The unified Rwandan initiative for national ZEBOVAC immunization (UMURINZI) program's community engagement component was enacted to mobilize and vaccinate high‐risk community members. This article describes best practices and lessons learned from the implementation of UMURINZI, a large‐scale Ebola vaccination program.The population deemed to be at risk for EVD consisted of people who frequently cross Rwanda and the Democratic Republic of Congo (DRC) borders including those coming from Kigali City, potential first responders who have not previously been vaccinated against EVD, as well as people who reside in high‐risk border‐proximate areas of the Rubavu and Rusizi districts in the Western Province of Rwanda. These districts were selected because of their proximity to high‐traffic borders linking Rwanda to DRC's cities near an active Ebola outbreak. Volunteers of this program were adults, adolescents, and children aged 2 years or above who resided in the selected communities. Recruitment at the sites was conducted in close collaboration with each health area's Community Health Workers (CHWs). Volunteers were informed that the program involved being fully vaccinated (two doses of Ebola vaccines) within 2 months apart in the allocated vaccination sites.Lessons learned were categorized into four pillars: infrastructure, leadership, myths, and partnership with respect. The best practices that were used during the implementation of the UMURINZI program were the results of a collaboration among CHWs, the involvement of national and local leaders, the use of a comprehensive engagement plan, and training. The study also had limitations.We described best practices and lessons learned during the implementation of the UMURINZI program in Rwanda. These practices and lessons learned represent promising options that could contribute to better community members' participation in mass vaccination programs. Hence, we demonstrated that rigorously designed community awareness and sensitization programs are effective for the implementation of similar programs in resource‐limited settings. These factors include social networks, community awareness, partnership and collaboration, selection and training, provision of incentives, and political pressure/political will .Discussion of the best practices and lessons learned from the implementation of the Unprecedented Movement to drive a unified Rwandan initiative for national ZEBOVAC immunization (UMURINZI) community engagement program opens the dialog to initiate similar large‐scale efforts in the future is vital. The program aimed to engage more than 200,000 community members to become fully vaccinated against the Ebola virus in the Rubavu and Rusizi districts of Rwanda.2Documentation of the best practices and lessons learned from the UMURINZI vaccination program is vital to inform policymakers as well as similar programs in Rwanda and globally. The purpose of this paper is to describe the identified best practices and lessons learned during the implementation of the 2‐year UMURINZI community engagement program within the Rubavu and Rusizi Districts of Rwanda.33.1The population deemed to be at risk for EVD consisted of people who frequently cross Rwanda and the Democratic Republic of Congo (DRC) borders including those coming from Kigali city, potential first responders who have not previously been vaccinated against EVD, as well as people who reside in high‐risk border‐proximate areas of the Rubavu and Rusizi districts in the Western Province of Rwanda. These districts were selected because of their proximity to high‐traffic borders linking Rwanda to DRC's cities near an active Ebola outbreak; this proximity indicated an increased likelihood of exposure to Ebola and therefore the greatest potential for vaccination against Ebola to contribute meaningfully to Ebola prevention in Rwanda.3.2The inclusion and exclusion criteria for this study are described below in Table 3.3Before the implementation of the UMIRINZI program, a community engagement guide that contained program sensitization, community mobilization, volunteers' recruitment, and follow‐up, as well as retention strategies, was developed by the Rwanda Biomedical Center, Rinda Ubuzima, and the Projet San Francisco team members. This tool was later approved by the Rwanda Biomedical Center because of its official role in managing all health data concerning citizens in Rwanda. With this tool, two approaches were used to recruit volunteers (2 years of age and above) with considerations for site specifications among both districts (targeted invitations and open enrollment). Targeted invitations were issued to border crossers at major border posts, target communities, and their potential contacts for instance family members and neighbors. Individuals who routinely crossed the border were encouraged to participate in the program. As UMURINZI progressed, vaccines were made available to all eligible individuals on a first‐come‐first‐served basis. Recruitment was conducted in close collaboration with each health facility area's community health workers (CHWs) as well as local authorities.3.4Ebola is a rare but dangerous virus associated with severe hemorrhagic fever that can lead to serious illness, including death. Due to the proximity of Rwanda to the DRC which has had several Ebola epidemics, the UMURINZI program was initiated. UMURINZI's program defines community engagement as “a systematic and ongoing process of working collaboratively with and through relevant community groups and partners.” The program was initiated in December 2019 to vaccinate community members with the Ad26.ZEBOV (first dose) and MVA‐BN®‐Filo (second dose) vaccines. UMURINZI's community engagement approach aimed to bring a supportive environment and positive behavior change amongst the communities at risk of an Ebola infection outbreak. It maximized opportunities for dialog, consultation, and formation of authentic partnerships and was mutually mindful and respectful of the social, cultural, and political realities of the individual communities alongside the border with DRC.Specifically, the community engagement strategy aims to: mobilize the target population to receive vaccination; manage the recruitment process to ensure that the flow of potential vaccine recipients does not exceed daily per‐site capacity; and foster a conducive environment for voluntary participation in the vaccination campaign by addressing rumors, building community trust, and providing accurate information about risk and prevention strategies.UMURINZI program collaborated with all stakeholder parties such as local government, community leaders, and public and private sectors to maximize the awareness, commitment, and participation of eligible citizens in the target area. The community engagement team used several best practices during the UMURINZI program while maintaining acceptable principles to foster trust in the community about the approach and the vaccine.All vaccine recipients were informed that the full vaccine regimen requires two doses of the vaccine approximately 2 months apart. The first day of the campaign was launched with an introductory workshop and with 50 people invited for vaccination. Those offered to be vaccinated on that first vaccination day comprised well‐known, influential individuals from various groups in both districts. A list of invitees was first generated from various community leaders who had already expressed interest in vaccination, including leaders of associations; local government authorities; local health authorities; and others. All vaccine recipients received a health screening and had the opportunity to ask additional questions  on launch day.Mobilizers identified members of association members who met the program's behavioral inclusion criteria (routine border crossing and/or working at border sites) and thus were included in the program. Association‐level meetings were held to mobilize these groups for vaccination and to schedule appointments/issue invitations. Leaders of the association collaborated in the scheduling of members of the association to ensure a smooth and fair process. From these associations, and through active community engagement and outreach activities, community members became aware of the program and then became interested. People expressed interest in vaccination after being mobilized by voluntarily communicating when they were available to visit the vaccination sites. It was only after then that appointments were given. A list was generated for each day's appointments and those who arrived for vaccination were checked to ensure that they had an appointment for that day. However, following a thorough screening procedure, those considered “walk‐ins” were served as well.The program started with few vaccination sites but as it scaled up, additional vaccination sites were opened in Rubavu and Rusizi districts.3.5The method used for quantitative data collection during the UMURINZI program has been explained elsewhere by Nyombayire et al.44.1Discussing lessons learned from the implementation of a successful program like the UMURINZI program's community engagement component is vital to inform policymakers as well as similar programs in Rwanda and the global community for the enhancement of global health practices aimed at bettering the population's health. These lessons learned are categorized into four main groups: infrastructure, leadership, myths, and partnership with respect.4.1.1UMURINZI program utilized brick‐and‐mortar buildings or tents to accommodate operations, staff, and volunteers. Sometimes, locations had a high daily attendance beyond expectations causing people to wait for long hours and could return to their homes without being vaccinated that day. To resolve this high influx of volunteers, more vaccination sites were established in targeted geographic locations, and the staff was deployed in those areas. These sites were established in collaboration with local government authorities to target the broader community who are eligible by the geographical inclusion criteria. These established vaccination sites might advance future vaccination programs within these districts. Limited space and distance to health facilities are commonly known as factors that make community members not uptake some health promotion programs, especially with the case of the Ebola vaccine whereas no case had been recorded in Rwanda at the time of the UMURINZI program. Hence, considerations for vaccination site capacity and methods to address the potential overflow of volunteers were key learnings that often are not being captured in most programs probably because of tight funding in the programs.4.1.2The engagement and visibility of leadership were key to the implementation of the UMURINZI community engagement program—the then Minister of Health launched the vaccination campaign in Rubavu district but also at Nkombo Island Health Center and the then Vice Minister of State in charge of Primary Healthcare, opened the vaccination campaign in Rusizi district. Visits by Wellcome Trust and Johnson & Johnson leaders were also scheduled while presentations to districts and province officials were also performed. In addition, health sector leaders were involved from the central level to the lower level . These key leaders' involvements created and maintained a supportive environment for citizens who were volunteering to receive the vaccine as they are trusted and believed to bring only what is good for the citizens. With the outbreak of COVID‐19, the attention of these leaders was divided, and they were forced to implement certain measures such as border closures and curfews among other restrictions. Potential UMURINZI volunteers were either caught up by curfews or by the limited numbers accepted at program sites. However, these leaders still played a key role in making room for the program to continue for instance allowing the program sites to halve the number of volunteers on sites in a day and issuing travel clearance for vehicles transporting volunteers to and from the vaccination sites. Depending on the context but unlike in Rwanda, if leaders such as health sector leaders are not involved in a program, community members are most likely not going to participate. Thus, having strong buy‐in from leadership was a key component to the success of this campaign, especially during a time of an unrelated communicable disease outbreak4.1.3Myths arose within the community since the Ebola vaccination was a novel preventive option. For example, it was common to hear people saying that following the Ebola vaccination, volunteers will become infected with the Ebola virus. Efforts through mobilization from some program managers such as Rinda Ubuzima and their partners  enabled volunteers to understand and reject those myths and rumors. In addition, the social mobilization used multiple communication approaches such as CHWs and community advisory groups that actively helped to mitigate some of the raised myths. Again, the fact that Rwandans normally have a high rate of vaccine acceptance, demand, and uptake as is the case with routine vaccines4.1.4Stakeholder involvement during the implementation of the UMURINZI program was essential. The partnership created between Projet San Francisco and Rinda Ubuzima supported the awareness and sensitization of the program aimed at fully vaccinating more than 200,000 individuals. Both organizations during the program implementation were mutually mindful and respectful of the social, cultural, and political realities of the individual communities , we engaged all leaders of associations  and requested for best strategies to fully involve community members. One of the suggested and used strategies was recruiting program staff within the program communities. This aspect is sometimes forgotten in programs that make community members feel not valued and thus not adhere to program goals. Effective collaboration and communication during all stages of the program were vital to the program's success. They strive to respect volunteers at every step of the process, thus, cultivated a supportive environment for all volunteer participants.4.2These were techniques that were experienced and proven reliable to lead the UMURINZI program to the desired results and were a collaboration with CHWs, involvement of national and local leaders, use of a comprehensive engagement plan, and training.4.2.1CHWs, after they received training on the UMURINZI program (with a focus on inclusion/exclusion criteria and daily vaccination site capacity) issued invitations to eligible community members. CHWs leveraged a variety of outreach strategies including village‐level mobilization meetings, meetings of associations/clubs in target areas, and home visits. CHWs mobilized volunteers by enumerating (counting/listing of people) community members, teaching about Ebola and the vaccination in community, and follow‐ups with volunteers to encourage retention. To ensure participant retention, CHWs reminded participants of the second dose , and actively listened to and monitored participants during the implementation of the program. CHWs also responded to rumors (for instance by providing facts that they were taught about the disease and the vaccine to those concerned) to help boost the turnout at vaccination sites. This collaboration helped in the success of the program since CHWs in Rwanda are a trusted channel by community members within their respective communities.4.2.2UMURINZI program in general collaborated from its start to the endpoint with different key persons such as government entities such as the Ministry of health both in Rwanda and the DRC and the Rwanda Biomedical Center that provided initial vaccination sites or existing health posts and CHWs. These government entities also laid a solid foundation for the implementation of the program by getting involved which served as a guarantee and a sign to community members that the program was trustable. Also, with the aid of local leaders (from the district level to the village level), meetings were organized to facilitate the flow of communication between the program and the community, hence increasing the population's understanding of the UMURINZI program benefits and uptake.4.2.3A couple of social networks were used during the UMURINZI program. All participants who were eligible for vaccination and volunteered to participate received the first dose and those with a mobile phone number were automatically enrolled into tracking systems such as the MOTECH mobile messaging platform unless they chose to opt‐out. This platform sent pre‐scheduled voice and SMS messages to remind participants of their upcoming second dose. The messages were timed to ensure adequate advanced notice of the second dose and provided contact information for the program's staff should they need to reach out to the vaccination program team. UMURINZI vaccination cards were given to each participant and used to fill out the date of their second dose appointments. The community needed to be sensitized extensively to maximize awareness and adherence to the vaccination program. As such, there were always group mobilizations where UMURINZI staff maintained communication with association leaders to ensure group‐level follow‐up of participants invited to the program. In addition to mass‐media communications, group‐based mobilization meetings were held with sub‐groups of the target population . Sensitization messages emphasized that vaccination is voluntary, that all potential vaccine recipients were to be screened or tested for pregnancy (when applicable), and that they should expect to spend 45–90 min at the vaccination site. The community engagement coordinators prepared all materials needed for recruitment . Radio and television advertisements, megaphone announcements, billboards, and giant screens were broadcasted within target areas with sensitization messages.4.2.4The training was a very important aspect of the implementation of the UMURINZI program. For instance, the training (Rinda Ubuzima and Projet San Francisco staff) of trainers to be involved in community engagement and mobilization was a vital tool that facilitate the sound implementation of the program. The trained trainers further provided training to trainees . The training equipped them with all the information, education, communication materials, and processes required for successful community engagement. This method used for sensitization during the UMURINZI program helped to fully inform key persons and empowered them to help their community members deny certain myths such as the vaccine being a tool used by the government and foreigners “White people” to kill or send Rwandans to hell. Overall, training was essential to the empowerment of UMURINZI staff and volunteers to promote trust and confidence in the vaccination campaign.4.2.5During the implementation of the UMURINZI community engagement program, several resources were mobilized including a formal documented community engagement plan. Flyers were produced for education, street banners pinned on strategic sites such as market places and bus stations, provision of remunerations (300 RWF) to program promoters  depending on the number of volunteers they referred to the program site, radio, megaphones, television spots, billboards, brochures, and flip charts . These helped create awareness of the program and ensured adherence to vaccination invitations. Furthermore, during this program, there was the outbreak of the COVID‐19 pandemic. As a result, transportation , face masks, and soaps were provided to all volunteers to help them participate in the program while limiting the transmission of COVID‐19.4.34.3.1The study's findings are based on the specific context of the UMURINZI program in Rwanda, targeting specific high‐risk populations in the border‐proximate areas, prone to active Ebola outbreaks. The effectiveness of the identified best practices may not be directly applicable to other regions or different infectious diseases.4.3.2The study mainly focuses on the participation of community members who reside in specific border‐proximate areas and may not fully represent the views or experiences of all community members, especially those living further away from the outbreak regions.4.3.3While the study highlights a high adherence rate to the second dose invitation, it doesn't delve into the long‐term effectiveness of the vaccination in preventing Ebola outbreaks or mitigating their impact in the targeted communities.5We described the best practices and lessons learned during the community engagement of the UMURINZI program. A rigorously designed community awareness and sensitization program that gets community members and leadership involved as well as respects their values and cultures could be effective during the implementation of similar programs in any resource‐limited setting. While many lessons  were learned from the community engagement of the UMURINZI program, some best practices  were utilized throughout, leading to 216,321 people adhering to the second dose invitations at the end of the program in September 2021 as described elsewhere (Community members' perspectives and adherence to invitations during the Ebola virus vaccination campaign in the Western Province of Rwanda). Although the lessons learned and best practices were specific to the context of the Ebola prevention strategy in Rwanda, some of the principles behind it may be transferable to similar mass community engagement programs.Roseline Dzekem Dine: Conceptualization; methodology; writing—original draft; writing—review and editing. Aline Uwizera Umutoni: Methodology; supervision; writing—original draft; writing—review and editing. Marie Michele Umulisa: Conceptualization; supervision; writing—original draft. Nnamdi Ezeanochie: Conceptualization; supervision. Jozef Noben: Conceptualization; supervision. Ellen Pagan Indoe: Supervision; writing—original draft; writing—review and editing. Clémence Dusingize: Supervision; writing—original draft. Fulgence Kamali: Conceptualization; supervision. Julien Niyingabira: Supervision; writing—review and editing.Nnamdi Ezeanochie, Jozef Noben, and Ellen Pagan Indoe are employees of Jassen as well as Johnson and Johnson. Other authors declare no conflict of interest.The lead author Roseline Dzekem Dine affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned  have been explained.While the UMURINZI community engagement program adhered to universal ethical principles, it received an ethical waiver from the Rwanda National Ethics Committee. All mobilized volunteers provided informed consent to participate.


Mental health problems increase the risk for unstable career paths and often lead to early transition to disability pensions. Individual Placement and Support (IPS) is an evidence-based program integrated into psychiatric care helping individuals with serious mental illness to find competitive employment. It comprises personalized job search as well as individual in-work support for both the employee and the employer.The Finnish Individual Placement and Support Evaluation Study (2020-2023) aims at investigating the implementation, feasibility as well as perceived benefits and outcomes of the IPS program implemented for the first time broadly in Finland. The present study focuses on the changes observed among program participants in employment status and psychosocial well-being during the 6-and 12-months follow-ups.Both quantitative and qualitative data from different stakeholders have been and will be collected. The data collection will be finished at the end of 2022. The presentation focuses on findings from interviews (n=31) and from questionnaire data collected among program participants at baseline and at 6-and 12-months follow-ups. The total sample will comprise approximately 300 program participants (18−64 years of age) diagnosed with a severe mental illness.Findings on changes in employment status as well as in psychosocial well-being  will be discussed at the congress. The preliminary findings of the study show that about half of the program participants have succeeded in getting employed at least once during the follow-up. However, becoming employed does not always result in increased psychosocial well-being. Work-related stress, meaningless or unsuitable job, problems at the workplace community or fear of being stigmatized may contribute toward decreased psychosocial well-being.Meaningful work can play an important role in the process of recovery from mental illness. However, individuals with severe mental health problems need support with the working life related concerns and stress especially at the beginning of employment.None Declared


Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) has proven to be highly accurate in lung cancer diagnosis and staging. However, its efficacy in diagnosing lymphoma, especially Hodgkin’s lymphoma, remains controversial, mainly due to the need for larger biopsies for definitive diagnosis. This case study presents a 53-year-old HIV-positive man with a controlled viral load, who presented with a large left hilar mass and a left upper lobe nodule, both showing significant uptake on positron emission tomography scans. The patient underwent bronchoscopy with bronchoalveolar lavage, EBUS-TBNA using an Olympus™ Vizishot 2 needle , and EBUS-guided transbronchial forceps biopsies (TBFB) of a left hilar lymph node using a 1.8 mm Boston Scientific™ forceps . The EBUS-TBNA revealed granulomas, while the subsequent EBUS-guided TBFB revealed nodular lymphocyte-predominant Hodgkin's lymphoma. EBUS-TBFB may be a promising technique for obtaining larger tissue samples and enhancing diagnostic yield in cases of mediastinal lymphadenopathy with suspected lymphoma. Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is a widely used procedure and has been validated for the diagnosis and staging of lung cancer and the diagnosis of sarcoidosis. Despite its established role in lung cancer staging, its diagnostic accuracy in lymphoma remains a subject of debate due to certain disadvantages, such as lesser core tissue sampling and inferior negative predictive value . This arA 53-year-old man with a medical history of obstructive sleep apnea, pulmonary nodule, and HIV infection presented with PET-positive left hilar mass Figure  and leftTM  and wedged into the LUL bronchus. BAL was performed, and the fluid was sent for cultures, cytology, and antigen testing. EBUS-TBNA was then performed on the station 11L lymph node using a 22-gauge Vizishot 2 needle . A tract was formed by pushing the sheath in and dilating the area. Additionally, six transbronchial biopsy (TBBX) samples were obtained from the same lymph node under ultrasound guidance using 1.8 mm forceps. The lymph node TBNA revealed granulomatous inflammation. The lymph node biopsy using transbronchial forceps revealed nodular lymphocyte-predominant Hodgkin's lymphoma of intrathoracic lymph nodes, indicating HIV-associated Hodgkin's lymphoma. Figures The patient underwent bronchoscopy with bronchoalveolar lavage (BAL) of the LUL. The bronchoscope was introduced through an iGELDuring histopathological examination of the tissue samples, specific cells exhibited weak staining for PAX5, a critical transcription factor associated with B-cell development. This weakened staining pattern strongly suggests a decrease in the expression of B-cell markers, a hallmark characteristic of classic Hodgkin's lymphoma . On immuEBUS-TBFB provides a minimally invasive and accurate method for obtaining tissue samples from mediastinal lymph nodes, aiding in the diagnosis and staging of various pulmonary conditions, including Hodgkin's lymphoma. In scenarios where EBUS-TBNA fails to yield a diagnosis, as in our case, EBUS-TBFB can be a safe and effective alternative to improve diagnostic accuracy when performed in conjunction with EBUS-TBNA.In a recent investigation, Pathak et al. studied a cohort of 30 patients, eight patients had a history of lymphoma, one patient had a history of squamous cell carcinoma, and one patient had a history of chronic lymphocytic leukemia with 25 of them undergoing EBUS-TBFB. The overall diagnostic yield of EBUS-TBFB was found to be 73%. However, when EBUS-TBFB was combined with EBUS-TBNA, the diagnostic yield significantly improved to 86% (26 out of 30 patients). While TBFB provided additional diagnostic information beyond TBNA in some cases, the study was not powered to thoroughly evaluate the diagnostic yield. These findings suggest that combining EBUS-TBFB with EBUS-TBNA may enhance diagnostic accuracy in the evaluation of patients with suspected lung pathology [Mehta et al. aimed to assess the effectiveness and safety of a novel technique called EBUS-TBFB when conventional EBUS-TBNA with rapid on-site evaluation (ROSE) failed to provide a diagnosis. The study included 30 consecutive patients with enlarged mediastinal lymph nodes and negative EBUS-TBNA ROSE results. EBUS-TBFB successfully obtained adequate tissue samples in all cases where both EBUS-TBNA and EBUS-TBFB were performed. Particularly, in patients with non-diagnostic EBUS-TBNA ROSE, EBUS-TBFB yielded positive diagnostic results in eight out of 30 patients 27%), of which six were diagnosed with tuberculosis, one with aspergillosis, and one with Hodgkin’s lymphoma. For patients with a negative EBUS-TBNA ROSE, EBUS-TBFB proved to be a safe and valuable technique, contributing to the diagnostic yield. The findings indicate that EBUS-TBFB is a valuable addition to EBUS procedures, especially in benign causes of mediastinal lymph node enlargement [%, of whiIn their study, Diab et al. compared the diagnostic yield of EBUS-TBNA and EBUS-TBFB individually with their combined approach in cases of mediastinal lymphadenopathy with unknown etiology. The combined technique provided a definitive diagnosis in 31 out of 35 cases 88.6%), accurately identifying both Hodgkin's and non-Hodgkin's lymphomas in 90% of cases without the need for further invasive procedures. Additionally, the combined approach successfully confirmed all cases of granulomatous inflammation. The study concludes that the safe and high diagnostic yield of the combination of EBUS-TBFB and EBUS-TBNA makes it particularly effective for diagnosing mediastinal adenopathy of unknown origin, especially in lymphoma cases. The larger samples obtained from TBFB also improved sensitivity in detecting granulomatous disease and provided specimens for clinical trials in malignancy cases when needle aspirates were insufficient [8.6%, accRecently, there has been evidence supporting the high diagnostic success and safety of EBUS-TBFB for mediastinal lymph nodes. However, a rare technical issue was observed during the procedure, where a rupture of the steering band prevented the closure of forceps jaws in a subcarinal lymph node. This problem could lead to severe complications. The report highlights the importance of addressing such complications during transbronchial sampling of mediastinal lesions and presents a solution to this specific issue, along with other procedure-related complications reported in the literature .In another study, combining bronchoscopic tissue forceps biopsy (BBX) and EBUS-TBNA improves diagnostic yield in lung lesion evaluation. In 115 patients, the combined approach provided a definitive diagnosis in 93% of cases, with 81% being malignant. Seventy-eight patients underwent BBX and EBUS-TBNA of the lymph node(s) only; malignancy was diagnosed in 63 (81%) patients; 28 (36%) had malignant cells in both specimen types, 19 (24%) had malignant cells only in the BBX, and 16 (21%) had malignant cells only in the EBUS-TBNA. In the remaining 15 patients who underwent BBX and EBUS-TBNA of the lymph nodes only, 10 (67%) were diagnosed with either granulomatous disease or evidence of infection, and five (33%) with malignancy on subsequent procedures. EBUS-TBNA was especially valuable when BBX results were negative, increasing diagnostic yield by 18% and assisting in tumor staging. Additionally, the combination allowed for more tissue sampling for immunohistochemistry and molecular testing, facilitating personalized management in a minimally invasive manner [Our case demonstrates the importance of performing EBUS-TBFB in cases of mediastinal adenopathy of unknown etiology. Had we not performed EBUS-TBFB, EBUS-TBNA alone would have led us to a misdiagnosis of sarcoidosis in this case.EBUS-TBFB provides a minimally invasive and accurate method for obtaining tissue samples from mediastinal lymph nodes that may aid in the diagnosis and staging of various pulmonary conditions, including Hodgkin's lymphoma, non-Hodgkin’s lymphoma, and sarcoidosis. In scenarios where EBUS-TBNA fails to yield a diagnosis, EBUS-TBFB can be a safe and effective alternative to improve diagnostic accuracy when performed in conjunction with EBUS-TBNA. Further randomized controlled prospective trials are needed.


Introduction: One of the noted areas of weakness for internal medicine residents is pharmacology. However, there is little data documenting the creation and effect of a comprehensive pharmacology didactic program. Our goal was to create a two-year clinical pharmacology didactic program focused on areas of stated weakness and to evaluate this program for an increase in knowledge and prescribing confidence of the participants.Methods: From August 2020 to June 2022, a two-year pharmacology program was developed, which included 20 didactic lectures on a variety of topics. Pre- and post-tests were given for 15 of the lectures, and four surveys were given, two during each year of the program. Four questions on each survey were the same and asked about confidence in choosing an appropriate medication based on current guidelines, patient-specific factors, primary literature, and pharmacokinetics.Results: Over the two years, participation in the pharmacology sessions ranged from 17 to 29 residents (65-74% of the residency class). The average pre- and post-test scores increased by an average of 25.1%, which was a statistically significant increase . A Kruskal-Wallis H test showed a statistically significant difference in resident-reported confidence adjusting medications based on primary literature between the different survey groups, χ2 = 9.871, p = 0.02.Conclusion: A two-year, didactic pharmacology program improved the knowledge of resident participants and confidence in their ability to choose an appropriate medication based on primary literature. One of the areas where internal medicine residents and house staff often struggle is pharmacology ,2. MoulsPharmacology is a part of the medical school curriculum but is not a traditional part of residency training. Given our awareness of this weakness, it is surprising that few programs incorporate a pharmacology didactic program into training. Pharmacists are well-established clinical partners and are often involved in internal medicine rounding teams. Jorgenson et al. found in a qualitative review that pharmacists were valued as part of family medicine residency programs . HoweverOur goal was to create a two-year clinical pharmacology didactic program focused on areas of noted weakness and to evaluate this program using pre- and post-tests as well as a longitudinal survey for an increase in knowledge and prescribing confidence by the residents.Setting and participantsThe program was implemented in a 194-bed secondary, teaching, community hospital. The hospital has an internal medicine residency with 13 residents in each class. The subjects were residents in all years of study who attended weekly half-day didactic sessions. The two-year clinical pharmacology didactic program was implemented in August 2020 and ran through June 2022, and then another two-year program was restarted in August 2022.InterventionsThe internal medicine residency program was started at the hospital in 2019. When the program was created, a half-day of didactic lectures was built into the residents’ schedules. Initially, these were mostly hour-long talks from physician specialists with the goal of preparing students for board certification. In 2020, in response to a concern about the residents’ confidence regarding pharmacology topics, a dialogue was started between the residency directors and two university-affiliated pharmacists to create a formal, didactic, pharmacology program.The development of this program was based on the hypothesis that a structured didactic program on clinical pharmacology provided by two pharmacists with teaching experience would increase the knowledge and confidence of the internal medicine residents in clinical pharmacology topics. The program planning was done using a constructivist approach and focused on selecting diseases and medications that the residents most often encountered and providing this information using a case-based method.A mission statement, as well as goals and objectives, was developed as a group based on published data and the WHO “Key Clinical Pharmacology Services in Patient Care,” as seen in Table At the start of the program, each presentation was 120 minutes in length and was given once a month. However, over time this was shortened, first to 90 minutes and then to 60 minutes based on feedback from residents. Instead of longer sessions, if needed, topics were broken into two 60-minute sessions provided within the same month. Each lecture was PowerPoint-based, and the use of interactive questions and patient cases were encouraged. After a mid-program review, more emphasis was given to increasing both the interactivity and the patient cases in each lecture.Outcomes measuredAn increase in knowledge was assessed by a pre- and post-test for 15 of the lectures. Each lecture provided by the two pharmacists included a brief three to five-question pre-test and a post-test. The lectures provided by guest lecturers did not include pre- and post-tests. The same questions were asked in the pre- and post-tests to eliminate the risk of differences in question difficulty. The questions were developed by the two pharmacists who have additional training in question writing as well as experience in writing questions for pharmacist education, post-graduate pharmacy continuing education, and pharmacist board certification.The acceptance and effect of the program were assessed by four surveys, given twice yearly for the two years of the program. The Likert-style survey questions were created by one of the pharmacists who have additional training in survey development and followed the process suggested for graduate medical education by Magee et al. . A draftThe surveys consisted of five sections, the first two sections included questions that changed each survey and were focused on the confidence and knowledge gained from each lecture. The third section of each survey was consistent between each survey and included four questions assessing the residents' confidence in choosing an appropriate medication based on current guidelines, patient-specific factors, primary literature, and pharmacokinetics. The third section also included one question assessing how often the residents utilized information from the clinical pharmacology didactic lectures. The fourth section of the survey included two open-ended questions asking about additional topics they would like the program to cover and any suggestions for the program. The final section was baseline characteristics and consisted of just a single question on post-graduate year to maintain resident anonymity.In addition to the surveys, after the first year of the program, a residency panel was convened to discuss possible improvements to the didactic lectures, including the clinical pharmacology program. Changes made to the program based on this discussion include the shortening of lectures and utilizing multiple lectures in a month if needed to cover the material. There also was a renewed focus on providing case-based lectures and using interactive teaching methods. Finally, there was a list of board certification preparatory materials provided to the pharmacists so that these could be used to better tailor the content to what the residents will be tested on for board certification.Analysis of the outcomesChanges in the percentage of correct responses on the pre- and post-tests were evaluated using descriptive statistics and paired t-tests. Changes in the Likert-scale survey results were evaluated using descriptive statistics, the Kruskal-Wallis H test, and post-hoc Mann-Whitney U test for intergroup comparison. SPSS Statistics version 28.0  was utilized for statistical analysis.IRB statementThis was determined to be exempt from review by the facility’s institutional review board (349).Over the two years, participation in the pharmacology sessions ranged from 17 to 29 residents (65-74%). During the first year, there were two classes of residents , and during the second year, there were three classes of residents 39 total). Pre- and post-tests were given to each of the participants for 15 of the 20 sessions. Average scores for the pre-tests ranged from 32.3% to 71.0%, with a mean of 53.0% (SD= 10.6%), as seen in Table 9 total. The total number of surveys completed was 43-15 for survey one, 12 for survey two, seven for survey three, and nine for survey four. The overall response rate was 50%  and ranged from 29% to 88% for each survey. Each of the four surveys asked questions about the knowledge and confidence gained from each lecture. These questions were unique to each survey. The percentage of participants who answered “positive impact” or “extreme positive impact” for the lecture-specific confidence and knowledge questions was an average of 64.8%. Each survey also asked how often the residents utilized the information from the lectures. The lecture information was used at least once a month by an average of 79.1% of survey respondents.Four questions were asked on every survey regarding confidence in choosing an appropriate medication based on current guidelines, patient-specific factors, primary literature, and pharmacokinetics. An average of 64.2% of respondents answered “fairly confident” or “very confident” to all of these questions. The lowest confidence was in adjusting based on pharmacokinetics (55.8%), and the highest was in adjusting based on patient-specific factors (70.7%). These results fluctuated over time, with the highest confidence rates reported in the final survey, as seen in Table The only statistically significant increase in the survey data was for confidence adjusting based on primary literature. A Kruskal-Wallis H test showed a statistically significant difference in confidence adjusted based on primary literature between the different survey groups, χ2 = 9.871, p = 0.02, with a mean rank confidence score of 23.17 for survey one, 28.79 for survey two, 18.29 for survey three, and 13.89 for survey four. A score of one was assigned to “very confident” and ranged down to a five assigned to “not confident,” with a lower mean rank indicating higher confidence. A posthoc Mann-Whitney U test found that the increase in confidence between surveys one and four was statistically significant (p= 0.015), as was the increase between surveys two and four (p= 0.006).Our data indicates that the participants’ knowledge increased from each of the lectures, and their confidence in choosing an appropriate medication based on primary literature increased. The data did not show an increase in confidence in choosing an appropriate medication due to current guidelines, patient-specific factors, or pharmacokinetics.To help control the quality of the lectures, the majority of lectures were created and presented by two university-affiliated pharmacists. Each lecture took approximately eight hours to create, and each pharmacist created approximately eight lectures over the two years. For large health systems with multiple clinical pharmacy specialists, one option to reduce this workload could be to share this responsibility with a larger number of pharmacists. However, an increase in lecturers would likely require a process to assure consistency and quality. In addition, each of the outside lecturers was paid a small stipend ($200) for the creation and presentation of their lectures. This should be included in any proposed didactic series in order to provide expertise that resides outside the facility.One possible limitation of the study was the number of survey respondents. It is also unclear why the spring 2021 respondent rate was lower than the other surveys. The average response rate of 50% is good and is similar to the rate seen in other curricular assessments but may have still affected the overall results ,11. One Another possible limitation was the use of the same questions within the pre- and post-tests. Although this was done to decrease any bias due to pre- and post-test question difficulty differences, it is possible that question familiarity could have affected the results. In addition, the pre- and post-tests and surveys focused on assessing a change in knowledge and self-reported confidence, and direct application to patient care was not evaluated. Future research areas include evaluating changes in medication use or clinical outcomes related to lectures or board exam results.Our program appears to be the first comprehensive didactic clinical pharmacology series described in the literature. A PubMed search using the combination of National Library of Medicine medical subject headings (MeSH) "internal medicine," "internship and residency," and “pharmacology, clinical" found only four results -15. Of tReflecting on the implementation of the program, we underestimated the value of resident feedback to refine the topic selection and presentation method. Each of the surveys provided new topics and suggestions to optimize learning. Topics suggested based on this feedback that were not included in the original schedule included antifungal and antiviral medications, psychiatric medications, critical care support, and medications for nausea and vomiting. There was also a change in the length of the lecture, as well as a continued focus on case-based and interactive lectures. Incorporating residents into the design and structure of a pharmacology didactic program is necessary for optimal success.A two-year, didactic pharmacology program improved the knowledge and confidence of resident participants. Specifically, an increase in knowledge was demonstrated for each of the post-tests, with an average increase of 25.1%, which was statistically significant. This also translated into a self-reported increase in confidence in choosing a medication based on primary literature. Although the didactic sessions required a considerable amount of preparation from the pharmacist educators, this could be lessened by using a broader group of pharmacists.


A smoking cessation program for adolescents, TABADO, demonstrated its effectiveness following a controlled trial conducted in 2007/2009. The program is now being scaled up nationally. In order to retain its efficacy across the diversity of contexts in the generalization process, we needed to assess the processes and mechanisms that inform its effects. Theory-driven evaluation is one approach used to address these issues. The aim of the present research is to develop the TABADO program theory. More specifically, we attempt to identify the factors and mechanisms that promote or hinder the enrollment and retention of student smokers in the program.We conducted a realist evaluation of the TABADO program through 1) a documentary analysis to construct the initial program theory, and 2) a multiple case study (n = 10) conducted in three regions in France to test and enrich the initial theory with contextual, organizational and mechanistic components. We used the Intervention-Context-Actors-Mechanisms-Outcomes configurations to guide our analysis and to present our results.Our analysis highlighted 13 mechanisms that foster the enrollment and retention of student smokers in the TABADO program . To activate these mechanisms, the involvement of various actors is required , together with a combination of interventional and contextual factors .These findings allowed us to transform the TABADO program into a new optimized strategy, TABADO2, which is theory-based. Our research helps to explain why adolescent smokers enroll and stay in a school-based smoking cessation program. TABADO2 needs to be considered in a more comprehensive way than the original research-based TABADO, and should be tailored to its implementation context. To address the major issue of adolescent smoking, a school-based cessation program was launched in France, the TABADO program . It was The TABADO program is a complex intervention –8, becauTheory-driven evaluation is an approach that can be used to address these issues. Its central concept is that of program theory . Two maiThe overall aim of this work is to develop the TABADO program theory. More specifically, we attempt to identify the factors and mechanisms that promote or hinder the enrollment and retention of student smokers in this program, which has already proved its efficacy.From a pragmatic point of view, the answers to this scientific question also allow us to put forward recommendations to accompany the national scale-up process , 4.TABADO was developed as a smoking cessation program for vocational schools, which was accessible, free of charge and completely confidential . It is bAn information session on tobacco in whole classes for smokers and non-smokers. At the end of the session, students who smoke are given the chance to join the TABADO program to help them stop smoking.The volunteers then join a free-of-charge support program directly in the school. It includes an initial individual diagnostic consultation with a tobaccologist, then a monthly follow-up consultation for four months, accompanied by a small group session with the other volunteers enrolled in the program. Nicotine substitutes are given free of charge by the tobaccologist if they are deemed necessary.The techniques used during the individual consultations and group sessions are inspired by cognitive-behavioral therapies, designed to reinforce the motivation to quit and to encourage peer support.This study uses the RAMESES II standards as recommended for reporting realist evaluations  15]..15].The method adopted is that of realist evaluation, from Pawson and Tiley , 16. It In our realist approach, we followed the following three steps  16]: 1): 1)16]: The initial theory underlying the TABADO program was not formalized by the intervention designers. A documentary analysis was conducted on the TABADO research protocol  and on published articles , 2, 22. In order to compare the initial theory with the realities in the field, we conducted a multiple case study . The puran exploratory case study (three cases): its specific objective was to describe how the TABADO program was implemented in practice, to identify the main elements influencing its functioning in order to enrich the initial theory, and to build adapted investigation tools for the following case study. Here, TABADO was implemented in 2016/2017 as part of an underlying research program led by the Institut national de la santé et de la recherche médicale (Inserm)  in threean explanatory case study (seven cases): its specific objective was to test and enrich the preliminary hypotheses from the previous stages by studying TABADO in new implementation contexts, using investigative tools designed with the findings of the exploratory case study. Here, TABADO not only included purely vocational schools, but was extended to high schools that offered vocational tracks. In total, five high schools were included in the Ile-de-France region in 2017–2018, and two vocational schools in the Nouvelle-Aquitaine region in 2016–2018. These schools were recruited in the framework of the projects led by the Ligue contre le cancer d’Ile-de-France and the Instance Régionale d’Education et de Promotion de la Santé Nouvelle-Aquitaine, respectively. Another novelty was that the program was implemented outside the original research conditions and was therefore conducted and implemented by on-the-ground actors and not by researchers. The initial protocol was thus adapted accordingly. Unlike the previous phase, the researcher (AV) was not the local implementer, but an independent observer of the program implementation.Their respective contents are detailed in In order to better understand the different facets of the program and to strengthen the validity of our results, we carried out data triangulation (interviews with the program beneficiaries and the different actors on the ground), and method triangulation , as recommended in qualitative research , 26. Tri2.4.1.1 Observations. Observations of the different components of the intervention were conducted . The researcher did not observe the individual consultations with the tobacco specialists in order to maintain confidentiality between the tobacco specialist and the students. For the explanatory case study, an observation grid was developed and included information on: the speaker , the audience , the intervention and its environment , student reactions and attitudes , program enrollment .Moreover, observation of the environment and organization of the program  was conducted by in-depth immersion in the field several times a week during the intervention period , 29. Thi2.4.1.2 Interviews. The interviews were conducted face-to-face (in the schools or at the respondents’ place of work) or by telephone. They were recorded with the respondents’ consent, and were fully transcribed. The interviews from the explanatory case study were a secondary use of the interviews from the underlying research project [ project , 27, wit2.4.1.3 Seminars. Three feedback seminars were organized to bring together all the stakeholders  to share experiences between schools (obstacles/levers throughout the program’s implementation), and to propose adaptations to best suit local contexts. This helped to enrich and refine the program theory hypotheses.As part of the underlying TABADO research and evaluation projects, self-administered questionnaires were distributed to students who attended the information sessions and/or enrolled in the program. Questionnaires were developed by each structure in charge of the implementation of TABADO (available on request). Questions that described the students  and their declared smoking habits  were selected for secondary use in this work.We conducted a directed content analysis on the data from the interviews, the logbook and the observations . The maiAfter the last seminar, a coding table was developed using the elements identified in the initial theory and during the exploratory case study. The main themes were I, C, A, M, and O, according to the realist evaluation principles. Repetitive factors identified during the intervention and the seminars were used as subthemes of each of the main themes. The content of this table was intended to evolve as the analysis was performed. A vertical analysis was conducted first, with the aim of identifying and classifying all the items of interest case by case according to the coding table. A horizontal synthesis was then carried out, aimed at analyzing the content of each theme  in a transversal way across the different cases, and to establish links between the different themes. The ICAMO configurations were thus gradually constructed.To describe the study population, we used aggregate data collected from the three program implementations . Qualitative variables were expressed as percentages, quantitative variables by the mean with the standard deviation.TABADO was implemented in a research context in the Grand-Est region of France after obtaining the authorization of the Comité de Protection des Personnes Est III . It was implemented in a routine context in the other two regions and fell within the framework of intervention authorization for the structures concerned. In all cases, students and parents of minors were informed about, and had the possibility to object to, the collection of individual data. To enroll in the program, students and parents of minors had to sign a written consent.ad hoc collection of qualitative data (interviews and observations). The data collected were anonymized and protected according to the usual procedures of the supporting structures . In view of the documents at its disposal, the Research Ethics Committee of Bordeaux issued a favorable opinion for the publication of this research (Reference CE-GP-2021-25).The present investigation is based on secondary exploitation of the data collected in the framework of the three program implementations, completed by an The initial theory presents the different components of the intervention and the conditions that allow the activation of the main mechanisms that lead to smoking cessation. It is shown in Figs color coding for the identification of ICAMO configurations in the program theoryBrown: InterventionGreen: ContextBlue: ActorsPink: MechanismsRed: OutcomesThe three interventional components are the information session, the individual consultations and the group sessions. The last two were conducted by the tobacco specialist. Contextual elements encouraged the smokers to enroll in the program: free access, accessibility in terms of time and place, voluntary participation and confidentiality with respect to parents. According to the designers, these interventional and contextual aspects were the most likely to trigger mechanisms that would incite enrollment in the program and, subsequently, smoking cessation.Ten schools were involved in the three regions, and the study included between 269 and 509 students . The presee 3.2.2.1. Enrollment in the program).In total, 94 students who smoked enrolled in the TABADO program . This number should not be compared to the number of smokers who completed the questionnaire, as some students who did not come to the information sessions and were therefore not considered as part of the target group also enrolled in the program . The qualitative survey showed that about half of the smokers enrolled in TABADO attended the information session; the others were recruited differently  or particularly important components which were transversal to all time periods. The verbatim accounts are available in 3.2.2.1 Enrollment in the program. The initial theory was that smokers would be enrolled via the information session (IS). However, the information session was only one of the entry points to the program, and enrollment was also encouraged before the meeting and outside the meeting.mechanisms (M) came into play that led to the enrollment of smokers in TABADO (O). These mechanisms acted in an interdependent and synergistic manner. To increase the chances of smokers enrolling, they had to have been prepared for the idea of quitting smoking (M1) prior to the presentation of TABADO. In addition, they had to be made aware of their own smoking habit and its consequences (M2), be given answers to the questions they asked themselves or to the life situations they encountered (M3), and they have confidence in the speaker who presented TABADO (M4). They needed to feel listened to with regard to their questions/experiences (M5), and to feel encouraged in their attempt to quit smoking (M6). On the other hand, they needed not to feel judged at any time (M7). Finally, they had to feel that their enrollment in TABADO could be useful (M8); this last mechanism was derived from mechanisms M1, M2, M3 and M5, in particular. Some other mechanisms explaining enrollment were expressed more independently: enrolling because they have nothing to lose (M9) or enrolling to please someone else (M10).Several contextual conditions (C) and interventional levers (I) had to be met.For these different mechanisms to occur, several Awareness of their own smoking habit and its consequences (M2) was boosted by having students fill out a questionnaire (I) a few weeks before the date of the IS, which allowed them to take stock of their smoking habit and gave them benchmarks  . This would also prepare them for the idea of quitting (M1). The school’s active participation in the Mois sans tabac (C) prior to the start of TABADO also provided a context that reinforced these two mechanisms (note: The "Moi(s) sans tabac" campaign is an annual national event in France, which encourages the population to stop smoking for 30 days in November [In order for the students to answer honestly and really question their own consumption, November ).to feel listened to and be able to express their opinions (M5), leaving the IS with answers to questions they had about tobacco or even about co-consumption (M3). This gave smokers the feeling that their enrollment in TABADO would be useful and that they would benefit personally (M8). Therefore, the IS should not have an academic format, speaking time should be shared between the speaker and the students, and among the students themselves (I) to be participatory/interactive and dynamic (I). It should be student-centered, focused on students’ questions, ideas (I). However, an IS focused solely on the fun aspect (I), even if it appealed to the students, was not enough to get them to enroll as it would not trigger students’ reflection, and thus would not raise their awareness of their own smoking habit and its consequences (M2)  .Key messages (I) that were relevant to students are listed in the TABADO 2 guide, such as the composition of cigarettes, the different types of dependence, and the health effects related to physical appearance and sexuality.Fun facilitation tools could be used, such as an interactive quiz, but each question/answer should be picked up on by the speaker for discussion and debriefing. a dialogue to take place between the speaker and the students (O), the latter had to trust the speaker (M4). For this to happen, confidentiality had to be guaranteed (C) . Moreover, the students needed not to feel judged (M7). The speaker (A) therefore had to be careful not to moralize (I) and to ensure mutual respect among all the students (I).In order for awareness of their own smoking habit and its consequences (M2) was enhanced by the fact that the IS speaker is a tobacco specialist (C). Indeed, even if students were aware of certain health warnings related to tobacco, they tended not to believe them . However, when the facts were presented (I) by a speaker (A) who is a tobacco specialist (C), students gained confidence (M4) and thus greater awareness of the truth behind the health warnings (O)  .Awareness (M2) could also be promoted by the presence of non-smoking students during an IS (C), who explained their experience of their classmates’ smoking  (rettes…) .non-smokers (A) were not to be left out during the IS, as they could help to spread the messages and the information given, and thus encourage their friends who smoked to enroll and not give up (M6)  .non-smokers do not feel concerned by IR (C), they may not listen and can be disruptive, which hinders smokers who want to listen (O).In cases where to prepare for the idea of quitting (M1).Students should not be expected to enroll directly after an IS, which is often dense with information, debate and discussion. Agreeing to engage in the cessation process may require additional time Contacting the students again some time after the IS (I) may be a good way to trigger enrollment (O). When the school participated in the Mois sans tabac (C) before the IS, the thought of starting a cessation program may have already been initiated, and the chances of enrolling in TABADO may have increased (ncreased .keep some free time at the end of the IS (C) to present TABADO, then go through the rows and discuss it individually and informally with the students (I), especially those who said they were smokers. The idea was to open up the discussion with an open-ended question that prompted them to react to the TABADO program; e.g., "What do you think of the program that was just presented?" (I). These individual and informal discussions both reinforced the feeling of being personally listened to and encouraged , and heightened awareness (M2) by encouraging students to respond to the exchanges that had just taken place. In addition, such informal exchanges were more confidential than speaking in front of the whole class, and so was is less fear of being judged (M7), making it easier to address the specific and sometimes personal questions that some students had (M3)  .reinforced the feeling for smokers that enrolling in TABADO would be useful (M8). Thus, when this informal time was taken, additional students enrolled (O). It is even more important when the group size is larger during the IS (C) as the speaker cannot hear all the comments students make to each other. Without this time, students tend to leave the room as soon as the bell rings and do not enroll (O). It is easier for the IS speaker to have another person to help with the informal discussions with students: e.g., the school nurse (A) or the school’s referent (A) (Activating these mechanisms rent (A) .back-to-back IS to take place in the same room (C) so that the speaker remains available at the end of the IS, rather than having to pack up his or her equipment and go to another room, in which case informal exchanges cannot take place (O).It is also a good idea for discussions initiated by the school referent and/or the nurse with students who smoked (I). This targeted recruitment was facilitated when the people in the school involved in TABADO (A) knew the students well, and knew who was a smoker (C) and when they were given dedicated time for TABADO by the school head (C)  .mechanisms  that encouraged smokers to enroll in TABADO (O). The encouragement to join sometimes came from friends (A), rather than from an adult in the school. In this sense, the IS introduced TABADO to entire classes (I) and activated the support that friends (A) could provide.As described above, such individual and informal discussions activated many of the Thus, the IS was essential on several levels: to raise awareness and inform all the students about tobacco and cessation, to create information relays among peers to encourage smokers to enroll, and to directly encourage smokers to enroll.an enrolled smoker was satisfied with his/her first TABADO consultation (C), (s)he would talk about it with others, leading to new registrations (O)  .TABADO program was completely free (C), took place in the school (C), and was scheduled entirely during school hours (C) facilitated enrollment and retention in the program (O). While some students who smoke enrolled in TABADO because they really wanted to try to quit or cut down on their smoking (the perceived usefulness of the program (M8) being that it would help them to achieve their goal), for others, enrollment was motivated by other reasons. For some smokers, the reason for enrolling (M8) was directly and solely related to missing classes. At other times, students enrolled (O) because they felt they had nothing to lose (M9), the program was free (C) and it was on-site at the school (C) (The fact that the hool (C) .please a third party (M10) . If these non-tobacco motivations did not change, students tended to abandon the program quickly of their own accord (O). For others, however, a real motivation to quit smoking developed unexpectedly, and these students then followed the program seriously (O). This motivation was supported by the fact that they felt listened to (M5) and encouraged (M6) by the tobaccologist (A) and by the other smokers in the group (A) (see 3.2.2.2 Staying in the program). It was therefore essential to accept all enrollments in the program (I), regardless of the initial reason for enrolling.Sometimes they enrolled to ensuring confidentiality of exchanges and written documents (C). This condition was valid as early as the IS so that students would not be afraid to open up and to enroll in TABADO (O). It remained essential throughout the program to keep smokers in the program (O). For example, students needed to be assured that their discussions were confidential and that their parents, teachers and employers would not be informed of their use of tobacco. When the speaker was a health professional (C) , students were reassured by the obligation of medical confidentiality. In a confidential atmosphere, students can confide, allowing them to obtain answers to the questions they ask themselves or to the life situations they encounter (M3), which then triggers awareness of their smoking habit (M2) and a feeling of usefulness concerning TABADO (M8).A necessary condition for the various student-related mechanisms to occur was the presence of teachers (C) as confidentiality was no longer ensured (C), and students were afraid of being judged (M7)  .less likely that they would enroll in the program after the meeting (O).For some students, their use of tobacco or other substances was taboo and a personal subject that they did not want to discuss in front of their teachers, or sometimes in front of any adult in the school. They were afraid to participate or ask questions, which made it where smoking was often considered as taboo (C), but not in vocational schools where smoking was seen as the norm (C) and students talked about it freely, even in front of the teachers. In a climate where smoking is considered taboo (C), the various on-the-ground actors  (A) must be particularly vigilant in their discourse so that smokers do not feel judged (M7), as this would block any discussion. It should be noted that students may fear judgment from adults in the school, from other students, or from people around them outside the school . The fear of judgment is less pronounced with people from outside the school . However, the presence of teachers at the IS (C) can have certain advantages, in particular raising their awareness of smoking cessation and TABADO (O), encouraging their acceptance of the TABADO program (O) (the consultations took place during school hours), and making it possible for them to act as information relays (O), to encourage smokers to enroll and to give them support during the cessation process.This effect was observed in high schools 3.2.2.2 Staying in the program. to keep smokers in the program (O). That is, throughout the program, young people needed to feel that they could trust the tobaccologist (M4), that (s)he would give them answers/advice tailored to their own questions and life situations (M3), listen to their experiences (M5), and encourage them to quit (M6) without them feeling judged (M7). Finally, when they felt that their participation in TABADO was personally useful (M8), they tended to continue the program until the end (O). However, two mechanisms were much stronger than the others in this phase of the program: the feeling of being listened to (M5) and the feeling of being encouraged  (M6). They were also linked to a new key mechanism during this phase: confidence in the chances of managing to quit smoking (M11). Two other mechanisms were important in keeping students in the program: expectations about the program (M12) and worry about regularly missing classes (M13).The M3 to M8 mechanisms presented for program enrollment apply equally to individual consultations (IC) and group sessions (GS) scheduling of intervention times during class time (C), which presented an additional specificity that will be detailed below. The intervention levers that applied to the IS applied equally to IC and GS .The contextual conditions related to all of the already known mechanisms remained the same for keeping smokers in the program , with the exception of the get personalized answers (M3). The GS allowed students to share their experiences (M5) and support each other (M6). These two components are complementary, and it is best for students to participate in both (The two main follow-up components (IC and GS) did not have quite the same function. The IC had a more intimate function; students could confide in the tobaccologist about more intimate issues related to their tobacco use or other products, or their life context, and  in both .They should not be forced to participate in either (I) since they could abandon the program (O).But for some students, talking in a group or being alone in a consultation with an unknow adult was not possible. the duration of the IC (I) needed to be adapted to each student: some young people may have co-addictions (C) and/or a physical dependence on nicotine (C), requiring the introduction of a substitution treatment. The tobaccologist (A) who dealt with the students needed to determine the duration of the consultations necessary for each student, so that each one benefited from a treatment corresponding to his or her needs. This helped students to increase their confidence in their chances of successfully quitting smoking (M11), thus avoiding program drop-outs and/or cessation failure (O).In addition, alternating between attendance at school or at their employer’s (C), did not always allow for the desired scheduling of intervention times. However, the most important thing was to ensure a follow-up. If it could not be done physically at the school, a remote consultation was proposed  (I)  (I) .The school nurse (A) played a pivotal role in TABADO. For the tobaccologist, (s)he represented a colleague trained in health, who knew the students’ medical records and who therefore provided precious assistance in adapting the care of enrolled smokers to each personal situation (O) during follow-up. Moreover, (s)he was a close contact for the smokers between two appointments with the tobaccologist (O) or even after the TABADO program ended (O) (advice and/or delivery of nicotine substitutes), giving the students the possibility to talk about their difficulties (M5) and encouraging them to continue their cessation process during difficult moments (M6), even in the absence of the tobaccologist  and independence from their schooling (C) was a factor that fostered trust (M4) and therefore promoted discussion on topics related to the use of products such as tobacco (O). Through their various roles, nurses promoted enrollment in the program (O) and the upkeep of cessation efforts (O).For the students, Confidence in their chances of quitting (M11) encouraged students to stay in the program and to continue trying to quit (O). This mechanism was greatly enhanced when a student in the follow-up group (A) successfully quit smoking (C), proving to his or her peers that it was possible to stop ( to stop .thought (s)he had no chance of successfully quitting smoking (M11), this blocked any attempt to participate in the program (O). For these students in particular, it was important to help them to gain confidence in their chances of quitting successfully (I).Conversely, if a student Confidence in the chances of quitting (M11) also strongly interacted with feeling listened to about smoking (M5) and feeling encouraged and supported by the tobacco specialist (M6). While any support can help motivate students, this was particularly noticeable when the support came from the tobacco specialist (C). It was thus extremely important for the tobaccologist (A) to encourage the students (I), and to value every effort and minor success (I) (cess (I) .students’ expectations about the program were too high (M12) , they quickly dropped out (O) as they were disappointed that the program did not meet their expectations.It is also important to note that when worried about repeatedly missing certain classes (M13). These were courses for which there was an end-of-year exam (C), courses specific to technical learning for their future career (C), or courses that they particularly enjoyed (C). These students sometimes preferred to miss their TABADO appointment rather than the course in question, and therefore did not attend the full program (O)  .the scheduling of intervention time during class time (C) was sometimes a barrier to keeping students in the program. This was reinforced by teachers (A) who, especially if they were not informed or were ill-informed about the TABADO program (C), refused to let students out of class, their goal being their students’ academic success.In this context, the end-of-year exams (C). The referent in the school (A) therefore had to take care to plan the different intervention times to fit in with the courses  (I), varying them so as to not always impact the same teacher or the same course (I). In addition, the referent had to be careful to start TABADO early enough in the school year (I) so that the program did not overlap with end-of-year exam periods.This was especially noticeable at the end of the school year due to The revised TABADO theory includes all the results described above. A synthesis of the theory is described in This work helps to explain why adolescent smokers enroll and stay in a school-based smoking cessation program such as TABADO. In addition, we showed that we need to consider TABADO in a more comprehensive way than was done with the original TABADO research protocol:through the diversity of the on-the-ground actors involved ,by the program’s continuity, even outside official intervention times Mois sans tabac).and by collaborating with existing national strategies  or who had dropped out of the program prematurely (n = 3), as these profiles were less willing to take part in a research interview. Thus, the mechanisms related to not enrolling or dropping out of the program were probably less well explored than those related to enrollment and staying in the program. Similarly, teachers who were not supportive of TABADO did not respond to our invitation to be interviewed, so we were unable to explore some of the barriers. In addition, the investigations were uneven among the ten cases, due to logistical constraints and the availability of the various stakeholders. Some cases were therefore studied in greater depth, and their results may be more extensively represented in the program theory than others. However, the evaluation of the national scaling-up will provide the study with new large-scale contexts . As withThe ICAMO configurations resulting from this work illustrate the strong link between the components of an intervention, the implementation methods and the environment in which the intervention is implemented. This environment is governed by a multitude of factors: numerous stakeholders with equally varied attitudes and reasoning, organizational and financial constraints, a well-defined legislative framework . The intHowever, an intervention should not be considered as a fixed system to be reproduced identically in all intervention contexts. Indeed, adaptation may be necessary for various reasons: to culturally appropriate a program for a new target population, enhance acceptability and local commitment, increase satisfaction with the intervention, or improve the ease and feasibility of implementation with the local context , 43. In Finally, this study shows that we can encourage smoking cessation among adolescents in a school environment if the contextual elements are taken into account to tailor the intervention to the context in which it is implemented.To our knowledge, there is no other published work on school-based smoking cessation programs using realist evaluation. However, some realist evaluation protocols in school settings aiming at reducing smoking among adolescents have been recently published , 48. TheIn other school-based smoking cessation programs that are not using realist evaluation, some results are in step with ours. A phenomenological study in Korea suggested that getting students to self-reflect  can change their smoking habits. Plus, as well as increasing self-efficacy to quit smoking (our mechanism M11), increasing self-efficacy and self-esteem more generally in life may strengthen the motivation for adolescent smokers to quit smoking . On ensuTABADO is now theory-based and its main key functions have been identified. Using this theory, an optimized intervention has been created, TABADO 2, which can now be transferred on a large scale and in real-life settings. This research led to the development of a guide for policymakers and practitioners on how to scale up the intervention.S1 TableCompleted RAMESES II checklist for this article.(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S1 Fig(PDF)Click here for additional data file.S2 Fig(PDF)Click here for additional data file.


The Patient Protection and Affordable Care Act (2010) directed the Centers for Medicare and Medicaid Services to implement a hospital readmissions reduction program that reduces payments to hospitals for excess readmissions that began in October 2012. As such, hospitals across the country have been trying to identify and implement successful strategies for reducing hospitalizations.To evaluate the impact of a combined pharmacist and social worker program on reducing 30-day, all-cause readmission rates to the same hospital.Our study design was a retrospective, cross-sectional study that included 100 inpatients discharged from a large academic medical center. Fifty patients were enrolled in the combined pharmacist and social worker program, and 50 received usual care; all were deemed high risk for readmission due to clinical or social factors. In the program group, a pharmacist performed a thorough medication history and review of discharge medications and, in some cases, communicated with the patient after discharge. The program group was also followed by a social worker team in the hospital and after discharge; as necessary, psychosocial interventions were performed.The 2 patient cohorts had similar demographic and clinical characteristics. Ten percent of patients enrolled in the combined pharmacist and social worker program were readmitted to the hospital for any reason within 30 days of discharge, compared with 30% of patients in the usual care group (P=0.012).The combined pharmacist and social worker program demonstrated a significant reduction in 30-day, all-cause readmission rates to the same hospital.