A matched-pair cluster randomized controlled trial was conducted on ten worksites (five intervention (n = 324); five control sites (n = 283)). Worker surveys were collected at all sites pre- and post- exposure at one- and six-months. Linear and logistic regression models evaluated the effect of the intervention on pain and injury, dietary and physical activity behaviors, smoking, ergonomic practices, and work limitations. Worker focus groups and manager interviews supplemented the evaluation. After controlling for matched intervention and control pairs as well as covariates, at one-month following the ergonomics program we observed a significant improvement in ergonomic practices , and a reduction in incidences of pain and injury  in the intervention group. At six months, we observed differences in favor of the intervention group for a reduction in physically demanding work , increased recreational physical activity  and higher consumption of fruits and vegetables . Process evaluation revealed barriers to intervention implementation fidelity and uptake, including a fissured multiemployer worksite, the itinerant nature of workers, competing production pressures, management support, and inclement weather. The All the Right Moves program had a positive impact at the individual level on the worksites with the program. For the longer term, the multi-organizational structure in the construction work environment needs to be considered to facilitate more upstream, long-term changes.This study evaluated the efficacy of an integrated Total Worker Health Internationally, construction workers have higher rates of musculoskeletal disorders, and chronic diseases related to obesity, lack of physical activity and smoking than workers in other industries ,2,3,4. IConstruction workers also have high rates of chronic health issues. Over 70% of construction workers are overweight . Obese cExtensive research has linked these injury and poor health outcomes to individual factors, as well as the conditions of work, including job demands, physical work environment and psychosocial work factors  . ConstruWhile these factors are prevalent in the construction industry, the complex work organization of construction work provides additional challenges for implementing traditional workplace prevention programs. The hierarchical structure between the site owners, general contractors, and subcontracting companies results in a fissured workplace . The dyn® program. Such approaches target the conditions of work that affect workers injuries and health outcomes  would have to financially support the program running on their site.”The goal of this study was to evaluate the efficacy of a construction worksite-based integrated intervention targeting both the conditions of work, and workers’ health behaviors, simultaneously. We observed short-term improvements in ergonomic practices and in incidences of pain and injury after an injury prevention program. We also observed an improvement in physical activity and healthier dietary behaviors, such as increased consumption of fruits and vegetables, after a health promotion Health Week program.At the individual level, we found a significant improvement in ergonomic practices, and a reduction in incidences of pain and injury, which supported the hypothesized pathways for the program. As promoted by NIOSH, ergonomic practices focus on workers modifying or establishing work procedures to reduce the risk of injuries ,49. WhilWhile we were encouraged that an improvement in ergonomics practices occurred, results also indicated that the program was not successful at addressing system level components. For example, while we saw ergonomics practices improve, we saw no significant change in the physical demands on the workers. Hence, we suspect that the intervention changed the way people completed their work but had limited effect on the physical demands of the job. In addition, the process evaluation revealed several important barriers and facilitators to our program at the organizational level. First, management and worker buy-in were identified to be integral to the success of the soft tissue injury prevention program. This was perceived to be key in a work environment that is fast-paced, unpredictable, and with tight production schedules tied to the requirements of the general contractor. For example, there was little time to complete task preplanning or for the safety manager to complete inspection protocols for injury hazards and ergonomic solutions. When management support for health and safety programs is not observed by the workers, other competing factors are often prioritized over health and safety, especially ergonomic practices . This waWhile we have had past success with a worksite safety program integrated within the complex structure associated with multiple employers, a large barrier to a systems approach ergonomics program was the challenge faced by subcontractors to make changes, even those changes that could improve site safety on their own worksite. Unlike our previous program that was designed to re-enforce existing safety practices , the ARMMoreover, system-level changes require better upfront planning before construction begins, such as during the bidding process for a job by setting out requirements from the multiple employers, and in the contracts for the jobs. The key informant interviews supported this concept. Expectations regarding safety programs in the contract is standard procedure in larger projects, especially owner-insured programs. An example is with respect to safety training, in which owners, especially public entities, require that construction workers have a minimum of OSHA-10 training to be onsite . Whilst Other researchers in the construction industry have also found mixed findings with respect to improvements in pain and injury and perceived physical effort after implementing ergonomic interventions, including participatory ergonomics programs ,56,57,58In contrast, the Health Week had many successes in overcoming some of these barriers associated with the multiemployer structure. For one, it simply required the participation of the workers and little, if any, infrastructure. In theory, the Health Week might have addressed some conditions of work regarding psychosocial factors around health, like supervisor or co-worker support. Anecdotally, we observed foremen and co-workers being supportive of ensuring their co-workers signed up for health coaching or NRT. Some foremen would cover for their workers to allow them to participate in the week’s activities. We also observed workers talking about eating healthier food with their coworkers during the week.Another major strength of the Health Week was how it aligned with companies’ current practices on the worksite and also with the interests and goals of the workers. This was also found in previous formative work we completed that found that policies, programs and practices are supported by management and workers alike if they can be easily integrated into company’s business structures and align with workers’ goals and needs ,60. HealResearch in construction has challenges with loss to follow up due to the dynamic nature of construction with workers coming and going on worksites as the construction job requires specific trades during the timeline of the study ,36. The Another challenge was the success of integrating the injury prevention and health promotion activities in this environment. Integration was achieved by linking the two programs by name and key messaging in the planning and implementation phases. In addition, messaging around Health Week included training on both injury prevention and health promotion giving workers the tools to improve their working conditions, as well as giving them control for their health. The ergonomics program prior to Health Week did have health messaging but without any specific health promotion activities.One limitation was that our intervention depended on the participation of the general contractor safety managers, whose involvement and dedication to the study varied across sites and between general contractors. This aspect of the intervention was by design, as we considered it important for integration and sustainability into current company processes, that the ergonomics inspections were performed by the safety managers. Giving the safety managers latitude to decide how invested they were in the program allowed us to assess the feasibility of the intervention being adopted without the aid of study staff. This would ensure that our observations were realistic and representative of barriers and facilitators to the intervention’s delivery by non-study staff.Further, this study involved worksites in commercial construction only. Thus, the results may not be generalizable to other types of construction . However, commercial construction accounts for a large portion of U.S. construction activities, and represents an important area for injury prevention research. Similarly, the construction workforce in the Boston metropolitan area may not be representative of commercial construction workers in other parts of the country or world, where work practices, demographics, and union membership differ.Despite these limitations, our study had several strengths, most notably the study design and the wide variety of general contractors and sites recruited into the study. The cluster randomized control trial design is a novel approach in commercial construction. Typically, approaches to improve the health and safety of construction workers have often focused on the individual worker, targeting workers when they are enrolled in apprentice programs ,65, targThe ergonomics inspection and communication protocol provided a method to identify broad areas for improving ergonomics in the dynamic construction work environment. It is important to understand the challenges and successes of intervention delivery in order to inform and improve future worksite-based interventions. It appears that the largest barriers to the success of the intervention were the inability of subcontractors to make changes to their worksite and the variability in the involvement and dedication to the study across different worksites and general contractors. These are real-world, as well as research study challenges. Subcontractors did not have the systems in place, or the available tools, to assist in changing their working conditions. Competing safety and production priorities also influenced the level of management commitment to the study. Additionally, construction safety research may have broader implications for an increasing number of industries that are becoming as dynamic and variable as construction, as more services once housed in a single facility are outsourced to multiple employers .The ARM program had a positive impact at the individual level on the worksites that implemented the program. The trial saw improved ergonomics practices, as well as, reduction in new pain and injury, and improved diet and physical activity, as reported by the workers. A number of obstacles were encountered which made integrating a health promotion and injury prevention intervention into the multi-employer, outcome-driven, dynamic work environment challenging. Process tracking suggested that our intervention had less impact at the systems/organizational level in terms of changing organizational programs and practices, due to the complex organizational structures on site. For the longer term, more organizations in the multiple employer environment should be involved in the implementation to facilitate more upstream changes.


Introduction: Earthquake is the most important cause of death from natural disasters in Iran. This paper brings attention to the main causes of loss of life due to the Kermanshah province earthquake (Nov 12 2017), and provides a wakeup call about the unsafe nature of buildings there. Methods: This study is based on official reports review and a field assessment in the areas affected by the earthquake in western Iran. Results: Although buildings in this area are mainly old structures, strangely, more than 70% of the destroyed buildings in this earthquake were under 5 years of age, newly built or renovated buildings according to mandated building codes. Discussion: Mandated building codes and construction rules and regulations are not respected even for the newly constructed or reconstructed structures buildings. Keywords: Earthquake, Iran, construct, reconstruct, Building codes At 21:48 local time, on Nov. 12, 2017, western Kermanshah Province in Iran was shaken by an earthquake of moment magnitude Mw7.3 for about 30 s,Due to this earthquake, 620 people died3Most of the local buildings were one-story adobe, covered with heavy flat roofs. Nevertheless, in larger villages and cities, more-storey brick-based and cement-based buildings were seen. Many of which were newly constructed or reconstructed structures that built according to developed and mandated codes after the bam earthquake of 25 Dec 2003 in Iran. However, around 80% of destructions occurred in buildings with no frame, both in the urban and rural areasAlthough buildings with no frame in the rural areas of the Kermanshah Province are 15% more than urban areas, number of residents at the buildings with no frame are 60% more in the urban areas than ruralIndeed, further evaluation of this analysis is required; however, the large number of fatalities, injuries, and displacements due to this earthquake is a wakeup call to the unsafe constructed or reconstructed. Poorly constructed or reconstructed buildings in this area can be due to several factors, including lack of quality control on the architectural and structural designs, owners’ employment of non-expert workers and use of non-standard materials, vaguely defined construction regulations, and owners’ right to hire architects, structural engineers, supervisors and contractors.Due to insufficient payments to supervisors and lack of restriction of law enforcement on them, surveillance is generally weak in structural designs. On the other hand, architectures are under surveillance of both owners and the city. Monetary deals between owners and supervisors are leading to unsafe structural designs. Law enforcement is another challenge in construction since duties of the institutes are not carefully distributed in the written laws and regulations. Considering these preventive factors, we suggest that some changes in the construction surveillance system and the owners’ rights are required for future building code enforcements.Mehdi Zare, Professor of Engineering Seismology, International Institute of Earthquake Engineering and Seismology (IIEES), and Associate member of Geology Division, Department of Basic Sciences; Academy of Sciences of the I.R. Iran. E-mail: mzare@iiees.ac.irThe authors have declared that no competing interests exist.The data underlying this study have been uploaded to figshare and are accessible using the following DOI: 10.6084/m9.figshare.6949988


The Annual Conference of the Society of Internal Medicine of Nepal was in progress at Hotel Crowne Plaza Soaltee in Kathmandu, when an earthquake struck Nepal on April 25, 2015. It seemed as if the world was ending. The lights went out, and there was a state of panic in the room. People collapsed as they struggled to run toward the exit of the conference hall, appearing as though they were on a ship hit by a massive wave.This massive tremor, a 7.8 on the Richter scale, the strongest since the great earthquake of 1934, destroyed a large part of central Nepal; ancient temples, palaces, and UNESCO World Heritage monuments were reduced to ruins. The quake was followed by numerous aftershocks that continued to rock the nation for more than a year. Thousands of people were buried under the rubbles of flattened homes in the capital city and surrounding hills. Millions more became homeless. Roads cracked open, sink holes big enough to engulf multistory buildings emerged, and giant rocks several feet high jutted out of the ground. Landslides caused roadblocks and avalanches created havoc, killing and injuring mountain climbers from around the globe.am central time in North America, ANMF members in the United Sates started raising funds on social media. Nepalese and others who loved Nepal from around the world started giving. We quickly reached more than $1 million, even though the initial goal had just been $20,000. We set up an ANMF command center in one of the hospitals in Kathmandu and recruited more than 50 physicians who were eager to help. Many other volunteers from within and outside Nepal joined us.On recovering from the initial shock to our cores, Nepali physicians who were present immediately jumped into action. We mobilized our organization, America Nepal Medical Foundation (ANMF), to perform surveillance and needs assessments on the ground in Nepal as well as gathering and dispatching help from the United States. The ANMF is a not-for-profit organization based in the United States with a sister chapter in Nepal consisting mainly of physicians. Its main mission is to uplift the health of the people of Nepal. As soon as the news of the earthquake broke on April 25, 2015, at around 1:00 The medical community in Kathmandu implemented their emergency workforce. Surgeons and nurses worked tirelessly around the clock without taking any breaks for days. Their compassion and generosity were evident in their attempts to selflessly care for the unfortunate. Some hospitals saw more than a 1000 trauma cases and performed 200–400 surgeries within the span of a few days. Many other hospitals were well equipped but could not function because of the damage caused by the mighty earthquake.Our team visited the major teaching hospitals that had supply shortages within Kathmandu and Dhulikhel, a city 30 km east of Kathmandu. Every hospital we visited was over capacity. We had to walk around injured patients lying in the hallways, waiting rooms, and other empty spaces. Moreover, these hospitals were short on medical supplies, including intravenous fluids, antibiotics, and even supplies and equipment for trauma and orthopedic surgeries. We delivered boxes of these much-needed supplies to these facilities— supplies we acquired by knocking on supplier doors because all stores were closed after the earthquake.Whereas the capital had suffered extensive damage, the earthquake’s epicenters were around Gorkha and Sindhupalchok, in the central region of Nepal. Our team drove in a pickup truck to Kavrepalanchok and Sindhupalchok, near one of the epicenters. Along the way, we saw destruction beyond our imagination. Rows upon rows of houses were destroyed and entire villages were flattened, leaving only rubbles of brick and wood visible on the ground. This was in stark contrast to the capital city, where most houses were still standing, except ancient temples, old palaces, and houses in certain pockets. Most modern buildings in Kathmandu are constructed with cement, concrete, and bricks and are supported by concrete pillars to withstand tremors. However, houses and huts in rural villages are built on mountain slopes and made of mud and bricks or stones. Some villagers lived in tents and homemade sheds. Others had nothing they could use for shelter and waited helplessly exposed to the elements for aid to arrive. Thankfully, the weather in Nepal during April–May is temperate, apart from wind gusts and cold nights. We distributed tents and blankets which we had brought with us on the truck.When glancing from hilltops, the resplendent beauty of this tiny Himalayan nation was evident with its lush green hills, glorious shining mountain peaks, and plentiful waterfalls and rivers running through the valleys. However, when viewing the villages and towns on the ground, harsh reality struck a severe blow at the sight of unfathomable destruction, ruins, and loss of human lives and livestock. Even the mountain hillsides reminded us of the earthquake, as many hillsides were dotted with fresh landslides that continued to grow with each aftershock.We were far from the only aid group; however, most were concentrated within the Kathmandu Valley as the extent of the damage prevented even an hour’s drive out of the valley. Our foundation mobilized more than 50 volunteer physicians from Nepal and United States providing medical and other relief services. We formed multiple teams, each consisting of medical and nonmedical volunteers, which included local youth volunteer groups. The Nepal Army provided transportation and security as we provided relief to more than 40 small towns and villages in the remote mountainous areas that are normally inaccessible by regular vehicles. A van carried our medical team and medical supplies, while a truck followed with daily villager needs such as food, blankets, and tents. As a preventive measure, our team also distributed water-purifying tablets, oral rehydration salts, hand soaps, and oral hygiene kits.Our doctors performed examinations and provided health-care services under the open sky alongside local health-care workers. A baby was delivered inside a taxi by a local midwife in front of a damaged health center, lacking a safe, closed delivery room. Patients were moved to tents and temporary shelters, if available. All of this activity stopped the moment night fell because the world around us would be submerged in darkness due to the lack of electricity. Drinking water and toilet facilities were nonexistent in some communities. Despite the enormous amount of support pouring in from the world community, the rugged terrain made transportation a herculean task. This massive earthquake further complicated the problem by causing landslides and damages to the roads. Some of the hospitals and many health centers continued to provide services in tents as all new construction was put on hold by the government of Nepal for a year because of the concerns of more destruction by ongoing aftershocks.Overall, more than 53,000 people received medical care from more than 2,600 health-care workers, and 8,856 people died because of the earthquake. Similar to any other natural disaster of this proportion, the relief and recovery efforts shifted from the initial stage of crisis for basic needs, including food, water, and shelter, to the next phase of rehabilitation and rebuilding. This second phase is still ongoing now, 4 years since the earthquake.In the earthquake-affected areas, 462 health-care facilities were completely destroyed and an additional 765 sustained partial damage, making them unsafe for patient care. America Nepal Medical Foundation volunteers worked tirelessly to raise funds both online and through events in the United States. Our Nepal team received approval from the government of Nepal to rebuild 13 health posts with prefabricated materials. All 13 were built and handed over to the government within a year of the earthquake. When we went back to inspect these facilities, our team was greeted with marigold garlands and smiles by the villagers. The district health officer took our team to visit the Chautara district hospital, where we had built an outpatient clinic with an attached maternity ward and a delivery room. The physicians were seeing more than 100 patients per day in this small outpatient unit. We were appalled to see that inpatient and emergency care was still in tents more than 18 months after the quake. Two torrential monsoons, two hot summers, notwithstanding the bitter winters—it was unimaginable. It was a hot day; there were flies buzzing around and a loud fan in the tattered and patched tent which was the emergency ward. There was a 2-year-old boy with high fever and seizures, most likely suffering from febrile seizures or even something more serious. The heat was not helping. We discovered that there would be a long delay before anything would be built there. Therefore, our ANMF team in the United States raised more than $80,000 and provided assistance to construct a beautiful building consisting of a medical ward and an emergency room.Currently, Nepal has an adequate number of basic health man power produced by 20 medical schools. However, there is a lack of much-needed specialists in trauma, infectious diseases, critical care, and psychological and physical rehabilitation. Developing more expertise in these disciplines and establishing more trauma centers and rehabilitation services would make a positive impact in the future. A massive public health campaign is another absolute requisite for the prevention of infectious disease outbreaks. Similar to other major natural calamities in resource-poor nations, outbreaks of diarrheal diseases and other food- and waterborne diseases are imminent among people living in shelters because of the lack of access to toilet facilities and clean potable water. This is a public health emergency needing urgent intervention in its immediate post-disaster period. However, learning from the Haiti experience and other disasters, the Nepal government, WHO, and international communities brought awareness to the people about water, sanitation, and hygiene and took preventive strategies such as distribution of hygiene kits and rebuilding toilets. Our team also visited rural villages with public health students and distributed hygiene kits and educated the villagers and children about proper hygiene and sanitation. There were no major outbreaks in post-earthquake Nepal. Based on our data from one medical center, most of the post-earthquake–related infections were wound infections acquired in the hospitals. Although there was a small outbreak of typhoid, it was contained quickly by taking appropriate preventive measures.The swift and effective reaction to the 2015 Nepal earthquake is an example of what can be achieved when the world comes together to aid during a massive natural disaster. Both the people of Nepal and the international community jumped into action and worked together side by side, complementing each other’s operations of rescue, relief, rebuild, and rehab. Nepal is still going through a long recovery process. Many of the houses have been rebuilt, but many other villagers are still living in temporary homes. When we visited 3 years later, we could still see tiny homes with shiny metal roofs scattered over the hillsides. These homes are built with corrugated sheets, bamboo, and prefabricated materials. Many villagers are still displaced and living somewhere else. Health posts and hospitals are still using the prefabricated buildings, as the original facilities are still closed and yet to be reconstructed. Although the overall recovery process has progressed well, there is a long way to go. However, the thousands of lost lives will never be replaced.


Little is known about the barriers to use of child car seats in Australian Aboriginal communities, or the acceptability of programs to increase appropriate car seat use. This formative evaluation sought to consult and partner with Aboriginal Community Controlled Health Services (ACCHS) to develop and evaluate the feasibility and acceptability of a program intended to improve optimal use of child car seats.Focus groups were conducted with parents and carers of Aboriginal children to identify the barriers and facilitating factors for child car seat use, and staff of two ACCHS were interviewed to inform program development. Following the implementation of the resulting multi-faceted program, consisting of staff training, education, hands-on demonstrations and a subsidised car seat distribution scheme, interviews were conducted to assess process issues and acceptability with 13 staff members.Parents and carers in the focus groups reported a lack of awareness of child car seat use, confusion about the right car seats for different aged children but agreed about the importance of safety and community responsibility to keep children safe in cars. Interviews with service staff informed an approach to deliver relevant information. Information and resources were delivered to families, while the car seat distribution scheme supplied 33 families with child car seats. Following the conclusion of the program, staff reported that the program was relevant to their role. They also valued the car seat distribution scheme. Staff training in selection and installation of car seats increased confidence in staff knowledge.We developed a program to promote child car seat use in ACCHS, which focused on developing capacity, made use of existing infrastructure and developed resources for use in this setting. The program shows promise as a means to promote child car seat use in Aboriginal communities; however, the impact on child car seat use will need to be evaluated in a larger scale prospective trial. Road traffic injuries are the leading cause of death and serious injury in Australian children. In 2016, there were 27 fatalities amongst children aged 0–7 years  in Australia .Aboriginal and Torres Strait Islander people comprise 3% of the Australian population, and a significant proportion live in major cities  . The subChild car seats are a proven, effective intervention that can reduce the incidence of serious injury and death amongst child passengers in motor vehicle crashes –9. UsingThe Australian government revised the national child restraint laws in 2009 and enacted these in New South Wales in March 2010  requirinAboriginal Community Controlled Health Services (ACCHS) are autonomous services governed and driven by the local Aboriginal community to deliver comprehensive and culturally appropriate health care. The model that underpins these services is founded upon research, evaluation and planning to provide effective community engagement, clinical services, health promotion, and cultural safety and awareness , 21. ACCThere have been a number of studies evaluating interventions to promote the use of appropriate child car seats. The 2006 Cochrane review by Ehiri et al. reviewed interventions to promote booster seat use in 4–8-year-olds . There wBuckle-Up Safely program was developed by the investigative team as a pre-school-based program and evaluated in a cluster randomised trial in South-Western Sydney ) [Buckle-Up Safely program sought to include the key components of hands-on demonstration and car seat subsidies as well as delivering a clear and consistent educational message.Prior to this formative evaluation, the (SEIFA))  and late(SEIFA)) , 27. TheThe aims for this study were (1) to identify the barriers to appropriate child car seat use amongst urban Aboriginal children to develop and implement a multi-faceted program and (2) to conduct an evaluation of the feasibility, in terms of ease of integration into the service and acceptability of this program in the setting of an ACCHS.Buckle-Up Safely program.Campbelltown and Mount Druitt are within greater urban Sydney and represent regions within NSW with higher concentrations of Aboriginal and/or Torres Strait Islander people . Both reThe Aboriginal Medical Service Western Sydney (AMS WS) was located in Mount Druitt—approximately 40 km west of the Sydney Central Business District (CBD), within the Deerubbin Local Aboriginal Land Council Area. Tharawal Aboriginal Corporation is located in Airds, 56 km south-west of the Sydney CBD. Both organisations are ACCHS.Consultation and program planning commenced in 2010 when the revised restraint laws were enacted in New South Wales , and theQualitative research was appropriate as we were seeking to explore behaviour and processes for implementation of a child car seat program in a specific setting. For the consultation with families and carers, and staff of the ACCHS’s research, staff used focus groups and in-depth interviews. Both are well-established qualitative methodologies, which have been used to explore barriers to child car seat use in other settings . These mThe transcriptions were coded in NVIVO software   within aA series of three focus groups were conducted at the ACCHS involving parents, expectant mothers and grandparents of pre-school children. The focus groups were as follows: AMS WS on 8 September 2010 attended by 3 men and 9 women and Tharawal 8 September 2010 attended by 3 women from the Indigenous Childrens Program, and then on 26 October 2010: 13 women from the Art Group. The focus group sessions, facilitated by one of the researchers (LK) and observed by one of the investigative team (ML or KH), covered the following topics: (1) attitudes and knowledge people have about how children should travel in cars, (2) influences on decisions about how children should travel in cars, and (3) resources, information access and needs. At the end of the focus group, a summary of the discussion was presented and the opportunity given for further input and confirmation.ACCHS staff were selected by research staff as ideal members of both communities to deliver the program. Their role embedded within the ACCHS and their pre-established relationships particularly with the targeted families gave them close insight into the nature of day to day interactions with families. Researchers met with the ACCHS staff on four occasions from October 2010 to February 2011 for an in-depth discussion to interview and discuss the program to identify ways that the existing program could be tailored to these two ACCHS sites. The intention of these consultations was to give staff members an opportunity to offer their knowledge of child car seat use within the community, to express what suggestions they had regarding the delivery of the program and also to advise on the program structure. The format of these consultations included planning meetings , staff workshops  and presentations at staff meetings (AMS WS: 6 December 2010).Buckle-Up Safely program was designed to (1) increase knowledge and engagement with the community on the issue of safe travel in cars, (2) provide access to subsidised child car seats and (3) train staff at the services to be able to check car seat installation for clients. Results from the focus group discussions and consultations with staff were used to tailor the program through its means of delivery so that it was designed to address the identified barriers and facilitators in this setting.The Child car seats were supplied to families at a subsidised cost. Staff at both services were provided with a bound manual including a script and the DVD inset in the cover. Individual training was provided to demonstrate how the manual could be used; however, the staff preferred the research team to facilitate these sessions as they were not confident with the content and the amount of information in the early stages of the program. An interactive session was designed including scripted responses to frequently asked client questions.Kids and Traffic Early Childhood Road Safety Education Consultants  and a full-day workshop on ‘Selection and installation of Child Restraints’ delivered by Mobility Engineering .Further staff training opportunities included a specialised 2-h workshop ‘Out and About with Kids in Cars’ delivered by Semi-structured interviews were completed with 13 staff within 4 months of program completion. The evaluation included nine staff from Tharawal Aboriginal Corporation and four from AMS Western Sydney encompassing program coordinators, program advisors, the supervisor of Ooranga Wandarrah Preschool at Tharawal, nurses, administrators involved in car seat distribution, health education officers, clinic coordinators and case workers.The purpose of this process was to gain insight into the acceptability of the program and to understand what elements worked well and what could be learnt from the delivery of the program.The research study was approved by the Human Research Ethics Committees at the University of Sydney (reference #12807) and the Aboriginal Health and Medical Research Council of New South Wales (reference # 732/10).The themes are described below in relation to the adapted child car seat model of behaviour change and are summarised in Table Not all participants were aware of the new legislation. Amongst those who were aware, there was confusion about the appropriate car seat for age and when to progress children to the next car seat. These findings reinforced the need for the program to increase awareness and include education about child car seat use.When focus group participants were asked to review program materials, they reported a preference for simple instructions with pictures. Participants also felt that the best approach to engaging parents was to just ‘have a yarnParticipants understood the risk of injuries in road crashes and reported that transport of children was a shared responsibility across community. It was also identified that transporting additional children posed a challenge to carers who were trying to use car seats correctly and that they often felt pressured to travel with extra children whether or not they had the right car seat.Obtaining a car seat was influenced by safety and cost considerations. Logistical issues discussed included the needs of large families—fitting multiple car seats in a car, but also, these families found it difficult to hand down car seats from child to child while ensuring each child remained in the right seat for their age. Participants felt that while ‘nothing in life is free’, they thought that subsidised seats should be available and suggested 50% of the retail cost was most suitable.Though there was interest in further information about correct use of car seats there was also a strong feeling of self-sufficiency: ‘work it out for yourself because there is nothing there to say if your kid doesn’t fit into this at this age, then do this’. There were also reports of children being excluded from trips due to inability to comply with child restraint law.The staff acknowledged that their daily work provides opportunities to teach clients about appropriate use of child car seats. Further, staff at both services explained that they had been active in checking and securing children during transport in their work. All agreed that there is a role for them to understand the new laws and to pass this information on to families.Staff stated that although they had been exposed to information regarding the revised laws recently and had a reasonable understanding of the safety benefits of age appropriate car seats, there was still confusion over the legal age at which a child can travel in the front seat and the transition ages for different types of car seats.Staff acknowledged the challenges of engaging with families on the issues of child car seats and relayed that there had been limited uptake in previous initiatives. They offered suggestions including providing programs that focus directly upon children, such as toddler groups; using posters and flyers; hosting discussion groups, information sessions, and one-on-one discussions; involving doctors; screening a DVD on a loop; identifying specific parents and following up on information provided. The staff felt that information should be concise, clear and easy to understand as clients are unlikely to read lengthy resources and should be accompanied by a ‘hands-on’ demonstration.Buckle-Up Safely program ACCHS health workers were encouraged to focus upon spending time engaging in personal and individual client interactions ‘yarning’ with families to communicate the core messages of safe travel for children. This would be later followed up in incidental conversations.The program components supporting each of the stages of behaviour change are summarised in Table http://www.thegeorgeinstitute.org/videos/buckle-up-child-car-restraints) [In response to the identified barriers and facilitators identified in the focus groups and in-depth discussions, resources were chosen to ensure high pictorial and interactive content while conveying clear simple messages about child car seat use and the new law. The resources available included a DVD explaining how child car seats protected children from injury, print material, a height chart and different types of child car seats for demonstration purposes (traints) , 33. TraAs parents and carers both acknowledged that the transportation of children was a shared responsibility of the community, educational content and advice was delivered at a ‘Close the Gap Community Day’ information stall in collaboration with the Aboriginal Program Officer at the Roads and Traffic Authority . An information session was also co-presented to the local community by the project team and staff . No family sessions were held at AMS WS.As a response to the cost of car seats being a restrictive barrier, staff and families agreed that having seats available at a subsidised amount rather than free of charge was preferable to ensure parents valued the purchase. As such, an amount of $50 was agreed upon (full retail price $150–$300), though some families had difficulty meeting the payment. A coordinator was appointed to manage orders and followed guidelines to deliver age- and size-appropriate car seats. The program made up to 30 child car seats available to each service. Thirty-three families placed orders for 21 seats (8 booster and 13 forward facing seats) at Tharawal and 12 seats (2 booster and 10 forward facing seats) at AMS Western Sydney.Two seats were provided to each service at no cost for use during demonstrations to clients. In addition, AMS WS received two seats for loan purposes to clients who were making ad hoc trips to regional areas. While having an authorised restraint fitter available on site was considered, staff reported that from previous experience these fitting days had low patronage.All respondents involved in client outreach programs indicated that communicating about safe travel in cars was relevant to their role at the health service and agreed that this was as important as other health issues.Staff responded that the best aspects of the educational content were (1) clear information, (2) practical demonstration, and (3) clear representation of the consequences of children being unrestrained or inappropriately restrained in a car crash. Staff reported that transporting children is a regular aspect of daily operations for health checks and participation in other programs and activities.The 145 cm height chart was particularly popular in engaging families to think about the size of their children and how well they fit an adult seat belt. There was enthusiastic support for the practical training in car seat selection and fitting. Seven of nine staff responded that they either agreed or strongly agreed that they now had a clear understanding of the laws. At one ACCHS, training at the general staff meeting was instrumental in establishing a uniform level of understanding of child car seat use where there were previous disagreements. Having an external advisor present was reported to help resolve and clarify these issues—this indicates the benefits of supporting program staff during the early stages of program implementation to feel confident and well informed. Further, staff at both services recommended having a person dedicated to the program implementation and that this would enhance the program fidelity.This pragmatic study has shown that a child car seat program delivered through ACCHS, informed by community consultation consisting of access to information, hands-on demonstrations, subsidised car seats and car seat checks performed by appropriately trained staff was feasible and accepted by the local staff of the ACCHS in Western and South-Western Sydney. Further, this study has shown that within both communities there exists a strong demand for subsidised child car seats to enable car seat use.A large part of this program was dedicated to building capacity within the ACCHS, and it has been the increased understanding of staff, their input and advocacy for the program, which has contributed to the program’s legitimacy within community thus strengthening the program beyond what could have been achieved by research staff within the given timeframe.Staff interviews highlighted that they felt there is a role for them to understand and pass on information about child car seat laws to families. Despite having been exposed to information regarding the revised laws recently, there remained some uncertainty about the law’s particular details. As Kakefuda et al. have found, health care workers (like the community) often do not realise that motor vehicle crashes are a major cause of death and serious injury in children .Buckle-Up Safely program found similar issues.Like the staff, many clients noted that they were somewhat confused or had little awareness of the changes made to child restraint legislation. Qualitative research in another population groups has found that a lack of parental knowledge of benefits, differences in risk perception and ‘negotiability’ in parenting style can be barriers to increasing correct car seat use . The BucThe clients and staff both conveyed that one-on-one demonstrations would be most effective and that the best means to communicate with families would be to have a ‘yarn’ rather than formal presentations. This approach was adopted, and text-heavy brochures were avoided. As community members felt that the safe transportation of children was the shared responsibility of the community, the program was delivered at a community event. In this community, large families and needing to pick up additional children posed a barrier to safely transporting children each trip. Further financial barriers were documented whereby families may not be able to afford the cost of a new child car seat to ensure that their child is in the right type for their age. These barriers and facilitators identified by staff, and family and carers represent the distinct characteristics of the Western and South Western Sydney Aboriginal community. Others have predicted concurrent barriers to child car seat use amongst Aboriginal communities, specifically the low rate of adult seat belt use, use of multiple vehicles, multiple carers being involved in transporting children and over-crowding of vehicles –37.It is important that health services are sensitive to, and acknowledge and respect, cultural factors and similarly are wary of potential physical and/or economic barriers that can prevent families from accessing and learning from the available health service . UnderstChild car seats have been part of several previous road safety initiatives targeting Aboriginal people in Australia. The Aboriginal Seat Belt Campaign in South Australia provided information on child car seats in the form of brochures and stickers featuring Aboriginal artworks and illustrations to facilitate the safety message to the community . Child cBuckle-Up Safely program has been able to tailor and navigate community factors [Understanding and harnessing the barriers and facilitators to appropriate car seat use has contributed to the degree to which the  factors –38. ThisIn summary, a program was developed to promote child car seat use in urban ACCHS, which was well supported by clients and staff. The program focused on developing capacity amongst staff, made use of existing infrastructure and adapted resources for use in this setting. It is clear that locally developed and owned programs are needed for Aboriginal communities. The program developed from this formative evaluation, with consideration of the barriers and facilitators to child car seat use, has shown promise, but will need to be tested in a larger trial.


Internet-based parenting programs have the potential to connect families to research-informed materials to promote positive child development. However, such programs can only succeed to the extent that the intended population engages with them.This study aimed to evaluate engagement in the 5-a-Day Parenting program, a technology-based program designed with low-income families in mind, to promote daily use of 5 specific parenting activities conducive to children’s school readiness. Following earlier pilot data, the program was enhanced with an initial motivational e-intervention and tailored text messages designed to promote engagement.Parents were recruited from local childcare centers and through a participant registry. We examined rates of receipt of program text messages and use of video-based content on the program website, 3 factors that may affect website use, and satisfaction with key program elements.A total of 360 parents of young children learned about the study and had the opportunity to use the 5-a-Day Parenting website. Of these, 94 parents participated in the study, and 33% (31/94) accessed the video-based content on the website at least once. No association was found between website use and program recruitment approach, program-affiliation message, sociocontextual risk, and baseline use of the five parenting activities. Satisfaction with text messages and video-based content was high.For some parents, technology-based programs appear useful; however, engagement could still be enhanced. Additional research should seek innovative strategies for promoting engagement in Web-based parenting programs. Young children’s successful entry into school is closely associated with their social, emotional, cognitive, and academic readiness , each ofFace-to-face parenting programs teach parenting strategies that promote children’s school readiness skills  and redWith this knowledge, we created the 5-a-Day Parenting program, a fully technology-based program, to promote school readiness in early childhood through positive parenting. Development of this program was influenced by the domain-specific approach to socialization proposed and outlined by Grusec and Davidov . This apThe program is intended to be highly practical rather than intensive to keep in mind the demands faced by busy parents who may be experiencing multiple sociocontextual stressors. As such, the program was created with low-income families in mind because these families face barriers to attending the face-to-face parenting program ,18. The general population of parents.The rate at which parents will use internet-based parenting programs in general, and the 5-a-Day Parenting program specifically, is still unclear. Current investigations of internet-based parenting programs often describe the final sample of participating parents but do not indicate what percentage of parents declined eg, ,20), but, but20])actual program use. Finally, given that parents who already regularly engage in the five parenting activities may be less inclined to use the video-based content on the website, we explored if baseline reports of using the parenting activities were related to website use.Specific to the 5-a-Day Parenting program, our initial pilot investigation  demonstrThis study had 3 goals. First, we sought to evaluate the use of the 5-a-Day Parenting program; specifically looking at how many parents would continue receiving text messages after going through a brief e-intervention, intended to prompt program use, and how many parents would use the video-based content on the 5-a-Day Parenting website. Second, we sought to evaluate potential factors that may affect use of the video-based content on the program website, including engagement approach , program-affiliation message , and sociocontextual risk. We also report parents’ use of the five parenting strategies at baseline and their relation to use of the video-based content on the program website. Third, we evaluated parents’ satisfaction with the text messages and video-based content on the 5-a-Day Parenting program website.the Consortium; see =3.4, P=.07). For the entire sample of baseline participants, program-affiliation message did not affect website use . When looking at the recruitment group separately, program-affiliation message still did not affect website use . There was also no evidence that sociocontextual risk affected parents’ use of the website . Given that an accumulation of sociocontextual risk was higher in the registry group, the impact of an accumulation of sociocontextual risk on website use was considered separately by recruitment group. An accumulation of sociocontextual risk was not related to website use in either the registry group  or the Consortium recruitment group . Finally, there was also no association between reported parenting activities at baseline and website use .Of the study participants recruited from a Consortium childcare center , 42% (20/48) used the website at least once, whereas only 24% (11/46) of participants recruited via text message from the registry used the website; this difference was not statistically significant  a brief e-intervention that introduces the program and promotes engagement, and (2) tailored text messages; it further sought to evaluate the extent to which dissemination method, program-affiliation messages, sociocontextual risk, and preintervention use of the parenting strategies might be associated with program uptake.Among study participants (n=94), approximately a third  went on to use the 5-a-Day Parenting program website. This rate of website use is lower than reported in other investigations; for example, Doty et al , reporteHowever, the majority of the 360 parents who learned about the study (74%) chose not to participate. Virtually none of the nonparticipating parents made use of the website (despite having a log-in ID to access the website outside of study participation), suggesting initial engagement (and completion of the brief e-intervention and receipt of text messages) is essential for promoting use of the website content. We do not know enough about this wider group of parents to draw conclusions. There is a need for more research to understand the processes that promote initial engagement in parenting-focused studies and use of parenting resources. Innovative strategies are needed to prompt initial engagement. For instance, providing parents’ space to complete the initial e-intervention of the 5-a-Day Parenting program through services they already use may boost program use. This may look like parents doing the e-intervention at an orientation for childcare or while waiting at a pediatric office. Moreover, direct input from parents may lead to further modifying the program to make it more attractive and appealing to parents. Hansen et al  found thsay having a scientific source of information is important, they also found that people rarely look for information on websites to investigate the background and training of those who created internet-based resources. This may suggest that program-affiliation may not be crucial in understanding actual use of information on the internet.We failed to uncover any factors that affect accessing the video-based content on the 5-a-Day Parenting program website. On the basis of the qualitative work of Bernhardt and Felter  and EyseOf parents recruited through a Consortium childcare center , 42% (20/48) used the 5-a-Day Parenting program website; only 24% (11/46) recruited through the registry  used the website. Although this difference did not reach statistical significance, results may have differed in a larger sample. Further investigation is needed regarding whether differences in recruitment approach (folder vs text) or context (childcare center vs registry) can influence engagement.make the most out of the time spent performing the activities .There was variability in how often parents reported performing the five parenting activities at baseline. Interestingly, reading was the least often reported activity with approximately half of parents reporting reading to their child less than 3 days in the week before project participation. This is surprising given the importance of book sharing and presence of initiatives to promote it in the preschool years . ExpressWe also did not find associations between cumulative sociocontextual risk and use of the 5-a-Day Parenting program website. Although a nonsignificant finding may be due to multiple factors , the results may also be encouraging. Families facing sociocontextual risk often face practical barriers, such as lack of transportation or childcare, which make participating in face-to-face parenting programs a challenge (see ). Web-baThere are a number of limitations in this study. First, a clear limitation is the small sample size of the project. Project budget and timeline limited the sample size. The small sample, coupled with the fact that recruitment took place in only 1 US city, limits generalizability of findings. Second, it is unclear why such a sizeable minority of parents  of those who started baseline participation did not complete it) initiated, but did not complete, baseline assessment see . Some paIn a general sample of parents who chose to participate in a research project, despite not seeking parenting assistance, approximately one-third of parents made use of internet-based parenting content. Furthermore, those who did use the website rated the program as helpful. These are important findings suggesting that many nontreatment seeking parents may receive benefits through online programs. However, we failed to uncover factors that differentiate those who make use of a Web-based parenting resource and those who do not. Participating parents accepted text messages at a very high rate and viewed them favorably. However, most participants chose not to initially engage in the research project at all, and approximately 70% of those who did engage in the research project did not make use of the website. More research is needed to identify factors predictive of engagement in online parenting interventions, as well as techniques for promoting greater engagement.


N-(2-fluorobenzyl)ethanamine, is a new psychoactive substance classified as a phenethylamine. It is a potent agonist of the 5-hydroxytryptamine receptor, but little is known about its metabolism and elimination properties since it was discovered. To aid 25B-NBF abuse screening, the metabolic characteristics of 25B-NBF were investigated in human hepatocytes and human cDNA-expressed cytochrome P450 (CYP) and UDP-glucuronosyltransferase (UGT) enzymes using liquid chromatography–high resolution mass spectrometry. At a hepatic extraction ratio of 0.80, 25B-NBF was extensively metabolized into 33 metabolites via hydroxylation, O-demethylation, bis-O-demethylation, N-debenzylation, glucuronidation, sulfation, and acetylation after incubation with pooled human hepatocytes. The metabolism of 25B-NBF was catalyzed by CYP1A1, CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6, CYP2J2, CYP3A4, and UGT2B7 enzymes. Based on these results, it is necessary to develop a bioanalytical method for the determination of not only 25B-NBF but also its metabolites in biological samples for the screening of 25B-NBF abuse.25B-NBF, 2-- New psychoactive substances (NPSs) are abused compounds with effects similar to those of controlled drugs such as cannabis, morphine, cocaine, and amphetamine-type stimulants. Since the United Nations Office on Drugs and Crime (UNODC) launched the international NPS monitoring system in 2009, the amount of NPSs has increased by 3.7 times to 479 substances in 2017  that binds to human 5-HT2A receptors and rat 5-HT2C receptors with pKi values of 8.57 and 7.77, respectively [N-(2-methoxybenzyl)-ethanamine], have been reported + ion owing to the characteristic isotope pattern of bromine. 25B-NBF produced three characteristic fragment ions at m/z 243.0015 [2-ethan-1-ylium], m/z 227.9780 , and m/z 109.0448 [(2-fluorophenyl)methylium], which served as a marker of fragment ions for metabolite identification methylium], and therefore, M1–M4 were formed via hydroxylation at the fluorobenzyl moiety but the accurate hydroxylation position of each metabolite was not determined ethan-1-ylium] and m/z 109.0451 (The [M + H]109.0451 D.+ ion at m/z 260.0281 and product ions at m/z 243.0014 (loss of NH3 from the [M + H]+ ion) and m/z 227.9780 ethanamine] on the basis of its [M + H]227.9780 E.+ ion at m/z 544.0977, 176.0321 amu higher than 25B-NBF, and a product ion at m/z 368.0292 (25B-NBF ion due to loss of glucuronic acid), suggesting that it was 25B-NBF N-glucuronide  produced the characteristic product ions at m/z 245.0046 (loss of fluorobenzyl moiety from [M + H]+ ion), m/z 228.9859, m/z 142.0663 (loss of 2-(4-bromo-hydroxymethoxyphenyl)ethane from [M + H]+ ion), and m/z 125.0398 , m/z 243.0015, and m/z 125.0399, suggesting that M18-M20 may be hydroxy-25B-NBF glucuronide via monohydroxylation at the fluorobenzyl moiety and glucuronidation (M18–M20 produced an [M + H]nidation . The exa+ ion at m/z 546.0769 and the product ions at m/z 370.0449 (loss of glucuronyl moiety from the [M + H]+ ion), suggesting that they were hydroxy-O-demethyl-25B-NBF glucuronides. M21 and M23 also produced the product ions at m/z 352.0345 (loss of H2O from m/z 370.0449), m/z 228.9859, m/z 214.9702, and m/z 109.0448, suggesting glucuronidation of M16 (m/z 422.0442 (loss of hydroxyflourobenzyl moiety from the [M + H]+ ion), m/z 246.0124 (loss of glucuronosyl moiety from m/z 422.0442), m/z 228.9861, and m/z 125.0399  and m/z 213.9597 (M27 and M28 produced an [M + H]213.9597 .+ ion at m/z 530.0820 and product ions at m/z 354.0499 (loss of glucuronyl moiety from [M + H]+ ion) and m/z 228.9859, indicating that M29 was O-demethyl-25B-NBF glucuronide (M29 produced an [M + H]curonide .+ ion at m/z 434.0068 and the product ions at m/z 354.0499 (loss of sulfate from the [M + H]+ ion), m/z 308.9427 [loss of (2-fluorophenyl)methanamine from the [M + H]+ ion), m/z 228.9859 (loss of sulfate from m/z 308.9427), and m/z 109.0451 , m/z 214.9701, and m/z 109.0451, indicating that M32 was bis-O-demethyl-25B-NBF (M7) glucuronide (M32 produced an [M + H]curonide .+ ion at m/z 302.0386 and product ions at m/z 260.0280 (loss of acetyl moiety from the [M + H]+ ion), m/z 243.0014 (loss of NH3 from the [M + H]+ ion) and m/z 227.9781, indicating that M33 was acetyl-2C-B  was incubated with major human cDNA-expressed CYP1A1, CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP2E1, CYP2J2, CYP3A4, or CYP3A5 in the presence of reduced form of nicotinamide adenine dinucleotide phosphate (NADPH). The metabolism of 25B-NBF was mediated by CYP1A1, CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6, CYP2J2, and CYP3A4 . Some meUGT enzymes responsible for the glucuronidation of 25B-NBF were investigated with incubation of 25B-NBF in major human cDNA-expressed UGT1A1, UGT1A3, UGT1A4, UGT1A6, UGT1A7, UGT1A8, UGT1A9, UGT1A10, UGT2B4, UGT2B7, UGT2B10, and UGT2B15 in the presence of UDPGA. The formation of 25B-NBF glucuronide (M9) was solely mediated by UGT2B7 . HoweverThe in vitro metabolism of 25B-NBF, including metabolic stability and metabolite identification, was investigated using human hepatocytes. 25B-NBF was extensively metabolized in human hepatocytes, resulting in an elimination half-life and hepatic extraction ratio of 29.7 min and 0.80, respectively. The structure-related derivatives such as 25B-NBOMe, 25C-NBOMe, and 25I-NBOMe have been reported to undergo extensive metabolism in human, mouse, and rat ,14,15,2079Br and 81Br. 25B-NBF was metabolized into 33 metabolites by human hepatocytes: four hydroxy-25B-NBF (M1–M4), two O-demethyl-25B-NBF (M5 and M6), bis-O-demethyl-25B-NBF (M7), 2C-B (M8), 25B-NBF glucuronide (M9), 25B-NBF cysteine conjugate (M10), seven hydroxy-O-demethyl-25B-NBF (M11–M17), three hydroxy-25B-NBF glucuronides (M18–M20), three hydroxy-O-demethyl-25B-NBF glucuronides (M21–M23), three hydroxy-O-demethyl-25B-NBF sulfates (M24–M26), two O-demethyl-M8 (M27 and M28), O-demethyl-25B-NBF glucuronide (M29), two O-demethyl-25B-NBF sulfates (M30 and M31), M7 glucuronide (M32), and acetyl-M8 (M33)  .N-dearylation, glucuronidation, sulfation, cysteine conjugation, and acetylation alone or in combination, comparable to those of structurally related derivatives such as 25B-NBOMe, 25C-NBOMe, 25I-NBOMe, and 25I-NBOH [The metabolic pathways of 25B-NBF were hydroxylation, demethylation, 25I-NBOH ,20,21,22N-dearylation to M8 was mediated by several CYPs including CYP1A1, CYP1A2, CYP2B6, CYP2C19, and CYP3A4. The glucuronidation of 25B-NBF to 25B-NBF glucuronide (M9) was catalyzed by UGT2B7.Multiple CYPs including CYP1A1, CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6, CYP2J2, and CYP3A4 were responsible for the metabolism of 25B-NBF . The hydN-dearylation of 25B-NBF to 2C-B (M8), which is a psychedelic phenethylamine that is highly abused worldwide [O-demethylation, oxidative deamination, and amine oxidation catalyzed by monoamine oxidase, aldehyde dehydrogenase, alcohol dehydrogenase, and CYP enzymes [O-demethyl-2C-B (M27 and M28) and an acetyl-2C-B (M33) were identified as the metabolites of 25B-NBF. These results suggest that abuse of 2C-B or 25B-NBF can be detected by 2C-B and a few other metabolites that persist in forensic biological samples.orldwide ,24, was  enzymes ,27,28. I25B-NBF was obtained from the Cayman Chemical Company . LiverPool™ cryopreserved human hepatocytes , InVitroGRO™ HT Medium, and InVitroGRO™ KHB were purchased from BioIVT . Honokiol (positive control in metabolic stability assays), ketoconazole  for metabolic stability), nicotinamide adenine dinucleotide phosphate, NADPH, glucose-6-phosphate, glucose-6-phosphate dehydrogenase, uridine 5′-diphosphoglucuronic acid (UDPGA), and ProteoMass™ LTQ/FT-Hybrid ESI Pos. Mode CalMix were purchased from Sigma-Aldrich . Homoegonol (IS for metabolic enzyme characterization) was purchased from Toronto Research Chemicals Inc. . LC–MS grade acetonitrile, methanol, and water were obtained from Fisher Scientific . Human cDNA-overexpressed CYP isozymes , and human cDNA-overexpressed UGT isozymes  were obtained from Corning Life Sciences . Other chemicals used were of the highest grade available. 6 cells/mL. Then a 60 μL aliquot of this hepatocyte suspension and equal volume of 25B-NBF (4 μM) in Krebs–Henseleit buffer were mixed into 96-well plates and incubated in triplicate for 0, 5, 15, 30, 60, 120, or 180 min in a CO2 incubator at 37 °C. Incubation was quenched by addition of 120 µL ice-cold acetonitrile to each well, and the samples were centrifuged at 15,000× g for 10 min at 4 °C after 5 min sonication. Then 100 µL of supernatants were vortex-mixed with equal volume of water and 2 μL aliquots were analyzed by an LC–MS/MS system. Honokiol (2 µM) was separately incubated for the positive control of this system. The peak area ratios of substances versus IS at each sampling point were used in subsequent calculations of parameters. The following equations were used in the calculation of elimination parameters, including t1/2, intCl, hepCl, and hepatic extraction ratio of 25B-NBF.Pooled cryopreserved human hepatocytes were carefully thawed in thawing medium and resuspended in Krebs–Henseleit buffer to a final density of 1.0 × 10hQ refers to hepatic blood flow [ood flow . Compariood flow .6 cells/mL) were mixed in 96-well plates and incubated in triplicate for 2 h in a CO2 incubator at 37 °C. Incubation was quenched by addition of 120 µL ice-cold acetonitrile to each well, and then the samples were centrifuged at 15,000× g for 10 min at 4 °C after 5 min sonication. Then the supernatants (200 µL) were dried using a speed-vac and residues were reconstituted with 10% methanol (100 µL). 5 μL Aliquots of each sample were analyzed using an LC–HRMS system.An amount of 60 µL 25B-NBF (20 μM) in Krebs-Henseleit buffer and human hepatocyte suspensions  to determine CYP enzymes involved in the metabolism of 25B-NBF. The 95 µL of reaction mixtures were prepared as follow: 10 µL of 100 µM 25B-NBF stock solution, 10 µL of CYPs (40 pmol), 4 µL of 250 mM magnesium chloride, and 71 µL of potassium phosphate buffer . The incubation was started by addition of NADPH-generating system (5 µL), and the mixtures were incubated for 30 min at 37 °C in triplicate.For the characterization of the UGT enzymes involved in the glucuronidation of 25B-NBF to M9, 25B-NBF was incubated with 12 human cDNA-expressed UGT enzymes . The 95 µL of reaction mixtures were prepared as follow: 10 µL of 100 µM 25B-NBF stock solution, 10 µL of UGTs (2.5 mg/mL), 1 µL of 2.5 mg/mL alamethicin, 4 µL of 5 mM magnesium chloride, and 70 µL of Tris-HCl buffer . The reaction was initiated by addition of 25 mM UDPGA (5 µL), and the mixtures were incubated for 30 min at 37 °C in triplicate. g for 4 min at 4 °C, 150 µL of supernatant was dried under N2 gas. The residue was reconstituted in 50 µL of 45% methanol and a 5 µL of aliquot was injected into the LC–HRMS system.By adding 100 µL of ice-cold methanol (containing 100 ng/mL of IS), the reaction was terminated. After centrifugation at 10,000× 18 column  was used as a stationary phase. The flow rate used was 0.3 mL/min, and gradient elution was performed as follows: 10% B for 0–1 min, 10–90% B for 1–2.5 min, 90% B held for 2.5–4 min, 90–10% B for 4–4.1 min, and 10% B for 4.1–6 min. MS spectra were acquired in positive-ion mode using electrospray ionization (ESI). ESI conditions were optimized as follows: gas temperature 200 °C, gas flow 16 L/min, nebulizer 40 psi, sheath gas temp 380 °C, sheath gas flow 12 L/min, capillary voltage 4.5 kV, and nozzle voltage 500 V. Selective reaction monitoring transitions were 367.9→242.9 at a collision energy (CE) of 20 for 25B-NBF and 531.2→489.2 at a CE of 34 for ketoconazole.To assess the metabolic stability of 25B-NBF, we used an Agilent 1290 Infinity UPLC coupled with Agilent 6495 triple quadrupole MS  in the quantification of 25B-NBF. For the chromatographic separation, 5% methanol containing 0.1% formic acid and 95% methanol containing 0.1% formic acid were used as mobile phase A and mobile phase B, respectively, and a Halo CFor 25B-NBF metabolites identification and their quantification, we used a Nexera-X2 HPLC system  coupled to a Q-Exactive Orbitrap mass spectrometer . The mass spectrometer was calibrated using ready-to-use calibration solution immediately before sample analysis. For the chromatographic separation, a Halo C18 column , 5% methanol in 0.1% formic acid (mobile phase A), and 95% methanol in 0.1% formic acid (mobile phase B) were used. Gradient elution was performed as follows: 10% B for 0–1.5 min, 10–50% B for 1.5–10 min, 50–90% B for 10–12 min, 90% B for 12–15 min, 90–10% B for 15–15.2 min, and 10% B for 15.2–18 min. The flow rate was 0.3 mL/min. Column and autosampler were maintained at 40 °C and 4 °C, respectively.m/z 100 to m/z 1500), and data-dependent MS/MS spectra were obtained at a resolution of 35,000 . Prediction of fragment ions was aided by Mass Frontier . Each metabolite was identified allowing 5 ppm mass error from the theoretical value. Owing to the absence of authentic standard of 25B-NBF metabolites, the formation rates of each metabolite were calculated using the standard curve of 25B-NBF.A heated electrospray ionization (HESI) source was interfaced and the MS spectra were obtained in positive mode. For the metabolite identification, HESI source conditions were optimized as follows: 35 for sheath gas flow rate (arbitrary units), 10 for auxiliary gas flow rate (arbitrary units), 4 kV for spray voltage, and 350 °C for heater temperature. Xcalibur software (Thermo Fisher Scientific Inc.) was used in acquiring and processing MS spectra. Full MS spectra were acquired at a resolution of 70,000 (from O-demethylation, bis-O-demethylation, N-dearylation, cysteine conjugation, glucuronidation, sulfation, and acetylation alone or in combination in human hepatocytes. 2C-B, one of the most widespread NPSs, was identified as a major metabolite of 25B-NBF. Multiple CYPs including CYP1A1, CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6, CYP2J2, and CYP3A4 were involved in hydroxylation, O-demethylation, bis-O-demethylation, and N-dearylation of 25B-NBF. UGT2B7 played a prominent role in glucuronidation of 25B-NBF to M9. The present study shows that it is necessary to determine the metabolites as well as 25B-NBF in biological samples to detect 25B-NBF abuse. These results may help to predict pharmacokinetic profiles aof 25B-NBF in humans and to address which metabolites should be synthesized for the analysis of 25B-NBF and metabolites in biological samples.25B-NBF was extensively metabolized into 33 metabolites by hydroxylation,


Challenges associated with the use of the CanMEDS physician competency framework (CanMEDS) have been the subject of several studies. Most of these have focused on the adoption of specific roles in an Anglophone context. This study aims to investigate how Francophone postgraduate medical education (PGME) program directors have integrated the CanMEDS framework into their programs.We invited Francophone PGME program directors to participate in group interviews aimed at exploring their experiences using the CanMEDS framework. We used an open-ended interview guide and realized a thematic analysis of the transcripts.We held five group interviews between February and December 2014 with 17 Francophone program directors representing 13 out of a maximum of 62 different specialties/subspecialties. Although program directors endorsed the framework, its integration was seen as challenging, particularly the assessment of non-medical expert roles. To overcome these challenges, they relied on common strategies including a longitudinal approach to the framework, improving inter-program collaboration, and subcontracting the teaching of certain roles.While integrating the CanMEDS framework into their programs, Francophone program directors struggled with teaching and assessing non-medical expert roles and ensuring their longitudinal integration over time. Directors relied on various strategies, some of which  may ultimately limit the adoption of the framework as a whole. ___ It de-emphasizes time-based training and promises greater accountability, flexibility, and learner-centredness”(p.636).6 CBE and CBE-based frameworks were developed in response to pragmatic pedagogical and societal needs8 to appropriately address society’s health care needs.9 The Royal College of Physicians and Surgeons of Canada (RCPSC) CanMEDS physician competency framework10 is one example of CBE being used around the world,13 in postgraduate medical education as well as undergraduate medical education programs.14 This framework is bilingual and it is used in both Francophone and Anglophone programs. The 2005 version included seven roles, namely, “medical expert,” “communicator,” “collaborator,” “scholar,” “manager,” “health advocate,” and “professional.” In the 2015 version, the “manager” role was renamed “leader” and redefined.There has been an increased interest in competency-based education (CBE) in recent years, with many different CBE frameworks published in the health professions education (HPE) literature.17 Pragmatic issues associated with the implementation of CBE-related frameworks have also emerged. Authors have called for increased alignment of the frameworks with specialty-specific considerations.19 Independent of specialty, it appears that the adoption of the CanMEDS framework requires some adaptation by its main users – program directors, administrators, and clinical teachers – in order to make implementation sustainable. Despite the publication of a CanMEDS implementation strategy11 many scholars have shown that integrating individual roles into training programs can be challenging, especially when it comes to the assessment of the so called “intrinsic roles” .26 Moreover, reports of the challenges associated with use of the CanMEDS framework have focused on individual roles, distinct from adoption of the framework as a whole.Many scholars have critiqued various competency frameworks suggesting that defining competence through a series of roles might minimize the concept of competence and not appropriately reflect its complexity.27 and efforts to be consistent with the implementation of “Competence by Design” (CBD) as defined by the RCPSC, have created an impetus for the investigation of the adoption of the CanMEDS competency framework as a whole. According to Rogers’s Diffusion of Innovations Theory, adoption refers to the decision of “full use of an innovation as the best course of action available” (p.177).28 A core principle of CBD is that competencies are acquired on a continuum. To our knowledge, Puddester et al.20 and Whitehead et al.29 are the only authors who have tried to investigate faculty members’ needs with respect to teaching and assessing non-medical expert roles in this manner. Still, little is known about the processes associated with the overall adoption of the CanMEDS framework by its users, whether in Francophone or Anglophone environments. Moreover, since perceptions and practices vary with culture, adoption of a framework could potentially vary across different contexts. According to Kramsch,30 language is a vehicle of thought and culture. Although the CanMEDS framework was rolled out in Canada in both English and French, its adoption overall has not been well studied in a Francophone context.In spite of its continuous evolution, arrival of the revised 2015 CanMEDS frameworkGiven these gaps, we conducted an exploratory study to investigate how Francophone postgraduate medical education (PGME) program directors in different faculties adopted and integrated the CanMEDS framework into their programs. More specifically, we conducted group interviews to identify specific challenges underlying the use of the CanMEDS framework, and strategies used to address these challenges in a Francophone context.31 Group interviews were preferred to individual interviews in order to facilitate and encourage inter-participant exchanges and to highlight program similarities. Informed consent was obtained from participants and group interviews were conducted in French by two co-authors (IG and KO), who had no connection with the program directors who were interviewed. We used a semi-structured interview to explore program directors’ experiences using the CanMEDS framework as a tool to guide curriculum development and teaching, as well as the assessment of medical competencies. The interview guide was loosely inspired by Rogers’s Diffusion of Innovations Theory28 where the relative advantage, compatibility and perceived complexity of the CanMEDS framework, as well as the main drivers of adoption of the framework for curriculum development, teaching, and assessment, were the focus of the discussion. The interview guide (process and questions), which is presented in In an effort to better understand the adoption of the CanMEDS framework in a Francophone context, all PGME program directors from all specialties of the four Quebec faculties of medicine were approached through their PGME deans to participate in group interviews. The number of specialties/subspecialties represented varies between faculties, but there are a maximum of 62 specialties/subspecialties educated in Quebec.34 based on the conceptual framework chosen for the interview guide. First, verbatim transcripts were read and coding categories were created using NVivo software Version 9.0 . These codes were then used to categorize excerpts of the transcripts until no new categories emerged. Coding and analysis were conducted independently by two co-authors (IG and KO) and any disagreements were discussed until a consensus was reached. The prominent codes were then extracted and only the themes that reached saturation were preserved; that is, themes for which sufficient data were collected to allow comprehension of a concept.35 The overall analysis was discussed regularly among all authors during and after the group interviews to improve the rigor of the analysis and the credibility of the findings. The whole process was conducted in French and only the excerpts presented were translated into English.We read and analyzed the transcripts in a stepwise manner using an iterative process to interpret the dataIn total, 17 residency program directors from two Francophone faculties of medicine participated in the study, representing 13 different specialties/subspecialties. Group interviews were scheduled by faculty and availability of participants guided the composition of each group. Whenever possible, efforts were made to vary the composition of each group in terms of specialities/subspecialties to enrich interview discussions. Five group interviews (between two and five participants per group) took place between February and December 2014, and discussions lasted on average for 51 minutes. Results are organized according to the two main findings of the study: 1) program directors’ endorsement of the CanMEDS framework ; and 2) challenges underlying the adoption of the CanMEDS framework and common strategies to address these.According to the CanMEDS 2005 framework, being a good physician requires integrating seven roles. The participants’ reported that the CanMEDS framework helps train residents as it guides them to develop competencies in addition to those of the medical expert. In doing so, they thought the CanMEDS framework was contributing to the training of more “complete” physicians: “For future generations, I think it makes for more competent, more all-round professionals, when they really have [acquired] all the CanMEDS abilities.” Giving formal expression to what was previously informal seemingly reinforced to participants the merits of adhering to the CanMEDS framework: “I find that it helps to put into words realities that have always been there. This is beneficial.” According to participants, the framework enables stakeholders to speak a common language; the seven competencies are “dissected,” allowing some standardization of the vocabulary used to describe what is expected of residents. Competencies form the common structure on which residents are assessed. Moreover, breaking down expectations into various competencies was seen as allowing for better organization of the different facets to be developed.For most participants, the division into seven roles allows for more targeted interventions. Additionally, the clearly identified and defined roles were seen as assisting in addressing the expected competencies within each role.It’s much simpler now when we meet [with residents to assess them], first, because we have a better understanding of the different roles, so we’re in a much better position to say, “Look, for this one competency, you’re doing very well.” For all of them, except for that one (…).” It’s a lot simpler now because it’s divided up, and I find it’s easier to take action. Despite adhering to the principles of the CanMEDS competency framework and the perceived benefits of proposing a common structure, participants reported several challenges, most of which were related to the operationalization of the framework. Strategies used by participants to minimize the impacts of these challenges within their programs were identified throughout the interviews.While the program directors who we met appeared to navigate easily through the process of teaching the clinical skills of the medical expert, the six non-medical expert CanMEDS roles , collaborator, health advocate, and scholar) posed greater challenges. Participants criticized the perceived lack of training available on how to teach competencies other than those of the medical expert. Most participants admitted feeling ill-equipped to teach these other competencies, regardless of whether their medical training took place prior to or after their introduction to a CanMEDS competency framework.The difficulty [for us] as program directors is that we’re used to training by role models. A good example is the example that residents will give. We’re well equipped to give technical training; we know how to do that. What’s harder, at least from our perspective, in terms of introducing the CanMEDS roles, is the lack of role models, plus the fact that we have to be creative. Participants also expressed the feeling that they have little support for teaching/assessing competencies other than those of the medical expert. They find the requirements for these vague and unclear, which obliges them to “create” their own teaching/assessment tools.We had to invent [our own 360° assessment form] because none really exists. How can it be that there is none? How can it be that we’re expected to do that? There are no tools. That’s what’s missing. Some participants also reported that they felt disadvantaged because many tools were created by other programs (instead of the RCPSC), and consequently, were not available in French.We [PGME program directors] help each other, we share documents: « Here is how I assess this part… » (…) But when they [Anglophone PGME program directors] send me their documents, I take what I want, but I have to do the translation. A handful of strategies to improve adoption of the CanMEDS competency framework are emerging in the face of these challenges. The first translates into a more longitudinal approach to the framework. While the framework reflects the RCPSC requirements, participants see it more like an “integrating” structure, as described in the following comment:I realize that sometimes, for certain CanMEDS competencies, rather than dividing them up by rotations, it would be better to have something a little more longitudinal; to really see the resident as a whole. A second approach to improving the framework’s adoption was inter-program collaboration. The creation of opportunities to share experiences with colleagues in other programs or to develop common inter-program activities, both appear to be worthwhile initiatives as new implementation strategies can emerge from these collaborations. While major differences sometimes exist between programs, these strategies allow inspiration to be drawn from other people’s work and boost the efforts within a given program to teach and assess the competencies.The creation of working groups with directors of other programs  or with other medical faculties offering similar programs fits this approach to improve adoption. As expressed by the following participant, these collaborations allow program directors to open their minds to new ways of doing things:Sometimes there are competencies where you say to yourself, “But we don’t cover this competency. How could we cover it?” So it might be helpful if we could work with other programs, precisely because that would give us more ideas than if we’re just focused on ourselves and turning around in circles because we don’t know how to go about teaching this competency. A third strategy emerged from the difficulty of teaching/assessing competencies other than those of the medical expert: the strategy of subcontracting the teaching to professionals “specialized” in the different roles. This strategy poses major difficulties – efforts to do so can be fruitless because “specialists” are rare. While some individuals may have developed a network over the years allowing them to delegate the teaching of certain competencies to various “experts,” others may not, thus making it a challenge to secure these experts. In this respect, all the participants regard the assessment of the CanMEDS competencies associated with the non-medical expert roles as a challenge, in that they see the assessment requirements as vague and non-prescriptive, which obliges them to “fumble their way along.”I find the manager role very difficult. I turn to the administrative director of our department and ask him to talk with the residents about all aspects of the department’s operations, like purchasing, upgrading equipment, and how we go about hiring professionals. Because I don’t know anything about that. And then there’s assessment, which is not as simple as that. In a case like that, I’d have to ask him to give a test, but he has already agreed to give the course… The relative advantages and compatibility of the CanMEDS framework and CBE with the participants’ needs is recognized, but Quebec Francophone residency program directors perceive the framework to be difficult to implement. Guided by Rogers’ Diffusion of Innovation Theory, five group interviews involving 17 program directors from two Quebec medical schools, revealed strategies in response to implementation challenges, particularly for the non-medical expert roles.et al.29 who reported, among other things, that program directors perceive themselves as lacking the expertise needed to teach and assess the non-medical expert roles. Puddester et al.20 focused more on competency assessment, also showing professors’ need for training in the assessment of the non-medical expert roles, which remains a disintegrated vision of the CanMEDS framework. Nonetheless, the challenge of operationalization is present in both Anglophone and Francophone contexts. The non-medical expert roles are seen as difficult to teach, and equally difficult (if not more so) to assess.Some difficulties may be experienced in shifting from a theoretical framework to practice: indeed, the challenges reported by our participants concern the difficulty of operationalizing the CanMEDS framework and even more with integrating the different roles over the duration of the training. This finding adds to the results of Whitehead 28 incentives may increase motivation, resulting in a more effective adoption of an innovation. Contrary to Puddester et al.’s study,20 none of our participants mentioned the lack of any kind of incentives  as a barrier to implementation of teaching the competencies of the CanMEDS framework. This is also contrary to what has been reported in the context of other competency frameworks like the Accreditation Council for Graduate Medical Education (ACGME) framework.36For Rogers,20 who, through an analysis of program directors’ needs in a single faculty of medicine (English-speaking context), identified the need for collaboration and a sharing of resources. Our participants believe that the CanMEDS roles should be taught and assessed in a more longitudinal and collaborative manner. Although having a longitudinal perspective on development may seem self-evident in a competency framework, its manifestation did not appear that simple for our participants. They reported struggling to implement the framework and often needed to break it down into smaller parts; however, this tactic runs the inherent risk of losing sight of the overall and developmental objective of the framework.We sought to move beyond the observation that “challenges” exist in the teaching and assessment of CanMEDS roles by bringing to the forefront strategies proposed by program directors to address these challenges. Our participants’ proposals echoed the results obtained by Puddester et al.27 The act of explicitly integrating several competency milestones, however, further fragments the roles. Residents are thus assessed in terms of a range of sub-competencies. In this context, and given the already overloaded curricula, the strategies proposed by our participants seem all the more pertinent. The challenge of “not reinventing the wheel,” by avoiding working in isolation,29 therefore still stands.The 2015 version of the CanMEDS competency framework appears to be congruent with these strategies: the framework integrates several competency milestones associated with an acquired and validated professional activity.37 this unease may be due to “a lack of understanding of what the roles actually represent” (p. 395). Competency assessment remains a problem when competencies are taught by one group of individuals but assessed by another. This perception of not having the expertise required to teach the non-medical expert roles may also mean that program directors do not capitalize on role modeling, even though this strategy is generally recognized as important.38 It could be interesting to explore “train-the-trainer” approaches for this problem so that a broader range of faculty consider themselves more comfortable modeling, teaching, and assessing the non-medical expert roles. In addition, the longitudinal integration of the non-medical expert roles over the duration of training could be facilitated by a model more closely connected with assessment.The strategy of subcontracting the teaching of the non-medical expert roles to “specialized” professionals may align with more longitudinal teaching and assessment, and with improved collaboration however, it may also, limit adoption of the framework as a whole. The fact remains, however, that this strategy highlights the program directors’ unease regarding the best ways to proceed teaching and assessing non-medical expert competencies. As underscored by Mickelson,The goal of this study was to explore Francophone PGME program directors’ adoption of the CanMEDS 2005 framework as a whole. Our results suggest that despite the presence of several challenges related to the operationalization of roles, Francophone program directors supported the concept of CBE and the CanMEDS framework. They relied on various strategies to overcome challenges encountered, but they struggled, just as Anglophone directors, with teaching and assessing the non-medical expert roles to ensure their longitudinal integration over time. In addition, some of the strategies used  may in fact have the untoward effect of limiting adoption of the framework as a whole.39This study has some limitations. First, the fact that participants were from two of the four faculties of medicine in Quebec may limit the transferability of our results. Indeed, it is possible that Francophone participants from other faculties might have a different point of view. The composition of each interview group may also have influenced the findings obtained. Additionally, we cannot rule out that program directors who volunteered for the group interviews might have had a bias (be it positive or negative) towards the CanMEDS framework and its use in the curriculum.ad hoc Band-Aid solutions. A theory-based evaluation of the implementation of CanMEDS, in partnership with program directors from different cultural contexts may optimize adoption in the future and in turn improve curriculum development, teaching, and assessment. Replication of this project in countries other than Canada where the CanMEDS framework is used may also offer a broader perspective on the local and cultural difficulties and solutions related to the implementation of the framework.While participants called for more guidance on how to teach and assess the non-medical expert roles, the solution may not lie in the sharing of resources. In fact, despite the CanMEDS implementation strategies made available by the RCPSC, program directors still struggle with teaching, as well as assessing, non-medical expert roles. A collaborative approach to finding true solutions is needed to do away with