and low tide were corrected as explained above.The elevation of the upper limits of selected rocky shore biota with respect to tide levels were measured at Pisagua Norte, Pisagua Sur and Chanavaya. The selected sessile biota included the barnacle t-test to compare the averaged H of the replicated samples collected during each of the post-earthquake sampling periods with the un-replicated pre-earthquake data. For the upper limits of the sessile species, we used two observed distributions with mean H1 and H2 for upper vertical limits recorded during pre- and post-earthquake periods, respectively. Because only a limited number of measurements could be collected during the post–earthquake period, we pooled the data from Pisagua Norte and Pisagua Sur, as well as those from Chanavaya.The direction and amount of the vertical displacement of the rocky intertidal zones at each site were compared by assessing the differences in elevation above mean tide level (H) of benchmarks and the upper limits of the vertical distributions of the five selected sessile species. For the benchmarks only a single measurement of elevation was available for the pre-earthquake period (August 2013). We used a two-tailed, one-sample 2—H1, with negative and positive values of ΔH indicating subsidence and uplift, respectively. To avoid the non-independence of all pair-wise differences between H1 and H2, we approximated the distribution of ΔH through simulations in a Bayesian framework [1 and H2 and their standard deviations S1 and S2. We computed the difference between H1 and H2 for each pair of simulated and independent values, and estimated the 95% Student’s t—test confidence interval for the posterior distribution of ΔH. This analysis is supported by the observation that the distribution of intertidal biota elevations of sessile species is usually not significantly different from Gaussian [The averaged differences in elevations between sampling dates were calculated as: ΔH = Hramework . Using aGaussian .Detailed observations on vertical distributions of rocky shore organisms may be used to define mean tide level datum and measure sudden changes in relative sea level, caused by coastal deformation during earthquakes . HoweverMw 7.6 aftershock that occurred 2 days after the mainshock at greater depths reaching below the coastline  show a persistent recruitment pattern, characterized by a positive relationship between spatial occurrence and persistence along time, which is highly correlated from one coastal segment to another from a few to tens of kilometers along the Chilean coast [Jehlius cirratus has shown consistently high recruitment rates across the upper tidal level, leading to persistent patterns of fast recolonization of vacant space at monthly intervals [Lessonia berteroana may exhibit between-site variations related to differential impacts of El Niño events [Physical factors and ecological processes operating at different spatial or temporal scales probably affect these differences and the accuracy of our estimates an coast . In partntervals , 68. In o events , and expOur integrated analysis shows that in general, rocky shore sessile species can provide accurate measurements of land-level changes during earthquakes. Due to time constraints we chose to survey different species and measure tide levels for positioning the benchmarks with respect to mean tide and deploying the campaign GPS stations over making a greater number of measurements. Our study highlights the need to conduct regular surveys of coastal zones prone to large earthquakes in order to determine the local variability of species-specific patterns of vertical distribution, and thus determining which may be most accurate for assess land-level changes. s. The choice of species will be largely dependent on the expected amplitude of the coseismic land-level changes , 69; forS1 Table(DOCX)Click here for additional data file.S1 File(XLSX)Click here for additional data file.


Aboriginal and Torres Strait Islander people have higher rates of chronic disease and a lower life expectancy than non-Indigenous Australians. In non-urban areas these health disparities are even larger. The aim of this qualitative study was to explore perceived barriers and enablers to attending an eight-week physical activity program in a rural and regional setting which aimed to improve health outcomes, but had a low attendance rate.n = 12) and the regional (n = 22) community. Qualitative semi-structured individual interviews were conducted at the follow-up health assessments with 12 participants. A thematic network analysis was undertaken to examine the barriers and enablers to participation in the program.Thirty-four Indigenous Australians participated in the intervention from the rural (Overall, there were positive attitudes to, and high levels of motivation towards, the physical activity program. Enablers to participation were the inclusion of family members, no financial cost and a good relationship with the principal investigator, which was strengthened by the community-based participatory approach to the program design. Barriers to program attendance were mostly beyond the control of the individuals, such as ‘sorry business’, needing to travel away from the community and lack of community infrastructure.More consideration is needed prior to implementation of programs to understand how community-specific barriers and enablers will affect attendance to the program.ACTRN12616000497404. Registered 18 April 2016. Indigenous Australians have a lower life expectancy compared to non-Indigenous Australians, mainly due to higher rates of preventable chronic diseases –3. ChronThere is a limited amount of research conducted with socially disadvantaged groups , 7, fundA recent systematic review investigated the effects on health outcomes of physical activity programs for Indigenous people in Australia and New Zealand . While tIn addition to a quantitative evaluation, one of the studies in the review, a 12-week fitness program for Aboriginal and Torres Strait Islander women , also haUnderstanding the barriers and enablers to participation in physical activity programs can assist researchers in interpreting contextual factors that influence the implementation of and attendance to a program . Thus, tThe two intervention sites were located in a rural and regional setting in Far North Queensland, Australia. The communities are not identified in this paper to protect the participants’ anonymity. To be included in the study participants had to be Aboriginal or Torres Strait Islanders aged 18–45 who have a chronic disease or a risk factor for chronic disease. Based on the definitions by the Australian Institute of Health and Welfare Guidelines , risk faThe program commenced in January 2016 in the rural community and in July 2016 in the regional location. At the commencement of the study, 34 participants were enrolled. A flowchart of participant recruitment and attendance is provided in Fig. What was your experience with the program?What could have been made better about the program?What would you like to see happen in the future?Is there anything else you would like to comment on?Interviews were conducted at the post-program assessments. The interviews were loosely based on the Health Belief Model , as it iDue to the complexity of a non-Indigenous researcher working with an Indigenous population group, the interview guide had limited questions to allow a better exploration of previously unidentified themes that may arise.An 8-week physical activity program was implemented in two communities. The free program was delivered through one-hour face-to-face group sessions, four times per week for eight weeks. Each week there were two sessions with vigorous activities and two with moderate intensity activities, delivered by a qualified sport and exercise scientist . The vigorous intensity sessions included small-sided team sports , such as soccer and touch football and circuit training with adaptations made to account for individual fitness levels. The remaining two sessions were self-paced moderate intensity walking sessions. After the program, participants were invited to partake in one-on-one interviews, regardless of their attendance to exercise sessions. Interviews were mostly conducted at the participants’ house by the principal investigator (PI) who already had established relationships with the participants.All interviews were digitally recorded by the PI and transcribed professionally by an external transcription service. Transcription files were presented in Microsoft Word and later uploaded into NVivo 11  for analysis. Interview transcriptions were read by the PI while listening to the corresponding audio file to cross-validate the content and to ensure the context was captured accurately. The interviews were coded and examined independently by a second person (CM) for a thematic analysis. The thematic network analysis was aimed at identifying global, organisational and basic themes , which wn = 12) and annual gross household income was frequently less than $20,000 (n = 7) or less than $60,000 (n = 12). Seven participants had not completed year 12 and 17 participants had completed a TAFE or university degree. Twenty-seven of the 33 respondents (missing n = 1) rated their general health either good (n = 16), fair (n = 9) or poor (n = 2). Only two participants rated their health as excellent. Quantitative results from the program will be provided elsewhere in an additional publication.Table Overall, attendance to the program was low. In the rural community, eight people who enrolled in the program did not attend a single training session, and four attended an average of seven sessions during the eight weeks. In the regional city, twelve participants did not attend a single training session, while the remaining ten participants attended an average of five sessions.The motivations to join the physical activity program were different between the rural and regional community. During the analysis, the regional community had a sub-theme develop in regards to motivations of health-related outcomes such as weight loss and fitness. For example, reasons to join included ‘To lose weight, get fit and be more active’  and ‘Weight loss and to get more into physical activity’ . For one participant, weight loss was a means of controlling the progression of her chronic disease: ‘Well, with the current condition I’m under it is very important that I control my weight…I’ve got diabetes’ . The rural community members more explicitly stated motivations to participate were due to chronic diseases. One participant stated ‘I'm determined not to be a [chronic disease] statistic… I'm pretty determined to break the cycle’ , and another explained ‘she [another participant] wanted to do it … her chronic disease wasn’t looking good so she had to start making changes’ .Many of the men who enrolled in the program stated that their main reason for non-attendance to activities was work commitments. Two of the participants who worked in the rural community stated ‘I do work away, all the time up the Cape’  while another often did shift work: ‘Yes, well, at that time I was doing all day shifts at work and the timing was sort of out’ . Both men were highly motivated to participate and attended the follow-up data collection, despite not attending a single training session. The men acknowledged their disappointment that they did not get any benefit from the program. One of the men in the regional community, who was also a university student, found it hard to attend as his work required him to travel away regularly, ‘I think the biggest barriers for me are work, study and travel’ .There were logistical barriers identified in the interviews, which were unique to the communities. In the regional community, logistical problems were mainly the timing of the class (despite being suggested by the participants), whereas the rural community members experienced problems with access to transport. The rural community also had issues with access to facilities. During the first four weeks of the program, no indoor facilities were available and classes were regularly cancelled due to rain. ‘You’ve got to take into consideration that a lot of outdoor activities can’t be run on a regular basis sometimes, due to - obviously we live in the tropics, the wet tropics. That’s why it’s called wet, as - it can set in for days, months sometimes’ . Despite being able to access a secondary facility five kilometres away, there were barriers in regards to access to transport to attend the classes. ‘But organising stuff, even when there is wet [weather], we don’t have indoor facilities…You’ve got to go in town or you’ve got to access a facility - fitness facilities, and then they cost money. Every time you want to do something, it costs money’ . There was a lack of public transport services and ‘not everybody has access to a car’ .There were other barriers to program implementation and attendance in the rural community, such as ‘sorry business’, which is a term used by Indigenous Australians that refers to a time of mourning in the community, following the death of a person. The process of mourning can take place over extended periods, and the intensity of the mourning is reflective of the importance of the individual that has passed away, respectively the importance of his or her family. ‘We run a program - we’ve always tried to start it with a start date. Obviously because of the weather, obviously because of sorry business or something, we can never start it when we want to start it. It got put off as much as we could. Then when it got up and running, by the time it was finishing, that’s when they started walking in the door’ . An identified sub-theme in the rural community was menstruation being a barrier to female participation. ‘Sometimes women won’t participate if they’re menstruating. I know quite a few say they can’t’ . Although there was no further elaboration from other participants in the interviews on this particular issue, several personal communications received prior to program sessions indicated that the reason for non-participation was menstruation. Specific concerns reported included feeling uncomfortable exercising, cramping and fatigue and concerns regarding hygiene in the rain.A lack of family and peer support were identified as a barrier to participating in physical activity. One of the participants who had a young family and a partner that worked away explained: ‘I think the only thing, sometimes I feel depressed there is not enough support from my partner, which is something that I’m wanting more is his support’ . A male participant explained his hardship of needing to take control of his health conditions and the effect it has on his family. ‘I suppose the receptive of the rest of the family is probably your key stumbling block if there’s one … see I’ve got a wife and four kids so it’s like I’ve got to have a separate meal’. He also expressed his feelings toward the impact that health choices have on his children: ‘because I think she’s borderline [his daughter] – at the age of 20, borderline diabetic, and we try to do that with her, but – yeah – sort of heartbreaking when they get emotionally upset because they’re not allowed to go and enjoy what they want to enjoy’ .The lack of peer support and family also transitioned into themes of shame and stigma around undertaking physical activity. There were previous negative experiences in regards to people wanting to exercise for their health. ‘Now or prior to the last five years, exercise was deemed as people who wanted to look good. There was always this negative attitude. Because I think obesity has become a norm in most – in the cultures now. You either need to look fat, so everyone stays fat, and if you want to lose fat, you're deemed as being sick. If you want to look good for the sake of being healthy, people think that you’re better than anybody else. Whereas I think the culture is shifting a little bit now, or the mentality is shifting’ .Several participants mentioned finances and money during the interviews as barriers to participate in physical activity and that having a free program acted as an enabler. Reasons for joining were because ‘it is good that it doesn’t cost money. Everything else costs money’ . Unemployment was as a financial barrier to undertaking exercise as ‘Money is a major barrier for myself. Only because you’re still looking for work’  and ‘it was free … Yeah, I couldn’t afford it, no money, no job’ . An identified enabler to joining in the physical activity program was the inclusion of family members into the activities. Figure Aside from family participation, peer support and guidance also assisted with facilitating participation. One person admitted to feeling uncomfortable when exercising on her own due to embarrassment: ‘It's just if I'm by myself in public and I'm going for a jog on the road, I feel very self-conscious … Look at this fat chick she’s jogging, what the hell’ . Another participant stated they needed support and guidance from a qualified person, ‘I tend to do things alone, and I don’t know if I’m doing it right or not. Whereas if you’ve got somebody there who can guide you, you sort of have a better understanding of the process … most of the time I go to the gym, and one of the fears I have is not knowing if I’m actually doing it right. You know that as you’re probably aware, you can hurt yourself…so I tend to do a lot of jogging’ .Themes of resilience also emerged in regards to the lack of peer support. It was encouraging to hear statements such as: ‘You have, yeah, those kind of people that would think [exercising is a disconnecting activity] like that, but, you know, just got to ignore them and do what’s best for you, I guess … Turn around and tell them where to go, say this is my life, I’m not going to end up with a chronic disease, are you going to look after me when I’m on dialysis or whatever?’  and ‘I think for me that’s what I’d like to see, is that exercising becomes the norm for our people … my mum comes from the dormitory [stolen generation] , so exerAn enabler to participation in the physical activity program was the participants’ relationship with the researcher. Many primary concerns to program implementation in the rural community revolved around the principal investigator being an ‘outsider’, female and non-Indigenous. When participants were asked about whether having a non-Indigenous female run the program could have been an issue, many positive responses were received. One of the male participants explained his thoughts on the principal investigator, focusing on the relationship and level of comfort: ‘Of course, because you really need to have a good relationship and it eliminates the shame factor. Because sometimes you're a bit too embarrassed, even though if you can’t – if you don’t have the strength or the capacity to do what you want to do or achieve’ .For one of the female participants, having a female principal investigator was seen as an enabler to participation: ‘Not really, when I met you, I was like yeah this is going to be easy. If it was like someone in their 30s, 35 and not like a male, yeah I'm probably not going to rock up to your session if they weren’t so welcoming like you are’ .Although there was not a negative reaction to the principal investigator being a non-Indigenous female, the need for a male role model was evident, particularly in the rural community. The principal investigator felt comfortable and welcome in the community, however, there were suggestions for future research. For instance, one of the men responded by saying there was a need for male role models: ‘To some extent yeah, a possibility. I mean it doesn’t matter … especially in communities, having a male would benefit, because a lot of the times, when you use girls, the girls always turn up to a lot of your stuff. But the blokes won’t because there’s too many women there. But if there was a bloke there and he sort of did it together, maybe they might turn up’ . In agreement, another male participant also offered his suggestion to increase attendance: ‘Just that it could have been a lot more user friendly in regards to that. I mean, I’m not saying that you’re an uncomfortable person to talk to. You’re very comfortable. But that’s just me. Other people might find it uncomfortable and it’s like role modelling too. So, if you’ve got an – even not so much of a young male or an older male who’s got some problems, health problems, they can actually role model or they’ve come from a background where there’s bad health in the families and so forth’ .The need for male role models was further emphasised by higher program attendance by women. One woman suggested ‘I think maybe it needs to have a male and a female, because it seemed to have worked more so for the women, than for the men’  whilst another believed ‘Culture is still focused on the men’s and women’s stuff … we did have a men’s group, but they do a lot of social outings. That’s something we could’ve tapped into’ . It would have been ideal to have a male involved in the program, as this was an issue discussed during the study design, it was extremely difficult to involve a male Indigenous role model. This was due to the lack of male Indigenous health workers and qualified people to run physical activities.This study sought to explore Aboriginal and Torres Strait Islander participants’ perceived barriers and enablers to attending a community-tailored physical activity program implemented in a rural and a regional setting. There were unique themes identified within the communities in regards to the barriers to attendance, however, the motivations to participate were similar across both sites. Firstly, the rural community had a lack of provisional infrastructure and access to resources. This impacted the program delivery and attendance due to inadequate access to an undercover facility during wet weather events.There was a contrast between the logistical barriers between the communities where participants in the regional community were unable to attend due to poor timing, as opposed to those in the rural setting for whom lack of access to transport was a major barrier. The rural participants also expressed the importance of having both female and male role models for community members. For many their main motivation to participate in the program was that they saw physical activity as a means for prevention and management of chronic disease. In the regional community motivations were more centred on physical activity-related outcomes of weight loss and increased fitness. Participants from both communities highlighted the importance of support from their family and peers with their journey to becoming more active.shame [Evaluations of physical activity interventions with Indigenous populations have reported several barriers to participation, which include the transient nature of the population, logistic issues and shame . The Indshame . Particushame . For theLogistical issues, mainly in regards to transportation, are also known barriers to attendance to research programs . Davey eshame refers to embarrassment in certain situations and is often due to attention or circumstance, rather than the action by oneself [shame occurring was during a walking group in the rural community, where the principal investigator was asked to walk on the opposite side of a participant to block her from the view of men who were sitting across the road. Thompson et al. [The concept of  oneself . The mosn et al.  examinedn et al.  reportedEnablers to participation in the physical activity program primarily revolved around relationships to the other participants and with the principal investigator. In the rural community, all participants had a kinship connection with at least one other member of the program. It became evident that recruitment to the project was largely through kinship connections, rather than through the wider advertisement throughout the community. In the regional community, kinship connections were also an obvious factor in recruitment. One family had five family members involved, while another family had three sisters participate. The flexibility in the program delivery was also well-suited to participants who were the primary carer for children or dependant adults. It was often observed that participants would bring their children to training sessions, and in one instance a participant brought her dependant adult mother to a class. During the walking groups, some women would bring prams or bikes for their children to join in with the activity. There were also several community members who were not part of the program, but who began to attend training with the encouragement of the existing participants.The fact that the principal investigator who ran the physical activity intervention in the two communities was a non-local, non-Indigenous female was seen as a potential barrier to conducting the research. However, positive feedback was received and participants often ‘vouched’ for the principal investigator during the recruitment of their family members. The only barrier with the principal investigator conducting classes was the lack of mentorship for the men who were involved in the program. This was highlighted during the interviews with the members of the rural community. There was an understanding that it is challenging to find Indigenous men to assist with the program, especially in a voluntary role as it would have been with this project. It is important to be aware of the cultural ideas of men’s and women’s business which refers to certain customs and practices in Indigenous communities that need to be undertaken by men and women separately . TherefoThe 8-week physical activity intervention lead to significant improvements in health outcomes, however, attendance was low across both communities. The research project utilised a participatory action research approach  and was The theoretical model utilised for the qualitative evaluation is a somewhat limiting model for a complex topic. The Health Belief Model was useful to identify barriers and enablers to program participation, but there are suggestions for future research. A limitation of this model is the lack of focus on external factors, such as access to transport, as opposed to individual factors, which can influence health behaviours . A suggeThe aim of this qualitative study was to explore perceived barriers and enablers for a rural and regional Indigenous community to participate in an eight-week physical activity program. Overall, there were positive attitudes and high levels of motivation towards the program. Enablers to participation were the inclusion of family members, no financial cost and a good relationship with the principal investigator. Barriers to program attendance were mostly beyond the control of the individuals, such as cultural obligations, the transient nature of communities and lack of community infrastructure. In conclusion, more consideration is needed before program implementation to understand community-specific barriers and enablers to physical activity programs. Furthermore, more work is needed to better understand how to improve participation rates.


Background: Alongside the dramatic increase of older adults in the United States (U.S.), it is projected that the aging population residing in rural areas will continue to grow. As the prevalence of chronic diseases and multiple chronic conditions among adults continues to rise, there is additional need for evidence-based interventions to assist the aging population to improve lifestyle behaviors, and self-manage their chronic conditions. The purpose of this descriptive study was to identify the geospatial dissemination of Chronic Disease Self-Management Education (CDSME) Programs across the U.S. in terms of participants enrolled, workshops delivered, and counties reached. These dissemination characteristics were compared across rurality designations . Methods: This descriptive study analyzed data from a national repository including efforts from 83 grantees spanning 47 states from December 2009 to December 2016. Counts were tabulated and averages were calculated. Results: CDSME Program workshops were delivered in 56.4% of all U.S. counties one or more times during the study period. Of the counties where a workshop was conducted, 50.5% were delivered in non-metro areas. Of the 300,640 participants enrolled in CDSME Programs, 12% attended workshops in non-metro adjacent areas, and 7% attended workshops in non-metro non-adjacent areas. The majority of workshops were delivered in healthcare organizations, senior centers/Area Agencies on Aging, and residential facilities. On average, participants residing in non-metro areas had better workshop attendance and retention rates compared to participants in metro areas. Conclusions: Findings highlight the established role of traditional organizations/entities within the aging services network, to reach remote areas and serve diverse participants . To facilitate growth in rural areas, technical assistance will be needed. Additional efforts are needed to bolster partnerships , marketing , and regular communication among stakeholders. As the population in the United States (U.S.) ages, the number of older adults (aged 65 years and older) residing in rural areas is also growing . Some esAging may be seen as a unique rural phenomenon in that migration to non-metro  has been shown to be associated with increasing age, in part, due to being seen by some as retirement destinations . An estiThe growing emphasis on community-based interventions to promote healthy aging reflects the growing recognition, that older adults with chronic conditions spend only a small proportion of time in healthcare settings , and are responsible for the day-to-day management of their conditions. Further, this emphasis is indicative of the U.S. evolving from a paternalistic healthcare system, to one that provides more autonomy and empowerment to older adults, with the support of healthcare providers and services. To combat the impact and consequences of chronic disease among older adults, numerous evidence-based programs have been developed and disseminated to improve lifestyle and self-management behaviors. The Chronic Disease Self-Management Education (CDSME) Programs are among the best known and most widely disseminated ,22. CreaNational Study of CDSMP, the grand-scale dissemination of the intervention maintained its effectiveness in terms of symptom management, physical and mental health outcomes, and self-reported healthcare utilization reductions  [The flagship CDSME Program is the Chronic Disease Self-Management Program (CDSMP). This process-based intervention is universal for people living with any/all chronic conditions and uses problem solving, action planning, and goal setting to build participants’ skills in managing their disease symptomology. Examples of topics discussed during the workshops include physical activity, nutrition, techniques to cope with health problems and negative emotions, communication with healthcare providers, and how to assess new treatments. The effectiveness of CDSMP was initially documented from a randomized-controlled trial conducted in the late 1990s ,25,26. O visits) ,28,29. In addition to being universally appropriate for any chronic condition, CDSMP has been developed to address specific conditions . These generic and condition-specific CDSMP versions comprise the suite of CDSME Programs. Each CDSME Program workshop is facilitated by two leaders who have undergone rigorous training. Detailed manuals exist for facilitation, implementation, and fidelity. Each small-group workshop consists of six sessions, each of which last 2.5 h. Workshop sessions take place once a week for six consecutive weeks. CDSME Programs are primarily offered in English and Spanish, although they are available in approximately 17 languages.In the U.S., the Administration for Community Living/Administration on Aging (ACL/AoA) has provided discretionary grants programs to support evidence-based health programs. From 2006 to 2016, there have been four main waves of funding to promote the dissemination of interventions to vulnerable Americans, defined as those who are underserved and in the greatest need for services  ,31. In aThe primary purpose of this descriptive study was to identify the geospatial dissemination of CDSME Programs across the U.S. in terms of participants enrolled, workshops delivered, and counties reached. Dissemination characteristics were compared across rurality designations, to examine program reach to serve vulnerable individuals. Secondarily, data were also stratified by CDSME Program workshop and delivery site-type, in order to facilitate a more detailed assessment of characteristics related to the participants, delivery sites, and workshops. These characteristics were examined to provide contextual information about this multi-year national dissemination effort. Data for this study utilized a national data repository created alongside a series of national funding initiatives to support the dissemination of CDSME Programs as part of the American Recovery and Reinvestment Act of 2009 Communities Putting Prevention to Work: CDSMP initiative ,33. KuliThe dependent variable for this descriptive study was CDSME Programs delivery in rural areas. To categorize counties, each was assigned a Rural-Urban Continuum Code (RUCC). RUCCs were developed by the United States Department of Agriculture and use a 9-point scale to indicate proximity to nearby metro areas ,35,36. FUsing data in the national repository, the total number of participants enrolled, workshops delivered, and unique counties reached were tabulated. Based on the ZIP Code of the workshop delivery location, the ZIP Code Tabulation Area (ZCTA) was identified, and population statistics were obtained. More specifically, the ZCTA of the workshop delivery location was used to identify the median household income , percent of residents residing in poverty , percent of residents who were white, percent of residents who were Hispanic, and percent of residents with less than a high school education. The average number of participants enrolled in each workshop was calculated. The average number of workshop sessions attended was reported . Additionally, the proportion of participants that completed workshops  was calculated . Because the CDSME Program suite consists of multiple tailored interventions, the dissemination of each unique workshop type was of interest. English-language workshops included: Arthritis Self-Management Program (ASMP); Chronic Disease Self-Management Program (CDSMP); Diabetes Self-Management Program (DSMP); Chronic Pain Self-Management Program (CPSMP); Positive Self-Management Program (PSMP), and Cancer: Thriving and Surviving (CTS) . SpanishGiven the diverse organizational infrastructure used to deliver CDSME Programs, the delivery site type for workshops was of interest. Delivery site types included: healthcare organizations; senior centers/Area Agencies on Aging (AAA); residential facilities; multi-purpose organizations ; faith-based organizations; educational institutions; county health departments; workplaces; tribal centers; and other site types ,44.Personal characteristics of the participants enrolled in CDSME Programs included age, gender, and number of self-reported chronic conditions.All analyses were performed using SPSS  for this descriptive study. Counts were tabulated for the number of participants enrolled, number of workshops delivered, and number of unique counties reached. These counts were stratified by workshop type and rurality see . Counts Overall, 300,640 participants were enrolled in CDSME Programs over the study period. The majority of participants attended workshops in metro areas (82%), followed by workshops in non-metro adjacent areas (12%) and non-metro non-adjacent areas (7%). Overall, 25,279 workshops were delivered over the study period. The majority of workshops were delivered in metro areas (80.5%), followed by workshops in non-metro adjacent areas (11.5%) and non-metro non-adjacent areas (8%). When examining CDSME Program delivery by workshop type, CDSMP was the most widely disseminated , followed by DSMP , Spanish CDSMP , and CPSMP . In the U.S., there are 3221 counties [On average, CDSME Program workshops enrolled 13.50 (±6.32) participants, of which 9.49 (±4.47) completed the workshops . On average, participants attended 4.31 (±1.75) workshop sessions. Compared to workshops delivered in metro areas, workshops delivered in non-metro non-adjacent areas enrolled fewer participants , but had higher overall attendance .This study provides a unique examination of a national dissemination of a set of evidence-based disease self-management interventions targeted toward older adults. Intervention penetration is an important issue in making a visible impact on population health . Over haDespite an attempt to reach more ethnically diverse older adults, the Spanish-language version of CDSMP was not as widely disseminated as the English-language version. Spanish-language workshops, and Hispanic residents, were heavily concentrated in metro regions. It was also observed that some workshop types were more prevalent in certain geographic settings. For example, CDSMP was predominant in non-metro counties , in terms of a simple comparison of the number of counties reached. However, rural areas are most at-risk in terms of the proportions . The presence and expansion of CDSMP was not surprising, and this is likely testament to its longer history and record of financial and community support . When introduced into a community, ample time is needed to develop a training and delivery infrastructure, capable of hosting ongoing workshops that will serve a sufficient number of individuals with chronic conditions residing in a particular area. Furthermore, host/sponsoring agencies  located in rural areas, or those delivering programing in rural areas, may have greater distances to travel, with higher associated travel costs  . In termn = 577), relative to healthcare organizations (n = 311), over half of which were in non-metro areas (n = 305). These findings highlight the established role of traditional organizations/entities within the aging services network, to serve remote areas and diverse participants, within the reach of 11,000 senior centers nationwide. Meanwhile, the growth of healthcare organizations as primary delivery sites denotes their organizational alignment with the intervention itself, as delivery settings able to identify and enroll patients with chronic conditions. The rise of healthcare organizations as primary delivery sites in this national dissemination shows the success in diversifying the delivery infrastructure to engage primary care practices, insurance carriers, and other healthcare payers, as a means of reaching patients with more complex disease profiles, and sustaining CDSME Program workshop offerings in communities across the country. The latter is also in line with recent grant announcements, highlighting the need to create innovative pay structures and incentives for scalability and sustainability [In previous studies examining the national roll-out of CDSME Programs, the majority of participants were enrolled in workshops in senior centers/AAA ,52. Howenability .When examining the delivery sites offering CDSME Program workshops, educational institutions, workplaces, and tribal centers were able to enroll more participants, deliver more workshops, and reach more counties in the most rural of settings . Despite less enrollment, delivery, and reach, relative to non-metro adjacent areas, other delivery site types had comparable dissemination efforts in the most rural settings . This signifies the strong role of these organizations/entities in more rural areas, and their established community trust, and their function as places for congregation ,54. BaseRelative to workshops delivered in metro areas, those offered in non-metro non-adjacent areas had larger proportions of families living below the poverty line. This finding highlights socioeconomic vulnerability in these communities, which are therefore, areas that can benefit most from low-cost and/or free resources. While rural areas had smaller workshop sizes in terms of participants enrolled, their completion rates  were higher than those for workshops hosted in metro areas. One explanation of this finding may be based on the community dynamics  within rural communities . AnotherThis study is not without limitations. First, there are many forms of rural designations, which have been created for a variety of reasons . It is aOverall, large gaps in availability of programing were seen in the Midwest and other areas through the U.S., with gaps in programing primarily affecting rural areas. Given the already present gaps in access to care in these regions ,46,60, p


Four schools participating in the experimental implementation phase of the Project P.A.T.H.S.  (Secondary 1 level) were randomly selected and invited to join this research study. After completion of the Tier 1 Program, Secondary 1 students in the participating schools were invited to write a reflective journal in the form of a weekly diary in order to reveal their perceptions and feelings regarding the Tier 1 Program and the related benefits. Results of the qualitative data analyses showed that most of the respondents (a) had positive views on the program, (b) had positive views on the instructors, and (c) stated that they had acquired competencies at societal, familial, interpersonal, and personal levels after joining the program. The present qualitative findings based on students' weekly diaries provide additional support for the effectiveness of the Tier 1 Program of P.A.T.H.S. in Hong Kong.


ARID1A mutations are more frequently identified in these tumors, in comparison to other gynecologic histologies, and loss of ARID1A tumor suppressor function is thought to be an essential component of carcinogenic transformation. Several therapeutic targets in ARID1A mutated cancers are in development, including EZH2 inhibitors. EZH2 facilitates epigenetic methylation to modulate gene expression, and both uterine and ovarian cancers show evidence of EZH2 over expression. EZH2 inhibition in ARID1A mutated tumors acts in a synthetically lethal manner to suppress cell growth and promote apoptosis, revealing a unique new therapeutic opportunity. Several phase 1 and 2 clinical trials of EZH2 inhibitors are ongoing currently and there is considerable promise in translational trials for utilization of this new targeted therapy, both to capitalize on ARID1A loss of function and to increase sensitivity to platinum-based adjuvant chemotherapies. This review will synthesize the molecular carcinogenesis of these malignancies and their unique clinical behavior, as a foundation for an emerging frontier of targeted therapeutics – the synergistic inhibition of EZH2 in ARID1A mutated cancers.Clear cell carcinoma and endometrioid adenocarcinoma are histologic subtypes of ovarian and uterine cancer that demonstrate unique clinical behavior but share common underlying genomic aberrations and oncogenic pathways.  Ovarian and uterine cancer represent gynecologic malignancies with significant morbidity and mortality in the advanced and recurrent settings. Clear cell carcinoma (CCC) and endometrioid adenocarcinoma are histologic subtypes of both ovarian and uterine cancer that demonstrate unique clinical behavior, although emerging literature suggests that they may share underlying genomic aberrations and oncogenic pathways. This review explores the evolving paradigm of targeted therapeutics, as the understanding of the pathogenesis of these cancers becomes paramount to exploring new therapeutic frontiers and achieving improved oncologic outcomes.Endometrial cancer is the most common gynecologic malignancy, with 61,380 estimated new cases and 10,920 estimated deaths in 2017 [Clear cell endometrial carcinoma is rare, accounting for 1–6% of all endometrial cancers. Endometrial CCC is more likely to present with extra-uterine spread compared to low grade endometrioid histologies and is an independent predictor of poor prognosis. The proportion of patients with FIGO stage III-IV disease at the time of diagnosis is 36% with a 5-year disease specific survival of 68% . Given iOvarian cancer, while less common than uterine cancer, is generally diagnosed at a more advanced stage, resulting in compromised long term outcomes, with an estimated 5-year survival of 46%. In 2017 there were an estimated 22, 440 new cases and 14, 080 deaths [Ovarian endometrioid carcinoma accounts for approximately 10% of epithelial ovarian cancers. Clinically, these often present with disease confined to the pelvis, may be bilateral in up to 28% of cases, and are generally low grade and early stage, portending a more favorable prognosis when compared to high grade serous carcinoma . ApproxiOvarian CCC constitutes approximately 5–10% of all ovarian malignancies. Although commonly identified at an early stage, with ovarian confined disease, patients may be diagnosed with advanced stage disease, or suffer recurrence, both of which are difficult to treat given the relative resistance of this histology to standard chemotherapy . When coGiven the rarity of these histologies as well as their unique characteristics, additional therapeutic strategies are urgently needed to improve survival in patients suffering from advanced stage or recurrent endometrioid and clear cell ovarian cancer.ARID1A, an acronym for the gene AT-rich interacting domain-containing protein 1A, encodes a component of the SWI/SNF complex and has high mutation rates across multiple malignancies [ARID1A interaction site with the SWI/SNF complex resulting in protein complex instability [Gene expression relies on the complex interplay of transcription factors, cofactors and chromatin regulators. The role of transcription dysregulation as a mechanism for cancer is well established. With the emergence of genome-wide analyses, the significant role of chromatin remodeling complexes on gene expression levels through modified transcription, replication, repair, recombination and methylation of DNA has been identified . One sucgnancies . Mutatiotability . This cotability .ARID1A mutations typically results in loss of protein function with implications for cell proliferation, differentiation and apoptosis – essential roles of a tumor suppressor gene. Initial efforts into understanding its role in tumorigenesis began approximately a decade ago. The knockout of ARID1A in embryonic stem cells resulted in loss of self-renewal properties and substantially modified cellular differentiation [ARID1A knockout leukemia cell populations, Fas-mediated cell death is inhibited, supporting altered apoptosis [ARID1A expression in ovarian cancer cells harboring deleterious mutations and noted reactivation of protein function. Additional work by Guan et al. in 2014 utilizing xenograft models confirmed that silencing ARID1A expression in nontransformed cells promoted cellular proliferation [ARID1A as a tumor suppressor gene.ntiation . In ARIDpoptosis , 15. In feration , 16. TheARID1A mutations were most pronounced in gynecologic cancers. Within ovarian cancer cohorts, mutation rates of 46–57% were identified in clear cell adenocarcinoma and 30% in endometrioid adenocarcinoma [ARID1A mutations in high-grade serous carcinomas.As the molecular characterization of solid malignancies expanded, it became evident that arcinoma , 18. ThiARID1A, have been recognized within atypical endometriosis and adenocarcinoma, suggesting a significant carcinogenic role [ARID1A is more frequent in endometriosis associated neoplasms, with loss of ARID1A immunohistochemical expression in 61% of endometriosis associated clear cell carcinomas [ARID1A mutations alone are sufficient to induce cancer progression, concurrent mutations in alternate pathways, including the PI3K/AKT pathway are frequent and appear to occur simultaneously to facilitate tumorigenesis [Endometrioid and clear cell ovarian carcinomas are uniquely associated with endometriosis, and have been recently referred to as endometriosis-associated ovarian cancer (EAOC). Between 14 and 42% of endometrioid and 20–36% of clear cell carcinomas are associated with endometriotic lesions or patient reported symptoms of endometriosis . Common nic role . Loss ofrcinomas . While iigenesis , 23.ARID1A mutations are also found frequently among women with endometrial cancers, with mutation frequency of 40% in uterine endometrioid adenocarcinoma [ARID1A is mutated in a high proportion of type I uterine cancers, particularly in the POLE hypermutated, microsatellite unstable (MSI) hypermutated, and copy-number low subgroups. These often occurred concurrently with inactivating PTEN mutations [arcinoma . Low graarcinoma . The Canutations .ARID1A mutation and prognosis has been elusive. In a 2015 meta-analysis of 5651 patients with a variety of tumor types, ARID1A was evaluated via genetic analysis and immunohistochemistry with findings that ARID1A deficient tumors had significantly increased cancer-specific mortality (HR = 2.55) and cancer recurrence (HR = 1.93) when compared to a matched ARID1A positive population [ARID1A mutations were not associated with clinical stage, depth of myometrial invasion, lymph node metastasis, or overall survival [ARID1A expression levels using immunohistochemistry correlated with prognosis and chemoresistance in stage III and IV epithelial ovarian cancers. Women with low ARID1A expression more frequently had incomplete response to chemotherapy (p = 0.026) and were more likely to experience relapse after achieving a complete response (p = 0.07). ARID1A-negative tumors had significantly worse progression free survival than ARID1A-positive tumors [ARID1A immunohistochemical expression and FIGO stage as well as prognosis, with stage I and II patients having 91% 5-year survival with normal ARID1A expression and 74% 5-year survival with negative ARID1A expression [Given the heterogeneity of gynecologic cancers, a consistent relationship between the presence of an pulation . Converssurvival –30. In ae tumors . Additiopression  Fig. 1)ARID1A muARID1A function facilitates tumorigenesis through its chromatin-mediated dysregulation of gene expression and loss of tumor suppressor gene function. As ARID1A plays an integral role in cell-cycle control and DNA damage repair pathways, the loss of ARID1A function with concurrent dysfunction in p53, p21, MLH1, or the PI3K/AKT/mTOR pathway allow malignant progression, and have revealed several potential therapeutic targets in ARID1A mutated cancers. These are detailed in Table Loss of ARID1A mutation, including cyclins, c-myc, and the Polycomb complexes [Functional studies of ovarian cancer cell lines reveal numerous gene targets of the SWI/SNF complex which may be impacted by omplexes , 34. Theomplexes , 36. EZHomplexes –39.EZH2 overexpression is found in 50–85% of ovarian carcinomas, with high expression correlating with high grade, more advanced stage disease and poor survival , 41. EZHEZH2 targets genes which may exhibit modified function in endometrial cancer including: p16, E-cadherin, SFRP1, DKK3, and β-catenin –45. EZH2Given the reversible epigenetic modifications which drive tumorigenesis, EZH2 methyltransferase activity is an ideal target for cancer therapeutics. Several new selective small molecules targeting EZH2 have been developed, including GSK126 , EPZ0056ARID1A and EZH2 through chromatin-mediated gene expression. Loss of ARID1A expression results in imbalanced EZH2 activity, and is hypothesized to drive tumorigenesis , with resultant silencing causing cell proliferation and promotion of anti-apoptotic effects through the PI3K-AKT pathway. In a pivotal study by Bitler et al., it was demonstrated that targeted EZH2 inhibition triggers apoptosis in ARID1A mutated cells and upregulates PIK3IP1 expression, thereby suppressing cell growth [ARID1A mutation and EZH2 targeted inhibition represents a synthetically lethal interaction. This is particularly exciting in that drug-gene synthetic lethality often allows utilization of low concentrations of drugs, minimal toxicity, and limited treatment resistance (Table Homeostasis requires balanced action of is Figs.  and 4. Ml growth . This coARID1A deficient ovarian CCC cells [ARID1A-deficient tumors via EZH2 inhibition [GSK126 was shown to be well tolerated in mouse xenograft models of ovarian CCC . Of numeCC cells . Bitler hibition .In advanced clear cell ovarian carcinoma, approximately half of patients progress while on platinum-based chemotherapy, in comparison to 29% of those with high grade serous histology. Additionally, patients with advanced stage clear cell carcinoma have compromised survival outcomes, with a median overall survival overall of approximately 12 months, significantly less than those with high grade serous histology . This coTranslational research suggests that combination therapies utilizing platinum-based cytotoxic chemotherapy and EZH2 inhibitors, may be particularly potent and synergistic in ARID1A mutated tumors . Within ARID1A mutated gynecologic cancers may represent a novel and exciting treatment paradigm in a subset of patients with limited treatment options. Capitalizing on the concept of synthetic lethality induced in this population using EZH2 inhibitors, as well as the potential synergistic effects with platinum-based chemotherapies, may help translate into improved oncologic outcomes.The potential therapeutic role of EZH2 inhibition in ARID1A mutations in patients with clear cell and endometrioid ovarian and uterine cancer, and the prognostic implications of loss of ARID1A expression, it is natural to explore the impact of EZH2 inhibition in these patient subsets. Given the above, clinical trialists are currently designing a basket trial concept of the EZH2 inhibitor, Tazemetostat, in patients with recurrent, measurable, clear cell and endometrioid ovarian cancer, as well as recurrent endometrioid endometrial cancer. In this study, subjects with recurrent, measurable disease, will be enrolled and treated with single agent Tazemetostat at the recommended phase 2 dose of 800 mg orally twice daily until disease progression or unacceptable toxicity. ARID1A mutation status will be an integrated biomarker, and will be assessed via BAF250a IHC, as well as next generation sequencing, allowing investigators to determine the correlation between ARID1A mutation status and IHC expression. Furthermore, sequencing studies will facilitate assessment of the mutation status of all other SWI/SNF members.Given the frequency of Ultimately, if single agent regimens using EZH2 inhibitors are shown to be effective in this subset of patients, then novel combinatorial approaches utilizing platinum-based chemotherapy, TP53 stabilizers, PI3K/AKT inhibitors, or mTOR inhibitors may be warranted.ARID1A mutations were frequently identified as mutated tumor suppressor genes, in clear cell and endometrioid ovarian cancer as well as low grade endometrioid endometrial cancer. Ultimately, clinicians will look to capitalize on this molecular aberration via novel targeted therapies, such as tazemetostat, as single agents or in combination regimens. As our understanding of the molecular mechanisms underlying malignant transformation evolves, the discovery of novel targeted therapies that lead to meaningful survival gains may become a reality.In an effort to expand the therapeutic portfolio for patients with advanced stage and recurrent ovarian and endometrial cancer, molecular characterization of theses lesions has emerged as a clinical priority. Using both institutional genomic data, and data from the NCI sponsored cancer genome atlas,