Childhood overweight and obesity is a major public health concern. Community-based interventions have the potential to reach caregivers and children. However, the overall health impact of these programs is rarely comprehensively assessed. This study evaluated a physical activity and healthy eating family program  using the RE-AIM framework.Mage = 35.6] and 151 children [Mage = 13]) participated in the evaluation. Each RE-AIM dimension was assessed independently using a mixed-methods approach. Sources of data included archival records, interviews and surveys. Effectiveness outcome variables were assessed at pre- and post-intervention and 6-month follow-up.Ten sites implemented the 5-week program. Thirty-nine staff members and 277 program participants . Participation in HT was not associated with significant changes in physical activity or nutrition behaviour or perceived social support (ps > .05). Knowledge surrounding healthy diets and physical activity increased in children and caregivers (ps < .05). Adoption: Thirty-five percent of sites approached to implement HT expressed interest. The 10 sites selected recruited existing staff members to implement HT. Implementation: Program objectives were met 72.8% of the time and 71 adaptations were made. HT was finance- and time-dependent. Maintenance: Two sites fully implemented HT in the follow-up year and 5 sites incorporated aspects of HT into other programs.comprehensive, arms-length evaluations can systematically highlight areas of success and challenges. Overall HT represents a feasible community-based intervention; however further support is required in order to ensure the program is effective at positively targeting the desired outcomes. As a result of this evaluation, modifications are currently being implemented to HT.Working alongside organizations that develop community programs to conduct The online version of this article (10.1186/s12966-017-0638-0) contains supplementary material, which is available to authorized users. Childhood overweight and obesity are related to numerous proximal and distal health problems including heart disease, high blood pressure and diabetes –4, with Several social and environmental factors have been associated with an increased risk of childhood obesity including being of aboriginal or multi-ethnic descent , low-socThe RE-AIM framework provides a systematic method through which to assess the overall impact of an intervention taking into consideration both internal and external validity , 18. TheThe purpose of the current study was to use the RE-AIM framework to comprehensively evaluate the first iteration of Healthy Together, an education program designed for children and their caregivers, developed by a community organization.http://healthy-together.ca). The first iteration of HT comprised of 3 age-based modules: Happy Healthy Beginnings , Fun Healthy Habits , My Life, My World, My Choice . Each module consisted of five weekly sessions lasting approximately 2.5 hours, incorporating children and caregivers. Each session was designed to provide attendees with information, skills and experiences to support families in making healthy food and activity choices, and included 15–30 minutes of play-based physical activity, 30–60 minutes of group discussion and 45–60 minutes of cooking and eating together. Caregivers and children were provided with take home sheets after each session to complement discussions. Implementation sites were encouraged to adapt the discussions and handout material based on the needs of their population. Ten organizations from five regions across Canada implemented HT over 2 years (five sites per year) and took part in the program evaluation between October 2013 and June 2015.Healthy Together (HT) is a family centered education program developed by The Bridge Youth and Family Services (hereon in referred to as ‘The Bridge’) to promote healthy weights in children from vulnerable populations  who registered for HT were eligible to take part in the evaluation of program effectiveness. Children aged 0–6 were not asked to complete any evaluation documentation. The community site director, HT program coordinator, and facilitators were all invited to participate in the evaluation. Facilitators conducted each of the HT sessions; the HT program coordinator oversaw all logistical aspects of running the program and the community director oversaw all financial and community programing. Each site had a trained onsite evaluator who obtained written consent from all participants and assent from caregivers of children 7–16 years of age.Each RE-AIM dimension was assessed independently using a mixed-methods approach to provide an insightful evaluation enabling greater validity of inferences . A mixedEthical approval for this study was granted by the University of British Columbia research ethics board and the Public Health Agency of Canada ethics committee. Prior to implementing HT all facilitators received 2-days of program training from The Bridge. Training consisted of a) project orientation , b) education on group facilitation, c) review of the program content and the facilitator manual and d) planning and role playing one program session in groups of three. Facilitators were also educated on dealing with shame and trauma and general considerations when working with children-in-care. Simultaneously, the evaluation team provided 2-day training for staff members of the implementation sites who would be acting as onsite evaluators. Onsite evaluators were responsible for collecting all survey data from participants and conducting observations.Directors completed surveys at baseline (n = 9) and 1-year follow-up (n = 5), while coordinators completed surveys at baseline (n = 8), post intervention (n = 6) and at 1-year follow-up (n = 4). Each survey took approximately 20-minutes to complete  and after each program session, which took approximately 10-minutes to complete.Staff surveys were used to gather demographic information and information pertaining to Reach, Adoption and Maintenance using a variety of open-ended, categorical and likert-type questions. n = 12) to assess readability and receptiveness. The caregiver survey assessed knowledge, efficacy beliefs and behaviour in relation to health eating, physical activity and screen time. Perceived social support provided to children and caregivers’ reports of child health related quality of life was also assessed. Cronbach’s alpha for composite measures within the caregiver survey ranged from .57 to .84  and post intervention (n = 10). Baseline interviews including questions pertaining to HT reach and staff level adoption, while post interviews included questions pertaining to the consequences of running the HT (effectiveness). Two in-depth group interviews were conducted with facilitators post intervention (n = 19). One group interview was conducted in year 1 and the second in year 2. Questions assessed the dimensions of program effectiveness and implementation and lasted 1-h.Directors completed individual interviews at baseline , presented and ran each activity, and whether facilitators adapted or added any material to the session using a ‘Yes’ or ‘No’ response scale.Internal program documents describing the process of community site involvement in HT was obtained from the Bridge to assess setting level adoption as well as financial information pertaining to the implementation of the program. Summary forms completed by each community site were obtained to assess program reach. Archival records included census data from Statistics Canada and school statistics. To gain an understanding of program maintenance, emails were sent to directors and coordinators of sites that did not return their 1-year follow-up survey.r for Wilcoxon sign-test . Descriptive statistics were calculated for all study variables. Data was screened for outliers using box-plots and assumptions of normality were assessed using the Shapiro-Wilk test of normality using difference scores. Partial missing data  were replaced using a series mean . If diff, 2016. DTo provide a further insights into processes that may have influenced quantitative findings, interviews and qualitative survey data were deductively analyzed using the RE-AIM framework . All intTwo of the 10-implementation sites reported specific inclusion criteria, beyond the age requirements specified by the modules  existing programs offered at the site, b) community partners and c) local schools and school boards. Three sites created HT information pamphlets and offered information sessions with incentives to encourage attendance. Four sites worked with local schools to recruit and offered HT as part of the school curriculum or during school time. For module 1 and 2 the majority of participants were recruited from other programs being offered at the sites.The most commonly cited barrier to recruitment was a lack of connection to the population of interest, particularly the 13–18 year olds and a desire from this age group to participate independently of caregivers. As such, five sites ran module 3 without caregivers. A lack of trust regarding new programs with also highlighted as a barrier to recruitment. Directors explained that families with children of Aboriginal descent need extensive information about a program prior to participation to understand the motivation of the program and potential consequences of participation. Two sites stated that transportation was an issue for recruitment and that the cost of providing transportation for participants was limiting.The most commonly cited enabler to recruitment was the presence of pre-existing programs within the site from which to invite individuals to participate. In addition, working closely with community partners helped to build the trust of participants and to recruit populations that the sites did not previously serve.ps > .05). There was a significant difference in education level (χ2(5) = 12.12, p = .03) such that caregivers who completed the post survey had a higher level of education than those that did not. There were no significant differences in outcome variables pre-intervention between those that completed the post survey and those that did not (ps > .05).A total of 126 caregivers completed the baseline survey  = 4.13, p = .04. Females were 3.56 times more likely to complete the 6-month follow up than males. There were no significant differences in outcome variables pre-intervention between those that completed the 6-month follow-up survey and those that did not (ps > .05).At 6-month follow-up there was no difference in age, ethnicity of adult or child, marital status or level of education. There was a significant difference in sex between those that completed the survey and those that did not, χMage = 13(±3); 57% female). Of these, 80 completed the post survey (47% attrition) and 46 completed 6-month follow-up (70% attrition). No differences in sex, age or any outcome variables were found between those that completed the post survey and those that did not, or those that completed the 6-month follow-up survey and those that did not (ps > .05).A total of 151 children completed the baseline survey   Table .Table 2Ct(64) = −2.37, p = .02, d = .32. This increase was maintained 6-month follow-up, t(31) = −2.25, p = .03, d = .47. Individual site analyses revealed that caregivers from site B showed increased confidence to engage in healthy eating practices immediately after HT, t(5) = 3.16, p = 0.25, d = .27. This increase was not maintained at 6-month follow-up, though only 2 individuals completed both time-points. There was a significant increase in caregiver’s confidence to cook immediately following HT, t(63) = −3.40, p = .001, d = .43, this increase was maintained at 6-month follow-up, t(31) = −2.78, p = .01, d = .49. Individual analyses showed that caregivers at site C showed increased confidence to cook both immediately after HT and at 6-month follow-up . Immediately after HT there was a significant increase in caregiver’s confidence to involve their child in cooking, t(61) = −2.02, p = .05, d = .32. No change in confidence to engage children in cooking was found between pre-HT and 6-month follow-up or amongst sites individually (p = .50). There were no changes in confidence to engage in physical activity from pre- to post-program or from pre to 6-month follow-up (ps > .05). However, individual site analyses revealed a significant increase in confidence to engage in physical activity for sites B and J from pre-post HT, t(5) = −2.93, p = .03, d = .44 and t(11) = −3.541, p = .01, d = 1.04 respectively. Site J appeared to marginally maintain this increase at 6-month follow-up, t(11) = −2.115, p = .06, d = .55.Immediately following HT, caregivers were more confident that they could engage in healthy eating practices, ps > .05). There was, a significant decrease in the availability of unhealthy food immediately after the program (t(54) = 2.37, p = .02, d = .31) and at 6-month follow-up (t(27) = 2.79, p = .01, d = .53) compared to pre-program. Analyses of individual sites revealed a significant increase in healthy shopping practices pre HTand at 6-month follow-up for sites D and I . Site A showed a decrease in the availability of unhealthy food immediately post program, t(7) = 2.78, p = .03, d = .67. Maintenance statistics were unavailable due to the limited sample size. While Site J showed a decrease in the availability of unhealthy food from before the program to 6-month follow-up, t(8) = 2.89, p = .02, d = .57. Caregivers reported no changes in their children’s fruit and vegetable intake, their personal fruit and vegetable intake or their personal breakfast consumption after HT (ps > .05). No changes in the frequency of consuming an evening meal with their child were reported following HT (ps > .05). No changes were found in caregiver’s reports of children’s physical activity behaviour or screen time hours outside of school hours or in caregiver’s personal physical activity post HT or at 6-month follow-up compared to pre-intervention (ps > .05). Individual analyses revealed that caregivers in site A reported a decrease in children’s physical activity from before (Mdn = 7) compared to after the program (Mdn = 4), Z = −2.06, p = .04, r = .73.Caregivers self-reported shopping practices did not change post HT or at 6-month follow-up compared to pre HT, nor did the availability of healthy food in the house (ps > .05). However, site A showed a significant decrease in social support for physical activity immediately following the program, t(6) = 2.68, p = .04, d = .78. Insufficient sample size eluded examination of social support for physical activity at 6-month follow-up for site A.There were no changes in parental social support provided for physical activity or healthy eating immediately after HT or at 6-month follow-up compared to baseline (ps > .05). No differences in health related quality of life were found within sites.No changes were reported in parental reports of children’s’s total health related quality of life after HT or at 6-month follow-up compared to pre-intervention (ps > .05). Knowledge of the recommended number of minutes of daily physical activity increased from pre- to post-program, χ2(1) = 4.65, p = .03, OR = .21. This increase was not seen between pre-program and 6-month follow-up (p = .18). Knowledge of screen time recommendations was not changed  (Table There were no short (post-program) or long-term (6-month) changes in children’s knowledge of the daily fruit and vegetable requirements or sugary drinks (ps > .05). Individual site analyses revealed that children at site B were more confident to engage in physical activity at 6-month after HT compared to before, t(2) = −5.05, p = .04, d = 2.89. Children were 0.33 times more confident that they could consume fruits and vegetables immediately after HT (Mdn = 4.0) compared to before HT (Mdn = 4.0), z = 2.70, p = .01. Individual analyses revealed that children specifically from site C were 0.85 times more confident that they could consume fruits and vegetables immediately after HT (Mdn = 2.75) compared to before HT (Mdn = 3.5), z = −2.55, p = .01. No changes were reported in confidence to eat breakfast, choose healthy drinks or cook from pre- to post-HT or pre-HT to 6-month follow-up for the group as a whole or by site.Immediately after HT and at 6-month follow-up children reported no changes in their confidence to engage in physical activity compared to baseline (ps > .05). Individually, children from site A showed an increase in the consumption of unhealthy food from before to after HT, t(8) = −2.32, p = .49, though the effect size was small (d = .12). Children at site I showed a decrease in their consumption of unhealthy food from pre to post program, t(3) = 4.38, p = .02, d = 3.31. Children in Site H showed a reduction in unhealthy food consumption from before to 6-months after the program t(7) = 2.755, p = .03, d = 1.11 and a decrease in the consumption of pop intake from pre (Mdn = 3.5) to immediately after HT . Children did not show any changes in screen time or physical activity behaviour following HT as a whole or when assessed as individual sites (ps > .05).No changes were reported in children’s self-reported fruit and vegetable consumption, consumption of unhealthy foods or pop intake, frequency of breakfast consumption or frequency of assisting with cooking immediately after HT or at 6-month follow-up compared to baseline for the whole group (ps > .05). Children from site A reported an increase in perceived social support for both physical activity and healthy eating immediately after the program, t(12) = −2.28, p = .041, d = .35 and t(12) = −2.28, p = .04, d = .30 respectively. The sample size did not permit analyses of site A at 6-month follow-up.No changes in perceived social support for physical activity or healthy eating were reported from pre- to post-program or from pre-program to 6-month follow-up (ps > .05).Total health related quality of life did not change between pre- and post-program or pre-program and 6-month follow-up for the group or as individual sites . Of those sites that could commit to implementing the program, 10 were selected by The Bridge to include a representation of diverse community settings for program implementation. This included a) children in care, b) children with special needs, c) families of Aboriginal, Inuit, and/or Metis descent, d) immigrants and refugees, e) families living in rural/remote, areas, f) families living in northern communities, and g) families with low income.Data on staff recruitment was available from 9 of the 10 sites  or area of interest.. The majority of facilitators reported that they had been involved in implementing nutrition and/or healthy eating programs in the past, while only two facilitators reported having implemented any physical activity related programs in the past. Staff demographics are shown in Additional file Three of the 10 site directors felt that their facilitators were typical of the staff working at their site. One site felt that their facilitators were those that enjoyed group-based work, which was not common within their child welfare agency. Healthy Together facilitators had more experience working with children and facilitating groups than the other organization staff members and had more interest in general health. One director commented; “The staff who are involved are more curious and positive and adventurous -  all interested participants have a stake in being healthy”On average, program objectives were met 72.8% of the time across all modules . Eight adaptations related to changing the order of the session activities. Three adaptations involved omitted activities, specifically site E did not conduct the physical activity during one session and site B did not cover the topic of family traditions due to fears of emotional distress to participants. Ten adaptions involved added components to HT, for example demonstrations of the sugar in drinks using sugar cubes by site C and bringing in a yoga instructor to teach the children basic yoga poses at site E. Two adaptations were made that were unspecified.. Due to the extenstive content particiapants were reportedly overwhelmed with the amount of information; “I think sometimes though by the end of the um, material they were a little overloaded with just the amount of content that they— the information they were given in one session”. Faciliators felt that the literacy level of the content and handouts, compared to the literacy levels of their participants was a barrier to providing some of the recommended handouts; “I think for me um, just ethically when I'm presenting information I'm always conscious of literacy levels. So at some point I did struggle with how we were presenting information, and just knowing some of the barriers that our families faced, following through on homework and stuff like that? I was a little hesitant with some of the material”. In addition, some cultural and social factors arose within the groups that affected how the facilitator implemented HT. These included; religious-based food restrictions impacting usability of recipes, the family traditions program content for children in care and concerns regarding the use of the word ‘family’ and the economic struggles faced by some of the families and facilitators feeling uncomfortable discussing purchasing certain types of food. A number of quotes highlight these concerns; "We have some families that, like, for like, religious reasons they don't eat certain foods", and "We were very cognitive that we had children in care, and some of their triggers. We cut out parts of the program based on that". In addition some facilitators commented, "For me I struggled with the economics of, and the financial situations of many of our families. They might want to eat healthier but might not be able to afford the healthy fresh vegetables, and fruits, and that kind of thing. So not that they don't want to, but just can’t with what they’re given".All facilitators highlighted time constraints as the hardest element to overcome when implementing HT. Facilitators felt that the content of the program was too extensive for the 2-hour time period in which implementation was meant to occur. This restricted the facilitators from delivering HT in its entirety or developing appropriate adaptations. One facilitator commented; “Time. It was really hard to fit in everything that you were expected to fit in, in each module in the time that was allotted”Facilitators felt the HT manual was easy to follow and contained a lot of good information; "Very well organized and prepared, easy to just take the book and be able to do the program with the family and the kids". In addition, many facilitators felt that they could adapt the program to their communities needs such as including local fruits and vegetables to their region or adapting recipes to accommodate religious needs. Facilitators with more experience reported a greater ease in modifying the content then those with less experience.The original manual suggested that facilitators allocated 6 h per week to prepare for and deliver HT, while program assistants should allocate 4 h. On average facilitators spent 6.41 h per week prepping and delivering HT, while program assistants spent 4.28 h per week on average prepping for HT. Facilitators reported that preparation took longer for HT as they had never delivered the program before and because they sought out alternative resources to those provided within the manual.As part of the project each site was allocated $36,000 to implement the program. This money was provided to cover staff wages and program supplies, including physical activity materials and cooking ingredients. Only two sites provided information regarding the cost of running HT. One site reported that the program cost the full $36,000 to implement with the majority of money spent on staff wages . Additional funds were spent on purchasing resources ($3302) and miscellaneous costs including insurance, computers, promotion, rent and transportation ($5958). The second site reported the program costing $14,059 to implement. Costs included staff wages  and resources ($2141). Directors noted that HT cost a significant amount of money to implement given the cost of cooking ingredients and physical activity resources. In addition, some sites had to rent spaces in which to conduct the cooking component of the program. The majority of sites felt that this program was not sustainable without additional funding.Two implementation sites completed HT in full in the year following initial program implementation  reached a small portion of eligible families. Although all sites stated serving vulnerable populations as part of their organization mission only two sites expressed definitive eligibility criteria beyond the HT age requirements. This was due to low response rates from the target populations, leading to the expansion of recruitment to all families within the sites catchment areas. Broadening the target population limits inferences regarding the reach and impact of HT on the vulnerable populations for which it was developed. While recruiting children for community programs is challenging  it is reHT increased caregiver’s confidence to engage in healthy eating practices and to cook. Furthermore, caregivers reported a reduction in the availability of unhealthy food available in the house immediately after HT and at 6-month follow-up, replicating the finding of Robertson and colleagues  in theirHT did not impact self or proxy reports of individual behaviour, perceived social support for physical activity and healthy nutrition or the broader outcome of quality of life. One explanation for the lack of changes to behaviour, social support, and quality of life in general is the atheoretical nature of the program. A recent literature review demonstrated that theory-based interventions are more successful than atheoretical approaches in changing adolescent’s physical activity behaviour . Similartime as the biggest barrier to program implementation. Due to limited time, and the large amount of content contained within HT, facilitators felt unable to implement all components. Observations from site A revealed that the percentage to which session objectives were met was low in a number of sessions due to the facilitators dropping aspects of the program due to time, often the physical activity section. Interestingly, in site A caregivers reported a decrease in children’s physical activity behaviour from before to after HT as well as a decrease in the amount of social support they provided. The degree to which nutrition-related components, such as cooking, were completed was 20% higher than physical activity related components. Given that implementation fidelity can influence program effectiveness [In this iteration of HT (version 1), fidelity was moderate with facilitators stating tiveness , higher tiveness , 39. It tiveness , 31, 35.tiveness  to a 4-wDue to the perceived high cost of implementing HT many sites incorporated specific components of the program within other existing programs in the follow-up year. Community sites are tightly bound by financial constraints and determining methods to reduce costs is essential if a program is to be sustained. Sites that worked in close collaboration with community partners, such as schools, were able to reduce costs by utilizing school facilities. Furthermore, collaboration with schools assisted in the recruitment of a number of participants. The development of community partnerships has been highlighted as essential in ensuring the success of a program  and as sAs is common when conducting community-based interventions , 41, lacThis is the first evaluation of the first iteration of HT, a family-education program designed and implemented by a community organization to address healthy weights in vulnerable children. Given the growing evidence in support of caregiver-inclusive interventions to address pediatric obesity  HT has tOverall Healthy Together represents a feasible community-based healthy weights initiative that can be successfully implemented in a variety of populations across Canada. However, further refinement of the program is required in order to ensure the program is effective at positively impacting physical activity and healthy eating cognitions and behaviour. In is recommended that community organizations, such as the Bridge, work closely with behaviour change experts to ensure that community designed interventions target key theoretical constructs found to promote behaviour change. In addition, program implementation and dissemination experts should be consulted to increase potential of the program to positively impact public health. Simultaneously the continued evaluation from arms-length evaluators that examine changes in outcomes of interest through both qualitative and quantitative means is warranted.Additional file 1:Overview of measures used in the Healthy Together evaluation, data collected and timeline. Description of what measures were taken and when during the Health Together evaluation. (DOCX 59 kb)Additional file 2:Description of Child Survey. Explanation of the items used within the child and youth surveys and associated reliability statistics. (DOCX 18 kb)Additional file 3:Description of Caregiver Survey. Explanation of the items used within the caregivers surveys and associated reliability statistics. (DOCX 19 kb)Additional file 4:Individual site analyses and details of which sites had sufficient data to perform analyses (caregiver and child). (DOCX 25 kb)Additional file 5:Statistics related to the Reach of the Healthy Together program. Description of data used examine program reach. (DOCX 14 kb)Additional file 6:Demographic characteristics of the caregivers at baseline based on site. (DOCX 21 kb)Additional file 7:Staff adoption of Healthy Together. Description of internal and external recruitment for Healthy Together across sites. (DOCX 54 kb)Additional file 8:Healthy Together staff demographics. (DOCX 47 kb)Additional file 9:Facilitator demographics by site. (DOCX 15 kb)Additional file 10:Evaluator’s Observations Module 1 (Data from 8 implementation sites). Description of specific module and session outcomes for Module 1 based on observations. (DOCX 16 kb)Additional file 11:Evaluator’s Observations Module 2 (Data from 10 implementation sites). Description of specific module and session outcomes for Module 2 based on observations. (DOCX 16 kb)Additional file 12:Evaluator’s Observations Module 3 (Data from 10 implementation sites). Description of specific module and session outcomes for Module 3 based on observations. (DOCX 16 kb)Additional file 13:Setting level maintenance of Healthy Together in the past year. (DOCX 15 kb)


Introduction: Evaluating patient satisfaction with self-care program can increase the likelihood of complying with treatment. There is no valid and reliable tool to be used in measuring Iranian patient’s satisfaction with self-care program. So, this study intends to develop the patient satisfaction questionnaire in the context of cardiac rehabilitation and test its validity and reliability in Iranian patients.Methods: A cross-sectional study was conducted to develop and validate the patient satisfaction with self-care program questionnaire using structural modeling. A total of 155 cardiovascular patients referring to cardiovascular rehabilitation center in Isfahan were participated in this study. Construct and criterion validity, and test-retest reliability were used to validate the scale.Results: After reviewing literature and receiving expert’ comments for items pooling as well as conducting exploratory factor analysis, 10 statements in the model remained which are loaded on 2 factors. These 2 subscales explained about 63 percent of variance of all constructs. The Cronbach’s alpha coefficient ranged between 0.87 and 0.89 for the whole questionnaires and its subscales. Besides, scale had excellent stability (intraclass correlation = 0.86). Criterion validity analyzed through correlational analyses revealed significant relationships between the current scale and Patient Satisfaction Questionnaire Short Form (PSQ11). CFA revealed an acceptable overall fit for two-factor model.Conclusion: The scale integrated 10 items in two dimension including patient satisfaction with rehabilitation program and patient satisfaction with personnel of rehabilitation team. In total, most of the psychometric properties of the 10-item patient satisfaction with self-care program scale achieved the standard level and were sufficient to recommend for cardiac rehabilitation settings. Patient satisfaction with personnel and program content is accompanied with important outcomes, such as improved quality of health care services5 superior compliance and better prognosis.6It seems compliance with treatment can be mostly resulted from patient’ satisfaction of self-care program. In fact, lack of satisfaction has known as one barriers to practice self-care program.7 as well as Seattle Angina Questionnaire.8 In Iran, some studies have been conducted regarding self-care models in cardiovascular disease10 but, there is no tool for measuring satisfaction with self-care program in Iran. Understanding and determining the concept of satisfaction based on social differences is essential for promoting positive health outcomes in Iranian cardiovascular patients. Furthermore, no study has yet addressed developing the tool of Patient satisfaction with self-care program in Iranian context, particularly in cardiac rehabilitation centers. So there is an important gap in this regard. Due to context of Iran, it is essential to develop a psychometrically valid and reliable questionnaire to measure satisfaction with self-care programs in the field of cardiac rehabilitation.Several tools have been developed to measure satisfaction with self-care program around the world, including Cardiac Rehabilitation Preference FormThis study is a cross-sectional design using structural model aimed to construct and validate satisfaction with self-care program scale.The study population consisted of patients who were referring to cardiovascular research center in Isfahan, in this study 155 patients with coronary heart disease, who were referring to cardiovascular research center in Isfahan, were randomly recruited (from October 2016 to March 2017)Participants were eligible if they were attended in self-care education program during three month ago and willing to participate in study.The inclusion criteria include having attended in self-care education program, aged 18 years or above and having the ability and willingness of patients to participateAfter reviewing the different literature regarding satisfaction with self-care program in cardiac rehabilitation setting .An exploratory factor analysis  was used to prove the construct validity.df is lower than 2, RMSEA and SRMR lower than 0.08, CFI, GFI and AGFI higher than 0.90.12It was assumed that the model can be considered satisfactory when the χ²/13 Data were analyzed using SPSS Software. And structural equation analysis with latent variables (SEM) using AMOS module 20.0 was employed.In our study internal consistency was assessed by Cronbach’s alpha (should be >0.07) for 150 patients. We employed the test-retest method to evaluate the repeatability of the questionnaire. To do so, 25 patients completed this scales twice . To interpret the achieved coefficients values above 0.7 were considered as excellent reliability.In this study, out of all participants, 112 (72.3%) were male and 43 (27.7%) were female. The mean age of them was 57.9 ± 9.40. 153 (98.7%) were married. 132(83.0%) were diploma and lower than diploma.The KMO and Bartlett’s test equaled 0.85 and 0.001 respectively. As mentioned above, the final version of the questionnaire consisted of 10 statements which be placed in two dimensions including patient satisfaction with rehabilitation program (6 items) and patient satisfaction with personnel of rehabilitation team( 4 items) according to exploratory factor analysis. These two subscales explained 68.6% of the variance in the data that can be considered reasonable for a questionnaire .P < 0.05; RMSEA = 0.07 (90% CI: 0.05 - 0.1), P close to fit <0.05; GFI = 0.99, AGFI = 0.92 and CFI = 0.96)  .Examination of Cronbach’s alpha highlighted good internal consistency for the whole scale (α = 0.87) and for each factor: “Patient satisfaction with rehabilitation program” (α = 0.89) and ”Patient satisfaction with personnel of rehabilitation” (α = 0.87). Moreover, conducting test-retest method to evaluate the repeatability of the questionnaire revealed good results .Concurrent criterion validity was computed by correlating the total and subscale score of questionnaire in current study with scores of Patient Satisfaction Questionnaire Short Form (PSQ11). According to the results, patient satisfaction , patient satisfaction with rehabilitation program and patient satisfaction with personnel of rehabilitation team were significantly positive and moderate correlation with PSQ .As the results showed, after initial reviewing and content analysis, the scale integrated 10 items in two dimension which can account for 68.5% of variance in total questionnaire.Confirmatory factor analysis of questionnaire revealed satisfactory fitness. Regarding reliability, the result shows good internal consistency in two subscales and total score. Besides, test-retest correlation coefficient was reported satisfactory indicating good repeatability.14 in other studies prospective cohort research design15 or interventional design16 were employed. In all of these studies, satisfaction with rehabilitation program and satisfaction with personnel of rehabilitation team are among the important factors of cardiac rehabilitation program.In developing tools such as satisfaction with the cardiac rehabilitation program, some studies have used cross-sectional study as current study17 compared with our questionnaire, does not measure satisfaction with Personnel of rehabilitation team, but newer version of this scale18 measure a broader range of aspects, including satisfaction with care program, with good psychometric properties.Outpatient satisfaction in rehabilitation scale19 So it is not clear that this questionnaire is enough much effective in cardiac rehabilitation settings.Seattle Angina Questionnaire, as comparable questionnaire with developed one in current study, does not measure some dimensions such as other aspects of satisfaction with personnel of rehabilitation team. Studies also showed no significant difference in patient satisfaction attending in cardiac rehabilitation program.7 This instrument was developed to measure the extent to which client preferences for specific CR program features were met in both the importance and the experience measure, so this scale, in this regard differs from our questionnaire.Compared with other questionnaires regarding cardiac rehabilitation, we can refer to Cardiac Rehabilitation Preference Form.Overall, by developing one 10-item tool comprising two subscales, this study showed that questionnaire of patient satisfaction with self-care program has satisfactory psychometric properties in sample of Iranian patients referring to cardiac rehabilitation center.Authors declare no conflict of interest in this study.This study was approved by Ethics Committee of the Isfahan University of Medical Sciences.


Background: In face of the looming shortage of general practitioners, primary healthcare providers and post-graduate training in general practice are increasingly becoming part of the political agenda in Germany. In 2009 the program “Verbundweiterbildungplus Baden-Württemberg” (VWBplus BW) was developed by the Competence Center for General Practice in Baden-Wuerttemberg to ensure primary healthcare in the future by enhancing the attractiveness of general medicine. This paper describes the experiences that have been gathered in developing a post-graduate training-program for physicians undergoing specialist training in general practice.Project description: The Competence Center for General Practice in Baden-Wuerttemberg supports the organization of regional networks dedicated to post-graduate medical education. First core element of the VWBplus BW program is a special seminar series for physicians pursuing post-graduate training. This seminar program is aligned with the German competency-based curriculum in general medicine and is meant to promote medical expertise and other related competencies, such as business and medical practice management and communication skills. Mentoring and advising the physicians regarding professional and personal planning form the second core element. The third core element is seen in the train-the-trainer seminars that address the competencies of the trainers. In order to focus the program’s content closely on the needs of the target groups, scientifically based evaluations and research are carried out.Results: Since starting in 2009, 685 physicians have entered the program and 141 have passed the examination to become medical specialists (as of December 2016). In total, 31 networks, 60 hospitals and 211 general practices have participated. The seminar sessions have been rated on average with 1.43 on a six-point Likert scale by the physician trainees . Alongside the medical training, these physicians viewed the exchange of information and experiences with other physicians as very positive and important. In 185 seminars lasting 90 minutes each, the seminar program has presently covered 250 out of 320 units in the competency-based curriculum for general medicine. A total of 281 trainers have been trained in 13 train-the-trainer courses and have rated this course on average with 1.36 on a six-point Likert scale. Above all, the trainers emphasized the exchange of information and experiences with other trainers as very positive. In 2013 the DEGAM concept for its Verbundweiterbildungplus program was developed based on that of the VWBplus BW. Since 2008 over 40 articles on the topic of post-graduate medical education have been published.Conclusion: The steadily increasing number of participants over the years demonstrates that the VWBplus BW is relevant for recent medical graduates and contributes to the attractiveness of general practice. The consistently excellent evaluations of the training program and the train-the-trainer course affirm the focus on the needs of the target groups. The post-graduate VWBplus BW program advances structured, competency-based and quality-oriented specialist training and fosters professional sharing between physicians – something that could also be relevant for other fields. The increasing numbers of participating physicians and specialists in general practice in Baden-Württemberg lead to the conclusion that the VWBplus BW program positively influences the number of general practitioners. While searching for the root causes of this shortage of general practitioners, structural weaknesses in post-graduate education, such as the absence of a curriculum for physicians undergoing post-graduate training, were found and criticized. The unattractiveness of general practice in comparison to other medical specialties was also identified as a reason . An. Anshort10.9% n=137 [3]. D1% n=1089 to 10.9%quality of post-graduate medical education in general practice is under particular scrutiny: the German College of General Practitioners and Family Physicians (DEGAM) commissioned a report in 2008. International experts in medical post-graduate study asserted in 2009 that specialty training programs in general practice in Germany meet none of the European criteria for best practice , is now known as Verbundweiterbildungplus Baden-Württemberg (VWBplus BW) and serves as a model for all of Germany.From 2005 to 2007, a forum for post-graduate education existed at the Department of General Practice and Health Services Research of the Heidelberg University Hospital. Its goal was to support physicians undergoing specialty training and young medical specialists in general practice by offering seminars in parallel to professional practice, for instance on communication skills . In 2007lemented . The pilplus BW is a curriculum-based post-graduate program for physicians seeking post-licensure qualification in Baden-Württemberg as specialists in general practice. These physicians register voluntarily for the program. As participants they profit from key aspects of the VWBplus BW program (see below) in addition to the medical specialty training received at a hospital, medical practice or other educational institution.VWBplus BW program is formed by the cooperative agreements between the BW Competence Center  and the hospitals or medical practices as employers of the physician trainees. These agreements contain legal provisions regarding program financing, compensation, the number of days allotted for attending the special seminars, and the duties of the BW Competence Center . O. Oplus BThe topics for the day-long seminars are based on the competency-based curriculum in general medicine. This competency-based curriculum was designed and developed in a collaborative process between the DEGAM, JADE (a network of trainees and young GPs in Germany) and the BW Competence Center. It covers – as a supplement to the logbooks required by the medical associations – the basic skills and competencies defined for general practitioners . These aLandtage are held once or twice a year. During these locally-held events representatives of rural regions – doctors, mayors, district administrators, etc. – have the opportunity to come into contact with physicians still undergoing specialty training. The main objectives are to communicate expectations, dispel preconceptions on both sides, and become familiar with the life of a country doctor  . A. Aplus Bn detail . Other pnetwork gatherings are intended to encourage cross-sector exchange between trainers from hospitals and trainers from medical practices. To ensure structural integrity and quality assurance, once each year all of the people involved in the post-graduate training networks, trainers from hospitals and practices, and the physician trainees are invited to come and hear about new developments regarding VWBplus BW, and meet with each other to discuss these changes and other topics, such as the role of the trainers in respect to Gen X and the Millennials or the practical implementation of good teaching and training practices as part of daily medical routines.The plus BW to promote quality assurance are embodied in the regular evaluations of and scientific research on all the program’s components. These activities make it possible to constantly adjust the program’s focus to match the desires and needs of the participants, with regard for the competency-based general practice curriculum and the latest scientific knowledge. To accomplish this, regularly scheduled qualitative and quantitative surveys are conducted among the physician trainees and the trainers depending on the research focus.Further strategies of the VWBplus BW program; the growth in participants over time is shown in figure 2 plus BW through the end of December 2016. At the end of 2016, 141 physician trainees had successfully passed the exam to become medical specialists for General Practice (Facharzt). The number of network members with active cooperative agreements is 31, the number of hospitals 60 and medical practices 211. The cooperative agreements have provisions for increasing the physician trainee salaries during the out-patient training phase so that they match those of the municipal wage agreements for physicians. The agreements also include a contractual commitment to allot 10 days per year instead of three for parallel training to enable regular attendance of the VWBplus BW’s special seminars and other professional conferences and congresses.Since its begin in 2009, a total of 685 physician trainees have entered the VWBplus BW received the award for being an outstanding location (Ausgezeichneter Ort 2010) by “Germany, the Land of Ideas” – an initiative to promote and encourage the realization of outstanding projects in Germany and around the world. After a four-year set-up phase, the VWBplus BW received formal expert attestation in 2012 confirming that it is the only post-graduate study program in general practice in Germany that meets the European best-practice criteria . In addition, the number of subsidized training positions in general practice and the number of subsidized physician trainees (some part-time) have doubled with the Baden-Württemberg Association of Statutory Health Insurance Physicians (Kassenärztlichen Vereinigung Baden-Württemberg) between 2010  and 2015  [http://www.kbv.de/html/ (letzter Zugriff 07.04.2017)]. A study shows that many of the physician trainees in the VWBplus BW program remain in Baden-Württemberg [plus BW program and with now over 141 specialist physicians, it can be assumed that the VWBplus BW program clearly contributes to this positive effect.In Baden-Württemberg between 2011 and 2015, approximately 680 physician trainees have successfully sat for and passed the exam for specialization in general practice, with the number of administered exams increasing from 108 in 2011 to 192 in 2015 [ttemberg [. With aplus BW. These programs must be based on up-to-date scientific knowledge. Requirements for such programs have been jointly articulated with DEGAM [plus; these indicators are based on international standards [In order to continue this upward trend in post-graduate medical education, it will be necessary to find permanent funding for university-based post-licensure programs like the VWBth DEGAM . In additandards . We hopeplus BW employees which were not recorded within the scope of a scientific study. The program is located in Baden-Württemberg. Despite high numbers of participants, the results can be applied only to a limited extent to Germany or other countries. The scientific research conducted on VWBplus BW program is made difficult in that only rarely is data available for comparison with other (German) cohorts.One of this project description’s strengths is that it is an overview of a successful post-graduate medical program. Some of the discoveries reported as results refer to the experiences of physician trainees and VWBplus BW program is relevant for new medical graduates and contributes to the attractiveness of general practice. The overall very positive evaluation results for the accompanying seminar series and the train-the-trainer course demonstrate that the content focuses on the needs of the target groups. Post-graduate programs such as the VWBplus BW promote structured, competency-based and quality-oriented training, something that may also have relevance for other fields. The current developments in Baden-Württemberg regarding subsidized physician trainees and specialists in general practice lead to the conclusion that the VWBplus BW program has positively influenced the number of general practitioners.The growing numbers of participants over the years show that the concept of the VWBplus BW program.The authors wish to thank all trainers and participants engaged in the VWBplus. The authors declare that they have no competing interests. All of the authors have worked as part of the VWB


Interest has increased in programs offering self-admission to inpatient treatment for patients with severe psychiatric illness, whereby patients who are well-known to a service are afforded the opportunity to admit themselves at will for a brief period of time. The aim of the present study was to examine patient experiences of practical considerations during the start-up phase of a self-admission program in an eating disorder service.Sixteen adult participants in a self-admission program at a specialist eating disorders service were interviewed at 6 months about their experiences during the implementation phase. A qualitative content analysis approach was applied in order to identify recurring themes.Six subcategories regarding implementation and logistics of self-admission were identified: “Start-up problems”, “Problems associated with reserving a bed”, “Lack of staff continuity”, “Not enough emphasis on long-term goals”, “Too demanding in terms of freedom and responsibility”, and “Suggestions for alternative models”.Practical recommendations can be offered for the implementation of future self-admission programs, such as thoroughly informing all participants about the rationale behind self-admission with particular emphasis on patient accountability, establishing a waiting list procedure for occasions when all designated beds are occupied, and assigning an individual contact staff member responsible for each self-admitted patient.ClinicalTrials.gov as ID: NCT02937259 .The study protocol is retrospectively registered at The online version of this article (10.1186/s12888-017-1505-x) contains supplementary material, which is available to authorized users. Self-admission to inpatient treatment for patients with severe psychiatric illness has been offered in Norway and the Netherlands for over a decade , and simThe rationale behind self-admission is multifold, including increasing patient autonomy and agency, promoting self-monitoring and adequate help-seeking behaviors, avoiding repeated visits to the emergency ward, reinforcing the function of the inpatient ward as a safe haven, reducing coercive interventions, and reducing total time spent in inpatient treatment , 4, 5. GFollowing the mostly promising results seen in research on the Norwegian self-admission programs, there is currently an intensified interest in self-admission in other Scandinavian countries , 3, 10. The aim of the present study was to examine patient experiences of practical considerations during the start-up phase of a self-admission program in an eating disorder service, in order to be able to offer advice on “dos and don’ts” in the implementation of similar programs in psychiatry.The present study took place at the Stockholm Centre for Eating Disorders (SCÄ), which is a public specialist eating disorder service run by the Stockholm County Council. The catchment area is Metropolitan Stockholm in Sweden with a population of 2.2 million. The details of the self-admission program at SCÄ have been described elsewhere [At the time of this study, 18 patients were enrolled in the program. All of them were asked to be interviewed about their participation, and all but two agreed. Thus, the informants in this study were 15 women and one man with a mean age of 31 years  enrolled in the self-admission program at SCÄ. Written informed consent was obtained. At inclusion, all informants were diagnosed with anorexia nervosa and they had been suffering from an eating disorder for a mean of 15 years . During their first 6 months in the program, 14 informants had made use of the opportunity to self-admit, while two of them had not; these two informants were also included in the study. Previous research has shown that participants who do not actually self-admit often find their participation meaningful nonetheless, because of increased feelings of security in knowing that the opportunity exists [All informants were interviewed about their experiences in the program at 6 months after receiving their contracts for self-admission. A semi-structured interview guide was prepared, defining the research questions that were to be investigated during the interviews . The study protocol is registered at Six subcategories regarding the overarching theme of implementation and logistics of the self-admission program were identified: “Start-up problems”, “Problems associated with reserving a bed”, “Lack of staff continuity”, “Not enough emphasis on long-term goals”, “Too demanding in terms of freedom and responsibility”, and “Suggestions for alternative models”. Informant quotes illustrating the subcategories described below are presented in Table The occurrence of start-up problems, i.e., problems related to the initial implementation of the new routines at the ward, is not surprising given that self-admission is in many ways a novel way of thinking about inpatient treatment. On this subcategory, informants mentioned that they were sometimes given contradictory information from different staff members, which risked consolidating ambivalence about admitting themselves (quote a). On at least one occasion, a self-admission bed was “double-booked” because of misunderstanding among staff members (quote b).The initial procedure whereby program participants themselves were responsible for calling back to check if one of the beds had become available was also seen as stressful and potentially discouraging; however, this problem was solved by the establishment of a separate waiting list for the self-admission beds, whereby participants are now informed by phone when a bed is available for them (quote c). Informants generally spoke about this issue as being a thing of the past and most of these obstacles seemed to have been removed at the time of the interviews.Three informants had experienced that both designated beds had been occupied by other participants in the program when they had called to see if they could admit themselves (quote d). In addition, two informants reported that they would sometimes feel stressed when being informed that there was a bed available but that it could not be held until the next day, meaning that they would have to come to the ward immediately if they wanted to make use of the bed (quote e).Because of the brief nature of the self-admissions and the scheduled rotation of staff members at the ward, it had not been possible to assign a single personal contact staff member who the participants could see continuously for the entirety of their stay. Lack of staff continuity was thus raised as an obstacle by some informants who had previously appreciated having a fixed treatment contact during their time at the ward and found this system too vague (quote f).On this subcategory, one informant noted that it was simply not possible to reach any long-term treatment goals during such brief admissions (quote g).Several informants expressed that while they appreciated the agency and flexibility of the self-admission model, they were not always confident in handling this somewhat unfamiliar freedom and responsibility (quotes h and i). In hindsight, some of them felt that they had entered the program with unrealistic expectations about the concept and their own current ability to make constructive use of it (quote j).Three informants mentioned that for them, it would be useful to be able to plan their brief admissions ahead instead of having to contact the ward on short notice each time they wish to admit themselves (quote k). Generally, these suggestions were raised in a context of discussing ambivalence and difficulties in appraising one’s own mental state and responding to signs of deterioration, where having pre-booked brief admission dates was seen as a helpful solution (quote l).As a part of the self-admission model, there is an emphasis on flexibility whereby participants can choose to keep going to work or school during the days even when they are admitted or to spend the nights at home if they merely wish to partake in the daytime routines at the ward. One informant noted that she had felt guilty about formally occupying a bed even though she chose to sleep at home and suggested an additional day treatment self-admission model for those patients who do not need an actual bed at the ward (quote m).Although patients in the SCÄ self-admission program were generally satisfied with their participation , they idEnsure that all potential participants are thoroughly informed about the rationale behind self-admission and the emphasis on patient accountability in particular before they accept to participate in the program. It is also advisable to discuss expectations and worries beforehand, in order to instil a nuanced understanding of the concept.All involved staff members (at the inpatient ward as well as at associated outpatient facilities) must be thoroughly informed of the self-admission routines and provided with clear written reference material in order to avoid contradictory information, which could cause confusion and strengthen patient ambivalence.An explicit waiting list procedure should be established for occasions when all designated beds are occupied and an active outreach approach applied in informing the patients who are on this list, so that they know how long the current maximum queuing time is and do not have to make repeated calls to the ward.The assignment of an individual contact staff member to whom each self-admitted patient can turn to should be a priority. Naturally, the brief nature of self-admission episodes in combination with regular staff rotation schedules at an inpatient ward can make it difficult to achieve full continuity, but in order to counteract any negative effects of this it should nevertheless be clear who the patient’s current individual contact person is at all times.In order to avoid disappointment, ensure that patients are aware of the fact that although a central part of the self-admission concept is that they are free to admit themselves for whatever reason, the brief nature of these admissions makes it unlikely that they will be able to achieve any long-term treatment goals during any one stay. Instead, self-admissions are probably best seen as booster opportunities or brief respites at times when the risk of relapse is high.The present results have potential clinical implications. Based on the informants’ experiences, several practical recommendations can be made for the implementation of future self-admission programs, bearing in mind the ambiguities raised above:Interestingly, only one informant described the brief nature of self-admission episodes as an obstacle, and most informants did not experience poor availablity of the self-admission beds.Some informants suggested that it should also be possible to sign up in advance for future self-admission episodes. Notably, brief preventive admissions on a pre-planned basis have previously been evaluated for patients with borderline personality disorder with promising outcomes concerning viability and cost-effectiveness . While tIt should be noted that the findings in this study rely solely on patient experiences. Additionally, studying provider and clinician experiences could provide complementary aspects on the implementation of self-admission. To this date, there is only one study that specifically addresses this topic . As prevThis study has a number of strengths and limitations. Whereas previous qualitative studies have reported data on patients’ general experiences of self-admission, this is the first study to provide insight into practical and logistical issues to be taken into account during the implementation phase of a self-admission program in psychiatry. Participants were interviewed during ongoing program participation, which allowed them to discuss their experiences and suggestions in a “real-time” context. However, the main interviewer is employed at SCÄ  which could potentially have affected participants’ responses. It should also be emphasized that the SCÄ self-admission program is exclusively targeted to patients with an eating disorder, which may affect generalizability of the findings to groups with other psychiatric illness; however, eating disorder specific aspects of informants’ experiences have previously been reported elsewhere  and the This study is the first to provide patients’ experiences of participating during the implementation phase of a self-admission program in psychiatry. While informants were generally satisfied with their participation in the program they also identified a number of practical issues that should be taken into account in order to optimize the usefulness of the model. Since there is currently an intensified interest in self-admission at other sites, a number of recommendations based on informant experiences are provided to aid in the implementation of future self-admission programs.


Most emergency medicine (EM) residency programs provide an orientation program for their incoming interns, with the lecture being the most common education activity during this period. Our orientation program is designed to bridge the gap between undergraduate and graduate medical education by ensuring that all learners demonstrate competency on Level 1 Milestones, including medical knowledge (MK). To teach interns core medical knowledge in EM, we reformulated orientation using the flipped-classroom model by replacing lectures with small group, case-based discussions. Interns demonstrated improvement in medical knowledge through higher scores on a posttest. Evaluation survey results were also favorable for the flipped-classroom teaching format. Almost all emergency medicine (EM) residencies provide orientation programs for their incoming interns.6More recently, flipped-classroom methods have been adopted by EM residency programs.The purpose of our redesigned intern orientation program was to provide and assess intern’s core medical knowledge (Level 1 Milestone-MK) to enable them to succeed in residency. In an attempt to improve the didactic component of intern orientation, we developed case-based, pre-reading assignments organized by common EM topics. Our approach mirrored the flipped-classroom model we employ throughout our entire residency program.The orientation program was six weeks in length, running from mid-June to the end of July. Core EM knowledge teaching was allocated to 21 hours of direct instruction (seven hours per week) during the last half of the program. Each hour of direct instruction time represented a topic defined by a “chief complaint.” Hour- long lectures that had previously covered this core content were replaced by case-based, interactive small group sessions.Small group sessions were designed by core faculty and senior EM residents, and reviewed by the orientation director. Residents were expected to prepare for each session by reading a patient case and covering the prescribed learning material. Residents were provided with guiding questions for each patient case. These included questions about differential diagnoses, management, and dispositions. Residents were also encouraged to find their own resources to answer guiding questions. During the sessions, faculty members facilitated the discussion by navigating a facilitator guide that included the guiding questions. Examples of topics covered were chest pain, abdominal pain, shortness of breath, airway management, headache, and back pain, among others.To measure knowledge gains, we contracted with TrueLearn® to generate two parallel examinations, each containing 100 randomly selected items from their SmartBank for Emergency Medicine.Twelve of 16 residents completed both pre- and posttests. Knowledge test scores were reported by TrueLearn® as percentage correct. We analyzed these with a paired t-test and Cohen’s d effect size. Interns made an average gain of 12.6 percentage points between pre- and posttests. This was considered statistically significant with an extremely large effect size  residents said that they felt more proficient with the core content covered in the small group sessions than they did before completing orientation.Use of the flipped classroom during our orientation had the side benefit of preparing residents for the teaching methods employed throughout residency. While knowledge test results showed significant and large learning gains, we were not able to directly attribute these gains to the flipped-classroom approach. We did not assess resident preparation for, or participation in small group discussions. However most residents rated the small group sessions as beneficial.Other evaluation results suggested the need for faculty development with facilitating small group discussions. We also learned the importance of posting learning material on an easy-to-access online learning management platform, particularly for residents who worked clinically at dispersed sites.We observed some preliminary evidence that the flipped classroom model is an effective teaching method that provided learners with the ability to customize their study time. This is particularly helpful during orientation for interns who come from varied medical school backgrounds. We did not, however, make a direct comparison to a lecture-based orientation. Additional evidence is needed through controlled experiments comparing lecture to flipped-classroom methods.


Decoy receptor 3 (DcR3), also known as tumor necrosis factor receptor (TNFR) superfamily member 6b (TNFRSF6B), is a soluble decoy receptor which can neutralize the biological functions of three members of tumor necrosis factor superfamily (TNFSF): Fas ligand (FasL), LIGHT, and TL1A. In addition to ‘decoy’ function, recombinant DcR3.Fc is able to modulate the activation and differentiation of dendritic cells (DCs) and macrophages via ‘non-decoy’ action. DcR3-treated DCs skew T cell differentiation into Th2 phenotype, while DcR3-treated macrophages behave M2 phenotype. DcR3 is upregulated in various cancer cells and several inflammatory tissues, and is regarded as a potential biomarker to predict inflammatory disease progression and cancer metastasis. However, whether DcR3 is a pathogenic factor or a suppressor to attenuate inflammatory reactions, has not been discussed comprehensively yet. Because mouse genome does not have DcR3, it is not feasible to investigate its physiological functions by gene-knockout approach. However, DcR3-mediated effects in vitro are determined via overexpressing DcR3 or addition of recombinant DcR3.Fc fusion protein. Moreover, CD68-driven DcR3 transgenic mice are used to investigate DcR3-mediated systemic effects in vivo. Upregulation of DcR3 during inflammatory reactions exerts negative-feedback to suppress inflammation, while tumor cells hijack DcR3 to prevent apoptosis and promote tumor growth and invasion. Thus, ‘switch-on’ of DcR3 expression may be feasible for the treatment of inflammatory diseases and enhance tissue repairing, while ‘switch-off’ of DcR3 expression can enhance tumor apoptosis and suppress tumor growth in vivo. DcR3 has been shown to be a pleiotropic soluble factor to modulate cell functions via ‘decoy’ and ‘non-decoy’ actions . DcR3 isDcR3 expression is hardly detectable in physiological condition. Thus, most of studies focus on DcR3 expression in pathological conditions, and verify DcR3-mediated effects in DcR3 transgenic mice which overexpress DcR3 locally  or systeDecoy receptor 3 (DcR3) is a member of the tumor necrosis factor receptor (TNFR) superfamily member 6b (TNFRSF6B)/TR6/M68. DcR3 cDNA is initially identified from human cancer cells, and DcR3 gene amplification is also found in certain cancer cell lineages . Unlike The TL1A/death receptor 3 (DR3/TNFRSF25) axis is a novel immune pathway that participates in the pathogenesis of a variety of autoimmune rheumatic diseases , thus moHomo sapiens), chimpanzee (Pan troglodytes), and most of animals belonging to Phylum Chordata. However, DcR3 does not exist in mouse (Mus musculus) and rat (Rattus norvegicus) genomes, thus it is not feasible to understand its physiological functions by gene-knockout approach. It has been demonstrated that human DcR3 is able to bind and neutralize the functions of mouse FasL, LIGHT, and TL1A [DcR3 is found in the genome of human  from patients suffered from silicosis  and bactIn addition to cells in the synovial cavity during RA, DcR3 is also upregulated in Kaposi’s sarcoma-associated herpesvirus (KSHV)-infected human umbilical vein endothelial cells (HUVECs)  and skinIn addition to inflammatory diseases, DcR3 is upregulated in numerous cancer cells and tumor tissues . DcR3 isDcR3 in inflammatory region of colon is highly upregulated in patients of IBD , 42. In In addition to acute and chronic inflammation, elevation of DcR3 serum level is observed in patients suffered various infectious diseases. Elevated serum DcR3 level was found in patients suffered from sepsis , and is In cancer patients, serum DcR3 level also correlates with cancer staging. It was reported that malignant plasma cells and T lymphocytes from myeloma patients directly produce DcR3, and serum DcR3 levels in myeloma patients are significantly higher compared to controls . In addiIn cancer and inflammatory diseases, upregulation of DcR3 is via NF-κB activation pathway , 61–65, Because mouse and rat genomes do not contain DcR3, functional study of DcR3 in vitro is via knockdown of DcR3 expression in human cells by siRNA (loss of function), or overexpression of human DcR3 in mouse cells (gain of function).Endogenous DcR3 seems able to increase tumor resistance to chemotherapy, because knockdown of DcR3 dramatically increases sensitivity of pancreatic, gastric and ovarian tumor cells to gemcitabine-, 5-fluorIn contrast, overexpression of DcR3 promotes adhesion, migration, and invasiveness of tumor cells , 62, 73.Listeria monocytogenes infection was observed [+ Th1 responses against parasites [To understand DcR3-mediated functions in vivo, transgenic mice overexpressing DcR3 by rat-insulin promoter (RIP)  and CD68observed , 75. Thearasites . In CD68arasites .To explore the potential therapeutic effect of DcR3, DcR3 expression plasmids were introduced into mice with autoimmune diseases. It has been shown that administration of CMV promoter-driven human DcR3 plasmid (pCMV-DcR3) into mice can prevent the onset of autoimmune crescentic glomerulonephritis . DcR3 geA.Myeloid cells:+-monocyte differentiation into CD1alowCD40lowCD54lowCD80lowCD86high DCs, which then skew T cells differentiation into Th2 phenotype [+-monocytes to CD14lowCD16low CD68highCD206highHLA-DRlow M2 macrophages via epigenetic regulation [+-monocytes induces cell differentiation into osteoclasts, while OPG cannot inhibit DcR3. Fc-induced osteoclast differentiation [The recombinant DcR3.Fc fusion protein is able to induce CD14henotype   strain-induced B cell proliferation as well as TLR2-induced TNF-α secretion , NFκB acC.Tumor cells:DcR3.Fc has been shown to bind to ovarian cancer cells via HSPGs, and increase cells resistance to platinum-induced cell death . CompareD.Rheumatoid arthritis fibroblasts-like synoviocytes (RA-FLS):We have demonstrated that DcR3.Fc is able to upregulate the expression of gene characteristics of M2-macrophages via epigenetic regulation via activating of HSPGs . In addiCompared with endogenous DcR3, several studies demonstrate that recombinant DcR3.Fc fusion protein is more potent than endogenous DcR3 to modulate cell functions:It has been reported that intrathecal injection of recombinant DcR3.Fc fusion protein is able to 1) ameliorate experimental autoimmune encephalomyelitis , 94; 2) High serum level and mutations of DcR3 are concomitantly observed in patients with juvenile-onset systemic lupus erythematosus . DNA seqIn addition, DcR3 mutant defective in secretion from cultured cells is greater in the Crohn’s patients . Genome-It is almost 19 years since the observation that DcR3 is overexpressed in various cancer cells and is able to neutralize FasL-mediated apoptosis . DcR3 apHowever, the physiological functions of DcR3 are still unclear. Higher DcR3 expression was found in undifferentiated than in well-differentiated keratinocytes during tissue repair , and uprDcR3.Fc is able to induce signaling cascades via HSPGs (syndecan-2 and CD44v3), and activate PKC → c-Src → FAK pathway to induce cell adhesion , 105. Dc


The Recovery After Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study was a landmark investigation whose positive results led to increased funding and support to build first episode psychosis programs across the US. Every state in the country received dedicated funding to implement a coordinated specialty care (CSC) program designed to identify and treat persons with first episode psychosis within the context of the nation’s multi-payer health system. Since the funding began in 2014, numerous CSC programs have been developed but little is known about which models of treatment providers are implementing and the success of these programs. The research here presents data from a survey focusing on providing feedback from the first episode psychosis programs in the US implementing NAVIGATE, the CSC program utilized in RAISE-ETP. The survey targets the program directors in the NAVIGATE programs; the aims of the survey include 1) to describe the program characteristics of NAVIGATE teams in the US and 2) to better understand how NAVIGATE programs are identifying and enrolling people into their services. Capturing local data on CSC team composition and case identification strategies is particularly critical in multi-payer systems lacking guidance and oversight from a national health system.An online survey is being conducted to assess the implementation of NAVIGATE programs in the US and evaluate the procedures that the program director utilizes to identify and enroll NAVIGATE participants in services. Program directors from NAVIGATE programs are being identified and contacted to participate by national trainers to join a national database of first episode programs. Program data collected includes information about the location of the program, staff in the different NAVIGATE team roles , program enrollment criteria, number of participants screened and enrolled, and rates of planned and unplanned discharge. In addition, program directors are asked questions to report community based strategies to identify participants and screening procedures to enroll participants. Data analysis will focus on presenting the demographic and clinical characteristics of the programs. Common themes will be ascertained, including barriers and facilitators to identifying and enrolling participants with first episode psychosis. Helpful recommendations provided by the project directors on identifying and screening participants will be synthesized and reported.There are approximately 30 NAVIGATE programs in 14 states in the US. Results will highlight the dissemination of NAVIGATE in the US and implementation of these programs across a wide range of different communities. We will describe the dissemination of NAVIGATE across the US and similarities and differences across NAVIGATE programs. Results also will provide feedback on the challenges and helpful strategies that program directors have used to engage people in treatment.The findings from this survey will be the first to provide an overview of the implementation of the NAVIGATE program in the US. The results will provide an overview of the dissemination of the NAVIGATE program, the only CSC program evaluated in a national US trial. Recommendations could help inform the ongoing development and dissemination of coordinated specialty care programs.


The burden of severe acute malnutrition (SAM) is estimated using unadjusted prevalence estimates. SAM is an acute condition and many children with SAM will either recover or die within a few weeks. Estimating SAM burden using unadjusted prevalence estimates results in significant underestimation. This has a negative impact on allocation of resources for the prevention and treatment of SAM. A simple method for adjusting prevalence estimates intended to improve the accuracy of burden estimates and caseload predictions has been proposed. This method employs an incidence correction factor. Application of this method using the globally recommended incidence correction factor has led to programs underestimating burden and caseload in some settings.A method for estimating a locally appropriate incidence correction factor from prevalence, population size, program caseload, and program coverage was developed and tested using data from the Nigerian national SAM treatment program.Applying the developed method resulted in errors in caseload prediction of about 10%. This is a considerable improvement upon the current method, which resulted in a 79.5% underestimate. Methods for improving the precision of estimates are proposed.It is possible to considerably improve predictions of caseload by applying a simple model to data that are readily available to program managers. This implies that more accurate estimates of burden may also be made using the same methods and data.The online version of this article (10.1186/s13690-017-0234-4) contains supplementary material, which is available to authorized users. A child with severe acute malnutrition (SAM) has a high risk of near term mortality , 2. It hBurden is the sum of prevalent cases at the start of a period and incident cases that arise during that period. The number of prevalent cases in a population at a given point in time can be estimated using a combination of a prevalence estimate from a cross-sectional survey and population data. This information is usually already available to program managers. Incidence is more complicated and more expensive to estimate.The relationship between incidence and prevalence is frequently described using a “bathtub” metaphor . In thisThe simple relationship between prevalence, incidence, and duration of illness makes it possible to create a simple mathematical model that allows the estimation of burden using prevalence and population estimates together with other data (e.g. program coverage and program caseloads) that will usually be available to program managers.The Community Management of Acute Malnutrition (CMAM) Forum has proposed a simple method to estimate SAM burden and predict the number of cases that a program will treat over a given planning period . The numB) consists of both prevalent cases and new (incident) cases that are expected to occur in the program area over a given planning period:The population burden (K is a correction factor  on a 1.50% point estimate of SAM prevalence [Uncertainty regarding coverage  is a simple count of program admissions. This data is collected and reported on a routine basis and can usually be assumed to be measured with little or no error.Caseload (K). The average duration of an untreated SAM episode that is currently being used globally is 7.5 months. This is based on data from two cohort studies and provides an incidence correction factor (K) of 1.6 for a one-year planning period [K would apply in all contexts. Governments, United Nations agencies, non-governmental organizations (NGOs), and other SAM treatment program implementing partners have, in the absence of other evidence, been using this value of K to estimate the burden and expected caseload and to advocate for resources to treat children with SAM. Reports from SAM treatment programs suggest that the use of K = 1.6 has led to programs underestimating caseload in some West African settings. Recent work indicates that a single value of K for use globally may not be useful  program from 2014 and 2015 are presented in this article. This program started operations in 2009 and has treated between 300 thousand and 500 thousand SAM cases each year. During the course of implementation it was recognized that the use of K using the population of the program area, the number of program admissions, estimates of program coverage, and estimates of the prevalence of SAM in order to provide more accurate estimates of burden and expected caseload during program implementation. The method is illustrated using data from the Nigerian CMAM program. The revised estimate of K may also be useful to predict SAM burden and caseload from prevalence surveys in similar settings.This article presents a method to adjust or calibrate the value of K given the other terms:The caseload estimation formula:K can be found by substituting known values for L, C, N, and P with L being the observed program caseload (i.e. the number of admissions).A suitable value for N) and caseload (L) are measured with little or no error although the method can be easily extended to accommodate uncertainty in these terms. The principal sources of uncertainty in this analysis are, therefore, prevalence (P) and coverage (C). This can lead to considerable uncertainty in their product (PC) used in the estimator  and coverage (C) in this application):nP and nC are the sample sizes used to estimate prevalence (P) and coverage (C) respectively [nP and nC) will differ from reported sample sizes due to design effects introduced by the use of complex samples and / or the use of prior information [An approximate 95% confidence interval for the product of two proportions  and its associated upper and lower 95% confidence limits (UCL and LCL).The effective sample size associated with the estimate of a proportion can be calculated from the reported point estimate (VAR) is calculated as:Variance (neffective) is calculated as:The effective sample size  in 2014 and 2015 were taken from routine program monitoring reports. Population estimates were made using data from the 2006 Nigerian Census corrected for population growth and migration [R Language and Environment for Statistical Computing version 3.3.3 [We used the approach outlined above to find a suitable value for igration . Prevaleigration . An estiigration , 26, 27.on 3.3.3 .PC) is approximate. A less approximate 95% confidence interval  may be calculated using a bootstrap estimator [K) were made using a bootstrap estimator for the product of prevalence and coverage (PC). A percentile bootstrap estimator with one million replicates for prevalence and coverage drawn from appropriate binomial distributions was used [R Language and Environment for Statistical Computing version 3.3.3 [The method used to calculate the 95% confidence limits for the product of prevalence and coverage  caseloads and the revised incidence correction factors (K) for 2014 and 2015 together with the data on which the calculations were based. Use of K = 1.6 to predict caseload had resulted in gross underestimates in both years. The resulting revised estimates for K were K = 14.39  and K = 11.66  for 2014 and 2015 respectively. These estimates were pooled giving K = 13.02 . The final two rows of Table K and difference between the observed and expected caseloads. Table K) calculated using the approximate method and the bootstrap estimator.Table K estimated for 2014 to the population, prevalence, and coverage data for 2015 yields a predicted caseload of 484,766 cases. This is a 21.6% overestimate of the observed caseload for 2015. Some of this error may have been due to lower than specified coverage during the implementation phase of additional CMAM programming initiated in early 2015 as part of the ongoing emergency response in Northern Nigeria. This degree of error in caseload prediction is a considerable improvement upon the 79.5% underestimate experienced when using K = 1.6. Applying the pooled estimate of K (i.e. K = 13.02) to the population, prevalence, and coverage data yields predicted caseloads of 291,257 cases and 441,612 cases for 2014 and 2015 respectively. These are a 9.0% underestimate and 10.8% overestimate of the true cases for 2014 and 2015. Error are likely to decrease over time as more annual estimates of K become available. Not all errors have the same consequences. For example, overestimation may have positive consequences if program coverage is limited by stop-start funding and supply breaks caused by underestimation of burden and / or predicted caseload. Underestimation may lead to an under-resourced program in which program activities essential to achieving and maintaining coverage  are neglected in order to maintain core clinical activities. Underestimation, in some cases, may lead to supply breaks necessitating the temporary closure of programs.The approach outlined in this document can provide useful estimates of locally appropriate incidence correction factors. Applying the value of Confidence intervals for the bootstrap estimates of the incidence correction factors are wider than when the approximate method is used. Estimates made using the approximate method are likely to be spuriously precise. The use of approximate methods to calculate confidence intervals is, however, a widely accepted practice for many public health applications. The approximate method has the advantage of being easy to implement using software, such as Microsoft Excel, that is available and familiar to CMAM program managers.K) lack precision even when the approximate method is used. For example, the 95% confidence interval for the 2015 estimate of the incidence correction factor (K) using the approximate method ranges between K = 5.94 and K = 22.10. This translates into a 95% confidence interval for the caseload prediction of between about 218 thousand and 728 thousand. This degree of imprecision may limit the utility of the method as a planning tool.Estimates of the incidence correction factor (K) is estimated.The principal sources of imprecision are in estimates of prevalence and coverage. Improving the precision of estimates of prevalence and / or coverage will improve the precision with which the incidence correction factor . Precision of coverage estimates may, however, be a problem for smaller programs. We investigated this issue using data from 227 SQUEAC coverage assessments of district-level NGO-delivered CMAM programs performed between January 2010 and July 2015 and provided to us by the Coverage Monitoring Network. The median relative precision for coverage estimates between 40% and 60% was 42.6% . This is an expected result as SQUEAC coverage assessments are usually designed to estimate coverage with this level of precision .K) is estimated than may be achieved by efforts to improve the precision of coverage estimates. This is illustrated in Table The poorer relative precision of SAM prevalence estimates means that efforts to improve the precision of these estimates are likely to yield greater improvements in the precision with which the incidence correction factor , prevalence (P), and program coverage (C). Migration may, therefore, result in grossly inaccurate predictions of burden (B) and caseload (L) that are based on estimates of population size (N), prevalence (P), and program coverage (C). Monitoring population movements and adjusting burden and caseload predictions may help to address this problem. Adjustment may also require that additional prevalence and coverage surveys be undertaken. In the case of the Nigerian CMAM program there have been reports of SAM cases entering Nigeria from Niger and being admitted to CMAM sites in districts that border Niger. The effect of this on the work reported here is likely to be small since data for the whole country were used. It is important to note that this may have larger effects on burden (B) and caseload (L) predictions for (e.g.) small NGO-delivered programs operating in border districts.A limitation of the method described here is that burden and caseload may be influenced by migration into and out of the program area. Rapid and substantial changes in the population of the program area are likely to affect population size (L) is measured with little or no error may also be a limitation. In the case of the Nigerian CMAM program there have been reports from 3 of the 114 districts in which the program is operating of beneficiaries being registered at more than one CMAM site with the assumed intention of receiving additional food and drugs. New CMAM sites were opened in these districts and some of the double registration may have been due to informal transfers between sites. An informal transfer would have been reported as a new admission at the destination site and, some weeks later, as a defaulting patient at the originating site. The effect of this would have been to increase reported caseload (L). It seems likely that double registration will have had only a small effect on caseload (L) used in the work reported here. This would have caused only a small increase in the estimates for K reported here. The covert nature of some double registrations does mean that the magnitude of any increase will always be difficult to quantify.The assumption that caseload (The work reported here shows that it is possible to considerably improve predictions of CMAM caseload by applying a simple mathematical model to data that are readily available to program managers. This implies that more accurate predictions of burden may also be made using the same methods and data. The precision of estimates of caseload and burden may be improved by using PROBIT or Bayesian-PROBIT estimators of SAM prevalence.K will be needed to make local prediction of burden and caseload. These local estimates of K could be applied to local estimates of prevalence and population with the results summed in order to estimate global SAM burden.The implication of this study, and of similar reports based on a variety of approaches (see Table K using direct estimates of incidence from continuous monitoring of open cohorts and surveillance systems in similar settings may be warranted. Comparison with other indirect methods may also prove useful.Given the public health importance of having reliable estimates of burden and caseload and the uncertainties of this approach based on program data, a confirmation of estimates of


After our manuscript has been published, we have noticed in our acknowledgment section that the name and the code of our funding program were incorrect. Here, we provide the first sentence of the modified acknowledgment using the correct name and code. funded by the Ministry of Education ”.“This study was supported by the BK21 Plus Program