Adolescent transition programs are patient education programs. They are geared towards enabling adolescents with chronic or long-term illnesses to become active partners in their health care and manage their own health. Although there is agreement about their importance, there is not an agreement on content or how they should be delivered. The study reported here was part of the first steps of an action research project.Our aim was to explore how health professionals understand the program at our hospital, and their opinions of its implementation. This would advance our knowledge of the practice of the program to support its development.We conducted semi-structured individual interviews with 18 physicians and nurses. Data were analysed using qualitative content analysis. In our discussion of the generated data, we use the theory of practice architectures as a lens.“We are (back) at scratch”, “Time is always an issue”, “Getting them ready for what is to come–transition as a synonym to transfer” and “Raising topics that go beyond medical issues”. Changes to a practice requires changes to the practice architectures. Practice architectures can both enable and constrain a practice. Our analysis suggests a need for a more unified perception of the program goals, the cultural-discursive arrangements. Health professionals see time as a significant barrier to implementation and changes to the material-economic arrangements are particularly called for, i.e., more time, space and staff to practice the program. These also tie into the social-political arrangements of the program.We generated four themes through the analysis, namely There are arrangements in the practice architecture that currently seem to constrain the practice of the program. The practice is currently fragmented both within and across subspecialties. Efforts should be made to establish a more shared understanding of the program among health professionals. Furthermore, we should investigate how the practice of the program can be better supported. But we have started talking about it.When initially describing the program, health professionals refer to the use of checklists and program material in conversations with adolescents, having parts of the consultation without parents present and about themselves collaborating closer with the adult receiving department. Some subspecialties are perceived to be model implementers and some argue that others have never really managed to follow suit.The ones who have been particularly involved in transition are [specialists]. They have sort of been champions for it. It was in a way natural that they piloted [the program]. However, I feel that others did not really follow them. At least not in the field I work in.both professions.Some say that they did get a system up and running, but that for different reasons, most commonly due to turnover of key personnel, this system has collapsed. Participants who are new to the team and therefore define themselves as new to the program say they would have wanted more information about what their predecessor actually did when they delivered the program. However, knowledge about other topics and procedures was prioritised in the, often short, periods of training. Participants argue that for the program to run successfully there is a need for champions in Lack of implementation does not equal lack of relevance. In general, the participants describe a positive attitude towards the program in the clinic and among colleagues:Most people are positive. There are few reasons to… or, it is hard to find arguments for it being terribly wrong to make children able to become adults. It would be arguing against common sense to say you do not believe in it.Most speak of being at a different level of awareness about adolescent medicine and transition than before the program was launched. However, they admit that transition might not be the most common topic of conversation over lunch:I do not think there has been many lunch discussions about transition. […] I think that what one talks about from the outpatient clinic is the more rare clinical cases, not; that was a really good example of transition.There is a desire for more opportunities to discuss and exchange ideas about the program and to learn from each other. Those who belong to subspecialists perceived as model implementers also voice a need for more knowledge exchange and discussions. They too see flaws in their practice.Nevertheless, the participants perceive that a transition program and the focus on adolescent medicine has become lasting. Reasons for not having come further in implementation revolve mainly around two topics. First, the number of adolescents seen by the subspecialty:It is so much rarer within the field that I work, in comparison to others here at the outpatient clinic, that [we have someone who] will be transferred to adult services.The health professionals acknowledge that this is not an excuse for lack of focus on transition, but state that practice does make you better. The second main reason is caring for adolescents who will not transfer to one adult department. It is argued that some subspecialties have it easier, because their adolescents are all more or less walking along the same road to one clearly defined recipient. Because health professionals see their collaboration with the receiving adult service as highly central to the program, having no clear receiving service or having multiple receiving services in their opinion complicates matters.the amount of time allocated for a consultation and what topics one is able to raise in a very short amount of time.Time is a recurring topic in our analysis. First, time is problematized when it comes to When you are in a hurry, you are a bit afraid of opening up for things that you do not have time to follow up. So sometimes, you are a bit closed off [in your communication] on purpose.This concerns having time for a conversation on broader topics in that exact consultation, but also the potential time required to follow up topics raised by the adolescents:If you pose a question about something and you are preoccupied with something, to be trustworthy you have to set aside time to solve the problem that you ask the adolescent to present to you. I can’t pose a whole heap of questions that I know I do not have time to follow up.In other words, health professionals believe that if they had more time for each consultation they would be able to address more topics with the adolescents. Sometimes this refers to covering more topics from the program material. Other times it refers to covering topics they find to go beyond the material:What I think the transition program should have more of, both at the end and in the beginning. [Is] that one should focus not just on the purely medical [aspects], but also on being an adolescent.Yes. I do wonder how people are doing. I do. My problem is that I never have enough time to ask about it. The next patient is outside waiting. I wish I had the opportunity to. I am not afraid of talking about it.during consultations is problematized when it comes to being able to be more systematic so that all get an equal offer of the program. Yet, we found examples of subspecialties that have ‘made’ time without further ado. They schedule longer consultations for adolescents on a regular basis.There is a perception among the health professionals of a lack of time. A minority of the subspecialties have separate transition consultations. Most have to fit conversations about transition into an already packed consultation. Getting through the medical aspects thus takes priority. In other instances, time experience of being too short of time in general to be able to implement the program:The third issue to do with time is the But [I] experience it a bit like a lot of other things in a hospital where you have grand plans, and you put them into motion, and then you are done with it. Without having set aside extra time or us getting any resources or anything at all to enable us in the daily running. It is just another task that is to be done in the same amount of time as before. So I do not find it to be facilitated.In other words, time also ties into other resources such as number of designated staff, because it means enough time divided between enough people to follow through properly. Moreover, time is an issue when it comes to allocation of time in rooms that are appropriate for having conversations in private.the right time to start the program for the adolescents. The guideline states that the first phase of the program should start from around the age of 12. Some state that they have made adjustments from the original timeline.The fourth aspect of time involved discussions around what is When we started running the transition program it was meant to be from age 14. I experience that in practice it is too early. That they do not get too much out of it and find it a bit scary. So, we’ve waited till they’re 16 and then they have time alone with me first.Others state the opposite. That they currently do not start early enough and should have a goal to get started at the age of 12 as the guideline outlines.There is a general agreement that a main goal of the program is getting the adolescents prepared for what is to come in adult services:I think that amongst other things it is to ensure continuity from where the adolescent has received care in paediatrics to the adult department. And, of course to prepare the adolescent for what comes. There are quite large differences between paediatrics and adult care regardless of subspecialty.Health professionals see this as a strength of the program. Some also talk about ‘transition’ as synonymous with ‘being transferred’:I had almost never heard of transition before, in terms of transfer to the adult services.Knowledge and skills regarding their diagnosis and treatment are competences that are seen as central for the adolescents to be able to fend for themselves after being transferred and to make the transfer less of a shock. Medical management and knowledge about the diagnosis, how to book an appointment, and reorder prescriptions are emphasized by the participants. Furthermore, the participants stress the importance of making adolescents aware that these tasks are now increasingly their own responsibility.It is most important to make them cognisant. Cognisant of what their illness entails. Potential limitations, possibilities and cognisant of medication. The importance of taking them and how they work. That they learn why they need their medicine to stay well. And making them responsible, step-by-step.Aiding the adolescent to take over control of disease management and helping the parents to let go is a frequently raised topic.Our participants talked about topics they perceive to go ‘beyond medical management’. Frequently, they label these as ‘adolescence-specific topics’. This label refers to topics such as sex, alcohol, tattoos and further studies or vocational training. Some say that they frequently get questions about these topics. Others find the topics important to raise unprompted because these areas of life affect or are affected by the chronic condition of the adolescent.I think they find it important that we, that doesn’t really relate to the checklist though, but that we ask them about other things in life. That we are interested in them. Not just diseases and numbers. That is important. The checklist doesn’t really say too much about that.Topics that go beyond medical management are also topics that revolve around coping with an illness. Participants who raise this topic talk of a close collaboration with the CAMHS team. Others feel that this is a topic that is not raised enough.So that touches on coping strategies. How to live with [symptom]. If you cannot get rid of it completely, how do you live with it? We do have very little focus on that. On how to live with something. How to not get a hundred percent well but manage to live with things.Mainly two reasons are given for not bringing up these topics. One ties into the theme of time as they revolve around lacking the time to discuss topics beyond the medical. The second revolves around feeling one lacks knowledge and skills to be able to discuss such topics:There are probably some things that we could have worked on here as well. And some things we do. But often times I feel that I lack tools to land things with them here and put it to rest.In other words, some health professionals feel that they need a different set of skills to be able to raise certain topics with the adolescents.‘We are (back) at scratch’, ‘Time is always an issue’, ‘Getting them ready for what is to come–transition as a synonym to transfer’ and ‘Raising topics that go beyond medical issues’. We asked ourselves ‘what is going on here?’ can constrain and/or enable what it is relevant and appropriate to say (and think) in performing, describing, interpreting, or justifying the practice” [sayings, and they constrain or enable what is seen as relevant for the program both explicitly as in a shared language but also tacitly. The results from our analysis that show differences in the understanding of the programs goals fall under these arrangements. Paired with the results from our earlier analysis of the program material [et al. argue that:“For an intervention to have a credible chance of improving health or health care, there must be a clear description of the problem and a clear understanding of how the intervention is likely to work” [According to Mahon ractice” . In our material  we questto work” . Are we material-economic arrangements of a practice are resources that make possible or shape the doings in a practice. They are resources in physical space, human resources or financial resources [social-political arrangements, or relatings of the practice. It seems that not all health professionals feel that they have a mandate to make adjustments in the material-economic arrangements. This not only ties in to the social-political arrangements locally at our hospital but into the larger national debate on efficiency in health care.The esources . Our resThrough our analysis, we came to realise that even though our program is cross diagnostic, each subspecialty should be seen as a context of its own. According to the theory of practice architectures the site holds the practice in place . One couA text has multiple meanings , 29 and The results must be understood in light of the context(s) in which the interviews were performed. It is a strength of the study that all subspecialties and the two professions with main responsibility for the program are represented. We believe that this gave us a more complex picture.cultural-discursive arrangements. Efforts should be made to establish a more common understanding of what the main goals of the program are. This may be done through opening up spaces for discussions and exchange of thoughts about and experiences with the program. Each subspecialty should establish meeting places for such exchanges. Furthermore, we see a need for adjustments of how transition consultations are organised. Factors that influence implementation are strongly associated with time, more specifically, a lack thereof. This implies that changes to the material-economic arrangement are particularly called for, i.e., more time, space and staff to practice the transition program.Changes to a practice require changes to the practice architectures. Our analysis suggests a need for a more unified perception of the program goals, the


Participants in cardiac rehabilitation programs have low adherence to theirsessions, which makes extremely important to recognize the barriers thatcause non-adherence, identifying whether the type of service and level ofadherence influence these barriers.This is a cross-sectional observational study, in which 220 individuals(66.80±11.59 years) of both genders who are members of public andprivate exercise-based cardiac rehabilitation programs participated. Thevolunteers were divided according to the level of adherence, consideringpatients with low adherence (PLA) those with < 70% of attendance and highadherence (PHA) those with > 70%. Then, initial evaluation, CardiacRehabilitation Barriers Scale, analysis of socioeconomic level, HospitalAnxiety and Depression Scale, and Mini-Mental State Examination wereapplied.Higher total barriers were found in PLA in the public service compared to PHAin the private service (P=0.023). In the subscale “perceived need”, PHA inthe public service showed higher values than PLA and PHA in the privateservice (P≤0.001). The “access” barrier was higher for PHA in thepublic service when compared to PHA in the private service (P=0.024). PHA inthe public service exhibited a higher barrier regarding questions aboutdistance, transportation problems, cost, and time constraints.The public program presents higher barriers in the questions and categoriescompared to the private program, mainly the PHA. Furthermore, there aredifferences in the profile of the participants regarding socioeconomic andanxiety levels, treatment time, ethnicity, and city where they live. Besides, programs must be broad, simple, and low cost,these strategies being able to minimize the barriers found in this study.In this context, some strategies have been proposed to improve adherence to CR, suchas home rehabilitationAs limitations of the study, we point out the loss of participants due tologistical problems, as well as a smaller number of participants with lowadherence and belonging to the public program, which may have interfered withthe results. Furthermore, individuals were recruited from a specific region ofBrazil and from a public and a private program, which may not represent thereality of the entire country, due to cultural, socioeconomic, and programsoffering differences. However, the studies in the literature analyze only thebarriers and do not consider the level of adherence of the participants,highlighting the importance of considering this aspect since the participantspresent different barriers according to the level of adherence.Finally, we conclude that the main barriers observed in the analyzed programs were“total barriers”, “perceived need”, and “access”, mainly questions related to cost,distance, transportation problems, and time constraints, being the patients withhigh adherence in the public program those who present more barriers.Still, some general characteristics when evaluating the type of program and the levelof adherence show differences regarding ethnicity, socioeconomic and anxiety levels,city of residence, and treatment time.


To address health inequity and relieve shortage of rural doctors, China initiated Rural-oriented Tuition-waived Medical Education (RTME) to train doctors in rural areas for free since 2010. Little is known about job satisfaction of this particular group of rural doctors.Job Satisfaction Questionnaires for Village Doctors were distributed to 240 village doctors with RTME program in China, and 40 received in-depth semi-structured interviews. Descriptive analysis, chi-square test, univariate and multivariate logistic regressions in SPSS23.0 were conducted, and thematic analysis was applied to interviews.Job satisfaction rate of village doctors with RTME program was 56.50%. Full understanding of RTME policy, recognition of rural medical work, relevance of RTME curriculum with present job, education background, rural origin and renumeration were positively correlated with job satisfaction. Preferential policies of RTME program, relaxing working atmosphere, more promotion opportunity, and easier access to higher technical titles were the key factors to retain rural doctors.Our findings may interest healthcare authorities, medical colleges and primary healthcare establishments. Studying the job satisfaction of village doctors in China may also be beneficial in developing community and rural health services, and provide valuable insights into the training and retention of primary healthcare providers in other countries. Health equity has increasingly become one of the prominent objectives in health care reform in the world . ShortagOutline of the Healthy China 2030 Plan” promotes equalization of basic public health focusing on rural areas.As of 2021, China was the largest agricultural country in the world with 509.79 million rural residents, which accounted for 36.11% of the total population. It is essential to improve rural health services in China to deal with critical challenges. “The health workforce is the social and technical foundation of any health system , and theRural-oriented Tuition-waived Medical Education (RTME) program is one of them, which was initiated in 2010 to enroll students to study in designated medical schools for 3 or 4 years to pursue a diploma or a bachelor’s degree and then work in village hospitals for 6 years after graduation. In this programme, the medical students would sign a contract with the medical training college and local health administrative department. The government would waive the related tuition fee for the students and provide them with a certain amount of living allowance during their studies in designated medical schools. The RTME mainly recruits students with rural backgrounds who have reached the minimum passing score in college entrance exams and subsidizes their tuition to finish a 4-year medical undergraduate education or 3-year medical diploma education in colleges . In return, these RTME students must attend a 3-year or 2-year residency in general practice (GP), which is counted into the service period, and compulsorily serve in rural township health centers for a period of 3 to 4 years; that is 6 years in total. They can apply for township assistant practicing physician license 1 year after graduation and do real job as a physician.China has taken a series of measures to train and retain village doctors. The China Health Statistical Yearbook 2021, the number of village doctors in China has been on the decline since 2011, and there was a decrease of 205,000 village doctors in 2020 in comparison with that of 2016. Research Report of Living Conditions of Village Doctors, compiled by the Academy of Sciences of China in 2021, reported that men accounted for 70.8, and 96.04% village doctors expressed dissatisfaction towards the job. The fourth National Health Services Survey in China revealed that 12.2% village doctors had turnover intention, higher than that of urban doctors.Despite various efforts, according to Job satisfaction is defined as a personal positive subjective evaluation or attitude towards all aspects of a work environment . AssessmSimilar to Minnesota-Duluth Program in America, Jichi Program in Japan and CPIRD Program in Thailand, the RTME program has contributed substantially in training qualified general practitioners in rural areas in China, filled the gap of understaffed village hospitals and built a high-quality team of village doctors. However, studies on the RTME program are rather scant, mostly focusing on on-campus medical students with the RTME program in terms of curriculum design , professIt is of great significance to probe into the job satisfaction and its influencing factors of village doctors, and take corresponding measures to retain village doctors and achieve health equity. This study, by a mixed quantitative and qualitative method, focused on rural doctors in the RTME program in China, a national rural-oriented physician education policy to train primary care physicians free of charge to address the shortage of rural doctors, involving a 3-year study  in medical college, and 6-year service  in village hospitals. The participants invited in this study are those who have obtained township assistant practicing physician license.It aims to investigate the job satisfaction of rural doctors in the RTME program, and explore the influencing factors of job satisfaction of this particular group, thereby serving as reference for relevant authorities to optimize policies and provide individualized training, in order to maintain the stability of primary healthcare staff. It may also be beneficial in developing community and rural health services, and providing valuable insights into the training and retention of primary healthcare providers in other countries.A quantitative and qualitative design was used for this study. Stratified random sampling was used for quantitative study. Six cities in Anhui, China were selected, 3 counties in each city were selected, 3 towns in each county were selected, and at least 2 male village doctors were selected from each town. Altogether 240 village doctors graduating from the RTME program with diploma in medical science and working in village hospitals after graduation with township assistant practicing physician license, were chosen to fill out the questionnaires. Participant recruitment was carried out via WeChat, a social media platform in China, with a brief description of the study, necessary disclosures, and a direct link to the questionnaire in Wenjuanxing, an online survey application, after receiving approval from the health system’s review boards.t-test between the sub-sample and the full sample, and identified that there were modest significant differences in such variables as salary and educational background. Therefore, more participants were randomly added until there was no significant difference in main explanatory variables between these two samples and finally made a sub-sample of 40 interviewees.Semi-structured interviews were conducted online in order to get a better idea of the interviewees’ points of view about the questions in the questionnaire. To make sure the sub-sample statistics were not biased, we first randomly chose 4 interviewees from each cities, this made a sub-sample of 24 (4*6) interviewees. Then we conducted a Approval for this study was obtained from local health commissions (Decision no: 2021. 09. 30). Written informed consents were obtained from all the participants.α = 0.922; p < 0.05; KMO = 0.89).Job Satisfaction Questionnaires for Village Doctors, a well-received measurement tool that has been used in prior studies in China, was used in this study. It was developed by Doctor He Zhang in 2020 with satisfactory reliability and validity , educational background, length of service, etc. Second, comments on the RTME program and present job, including good understanding of relevant policies when enrolling in RTME, recognition of rural medical work, reasons for attending RTME, acceptance of required years of service in village hospitals, relevance of training provided in RTME with present job, willingness to recommend others to attend RTME, salary, main problems at work and future development. Third, job satisfaction, whose items are ranked on a 5-point Likert scale of which 1 is negatively stated (with 1 = strongly disagree to 5 = strongly agree). The higher the score, the more positive the job satisfaction.Why did you attend the RTME program?Will you recommend the RTME program to others? Why or why not?What do you think of the curriculum offered in the RTME program?What are the benefits of working in village hospitals?What are the main problems or difficulties of working in village hospitals?Will you continue working in the village hospitals when the contract expires? Why or why not?What suggestions do you have for the RTME program or to the medical students with this program?Three research group members with teaching experience or medical background did semi-structured interviews with 40 interviewees with an outline listed as follows:The data were collected from October 2021 to April 2022. Prior to data collection, all the participants were provided with informed consent and reminded of the right to withdraw during data collection. The link of the questionnaire was sent to all the participants via WeChat, a social media platform in China. Of the 240 village doctors in the RTME program invited to participate, 223 responded to the survey properly. Questionnaire-reclaiming efficiency was 92.91 percent.The final 40 interviewees were then invited to participate in a 30 min semi-structured interview one by one through Tencent Meeting, a popular social networking tool in China. All the interviews were recorded upon the interviewees’ approval.SPSS23.0 was used for data entry and data analysis. Statistical methods include descriptive analysis by means of constituent ratio, mean value and standard deviation; chi-square test to screen influencing factors; univariate logistic regression analysis into influencing factors; and multivariate logistic regression to identify independent influencing factors as a robust check. The qualitative data of semi-structured interviews were analyzed using thematic analysis: data transcription, initial coding, theme search, theme review and theme defining.Demographic characteristics of the respondents, 223 in total, are as follows: 189 (84.75%) village doctors in the RTME program have siblings; 207 (92.83%) are from rural areas; 139 (62.33%) have junior college diplomas; 162 (72.65%) doctors have worked in village hospitals for 2 to 4 years .The prominent problems at work were short age of medicine and equipment , and inadequate number  and quality  of medical staff. Doctors who clearly stated that they would stay in primary healthcare establishments when the contract expired only accounted for 31.84% (71 out of 223). Other preferred future career paths included seeking a position in large-scale hospitals , pursuing a master’s degree , and becoming a civil servant or a teacher  .The total score of job satisfaction of 223 village doctors in the RTME program was (22.28 ± 8.59). The top three variables were the job itself (2.64 ± 1.03), relationship with colleagues (2.41 ± 0.76) and work-related pressure (2.31 ± 1.01). Variables with the lowest score were salary and benefits (1.82 ± 0.83), social status (2.04 ± 0.87), and long-term engagement in primary healthcare (2.12 ± 0.89) . Job satp < 0.05)  . Whereasp < 0.05)  .p < 0.01)  . CompareThe following could be summarized through the interviews with 40 interviewees:Over 60 percent (25 out of 40) interviewees stated that schools should innovate curriculum design for the RTME training program. More medical courses in the rural context should be incorporated into curriculum, and clinical observations and internship in village hospitals should be arranged from time to time. Courses on professional identity and career planning oriented for rural medical work should be offered.One interviewee said that:Most of us attended this program because of lower entry requirement and free tuition. As far as I know, most of us have low professional identity, and do not want to be a village doctor. We have ever regretted or complained when we study in college or work in the village hospitals. You see, in college, we were grouped in a separate class, but we had exactly the same courses as other medical students. We had signed the contract and all of us had to work in the rural hospitals after graduation. The school should offer tailor-made courses focusing on rural settings to help us better adapt to the work in village hospitals, especially career planning courses and specialty courses.Seventy-five percent (30 out of 40) interviewees expected the RTME program to offer more preferential policies, especially in professional title assessment and further education, to doctors who have fulfilled the contract to work in village hospitals as stipulated.Over half of the interviewees (22 out of 40) said that they had such heavy workloads that they often felt exhausted and had no time to receive on-the-job training or do scientific research. In addition to basic healthcare to rural residents, they were required to undertake 11 public healthcare service, such as setting up health care records, health education, report and treatment of infectious diseases, and chronic disease prevention control.All the 40 interviewees expected that the salary and benefits could be further improved, and housing fund could be higher.Inadequacy of basic medicine and medical equipment was a common problem, which affected the diagnosis and treatment of diseases and hindered the improvement of medical skills.One male village doctor said that:I had met a Type II diabetic patient whose blood sugar could not be controlled well by oral medication, and insulin was highly recommended. But we had no insulin here, so, I couldn’t help the patient. Then, the patient had to go to municipal hospital. It made me feel frustrated.Approximately 78% (31 out of 40) of the interviewees stated that they would recommend others to join in the RTME program because of lower entry requirement, free tuition, and guaranteed employment. Graduates of the RTME program either have junior college diploma or a bachelor’s degree in clinical medicine. Generally speaking, it is hard for students without master’s degree to land a job as a doctor in hospitals in China. But this program provides a healthcare position for them.Before enrolling, it is suggested to know more about the RTME policies, village doctors’ duty and rural hospitals. While on the RTME training program in colleges, it is advisable for students to form a positive professional identity, make career plans and have a deeper understanding of future work as primary healthcare providers. In this way, they can better adapt to the job in village hospitals. More attention should also be paid to the improvement of interpersonal skills, learning how to communicate with rural residents effectively.One interviewee said that:I only got 348  in the entrance exam for colleges, and could only be admitted to a three-year vocational school. I have dreamed to be a doctor, but it is almost impossible to work as a doctor without a master’s degree in this competitive labor market. With the RTME program, I can study clinical medicine free of charge and become a doctor with a diploma only. So, I do think it is a fairly good chance.According to the respondents, continuous supports and preferential policies are the fundamental driving forces for them to continue working in village hospitals when the contract expires. Less competition and more promotion opportunity are important extrinsic factors. Sense of achievement is a primary intrinsic factor for the graduates of the RTME program to remain in rural areas. Salary is not considered to be closely relevant.The 2021 Statistical Yearbook issued by the National Health and Family Planning Commission of the People’s Republic of China reported that, in 2020, 0.3% of village doctors had a bachelor’s degree and 5.4% had a junior college diploma. Therefore, graduates of the RTME program are often thought highly by local hospitals and given more chances and attention, which in turn, contributes to the willingness to remain in village hospitals.One doctor who has worked for 4 years said that:Since I studied in the medical college, our teachers have introduced relevant preferential policies towards rural health care and general practitioners by the Chinese government. When I started working here, I have witnessed the great changes in village hospitals. More attention and chances have been given to us. So, I think support from the government will be one of the most important reasons for me to continue working here. I believe there will be better policies for village doctors in the future.Another doctor described:I love the atmosphere here a lot. In our hospital, we do not need to do research and write papers in order to get promoted in technical title. So we just need to focus on treating patients and improving clinical skills. This makes me feel good. My classmates who are working in the city are extremely stressful since there is fierce competition in technical title assessment. They have to work hard both in clinics and research. Therefore, I should say the relaxing atmosphere and favorable policy count a lot [sic].A newly-graduated doctor stated that:I am not sure whether I will stay here when the contract expires. But I can see the government is laying more emphasis on village hospitals. The working conditions are not quite good, but things are getting better. Actually, I like working here because of strong sense of achievement by helping local residents relieve pain with limited medicine and medical equipment. What’s more, there is lower requirement in professional title assessment for us, such as years of service, research projects or papers. Maybe right now the salary is not very high, but as we work longer and have higher professional title, we can earn more. So, considering sense of achievement, professional title promotion and development potential, most probably I will stay here.This study sought to provide insights into job satisfaction of village doctors in the Rural-oriented Tuition-waived Medical Education (RTME) program in China. Our findings highlighted four themes:Male village doctors with a rural origin reported higher job satisfaction in this study. A great deal of evidence has suggested that health workers with a rural background are more willing to work in rural areas . SimilarThis study reported that better understanding of the RTME was correlated with higher job satisfaction. Those who were fully aware of relevant policies of the RTME program only accounted for 15. 70% (35/223) were not aware, which indicated a relatively poor understanding and acceptance of the RTME program.Previous studies have identified that intrinsic motivation, i.e., the desire to do something for its own sake , can havIt is suggested that relevant authorities should strengthen publicity through various channels, explaining and interpreting RTME policies, training scheme, primary healthcare, rural medical work, payment and possible career paths in details. Then the students can make more rational decisions to choose the RTME program due to enthusiasm about primary health care, which may contribute to higher job satisfaction and retention rate.Prior studies  reportedIncentive Mechanism for the Training and Use of General Practitioners, issued by the State Council of China in 2018, has mandated competitive remuneration and salary reform. But it takes time to fully implement these policies nationwide.To improve job satisfaction, measures to increase the retention of the village doctors with RTME rather than simply recruiting them should be given greater attention , for insAs indicated in the investigation, the relevance of school training provided in RTME with present job was positively correlated with job satisfaction. The semi-structured interviews revealed that there was a lack of career planning and clinical courses specially designed for rural settings, and inadequacy of observations and internship in rural hospitals, which made these medical students in the RTME program have low professional identity and find it hard to adapt to the job in the very beginning. Improving the educational scheme in the medical college is conducive to the students’ job satisfaction and intention of remaining in rural areas when the contract expires.Efforts should be made to build on intrinsic motivation  during medical training . CollegePrevious research identified that the curriculum design for RTME program was not reasonable and practical. Most colleges put students in the RTME program in one class, having lessons separately. But there were no tailored courses for them. One to 6 months’ internship was arranged in community hospitals instead of village hospitals. So, many graduates found it hard to adapt when they started working in the countryside . RelatedThrough investigations into village doctors in the Rural-oriented Tuition-waived Medical Education (RTME) program in China, the pivotal members in primary health care teams, it was revealed that 56.50% (126/223) of the village doctors in the RTME program were satisfied with rural medical work. Doctors with good understanding of RTME policies and high recognition of rural medical work had the highest satisfaction; doctors whose school training provided in RTME was relevant to present job also had a higher level of satisfaction; similarly, doctors with rural origins and high salary reported a higher level of satisfaction. Relevance of school training provided in RTME with present job and place of origin were the independent influencing factors.Based on in-depth interviews, preferential policies of RTME program, relaxing working atmosphere, more promotion opportunity, and easier access to higher technical title were the key factors for the graduates with RTME program to remain in rural areas. Renumeration was not considered to be closely relevant in terms of retention.This study has a number of implications. First, the RTME program should attract and enroll more medical students with rural background due to the significant association between job satisfaction in village hospitals and rural origin. Second, RTME training should be optimized by providing tailor-made curriculum relevant to primary healthcare, offering individualized career planning courses for village doctors and arranging longer exposures to village hospitals during internships, in order to cultivate the ability to perform rural medical work, improve the cognition of the value of rural medical work and elevate professional identity of village doctors. Third, authorities are expected to offer supportive mentorship system and preferential policies, especially in terms of professional title assessment and continuing education.Since the RTME program was initiated nationwide from 2010, the number of graduates was not large enough. This study focused on village doctors with RTME program in Anhui, China only, so the samples were relatively small and limited. In addition, telemedicine counseling was used during the COVID-19 pandemic, which might have an effect on job satisfaction. The questionnaire in this study, a well-received measurement tool that has been used in prior studies in China, did not include this factor. We expect that future research can fill in these gaps. It is recommended that more research should be done to a broader range of primary health care providers. Additional studies among rural doctors of this particular group can be conducted with a larger sample size. Second, a longitudinal study is highly recommended to analyze the causal effects of birth place, understanding of RTME policy, salary and curriculum design of RTME training on job satisfaction. The interactive effects between explanatory variables should be further deeply explored. Third, the need for tailored courses for rural doctors has been advocated, therefore institutions can develop curriculum and mentorship program accordingly, which is an open area for further research.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by health commission of Anhui Medical College (Decision no: 2021. 09. 30). The patients/participants provided their written informed consent to participate in this study.YC designed, conducted the research, and wrote the paper. RJ analyzed the data and did the proofreading. All authors contributed to the article and approved the submitted version.The authors disclosed receipt of the following financial supports for the research, authorship, and/or publication of this article: This work was supported by Anhui Ministry of Education [grant number SK2021A0884], the National Office for Philosophy and Social Sciences of China [grant number 21BGL072], Anhui Social Science Foundation [grant number AHSKXZX2020D01], Anhui Ministry of Education [grant number 2020mooc243].The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Perinatal Mood and Anxiety Disorders and Substance Use Disorders are common and result in significant morbidities and mortality. Despite evidence-based treatment availability, multiple barriers exist to care delivery. Because telemedicine offers opportunities to overcome these barriers, the objective of this study was to characterize barriers and facilitators to implementing a mental health and substance use disorder telemedicine program in community obstetric and pediatric clinics.Interviews and site surveys were completed with practices engaged in a Women’s Reproductive Behavioral Health Telemedicine program  at the Medical University of South Carolina and telemedicine providers involved in care delivery (N = 4). Using a structured interview guide based on implementation science principles, we assessed program implementation experiences and perceived barriers and facilitators to implementation. A template analysis approach was used to analyze qualitative data within and across groups.The primary program facilitator was service demand driven by the lack of available maternal mental health and substance use disorder services. Strong commitment to the importance of addressing these health concerns provided a foundation for successful program implementation yet practical challenges such as staffing, space, and technology support were notable barriers. Services were supported by establishing good teamwork within the clinic and with the telemedicine team.Capitalizing on clinics’ commitment to care for women’s needs and a high demand for mental health and substance use disorder services while also addressing resource and technology needs will facilitate telemedicine program success. Study results may have implications for potential marketing, onboarding and monitoring implementation strategies to support clinics engaging in telemedicine programs.The online version contains supplementary material available at 10.1186/s12884-023-05463-2. Perinatal Mood and Anxiety Disorders (PMAD) and Perinatal Substance Use Disorders (PSUD) are common and carry significant morbidity and mortality for women and children. Estimates vary but approximately 16–25% of women will experience PMAD . Recent Fortunately, treatments such as evidence-based psychotherapy and medication are effective in reducing the maternal and child morbidity and mortality associated with PMADs and PSUDs , 18. HowDelivering treatment for PMAD and PSUD to pregnant and postpartum women in obstetric and pediatric practices via telemedicine is one potential solution to overcoming barriers and increasing access to treatment for women. However, telemedicine service delivery can pose an additional set of implementation challenges including the need for dedicated space, equipment and staff to assist with telemedicine visits in community clinics. Using qualitative methods, the objective of this study was to characterize the barriers and facilitators to implementing a telemedicine program for the treatment of PMADs and PSUDs in obstetric and pediatric providers in the outpatient community practice setting.The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used to guide methods and reporting . QualitaSix practices were selected for this study based on their geographic location, lack of access to services and variability in the number of telemedicine referrals completed. Data were collected from July 2019 to February 2020. The Medical University of South Carolina’s Institutional Review Board approved this study and granted a waiver of written informed consent [Pro # 00086783]. Verbal consent was secured and participants received a $10 giftcard.The Exploration, Preparation, Implementation, Sustainment (EPIS) framework was used to guide this study , 24. ThiEach selected WRBT clinic’s practice manager was contacted by email and phone to discuss the study. All practices contacted were willing to enroll and the practice manager completed an online survey to assess practice characteristics  and telemedicine referrals . Additionally, practice managers selected clinic team members currently involved in and most knowledgeable about the telemedicine program to participate in online discussion groups or interviews based on preference and availability. Online groups were conducted over Zoom with video and audio for convenience in the busy clinical setting. Finally, the MUSC clinicians and staff from the WBRT program (referred to below as the WRBT telemedicine team) completed in-person discussion groups on-site at the academic medical center.Two female interviewers  with doctoral-level training in qualitative methods moderated discussion groups using a structured interview guide informed by EPIS Table . InterviA combined inductive-deductive template analysis approach , 28 withFive online discussion groups and 1 online interview were conducted with obstetrics (n = 4) and pediatric n = 2) practices . All participants were female and the average time in the telemedicine program was 3.25 years (range 2–4).As displayed in Fig. Participants from clinics and the WRBT telemedicine team described that service demand for women’s mental health and substance use disorder treatment was high in rural areas and this acted as a primary facilitator of clinic interest in and willingness to implement the program. All participants described the urgent need for mental health and substance use disorder care in clinic locations as patients lacked access to specialists. While the majority of clinics had mental health screening protocols in place for pregnant and postpartum patients, and obstetrics clinics often also screened for substance use, limited access was available to counselors and treatment as follow-up. Patients needing services therefore had lengthy wait times and often also lacked transportation to specialists. In addition, teams from pediatric practices specifically noted additional complexities with referrals because mothers were technically not their primary patients and best practices for referrals were unclear. Thus, the demand for the telemedicine program was high and valued due to its ability to reduce obstacles to care for their high-risk patients.Obstetric and pediatric practices brought varied structural characteristics to the WRBT program. Clinics differed in size, number of providers and location, and the telemedicine team described that these factors either promoted or hindered the clinic’s capacity to complete telemedicine steps. Specifically, high patient volumes and limited staffing acted as barriers that deterred telemedicine program adoption. However, many clinics already had pre-existing processes in place for screening women at designated timelines for mental health and substance use challenges that could be adopted to identify potential referrals for the telemedicine program. In addition, clinics with previous telemedicine experience in other areas  described comfort with referral processes and management of appointments for the new program.As described in the While the majority of clinics described a clear commitment to caring for women’s well-being that guided their practices, despite these common norms and values across clinics, the telemedicine team uniquely highlighted a practice-wide resistance to addressing mental health and substance use disorder in some clinics. The telemedicine team described that this resistance existed either because clinics did not consider mental health and substance use as problems in their patients or instead because this was not their responsibility. The telemedicine team confirmed that this resistance was a persistent challenge in some clinics as they attempted to implement the program. In fact, one clinic continued to send patients to the academic medical center for mental health care even when the telemedicine program was available on-site in this clinic.Resources clinics devoted to the telemedicine program varied and impacted program delivery. Critical program resources included dedicated space and staffing and deficits in these areas impacted abilities to carry out the WRBT program. In clinics lacking a designated space for telemedicine visits, participants described the challenge to accommodate visits within current busy schedules. Likewise, having a dedicated staff member to oversee the telemedicine program appeared to facilitate program productivity. A specific need was highlighted for information technology (IT) staff to help troubleshoot technology or connection issues and when this was lacking on-site, this was frustrating for clinic and telemedicine staff. The WRBT telemedicine team also perceived that some clinics had or made time to prioritize the program and integrate it into existing workflow, but others were overwhelmed with competing demands and lacked resources to facilitate efficient implementation of the program. A recommendation for improving feasibility of the program integration and referral process included streamlining the registration process so patients could complete paperwork during the initial in-person clinic visit.Only the WRBT telemedicine team described leadership within the clinic as key to program implementation. They believed that program implementation went smoothly when one enthusiastic leader emerged naturally and helped disseminate program details, engage others in the practice and facilitate completion of planning, set-up and scheduling steps. In contrast, those clinics that lacked a solid WRBT program leader tended to lack productivity in scheduling and completing visits or were on a slower overall timeline for program implementation. In some cases, even when an enthusiastic clinician was clearly identified, this did not result in successful implementation if follow-through or detailed planning to fit the program into clinic workflow was lacking.Teamwork among clinic providers and staff was endorsed as important but just from the perspective of the WRBT telemedicine team. They reported that teamwork was often lacking in clinics that struggled with implementation. Specifically, when clinic teams were well coordinated around the technology and program workflow, they functioned better. Strategies that appeared to build teamwork included taking time to bring staff together to complete training, ensuring all team members were knowledgeable about program delivery steps and troubleshooting missed steps and challenges encountered.As telemedicine programs were implemented, positive attitudes about the program in team members appeared to play a role in promoting the program. This was evident most prominently when clinic team members described the program as a valuable resource that met their patients’ needs due to their deep commitment to supporting mental health and substance use challenges. Positive attitudes were also evident when clinic teams highlighted the convenience and feasibility of the program. In addition, a pediatrics office disclosed that they while were initially concerned about ongoing responsibility for mothers who were referred to the program, with an increased understanding of program logistics and understanding that their primary responsibility was to identify women and submit referrals, their concerns diminished.Clinic and WRBT telemedicine team participants also reported that patients were uniformly satisfied with the program and appreciated the ability to acquire appointments quickly and conveniently. A few clinics described positive attitudes about the program after observing the improvement in patient outcomes when women received telemedicine services. These improvements included clinical outcomes  as well as overall well-being. One pediatric clinic specifically explained the positive effects of mental health treatment for mothers and its impact on interactions with their infants.The partnerships established between the WRBT telemedicine team and clinics varied with some practices working closely with the telemedicine team in a fluid manner and others never establishing trusted relationships. The telemedicine team described that it was critical to build relationships with clinic stakeholders to facilitate understanding of the service and build enthusiasm for the program and its potential benefits. The telemedicine team also outlined the ideal plan for connecting with the full clinic team involved in program delivery but often expressed challenges in completing these steps due to scheduling concerns along with their own staffing shortages to travel and support on-site education. Education was centered on enhancing clinic understanding of workflows to screen, refer and schedule patients. Some clinics described the need for reminders and patient-facing materials.When strong partnerships were built, clinics described positive communication practices and that it was easy to contact the telemedicine team and access resources from them. The telemedicine team appreciated a flexible approach during ongoing program operations. However, they also described that they did not connect with all clinics in this way. They struggled in developing productive implementation processes in some clinics due to the lack of time and resources at these sites.To our knowledge, this is the first study to describe barriers and facilitators to implementation of a telemedicine service in obstetric and pediatric clinics for the treatment of PMADs and PSUDs in pregnant and postpartum women. The findings mirror a number of the barriers and facilitators identified in the delivery of telemedicine care in general and in community health centers, highlighting cost, technology, staffing and workflow issues , 31. HowThis study demonstrates that the primary program facilitator was demand for services, which was driven by a lack of available or accessible maternal mental health and substance use disorder services for pregnant and postpartum women. Other key facilitators, consistent with existing literature, included the need for infrastructure to support the service including dedicated space, equipment, IT support and staff to facilitate patient scheduling and visits , 31. WhiStudy results may have implications for potential implementation strategies such as marketing, onboarding and monitoring approaches to support clinics engaging in a telemedicine program for PMADs and PSUDs –34. For While the strengths of this study included the use of qualitative methods guided by a validated implementation science framework to allow an in-depth exploration of implementation experiences, there are limitations to consider. The study was modest in size with 6 practices and only 1–6 participants per clinic. Even though we used rigorous interviewing techniques and selected participants based on their role in the telemedicine program, this may not reflect the full range of experiences and perceptions at sites as a whole. Also, this study captured clinics at one timepoint and therefore does not capture the dynamics of implementation over time. We chose to conduct online discussion groups with clinics for convenience and this mode may have impacted the level of rapport we were able to build with participants. Finally, as the telemedicine programs launched the WRBT program at different timepoints, this may have impacted participant recall of important start-up implementation processes. Specifically, participants may have had trouble remembering early planning meetings and barriers and facilitators of that process; therefore future prospective methods may supplement our findings by assessing barriers and facilitators over the course of program implementation.Access to maternal mental health and substance use disorder treatment for pregnant and postpartum women is paramount in reducing the alarmingly high rates of PMADs and PSUDs and the associated morbidity and mortality associated with these untreated conditions. The use of telemedicine to achieve this end is feasible, acceptable to women and effective in reducing mental health symptoms and substance use , 36, 37.Below is the link to the electronic supplementary material.Supplementary Material 1: Peer review report.


A cost analysis of comprehensive HIV services for key populations at higher risk of infection in Kenya and Malawi showed that costs can be substantial at all program implementation levels, not just service delivery; all these costs should be considered during program planning. Activities done at the headquarters and country office levels, as well as community outreach activities to engage key populations (KPs), comprised substantial proportions of total costs, suggesting that focusing on the costs of service delivery alone will likely underestimate the total costs of delivering HIV services to KPs.This analysis highlights the heterogeneity in costs and cost structure between Kenya and Malawi, illustrating the importance of differences in country contexts, needs, service delivery infrastructures, and capacities in influencing costs.These findings are consistent with the complexity of comprehensive KP HIV services; the levels of stigma, discrimination, and violence against KPs; and the support and oversight needs of implementing organizations.Costing studies of HIV services for KPs should consider all activities conducted at all levels of program implementation.Resource needs assessments, budgeting exercises, and ultimately, funding allocations for KP HIV services in low-resource settings that only rely on service-level costs are based on flawed cost estimates. Timely data on HIV service costs are critical for estimating resource needs and allocating funding, but few data exist on the cost of HIV services for key populations (KPs) at higher risk of HIV infection in low- and middle-income countries. We aimed to estimate the total and per contact annual cost of providing comprehensive HIV services to KPs to inform planning and budgeting decisions.We collected cost data from the Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) program in Kenya and Malawi serving female and male sex workers, men who have sex with men, and transgender women. Data were collected prospectively for fiscal year (FY) 2019 and retrospectively for start-up activities conducted in FY2015 and FY2016. Data to estimate economic costs from the provider’s perspective were collected from LINKAGES headquarters, country offices, implementing partners (IPs), and drop-in centers (DICs). We used top-down and bottom-up cost estimation approaches.Total economic costs for FY2019 were US$6,175,960 in Kenya and US$4,261,207 in Malawi. The proportion of costs incurred in IPs and DICs was 66% in Kenya and 42% in Malawi. The costliest program areas were clinical services, management, peer outreach, and monitoring and data use. Mean cost per contact was US$127 in Kenya and US$279 in Malawi, with a mean cost per contact in DICs and IPs of US$63 in Kenya and US$104 in Malawi.Actions undertaken above the service level in headquarters and country offices along with those conducted below the service level in communities, comprised important proportions of KP HIV service costs. The costs of pre-service population mapping and size estimation activities were not negligible. Costing studies that focus on the service level alone are likely to underestimate the costs of delivering HIV services to KPs. There is a growing body of literature on the costs of HIV services for general populations in low- and middle-income countries.To allocate HIV resources efficiently and manage HIV programs effectively, funders and implementers require accurate and timely data on HIV service costs.,,,,–,,–The dearth of information on costs of comprehensive HIV services for KPs in low-resource settings is partly explained by the scarcity of well-documented HIV services for KPs in these locations and by their complexity.The Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) program aimed to reduce HIV transmission among KPs and improve their enrollment and retention in care and treatment services in countries in Africa, Asia, and the Caribbean. The program was funded by the U.S. Agency for International Development through the U.S. President’s Emergency Plan for AIDS Relief from 2014 to 2021. FHI 360 administered LINKAGES in collaboration with Pact, IntraHealth International, and the University of North Carolina at Chapel Hill. In each country, operationalization of LINKAGES comprised an initial start-up phase consisting of pre-service delivery activities. Subsequently, a comprehensive package of KP HIV services was scaled up. Many of the activities scaled up as part of LINKAGES are now supported by the Meeting Targets and Maintaining Epidemic Control (EpiC) project funded by the U.S. Agency for International Development through the U.S. President’s Emergency Plan for AIDS Relief.This study aimed to estimate the total and per contact annual cost of providing comprehensive HIV services to KPs in Kenya and Malawi to inform planning and budgeting decisions. We show cost estimates for the LINKAGES program in the 2 countries during U.S. Government fiscal year (FY) 2019 . Because the activities of the start-up phase are indispensable to the delivery of effective comprehensive KP HIV services, we also present the estimates of the costs for pre-service delivery population mapping, size estimation, and program planning activities conducted in FY2015 and FY2016 in Malawi and FY2016 in Kenya. Unlike most existing work on costs of KP HIV services in low-resource settings, we derived cost estimates using a costing approach that considered all activities undertaken in the LINKAGES program at all levels of program implementation—at the service level, above the service level in headquarters and country offices, and below the service level in communities.Kenya and Malawi were purposively selected in consultation with program implementers. Both countries have generalized epidemics with concentrated sub-epidemics among KPs.Supplement Figure S1). High-level program guidance and technical assistance were provided by LINKAGES program headquarters. In each partner country, a LINKAGES office provided program management and technical support. Services were delivered to KPs by local community-based organizations, including KP-led organizations, referred to as implementing partners (IPs). The LINKAGES program provided IPs with funding, capacity-building, program guidance, and technical assistance to enable them to provide a minimum package of comprehensive HIV services to the KPs they served. Services were delivered in communities through outreach activities and at drop-in centers (DICs)—sites where KPs received HIV services, met with peers, and conducted social and community mobilization activities. The specific KPs served and the range of services offered varied somewhat by DIC. In Kenya, DICs provided services to FSWs, male sex workers, and MSM; in Malawi, DICs provided services to FSWs, MSM, and TGW.LINKAGES program activities were executed at several implementation levels . All the programmatic work and technical assistance necessary for implementing comprehensive KP HIV services were organized along these program areas and elements. Global guidance informed the selection of services included in the LINKAGES service package.,––,The LINKAGES program comprised 7 core program areas: (1) engage KPs in population size estimation, mapping, and program planning; (2) KP empowerment and engagement; (3) structural interventions; (4) peer outreach; (5) clinical services; (6) program management; and (7) monitoring and data use. These core program areas were further divided into program elements, detailing the interventions implemented . In Kenya, we included all IPs and DICs that were part of the LINKAGES program in FY2019. In Malawi, we excluded 1 IP (and its DICs), given disagreements between FHI 360 and the IP at the time of the study, which ended in contract termination.The study sample reflected the multilevel LINKAGES program implementation structure. The sample comprised LINKAGES program headquarters; 2 LINKAGES country offices (1 per country); 18 IPs in Kenya and 2 in Malawi; and 30 DICs in Kenya and 15 in Malawi . To describe the ongoing activities undertaken at the service level in IPs and DICs and above the service level in headquarters and country offices, we developed costing frameworks for both countries for FY2019.We developed costing frameworks for each country to capture the activities at all implementation levels and ensure complete costing of the LINKAGES program.To complete the activities sections of the frameworks, we extracted each activity from country work plans, mapped it to the LINKAGES core program area and program element to which it contributed, and identified the level of program implementation: LINKAGES program headquarters and country offices, IP/DIC, and community. We defined start-up activities as those implemented early in the program’s life cycle that lay the groundwork for service delivery . These start-up activities included actions undertaken related to planning, mapping and population size estimation, staff recruitment, staff training, materials and systems development, infrastructure expansion, and the formulation of legal agreements. To complete the inputs sections of the frameworks, we extracted data on the resources required to conduct each activity from the work plans. To fill in the outputs section of the frameworks, we extracted outputs from indicator matrices incorporated in the country work plans. We mapped each output to the relevant LINKAGES program core area and program element and to the level of program implementation at which the output was produced. The frameworks were reviewed and validated by staff in LINKAGES program headquarters and in the LINKAGES country offices of Kenya and Malawi.The ethical review board of the National Institute of Public Health, Mexico, approved the study (CI: 1554). Informed consent was not required for this study, which did not involve human subjects research.Supplement Table S1). We collected monthly data on inputs irrespective of funding source. Corresponding output data were obtained from databases in IPs and DICs. We collected information on time spent on each of the 7 LINKAGES program areas from staff in country offices, IPs, and DICs.This costing study was implemented following the guidelines of the Global Health Cost Consortium.Costs were estimated from the provider’s perspective . We estimated economic costs, which consider the value of all resources used, including those for which there was no financial transaction, such as donated male and female condoms. Annual costs were estimated for FY2019. Our cost estimates also include start-up costs. Start-up and capital costs were annualized using a discount rate of 3% and assumed to have a useful life of 10 years.Supplement Table S2). LINKAGES headquarters and country office costs for FY2019 were distributed equally across DICs, assuming that all DICs received the same level of support from headquarters and country office staff. The start-up costs for FY2019 were apportioned equally across DICs.We calculated the above service level (headquarters and country office) and pre-service (start-up) costs and allocated them across DICs (Supplement Table S2). To estimate the costs at the DIC level for clinical supplies, staff, peer workers, other recurrent inputs, and equipment, we multiplied the quantity of inputs used with their prices, which were collected through our data collection tool. Total LINKAGES program costs per DIC were obtained by summing the headquarters and country office allocations to DICs with IP and DIC costs.We proceeded as follows for service level (IP and DIC) costs. For the 13 IPs in the sample with only 1 DIC, we allocated all IP costs to the corresponding DIC. For the 7 IPs with multiple DICs, the allocation approach used depended on the input. We distributed IP costs for staff, other recurrent inputs, and equipment proportionally across DICs. Transportation and training costs, which were available only at the IP level, were distributed across DICs based on service level staff time weights (Supplement Table S3). Program area staff time weights were used to allocate headquarters, country office, and start-up costs to the 7 program areas. The costs of IP/DIC equipment and other recurrent inputs were also allocated to the 7 program areas based on program area staff time weights. DIC costs for clinical supplies, staff, peer workers, and IP/DIC costs for transportation and training were apportioned to the 7 program areas using the detailed information on the share of these inputs allocated to program areas collected through our data collection instrument.To reflect LINKAGES program implementation, we disaggregated total DIC costs by core program area . We usedBOXLINKAGES Core Program AreasEngage KPs in population size estimation, mapping, and program planningKP empowerment and engagementStructural interventionsPeer outreachClinical services, including condom and lubricant promotion and distribution, sexually transmitted infection services, pre-exposure prophylaxis, post-exposure prophylaxis, HIV testing services, antiretroviral therapy, sexual and reproductive health services, and management of sexual violenceProgram managementMonitoring and data useUnit cost per contact was calculated for each DIC by dividing DIC total costs by the total number of contacts made by each DIC in FY2019. A contact was defined as an individual contacted by the LINKAGES program through individual or small group HIV prevention interventions . No data were available on unique individual contacts made.All costs are presented in 2019 U.S. dollars (US$). Country costs for FY2019 were converted from local currencies to U.S. dollars using midyear exchange rates for 2019 . Headquarters costs were reported in 2019 U.S. dollars. Start-up costs for FY2015 and FY2016, which were reported in U.S. dollars, were inflated to 2019 U.S. dollars.The total economic cost of LINKAGES program start-up activities in Kenya was US$1,648,460, with 24% spent at headquarters, 46% spent at the country office, and 30% disbursed as subawards to IPs in the country . In MalaThe total economic cost of the LINKAGES program in FY2019 in Kenya was US$6,175,960, with 34% spent above the service level at headquarters (12%) and at the country office (22%) and 66% spent at the service level in IPs and DICs . In MalaIn terms of the costs per LINKAGES program area, clinical services, management, peer outreach, and monitoring and data use were the costliest program areas in Kenya. Above the service level, the costliest program areas were management, monitoring and data use, and clinical services. At the service level, clinical services, peer outreach, and management were the program areas that incurred the highest costs.The costliest program areas in both countries were clinical services, management, peer outreach, and monitoring and data use.The distributions were similar in Malawi, where overall, clinical services, management, peer outreach, and monitoring and data use were the costliest program areas. Above the service level, management, clinical services, peer outreach, and monitoring and data use incurred the highest costs compared to clinical services, management, peer outreach, and monitoring and data use at the service level.Supplement Table S4. Condoms and lubricants and ART drugs were the 2 clinical inputs incurring the highest costs in both countries.Supplement Table S5. Unfortunately, our sample size does not allow for statistical analysis of the differences in cost across the different kinds of DICs in each country. Though mean unit costs in DICs serving MSM and MSM/TGW may be higher, this is likely driven in large part by the smaller numbers of persons contacted compared to DICs serving other populations.In this descriptive analysis of the costs of KP HIV services delivered by the LINKAGES program in Kenya and Malawi in FY2019, we considered all program elements and all levels of program implementation. Our estimates of total economic costs for both countries underscore that (1) actions undertaken above the service level at headquarters and the country office and work done in the community to reach and engage KPs comprise important proportions of costs and (2) the costs of pre-service activities are not negligible. In Kenya, above service level costs made up 34% of costs, while in Malawi, they constituted 58%. Whereas clinical services comprised 39% of total costs in Kenya and 28% in Malawi, outreach activities made up 13% of costs in Kenya and 15% in Malawi. The costs of start-up activities prorated over 10 years made up 3% of FY2019 costs in Kenya and 8% in Malawi. Our findings suggest that studies focusing only on service-level costs are likely to underestimate the costs of delivering HIV services to KPs. Our findings are consistent with the complexity of comprehensive HIV services for KPs; the levels of stigma, discrimination, and violence against KPs in Kenya and Malawi further adding to this complexity; and the support needed by implementing organizations to operate effectively, including program management support, technical assistance, training, and oversight from above the service level.Our findings suggest that studies focusing on service-level costs are likely to underestimate the costs of delivering HIV services to KPs.,Our analysis also highlights the heterogeneity in costs and cost structure between the 2 countries. Mean unit cost per contact was lower in Kenya than it was in Malawi. In general, organizations in Kenya delivered significantly more services than those in Malawi, and these differences in service volumes likely play an important role in cost differences between the 2 countries. In addition, some of the difference in cost was because of the higher start-up, headquarters, and country office costs in Malawi. Country contexts and needs differ, and the nature and capacity of community-based organizations also vary within and between countries. The LINKAGES program established the DICs operating in Malawi as none existed previously, while in Kenya, the program worked with already existing DICs. Therefore, service delivery sites in Kenya were older and more robust than those in Malawi and likely required less headquarter and country office support to provide services. Summaries of LINKAGES program achievements in Kenya and Malawi also suggest that the program in Malawi may have had a larger portfolio of above service level activities playing key roles in national HIV policy and guideline development.We also found differences in the costs and cost structure across DICs within each country and across DICs associated with the same IP. Some of the difference may be because of variations in the KPs served and services provided, but much of the heterogeneity in costs across DICs is likely associated with differences in the volume of contacts. In addition, variation in costs across DICs is also likely to represent differences in the efficiency of service delivery. We will explore the determinants of cost differences across DICs in future work.We are aware of only 1 other study that examined the costs incurred by a comprehensive HIV program for KPs at the various program implementation levels. A cost analysis of the Avahan program in India that provided services to FSWs, MSM, and TGW also considered the full above service level costs of program implementation.,A major strength of this study is that our analysis was a comprehensive evaluation of the costs of HIV services for KPs. Using detailed costing frameworks, we considered all activities undertaken in the LINKAGES program, including the start-up activities essential to the effective implementation of a comprehensive KP HIV program that were conducted before service delivery began. We also considered all levels of LINKAGES program implementation. This study is also among only a few studies conducted on the costs of HIV services for KPs in sub-Saharan Africa in recent years.Several limitations should be kept in mind when considering our findings. We used routine monitoring data to capture information on outputs, and the level of detail, quality, and completeness of these data varied. Although the LINKAGES program had a reasonably robust system for data reporting and verification, under-reporting of results would cause an overestimation of unit costs, and over-reporting would lead to an underestimation of costs. Documentation of donated goods also varied across IPs and DICs, and although we tried to capture these goods adequately, some misreporting of in-kind contributions is possible. While detailed micro-costing methods were used to assess costs in IPs and DICs, we used top-down methods to estimate above service level costs and allocate them to DICs and program areas. The allocation of above service level costs was based on assumptions and weights based on staff effort, but detailed time allocation information was not collected from headquarters staff.This study of the costs of comprehensive HIV services for KPs in Kenya and Malawi underscores the need for costing studies of HIV services for KPs to consider all activities provided at all levels of program implementation. Policymakers, planners, and implementers working on resource needs estimates, budgeting exercises, and funding allocations for HIV services for KPs should know that non-service level costs associated with KP HIV service delivery are considerable and ensure that these are considered.


The results showed higher catalytic activity for the laccase-immobilized LAC@HZIF-8 prepared using different methods than for the LAC@MZIF-8 sample, with 80% of 2,4-DCP removed under optimal conditions. These results could be attributable to the multistage structure of HZIF-8. The LAC@HZIF-8-D sample was stable and superior to LAC@HZIF-8-P, maintaining a 2,4-DCP removal efficiency of 80% after three recycles and demonstrating superior laccase thermostability and storage stability. Moreover, after loading with copper nanoparticles, the LAC@HZIF-8-D approach exhibited a 2,4-DCP removal efficiency of 95%, a promising finding for its potential use in environmental purification.Porous materials such as metal–organic frameworks (MOFs) are considered to be suitable materials for immobilizing enzymes to improve their stability. However, conventional MOFs reduce the enzymes' catalytic activity due to difficulties with mass transfer and diffusing reactants after their micropores are occupied by enzyme molecules. To address these issues, a novel hierarchically structured zeolitic imidazolate framework-8 (HZIF-8) was prepared to study the effects of different laccase immobilization approaches such as the post-synthesis (LAC@HZIF-8-P) and  Porous materials such as metal–organic frameworks (MOFs) are considered to be suitable materials for immobilizing enzymes to improve their stability. However, current immobilized enzyme carriers exhibit shortcomings such as uncontrollable pore size, high preparation costs, enzyme leaching, poor product stability, and reduced enzyme activity.13–15 However, metal–organic frameworks (MOFs) have attracted greater attention due to their high specific surface area and pore volume, their designable and controllable structure, and their chemical and thermal stability.16–19Biological catalysis provides an environmentally-friendly option due to its lower energy requirements, easier operating conditions, and non-toxic products.de novo encapsulation and post-synthetic packaging.20 For example, one research group describes biomineralization, which is widely used in de novo encapsulation.21–23Co-precipitation and mechanochemical encapsulation have also demonstrated their efficiency for the in situ immobilization of enzymes.24–26 Similarly, post-synthetic packaging prepared with different kinds of MOFs has also garnered considerable attention for its ability to protect laccase.27 Yet MOFs are mostly microporous, which is not conducive to diffusion and mass transfer; a mesoporous or graded pore structure matched to the enzyme size would be ideal. For this reason, hierarchical MOFs can not only protect the enzyme from external stimulation but also selectively transport the substrate and reaction products.28 These considerations motivated the present study's design of in situ and post-synthesis enzyme immobilization strategies.Depending on the sequence used, the strategies for synthesizing MOF-immobilized enzymes consist of via in situ and post-synthesis methods in the aqueous phase. These materials were then evaluated for their ability to remove 2,4-DCP. The removal efficiency of the LAC@HZIF-8 was predicted to exceed that of the LAC@MZIF-8 and LAC samples. In addition, the de novo-synthesized LAC@HZIF-8 sample (LAC@HZIF-8-D) was also expected to display greater stability than the MZIF-8 and post-synthesis (LAC@HZIF-8-P) samples. These investigations aimed to identify which enzyme immobilization strategy offers greater environmental stability and reuse ability, thereby improving the industrial application of laccase.Accordingly, a microporous and hierarchical ZIF-8 (MZIF-8/HZIF-8) was prepared for the study, with the HZIF-8 immobilized enzyme catalysts also developed 22.13)2·6H2O, triethylamine, l-histidine, and cetyltrimethylammonium bromide were provided by Hushi Co.  and the 2-methylimidazole was purchased from OKA Co. . All other chemicals were of the highest commercially available grade and were used as received.The laccase and 2,4-DCP were obtained from Sigma-Aldrich. The Zn2·6H2O (1 mmol) was first dissolved in deionized water (25 mL), and appropriate amounts of l-histidine (His) and cetyltrimethylammonium bromide (CTAB) with a 4 : 1 molar ratio were added and dispersed ultrasonically. 2-Methylimidazole (8 mmol) was then dissolved in deionized water (25 mL), and triethylamine (8 mmol) was added to the resulting solution. The two solutions were mixed and placed on a magnetic stirrer for 1 h at room temperature. The resulting product was centrifuged at 10 000 rpm, washed with a mixture of ethanol and water (1 : 1), and freeze-dried overnight to produce HZIF-8, a white powder.The HZIF-8 was prepared according to our previous work.30 First, Zn(NO3)2·6H2O (1 mmol) was dissolved in deionized water (25 mL). Subsequently, 2-methylimidazole (8 mmol) was dissolved in deionized water (25 mL), and triethylamine (8 mmol) was added to the solution. The Zn(NO3)2·6H2O and 2-methylimidazole solutions were then mixed and placed on a magnetic stirrer for 1 h at room temperature. After centrifugation and freeze-drying overnight, the white MZIF-8 powder was obtained.The MZIF-8 was also prepared in line with previous research.2.2.2de novo synthesis of the LAC@ZIF-8-D MOF was performed as follows: first, a certain quantity of laccase was dissolved in a pH 5 citric acid–disodium phosphate (CPBS) buffer solution (1 mL). This was then added to a Zn(NO3)2·6H2O solution under ultrasonication, with the procedure then following that of the HZIF-8 preparation process described above.The 2.2.3The LAC@HZIF-8-P was prepared as follows: a certain amount of HZIF-8 was first dissolved in 50 mL of deionized water and the laccase was then dissolved in 1 mL of a pH 5 citric acid–disodium phosphate (CPBS) buffer solution and added to the HZIF-8 solution. This mixture was then stirred for 1 h, centrifuged, and freeze-dried overnight, producing the white LAC@HZIF-8-P powder. The products were stored in a refrigerator at 4 °C to prevent the immobilized enzyme from being inactivated.2.2.431 and loaded onto the LAC@ZIF-8 as follows. First, 25 mg of laccase was dissolved in 1 mL of citrate disodium hydrogen phosphate (CPBS) buffer solution (pH 5). Next, 25 mg of the copper nanoparticles was dispersed in 1 mL of deionized water. The laccase and copper nanoparticle solutions were then added to a solution containing Zn(NO3)2·6H2O, followed by ultrasonication. The synthesis then followed the procedure for the HZIF-8 immobilized enzyme described above to produce nCu/LAC@HZIF-8. After freeze-drying, the product was ground and stored in a refrigerator at 4 °C.The copper nanoparticles were synthesized according to previous research2.2.5et al.32 using 2,4-DCP as a substrate. The free laccase (1 mg) or LAC@ZIF-8 samples containing the same amounts of enzyme were then added to the citric acid–disodium hydrogen phosphate (CPBS) buffer solution (pH 7) with ultrasonic dispersion. This solution was then added to the 2,4-DCP solution  and stirred to produce the reaction. After a certain reaction time, the absorbance of the solution was measured at 510 nm. The rate of 2,4-DCP removal was calculated according to C0 and Cf are the initial and final concentrations (mg L−1) of 2,4-DCP in the solution, respectively.The laccase activity assay followed the procedure described in Zhang The effects of the different reaction times were determined based on laccase activity. The absorbance of the solutions was measured at 15 min, 30 min, 1 h, 2 h, 4 h, and 6 h after the reaction without or after centrifugation for free laccase or the LAC@ZIF-8 sample, respectively. The temperature tolerance of the LAC@ZIF-8 and free laccase was determined by evaluating their enzymatic activity at 20, 30, 40, 50, 60, 70, and 80 °C, at specified pH levels  at each time interval. The storage ability of each sample was tested by detecting their enzymatic activity at 4 °C after 0, 3, 7, and 15 days.2.3−1. Fourier transform infrared spectra (FT-IR) were conducted on a Thermo Scientific Nicolet iS5 FT-IR spectrometer using KBr pellets in the range of 4000–500 cm−1. The confocal laser scanning microscopic (CLSM) analysis was performed using an Olympus FV1200 instrument to produce the fluorescence images of the immobilized enzyme. Nitrogen adsorption and desorption isotherms were recorded on an ASAP 2020 system and the surface areas were calculated using the Brunauer–Emmett–Teller (BET) equation.The scanning electron microscopy (SEM) measurement was conducted using a ZEISS Gemini 300 microscope and a Hitachi 7700 transmission electron microscope was used to carry out the transmission electron microscopy (TEM) analysis. The X-ray diffraction (XRD) analysis was performed with a wide-angle X-ray diffractometer (D8 ADVANCE). The thermogravimetric analysis (TGA) was recorded on a Q600 SDT thermogravimetric analyzer at a detection range of 50–800 °C and a heating rate of 10 °C min33.1in situ. However, the image of LAC@HZIF-8-P  was also tested to confirm the presence of laccase in HZIF-8  analysis of the samples confirmed the formation of ZIF-8 and the loading of laccase. The laccase FTIR spectrum  indicate8 Fig. S4. In gene37The weight lost from the samples was also measured. The weight of the laccase decreased rapidly below 300 °C while the MZIF-8 sample lost approximately 15% of its weight below 400 °C Fig. S2. However40Moreover, the LAC@ZIF-8 patterns exhibited no impurity peak but produced a sharp peak indicating its high crystallinity and stable structure. Given that the catalyst activity performed more effectively with less space between the copper nanoparticles (Cu NPs) and laccase, we synthesized the nCu/LAC@HZIF-8 based on the synthesis of LAC@HZIF-8-D. As Fig. S5P/P0 < 0.8) and hysteresis loops at a high relative pressure (P/P0 > 0.9).41 The BET specific surface area of the LAC@HZIF-8-D-P sample was 1021 m2 g−1, slightly smaller than that of the LAC@HZIF-8-D sample. Table S12 g−1, and their mesoporous areas were 468 and 410 m2 g−1, respectively. The large number of mesopores , the catalytic activity of the three immobilized laccase samples decreased to varying degrees—and fell significantly under alkaline conditions compared to the free laccase sample. It was speculated that temperature, agitation, ultrasonic interference, and other conditions involved in the process of synthesizing immobilized laccase with ZIF-8 destroyed the enzyme's activity and was manifested in its reduced stability in alkaline pHs.2+ as the ZIF-8 skeleton decomposed under acidic conditions, causing the imidazole ligand to bind with H+ in solution. This result indicates that a specific pH buffer is required to limit the destruction of the catalytic activity of the LAC@ZIF-8 under acidic conditions. In addition, it has been reported that various metal ions can activate or inhibit the enzyme activity of laccase.51 Among these, Co2+, Ni2+, Cd2+, Fe3+, Ag+, Al3+, Hg2+, and Fe2+ were strong inhibitors, possibly because they occupied the laccase's active centre and changed its structure, thus inhibiting its enzymatic activity.52,53 However, Na+, Zn2+, Cu2+, and Mg2+ ions can significantly activate laccase. The activation effect of Cu2+ on laccase is related to the fact that Cu2+ is an active centre of laccase.54 Therefore, the enhanced stability of the LAC@ZIF-8 materials under acidic conditions may be due to the Zn2+ produced by the instability of the ZIF-8 structure, which enhances the enzyme activity of laccase, to a certain extent.In another noteworthy result, the catalytic activity of the free laccase decreased by 40% under the pH 3 condition, while the catalytic activity of the LAC@ZIF-8 decreased by less than 5%. This poor activity under a lower pH range may be due to the release of Znet al.55 High temperatures destabilize free laccase, causing a loss of activity due to the decomposition of its protein structure. In contrast, the immobilized laccase material was stable at a range of temperatures; the optimum temperature was 60 °C, with higher catalytic activity observed between approximately 20 and 80 °C. At 80 °C, the catalytic activity of the LAC@MZIF-8 and LAC@HZIF-8 was maintained at 72.4 and 86.5% of this value respectively, indicating that the ZIF-8 greatly enhanced laccase durability at high temperatures. These results corroborate earlier research showing that the optimal temperature for immobilized laccase increased as catalytical activation energy rose due to the chelation between the laccase and ZIF-8.56 Moreover, the HZIF-8 demonstrated greater temperature stability than the MZIF-8, a finding related to the latter's poor crystallinity and pore properties.Finally, 4de novo strategy. However, the latter produced a higher removal efficiency when Cu NPs were added and can potentially broaden the pH stability of laccase. In conclusion, the LAC@HZIF-8-D showed greater promise for environmental applications due to its higher removal efficiency and excellent stability. The design of graded MOF channels and the pore size of mesoporous channels based on the molecular size of enzymes were also significant in enzyme immobilization.This study investigated the ability of HZIF-8 to immobilize laccase for the removal of 2,4-DCP, a widespread pollutant. The multistage structure of HZIF-8 enabled LAC@HZIF-8 to remove approximately 80% of 2,4-DCP under optimal conditions—about 5 times the removal efficiency of LAC@MZIF-8. In addition, LAC@HZIF-8 also enhanced the thermostability and storage stability of laccase compared to LAC@MZIF-8. Due to the size mismatch between laccase and the material's micropores, post-synthesis embedded laccase at a higher rate than the Xu Ran and Zhang Xujie performed and conducted the experiments, Osamn Ahmend drafted the manuscript and analyzed the data, and Wu Yi-nan and Eduardo Schott supervised the study. All authors were involved in manuscript editing.There are no conflicts to declare.RA-013-D3RA01571H-s001