Countries in sub-Saharan Africa are scaling-up voluntary male medical circumcision (VMMC) as an HIV intervention. Emerging challenges in these programs call for increased focus on program efficiency (optimizing program impact while minimizing cost). A novel analytic approach was developed to determine how subpopulation prioritization can increase program efficiency using an illustrative application for Zambia.A population-level mathematical model was constructed describing the heterosexual HIV epidemic and impact of VMMC programs  model). The model stratified the population according to sex, circumcision status, age group, sexual-risk behavior, HIV status, and stage of infection. A three-level conceptual framework was also developed to determine maximum epidemic impact and program efficiency through subpopulation prioritization, based on age, geography, and risk profile. In the baseline scenario, achieving 80% VMMC coverage by 2017 among males 15–49 year old, 12 VMMCs were needed per HIV infection averted (effectiveness). The cost per infection averted (cost-effectiveness) was USD $1,089 and 306,000 infections were averted. Through age-group prioritization, effectiveness ranged from 11 (20–24 age-group) to 36 (45–49 age-group); cost-effectiveness ranged from $888 (20–24 age-group) to $3,300 (45–49 age-group). Circumcising 10–14, 15–19, or 20–24 year old achieved the largest incidence rate reduction; prioritizing 15–24, 15–29, or 15–34 year old achieved the greatest program efficiency. Through geographic prioritization, effectiveness ranged from 9–12. Prioritizing Lusaka achieved the highest effectiveness. Through risk-group prioritization, prioritizing the highest risk group achieved the highest effectiveness, with only one VMMC needed per infection averted; the lowest risk group required 80 times more VMMCs.Epidemic impact and efficiency of VMMC programs can be improved by prioritizing young males , geographic areas with higher HIV prevalence than the national, and high sexual-risk groups. Three randomized controlled trials in 2005 and 2007 demonstrated that circumcision reduces the risk of males acquiring HIV through female-to-male transmission by approximately 60% –3. In seDifferent mathematical modeling studies have highlighted the potential gains of VMMC as an HIV intervention , 6–11. MSgaier et al. recently summarized the achievements of the global VMMC program to date and outlined key programmatic challenges the program is facing . While tTo explore opportunities for the VMMC programs to achieve greater efficiency, we evaluated the prioritization of subpopulations of males—optimizing targets so that the program focuses on the most impactful circumcisions to achieve the ultimate goal of averted HIV infections—as a key strategy for more efficient and effective scale-up of the VMMC program. This is a feasible concept, given that not all circumcisions contribute equally to public health outcomes . The epieffectiveness), 2) HIV incidence rate reduction, 3) absolute number of HIV infections averted (magnitude of impact), 4) cost per HIV infection averted (cost-effectiveness), and 5) total program cost. The second level of the framework assesses measures of program efficiency and policy outcomes using program expansion pathway curves [We developed the age-structured mathematical (ASM) model, a novel analytic framework, to describe the heterosexual HIV epidemic and to assess the impact of VMMC programs in sub-Saharan Africa (SSA). A novel three-level conceptual framework, complementing the ASM model, was also developed to ascertain whether it is possible to prioritize subpopulations based on age, geography, and risk profile of males to maximize programmatic efficiency . The firy curves  and poliWe constructed a deterministic compartmental mathematical model, based on extension of earlier models , 15–19, The model disaggregates Zambia’s population into 20 age groups, with each group representing a five-year age band . In order to account for heterogeneity in sexual risk behavior, we incorporated six sexual risk groups in the population, starting from lower to higher levels of sexual risk behavior (Risk group 1 being the lowest and Risk group 6 being the highest). It is assumed that people stay in the same risk group throughout their sexual activity lifespan (15–49 years of age). The distribution of the population across the risk groups follows a gamma distribution based on empirical data of the distribution of the number of sexual partners from SSA . The levWe describe partner choice or mixing between the sexual risk groups and age groups by mixing matrices that incorporate both an assortative component , and a proportionate component . For age mixing, we assumed males from a specific five-year age group will preferentially mix with females in the five-year age group below their age group , based on empirical data , 31.A fraction of males in the population are assumed to be circumcised (baseline circumcision) through background traditional circumcision. The efficacy of VMMC against HIV acquisition is modeled as a proportional reduction in the risk of HIV acquisition among circumcised males. The model accommodates risk compensation that may theoretically be experienced by circumcised males following VMMC, through a proportional increase in the level of sexual risk behavior. Nonetheless, given the inconclusive empirical evidence to support increases in risk behavior following VMMC –36, we aZambia Demographic and Health Survey (DHS) 2007, which is a nationally representative household-based survey [The model was parameterized using empirical epidemiological and natural history data from SSA. The model’s parameter values along with their references are listed in d survey , 40. Furd survey . Demograd survey . The VMMd survey . Followid survey .et al. [The model was fitted to HIV prevalence time series data using a nonlinear, least-square fitting method. This technique minimizes the sum of squares between all data points and the model, using the Nelder-Mead simplex algorithm as described in Lagarias et al. . There het al. . To fit effectiveness of the VMMC intervention was the number of VMMCs required to avert one HIV infection. This measure was calculated by dividing the number of VMMCs by the number of infections averted over the chosen time horizon.The implications of the VMMC program were assessed through epidemiologic, health economics, program efficiency, and policy measures , among others, were assessed at different points within the chosen time horizon. We applied an annual discount rate of 3% on future savings (HIV infections averted) [The metric used for the averted) .cost-effectiveness of the VMMC intervention was the cost to avert one HIV infection. This measure was calculated by dividing the total cost of the VMMC program by the total number of HIV infections averted over the chosen time horizon. Implicitly therefore the cost-effectiveness is the incremental cost-effectiveness ratio relative to a scenario of no VMMC intervention. The metric used for the total program cost was the actual VMMC program cost of delivering these VMMCs, including all direct and indirect costs related to the provision of VMMC such as personnel, VMMC commodities, and training. All costs were calculated in USD.The health economics metric used for the program efficiency of different VMMC programs (the second level of the assessment framework). The first metric of program efficiency was the VMMC public health program expansion path curve [Two metrics were used to determine the th curve . This mepolicy domains for decision making using policy-frontier plots. Two policy themes were used to generate these frontier plots. The first frontier plot was based on the theme of maximizing program efficiency (maximizing gain while minimizing cost), thereby displaying the Gain/Pain index versus the total VMMC program cost. Within the plot, the different subpopulation prioritizations were classified into four distinct policy domains, based on being favorable or unfavorable in terms of Gain/Pain and total VMMC program cost.The above measures were used collectively to generate The second policy-frontier plot was based on the theme of maximizing the total impact of the VMMC program, thereby displaying the total number of HIV infections averted versus the total VMMC program cost, but also factoring in cost-effectiveness. Within the plot, the different subpopulation prioritizations were classified into three distinct policy domains, based on being favorable or unfavorable in terms of total VMMC program cost, total impact, and cost-effectiveness.The third level of the conceptual framework is programmatic feasibility, and is related to on-the-ground country experiences and national health policy priorities.The original implementation strategy of the Zambia VMMC program scale-up aimed to reach 1.95 million VMMCs in a catch-up phase (2010–2015), by targeting the entire 15–49 year old uncircumcised male population . The proForecast plan based on no-growth scale-up scenario: We used the actual number of VMMCs that the VMMC program achieved between 2007 and 2013 , and theForecast plan based on current VMMC program scale-up: We used the actual number of VMMCs that the program achieved between 2007 and 2013 , and supWe modeled the HIV epidemic in Zambia and the scale-up of a VMMC program initiated in 2010. The uptake of VMMC among HIV-negative and HIV-positive males was based on program data for Zambia. Consequently, less than 1% of those circumcised in the modeled scenarios were HIV-positive .The intervention starts with a “catch-up” phase that lasts seven years rather than five . In this modeled baseline intervention scenario (reference scenario), the catch-up phase focuses on the 15–49 year old and ends by reaching 80% VMMC coverage in this population. This is consistent with the Government of Zambia’s original VMMC scale-up strategy following the WHO and UNAIDS recommendation . This scThe scale-up of VMMC during the catch-up phase was assumed to be at a fixed rate—that is, the likelihood of any male within the targeted subpopulation to be circumcised is fixed throughout the catch-up phase.At the end of the catch-up phase, a new “sustainability” phase begins, lasting up to 2025 in some projections and up to 2045 in other projections, where the attained coverage achieved during the catch-up phase is maintained by circumcising the incoming cohorts into the population of 15-year-olds (those turning 15 in each year). We based our predictions for the impact of subpopulation targeting with reference to this modified version of the original Zambia VMMC program scale-up.The intervention’s impact on the epidemic was evaluated in three time horizons: a short-term time horizon up to the end of the catch-up phase (2010–2017), an intermediate-term time horizon nearly a decade into the sustainability phase (2010–2025), and a long-term time horizon nearly three decades into the sustainability phase (2010–2045). In our analyses we mainly focused on the intermediate term, as the goal of the VMMC program is to impact the HIV epidemic in the near future, aligned with UNAIDS 2030 global epidemic impact goals .We focused on three subpopulation targeting scenarios based on age, geographic location, and sexual risk profile.Age-group prioritization: In this targeting scenario, we prioritized the VMMC intervention to specific age groups instead of the entire population of 15–49 year old. For each age-group targeting scenario, we assumed 80% VMMC coverage achieved by the end of 2017. We investigated age-group targeting through two approaches. In the first approach, we targeted each five-year age band . In the second approach, we targeted wider age brackets relevant to programming and policy considerations . Because programmatic experience indicates that 39% of VMMCs had been provided to males who were <15 year old, we also included an age band for males 10–14 year old, in the interest of comparing the relative advantages of scale-up across all adolescent and adult age ranges.Geographic prioritization: In this targeting scenario, we prioritized the VMMC intervention to males based on the distribution of HIV infection across the provinces in Zambia. We examined this targeting in three subscenarios. In the first one, we selected four provinces with HIV prevalence higher than the national HIV prevalence  and other interventions. Accordingly, we conducted two sensitivity analyses on our model predictions. In the first sensitivity analysis, we explored VMMC effectiveness in the presence of an optimistic roll-out of ART, as highlighted by recent WHO projections of reducing HIV incidence by 72% . In the Given predicted growth in population size , a totalThe age-stratified results of effectiveness of reaching 80% VMMC coverage are illustrated in As part of the first level in the assessment framework , we alsoAs was the case in the total adult population, in the short term the largest reductions in the incidence rate in the female adult population were achieved by targeting males 15–24 years of age 12%; , while iThe VMMC program efficiency of age-group prioritization is illustrated in In In this policy-frontier plot , targetiIn the intermediate term, the effectiveness of geographic prioritization ranged from 9 to12 VMMCs per HIV infection averted . The higThe effectiveness of risk-group prioritization showed vast variation . The effUsing a novel analytic approach and the most recent program data from Zambia, we demonstrated that program efficiency and public health and economic benefits of VMMC scale-up can be improved by prioritizing young sexually active males and by prioritizing geographic areas where HIV prevalence is considerably higher than the national. Prioritizing by sexual risk group can also markedly improve program efficiency, but the program feasibility of this approach remains to be explored and determined.Although the success of the current actual VMMC scale-up in Zambia is evident through the accelerated uptake among males year after year since the start of the VMMC initiative in 2007 , only 61Given the reality of program clients circumcised to date (up to 2014), we estimate that the program would avert 8% fewer HIV infections by 2025  than would otherwise be the case if all circumcisions had been provided to males within the target age group (15–49 year old). If the total number of circumcisions provided to date had been exclusively among 15–29 year old males, we estimate the program would have averted 51% more HIV infections by 2025  than would be the case with the current age distribution of VMMCs. These findings not only have important implications for the HIV epidemic, but also provide key considerations for demand generation, service distribution, and communication.As expected, we found that achieving 1.95 million VMMCs by 2015 is an ambitious target and unlikely to be achieved by any realistic or anticipated scale-up plan . TherefoOur results indicate that the optimal public health benefits of VMMC are dependent on the age at which males undergo circumcision. Prioritizing males ages 15–19, 20–24, or 25–29 year old maximizes the effectiveness of the VMMC program by up to 13%, and maximizes the cost-effectiveness of the VMMC program by up to 19%. However, VMMC impact on the scale of incidence rate reduction through age prioritization depends on the timeframe for which the effect of the VMMC program is assessed .If the program aims to achieve the largest reductions in incidence rate within the catch-up phase (2017), the optimal age groups to prioritize are 15–19 or 20–24 year old. On the other hand, if the program aims to achieve the largest reductions in incidence rate in the longer term (2025 or 2045), then the optimal age groups to prioritize are 10–14, 15–19, or 20–24 year old. These results suggest that the greatest impact of VMMC is achieved by prioritizing the age groups where the risk of infection—that is, the HIV incidence rate—is largest. The highest incidence rate in Zambia was predicted for the 20–24 year age group followed by the 24–29 year age group . VMMC prDeciding which age groups to prioritize depends on the specific goals of the program and national policy. Decision makers may have different policy priorities, such as program efficiency versus magnitude of impact, versus incidence rate reduction, versus effectiveness, versus cost-effectiveness. The availability of resources, supply and demand models, and on-the-ground country experiences are also key factors that influence policy priorities. Our findings therefore should be considered in conjunction with programmatic feasibility to decide on specific subpopulation prioritization and targets.To facilitate evidence-informed decision making, we factored epidemiologic and health economic measures collectively to assess optimal policy using program expansion path curves and policy-frontier plots  where HIV prevalence is considerably higher than the national. VMMC effectiveness can be improved by as much as 23% by prioritizing Lusaka province, which has the highest HIV prevalence in Zambia . PrioritProgram efficiency with geographic prioritization can be further enhanced by combining age group prioritization with geographic prioritization. For example, VMMC effectiveness can be improved by as much as 29% by prioritizing 20–24 year old males in Lusaka compared to prioritizing 15–49 year old males across the country (8.6 versus 12.2 VMMCs per HIV infection averted). As with age-group prioritization, deciding on which geographic areas to prioritize depends on national policies and goals. Decision makers may be required to balance priorities such as parity in service availability and considerations related to maximum VMMC impact and efficiency.The efficiency of the VMMC program can be immensely improved by prioritizing males with high sexual-risk behavior. Prioritizing males with the highest sexual-risk behavior in the population would increase VMMC effectiveness by an order of magnitude, while prioritizing males with the lowest sexual-risk behavior would reduce the effectiveness by an order of magnitude . Even siAlthough prioritization by risk can substantially improve the efficiency of VMMC programs, identifying such populations is a key challenge. Programs may also be viewed unfavorably if communities perceive that VMMC is only for males at high sexual risk, thus stigmatizing clients. Generating unbiased and precise measures of sexual risk behavior at the level of the individual is also challenging, as it relies on self-reported data . It is fAlthough the primary consequence of scaling up VMMC coverage is to reduce the number of new HIV infections in males, by reducing HIV acquisition the intervention indirectly prevents HIV infections in women as well, as it reduces females’ probabilities over time of encountering HIV-infected male sexual partners . Our resProjections of future HIV incidence are uncertain and subject to unknown factors, such as the scale-up of other HIV interventions. The further into the future that incidence is projected, the greater the degree of uncertainty. Scale-up of other interventions may reduce HIV incidence rate in the population substantially, thereby potentially diminishing the benefits of VMMC programs. However, our sensitivity analysis shows that even with an optimistic ART scale-up scenario (as highlighted by recent WHO projections of reducing HIV incidence by 72%), VMMC will remain an impactful and effective intervention, and the scale-up of ART is not likely to change our results of subpopulation prioritization. Although twice as many VMMCs could be needed to avert one HIV infection under an optimistic ART scale-up scenario, this does not undermine the fact that VMMC will remain a cost-effective intervention for an HIV hyper-endemic setting such as Zambia.In our main predictions we did not incorporate sexual risk compensation, though the ultimate impact of VMMC on HIV prevention will be determined, in part, by changes in sexual behavior postcircumcision. Although there is some evidence for risk compensation following VMMC , the majAnother uncertainty lies in estimates of VMMC provision costs. Cost-effectiveness of VMMC with age-group prioritization is dependent on the age-specific unit cost of VMMC. If unit cost were to vary widely by age, it may be equally or more cost-effective to reach a subpopulation of relatively lower epidemiologic priority, for instance. Current evidence is insufficient to determine how VMMC unit costs may vary over time and at scale, and how this variation may affect the age-specific unit cost. Informed by program data , we assuThough we used an elaborate mathematical model structure to capture the complexity of HIV dynamics, our results may depend on the type of mathematical model structure used. We assumed a fixed VMMC rate throughout the catch-up phase in all scenarios in our main predictions, but we examined the impact of the VMMC program using variable VMMC rates and the results were virtually invariable (not shown). We assumed that individuals stay in the same sexual risk group during their lifespan. However, as informed by earlier analyses , this asMoreover, our model is dependent on the availability of representative time-trend data for HIV prevalence, baseline male circumcision prevalence, and demographics such as total population size and future population projections. Limitations in the data input can lead to limitations in the model predictions. Therefore we conducted a multivariate uncertainty analysis on our model predictions to assess the impact of uncertainty in the input parameters . Though Finally, this framework for assessing the impact of subpopulation prioritization is not meant to impose country-specific performance targets, but instead to inform national policy and programming, by means of a thorough scientific analysis of the implications of subpopulation prioritization. For instance, country programs may decide to maintain current targets but intensify demand creation for particular subpopulations, to maximize epidemiologic and economic impact. VMMC scale-up strategies should be tailored to each country’s context, realities, and goals, as informed by a detailed analysis of their impact such as in the present study, given that subpopulation prioritization is dependent on the distribution of HIV incidence across age, geography, and risk profile.We developed a novel analytic approach, expressed in terms of a mathematical model and a three-tiered conceptual framework, as a planning tool to inform national policy and programming of the optimal public health benefits of VMMC through subpopulation prioritization. The framework consolidates epidemiologic, health economics, program efficiency, and policy measures to facilitate scientifically driven, complex decision making at the national level. The framework was applied using Zambia as a model country to demonstrate the utility of this approach. The framework is being implemented in additional countries, and is available for use in others.We found that prioritizing males ages 15–29 years improves VMMC program efficiency. Including males 10–14 years of age increases the long-term impact of the program, but is less programmatically efficient. Prioritizing males 35 years of age and older does not add more benefits to the efficiency of VMMC programs.The efficiency of VMMC programs can also be enhanced by prioritizing geographic areas with considerably higher HIV prevalence than the national prevalence as well as prioritizing individuals with higher sexual-risk behavior. Benefits of VMMC through subpopulation prioritization can also be improved with a combination of age, geographic, and risk-group targeting. However, any policy change based on these results should consider programmatic feasibility and national health policy priorities.Our study refines the strategic direction set by previous mathematical modeling studies, but it does not contradict the longstanding emphasis on making the comprehensive package of VMMC for HIV prevention services available to all adult males. Services should remain available for all males who seek circumcision; our recommendation is that a subset of the male population become the primary focus of services and demand creation.S1 Fig(DOCX)Click here for additional data file.S2 Fig(DOCX)Click here for additional data file.S3 Fig(DOCX)Click here for additional data file.S4 Fig(DOCX)Click here for additional data file.S5 Fig(DOCX)Click here for additional data file.S6 Fig(DOCX)Click here for additional data file.S7 Fig(DOCX)Click here for additional data file.S8 Fig(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S1 Text(DOCX)Click here for additional data file.S2 Text(DOCX)Click here for additional data file.


Historically, federal funding streams to address cancer and tobacco use have been provided separately to state health departments. This study aims to document the impact of a recent focus on coordinating chronic disease efforts through collaboration between the 2 programs.Through a case-study approach using semistructured interviews, we collected information on the organizational context, infrastructure, and interaction between cancer and tobacco control programs in 6 states from March through July 2012. Data were analyzed with NVivo software, using a grounded-theory approach.We found between-program activities in the state health department and coordinated implementation of interventions in the community. Factors identified as facilitating integrated interventions in the community included collaboration between programs in the strategic planning process, incorporation of one another’s priorities into state strategic plans, co-location, and leadership support for collaboration. Coalitions were used to deliver integrated interventions to the community. Five states perceived high staff turnover as a barrier to collaboration, and all 5 states felt that federal funding requirements were a barrier.Cancer and tobacco programs are beginning to implement integrated interventions to address chronic disease. Findings can inform the development of future efforts to integrate program activities across chronic disease prevention efforts. Tobacco control is among the highest priority prevention components to reduce cancer mortality rates and a major modifiable risk factor to control the growing epidemic of chronic diseases . In 2014Collaboration between both programs to leverage existing resources has been encouraged to increase efficiency . AlthougThe concept of collaboration as examined in this study is analogous to integration described in research by Salinsky and Gursky , in whicThis study used qualitative methods to document key program infrastructure factors, collaborative synergy, and the extent to which 6 programs implemented integrated activities. Factors that hindered or facilitated collaborative synergy and the relationships between collaborative synergy and integrated interventions were also examined.We used a case-study approach to characterize collaboration between funded programs in 6 states. The CCAT model was used as the framework to characterize the organizational attributes, internal organizational activities, and interventions these 2 programs engaged in together.Participants were staff of the programs in 6 states  from March through July 2012. The states were selected using the following criteria: demonstrated ability to conduct activities under both cooperative agreements as defined by CDC, a history of conducting epidemiological research with the ability to designate an epidemiologist who could participate in study activities, innovative tobacco cessation activities in place, and ongoing data collection for the National Quitline Data Warehouse or had a statewide quitline registry. Other states may have met the criteria; however, the states included were those that expressed interest through submission of an application to the study.To ensure anonymity, states were labeled A through F . ParticiWe used the CCAT model to develop the interview guides. As a result, the guides included questions relating to organizational characteristics, evidence of collaborative synergy between organizations, and the extent to which cancer and tobacco control programs integrated interventions. Interviewees were also asked to describe perceived barriers and facilitators to collaboration. Although the interview guides were developed and tailored to the type of interviewee , examples of similar questions asked of all interviewees include the following: 1) Do the CCC or TCP programs sit in the same division of the health department? 2) Are there ways in which the health department leadership requires programs to work together? and 3) Are there any barriers that affect TCP’s ability to communicate with the CCC staff?A designated contact person recruited and scheduled all interviewees, and no incentives were offered. A combination of individual in-person and telephone interviews was conducted, as were 16 in-person group interviews. The 6 telephone interviews were scheduled with staff members who were unavailable to meet in person. The interview team consisted of an interviewer and a note-taker. Each interview was recorded. The lengths of the individual interviews (n = 43) varied from 30 minutes to 1 hour. Sixteen group interviews (n = 42) lasted approximately 1.5 hours and included 2 to 5 participants per group. Group interview participants were selected on the basis of scheduling availability and the extent to which they shared roles in a program. One group interview consisted of both leadership and program staff members.Notes and interview transcriptions were analyzed using NVivo software . Other sParticipants described 2 categories of activities that were consistent with collaborative synergy (conducted within the organization) and integrated program interventions in the community . ParticiBetween-program activities consistent with collaborative synergy included staff engagement  and assessment and planning (collaborative strategic planning). Informal communication describes the casual conversations that occurred naturally in the workplace between the 2 programs. Program staff described formal communication as email distributions, including updates on quitline activities to both CCC and TCP staff, use of a listserv, or regular joint meetings. All 6 states described both formal and informal communication between the programs.Strategic planning involved developing formal opportunities for future integration of CCC and TCP activities in the community. One example of strategic planning is codevelopment, which is defined as the 2 programs contributing to each other’s state plans and joint grant writing. One state participant acknowledged that the state plan was not developed in as collaborative a manner as the participant had hoped; therefore, the participant intended to increase collaborative development of plans in the future. Two state participants described a long history of joint grant writing between CCC and TCP staff. However, one state participant viewed joint funding opportunities as an artificial means for future collaborations. The state was referring to a recent funding opportunity  that incParticipants described 4 types of interventions they conducted collaboratively in the community: networked partnerships, policy and systems change, health communication, and cross-promotion of programs.All networked partnerships in this study were coalitions. Coalitions typically include public, private, governmental and nongovernmental partners, youth-focused tobacco prevention organizations, local hospitals, and health care organizations. Participants reported that coalitions expand the reach of their programs; it appeared that the coalition was the main structure through which integrated interventions were implemented. In almost every state (n = 5), staff from one program served on the other program’s coalition. One state’s TCP conducted several presentations about the importance of protection from secondhand smoke at the cancer coalition’s state conference. Another state encouraged streamlining coalitions into one overarching council that could coordinate efforts across programs.Strategies to influence policy refer to the joint activities CCCs or TCPs implement, such as community awareness campaigns about policies that will be voted on or implemented or providing data to inform the public health benefit of policy interventions. One state’s TCP developed a fact sheet on the economic and public health impacts of a cigarette tax. The fact sheet was used by the state’s cancer coalition to inform key decision makers about the impact of a proposed tax increase. Systems change was another activity identified by 4 states. One state described plans to work with a subcontractor to update electronic health records to collect a more comprehensive list of chronic disease indicatorsSharing health communication and marketing materials was perceived as an easy way to integrate services in the community. For example, one TCP-funded program developed promotional postcards and brochures with both cancer and tobacco-use prevention information. One state’s CCC mentioned that a chronic disease multiprogram brochure — including cancer and tobacco control — is being developed. Two states described cross-promotion of activities as being centered on the state quitline, where the CCC website included the quitline telephone number and a link to the TCP website.Characteristics of the program, including funding sources, organizational processes, staffing, and leadership, were perceived as barriers or facilitators to CCC and TCP collaborative synergy and integration of activities at the point of service.Managed resources refer to the funding streams and allocation of money and staff across programs, which are affected by state funding requirements, federal funding requirements, trust regarding financial motives, and mutual funding benefit. State funding requirements were perceived as a barrier to collaboration between the programs in all states. Staff from all 6 states agreed that federal funding requirements hindered both collaborative synergy and integration of interventions. Trust regarding financial motives was also seen as a barrier; in one state, the TCP viewed another program’s collaboration request as possibly motivated by a desire to access the TCP’s funds. Mutual funding in this study refers to the ability of one program’s funding to serve another program’s benefit. One state received funding for a project that allowed for cross-program collaboration with the pooling of resources and viewed this as a facilitator. The state plans were a facilitator to conducting integrated interventions. For example, in some states the CCC-funded program included tobacco control strategies in its cancer plan and was working toward coordinating both programs’ work plans.Guidelines and recommendations found in the cancer plans consist of the integration of tobacco and cancer control state plans and the creation of state cancer plan subcommittees. They refer to the cancer and tobacco control goals and objectives of each program and the federal and state goals, objectives, and funding priorities that may affect the work of each program. The integration of tobacco and cancer control into each other’s state plans is not necessarily a predictor of integrated activities at the point of service. This was the case in one state where, despite having an integrated state health plan, the 2 programs did not work together. However, some states did collaborate in planning and perceived it as a facilitator of integration. Another perceived facilitator of integration was the creation of subcommittees that included members of both programs with the goal of moving toward addressing chronic disease risk factors.Infrastructure could be a facilitator or barrier to collaborative synergy. It refers to staffing, the extent to which programs were co-located , and the characteristics of program and health department leadership. Physical proximity  was presumed to be a facilitator of informal communications. Leadership and staffing was a main component under infrastructure, as it refers to the vision of the state health department. A lack of unified or overall leadership support was identified as a barrier. Staff in one state reported that there were 2 leadership perspectives about integration of CCC and TCP efforts. One state reported that the different leadership styles of TCP and CCC administrators led the programs in 2 directions, making it difficult to share resources and ultimately activities. For example, the state TCP was focused on policy strategies and cessation; however, the state CCC was focused on direct services. In another state, although both programs’ staffs were interested in collaborating, upper management did not appear to support collaboration; an opportunity for co-location of both programs in the same bureau was rejected.Conversely, leadership support was seen as a way to facilitate collaborative synergy between both programs. In multiple states, staff agreed that the leadership must define collaboration. Similarly, in states where program leaders had worked in each other’s programs, leadership support for collaboration was more readily noticed among program staff.High staff turnover was often noted as a barrier, leading to vacancies and a loss of institutional memory. Two-thirds of the states had problems with staff turnover or hiring freezes. One respondent explained that turnover made it difficult to know who the state’s partners were in the other program, thereby decreasing staff engagement in co-program efforts. However, several interviewees viewed high turnover as a facilitator to collaboration, because it pushed programs to combine resources to achieve their goals.Overall, the location of programs in separate office spaces and bureaus and divisions seemed to act as a barrier to collaboration, which is consistent with the notion that collaborative synergy between programs is facilitated by engaged staff members. Separate spaces made it difficult to see other program staff regularly and limited the opportunities for formally or informally reviewing each other’s materials or reports.We found that CCC- and TCP-funded state programs are building collaborative synergy and beginning to integrate their program interventions. This effort is a shift from the traditional “siloed” approach of program implementation that was associated with categorically funded chronic disease prevention programs. We also found that programs were engaging in more collaborative activities consistent with collaborative synergy than those indicative of interventions integrating both program priorities. Other findings consistent with the constructs and relationships in the CCAT model  highlighOf particular interest in our findings was the use of partnerships as the most frequently cited mechanism through which integrated interventions are implemented. It would be of interest to explore whether coalitions focused more broadly on chronic disease prevention could better promote integration of chronic disease interventions while ensuring that the interests of individual program staff are maintained.Collaborative processes can strengthen existing networks and partnerships and also may encourage the development of new links among organizations from various sectors and levels –17. InteThis study has 3 limitations. First, the small sample size may limit generalizability. Although the participants reflected a diverse range of roles in the programs, they may not be representative of those in other states. Second, data are subjective and could not always be verified against secondary sources. Finally, during the one group interview at which program leadership and staff were both present, this power dynamic may have produced undue bias in participant responses.Cancer and tobacco programs are beginning to implement integrated interventions to address chronic disease. Findings can inform the development of future efforts to integrate program activities across chronic disease prevention efforts, and if staff engagement and co-development of strategic plans continue, the quantity of integrated interventions should increase.


The present study aimed to qualitatively investigate patient experience and treatment efficacy of the Family Admissions Program (FAP) – a pilot treatment program being run at the Children's Hospital at Westmead for adolescents with Anorexia Nervosa (AN). Based on Maudsley Family Based Treatment (MFBT), the FAP involves an adolescent and his/her family undergoing a two-week family-based hospital admission at the outset of treatment. The program aims to increase intensity and support to a level needed by families at risk of responding negatively to traditional MFBT.Narrative Inquiry and Interpretative Phenomenological Analysis (IPA) were used to analyse data obtained from participant interviews, exploring both the prospective expectations and retrospective experiences of families and clinicians participating in the program. Results from both of the qualitative analyses indicate that in cases where the family unit has been particularly fractured as a result of AN, the FAP offers an opportunity for relational strengthening and reunification, particularly within the parental subsystem. Combined with the program's intensive support, contained transition from hospital to home, and proximity to necessary hospital services, this serves to provide struggling families and parents with a more skilled and consolidated foundation for traditional outpatient MFBT.


Based on evidence of parasympathetic activation, early studies defined meditation as a relaxation response. Later research attempted to categorize meditation as either involving focused or distributed attentional systems. Neither of these hypotheses received strong empirical support, and most of the studies investigated Theravada style meditative practices. In this study, we compared neurophysiological  and cognitive correlates of meditative practices that are thought to utilize either focused or distributed attention, from both Theravada and Vajrayana traditions. The results of Study 1 show that both focused (Shamatha) and distributed (Vipassana) attention meditations of the Theravada tradition produced enhanced parasympathetic activation indicative of a relaxation response. In contrast, both focused (Deity) and distributed (Rig-pa) meditations of the Vajrayana tradition produced sympathetic activation, indicative of arousal. Additionally, the results of Study 2 demonstrated an immediate dramatic increase in performance on cognitive tasks following only Vajrayana styles of meditation, indicating enhanced phasic alertness due to arousal. Furthermore, our EEG results showed qualitatively different patterns of activation between Theravada and Vajrayana meditations, albeit highly similar activity between meditations within the same tradition. In conclusion, consistent with Tibetan scriptures that described Shamatha and Vipassana techniques as those that calm and relax the mind, and Vajrayana techniques as those that require ‘an awake quality’ of the mind, we show that Theravada and Vajrayana meditations are based on different neurophysiological mechanisms, which give rise to either a relaxation or arousal response. Hence, it may be more appropriate to categorize meditations in terms of relaxation vs. arousal, whereas classification methods that rely on the focused vs. distributed attention dichotomy may need to be reexamined. In spite of the increasing interest in meditation, evidenced by its global popularity and output of scientific papers, the failure to accurately define or categorize different types of meditations has been consistently mentioned in the scientific literature Theravada or Mahayana Buddhist styles of meditation. On the other hand, studies on meditative practices of the Vajrayana tradition , which is central to Tibetan Buddhism  and Rig-pa (OM) and two types of Theravada practices: Shamatha (FA) and Vipassana (OM). We collected Electrocardiographic (EKG) and Electroencephalographic (EEG) responses (Study 1) and measured behavioral performance on cognitive tasks (Study 2) using a participant pool of experienced Theravada practitioners from Thailand  and Nepal  and Vajrayana practitioners from Nepal . In order to measure the physiological correlates of arousal and relaxation responses, in Study 1 we used EKG measures, which have been shown to be reliably related to the activity of autonomic system Furthermore, to examine the validity of the FA-OM classification that distinguishes between different types of meditations based on the attentional systems they involve, versus the classification that distinguishes between meditative traditions (Vajrayana-Theravada), we compared EEG data recorded during each type of meditation. We expected that the neurophysiological correlates of the four types of meditations examined in this study would differ significantly across traditions but not across the FA-OM classification.Since Vajrayana and Theravada practitioners are not trained in the same meditative practices, a within-subjects design was not feasible. As a consequence, we used a mixed design, with the data from the Theravada style practitioners recorded at Yannawa Temple , and the data from the Tibetan Vajrayana style practitioners recorded at the Shechen Monastery .Ten long-term Theravada style practitioners who practice meditation at Yannawa Temple in Thailand, Bangkok , with an average of 8 years of meditation experience participated in the study. In addition, nine long-term Vajrayana practitioners , with an average of 7.4 years of meditation experience from Shechen monastery in Nepal participated in the study. All of the participants reported having no cardiovascular conditions, and were free of medication for the duration of the study. The subjects provided written, informed, consent for their participation in the study. The study was approved by the National University of Singapore's review board, which implements commonly used procedures for data deposition.In Buddhist scriptures, Shamatha practice relates to training in the concentration of attention. During the practice of Shamatha, the practitioners are instructed to place undistracted attention on the object of meditation, while withdrawing their focus from other objects For the purpose of this research, we used Kasina meditation as a particular type of Shamatha practice. Kasina meditation refers to objects of meditation that possess certain characteristics described in the Pali Tipitaka generation or development stage, which is the first stage of the meditation practice Visualization of self-generation-as-Deity practice  originated in Hindu and Buddhist Tantric traditions in India and was later adopted by Tibetan Buddhism completion stages of the meditative practice During Rig-pa meditation, which follows the final stages of Deity meditation, and represents the The data from the Theravada style practitioners were recorded in a meditation hall at the Yannawa Temple , and the data from the Tibetan Vajrayana style practitioners was recorded at the Shechen Monastery library . EEG and EKG were continuously recorded throughout the study. At the beginning of the session, each participant performed a 10 minute Rest condition, during which they were explicitly instructed not to meditate but to remain seated with their eyes closed, and to simply relax. Following a 5 minute break, the Theravada practitioners were asked to perform 15 minutes of Shamatha meditation followed by 15 minutes of Vipassana. Tibetan Vajrayana practitioners were asked to perform 15 minutes of Deity meditation after the Rest condition, followed by 15 minutes of Rig-pa meditation. The orders of meditation were chosen per request of the participants who found that it is more natural first to meditate in Shamatha followed by Vipassana. Similarly, since Rig-pa (completion stages) follow the end of Deity practice (generation stage), Vajrayana practitioners performed Deity first followed by Rig-pa. For participants who did not speak English, interpreters translated all the instructions into their native language.In contrast to Theravada styles of meditation, which are performed with closed eyes, Vajrayana practices are often performed with open eyes. However, to make the experimental conditions as similar as possible, we instructed all the practitioners to meditate with closed eyes. Importantly, we ensured that all our Vajrayana practitioners were comfortable with such a request, and they all confirmed that this would not affect their meditation.EEG was continuously recorded at the POz,Pz,Fz,C3,C4,F3,F4,P3 and P4 scalp regions, positioned according to the standard 10/20 system Prior to the mid-1980s, heart rate variability (HRV) was typically analyzed through time domain methods but not frequency domain methods A cubic spline interpolation with a 500 Hz sampling rate was performed on the EKG data, in order to improve the accuracy of the heart rate variability estimations For each electrode and 1 second epoch, the power spectral distribution (PSD) was calculated using Welch's method Theravada and Vajrayana meditations were first analyzed using within subject ANOVAs, for which the independent factors were Condition  and Location. In order to test for potential effects of hemisphere , which are often observed The mean squared coherence was measured between electrodes F3 and F4 , the average between F3 and F4 and the average between electrodes C3 and C4 , P3 and P4 (Posterior), and the average between P3 and P4 and the average between F3 and F4 (Fronto-Posterior), separately for Alpha, Beta, and Gamma power. Subsequently, each one of the 12 frequency-coherence combinations  was separately analyzed as the dependent variable in a repeated measures ANOVA, with Condition (meditation vs. rest) as the independent factor. Furthermore, significant results were analyzed in a mixed ANOVA (2×2) using Attention (FA vs OM) as the within-subject factor, and Tradition (Vajrayana vs Theravada) as the between groups factor.In Study 2 we investigated whether the practice of Vajrayana or Theravada types of meditation will elicit an immediate significant enhancement in cognitive tasks as a result of an increase in phasic alertness, associated with arousal Similarly to As in Study 1, all participants reported having no cardiovascular conditions, and were free of medication for the duration of Study 2. The first (Kasina) group of participants consisted of 12 long-term Theravada practitioners from Yannawa Temple, Bangkok  with an average of 10 years of meditation experience (10 practitioners from this group participated in Study 1). This group of participants performed Kasina meditation. The data of this group were collected at the Yannawa Temple .The second (Vipassana) group consisted of 14 Theravada practitioners who were asked to perform Vipassana meditation  with an average of 12.3 years of meditation experience. The ten male practitioners were recruited from the International Buddhist Meditation Center , and the four female practitioners were recruited from the Amarapura Buddhist Nunnery in Nepal. The data of this group of participants were collected at the International Buddhist Meditation Center .The third (Rig-pa) group consisted of the same 9 long-term Vajrayana practitioners from the Shechen monastery in Nepal  who participated in Study 1, and have an average of 7.4 years of meditation experience. The data from this group of participants were collected at the Shechen monastery library and they were asked to perform Rig-pa meditation. Although Rig-pa is usually practiced right after Deity meditation in one session, our experimental design required that each participant would perform only one type of meditation. All participants acknowledged that they were comfortable in performing Rig-pa meditation not preceded by Deity.The behavioral data from two visual tasks administered before and after a meditation session in the above three groups were compared with the data from the same tasks performed before and after Deity meditation, which were previously published in Kozhevnikov et al.'s study On each trial of the MRT, participants viewed a pair of three dimensional pictures, which were rotated relative to each other around the x, y, or z-axis. Across trials, the amount of rotation ranged from 40° to 180°, in 20° increments. Participants were required to judge whether the two pictures were of the same form, or whether the forms were mirror-reversed. The test consisted of 36 trials, 18 in which the forms were the same, and 18 in which they were mirror-reversed.see The VMT The procedure for Study 2 was similar to the procedure reported in Although different groups of meditators were tested in different locations, we tried to make the testing conditions as similar as possible. In particular, during all the tests, we used a quiet room in the monasteries with moderate temperature; the same laptop computers were used during all the procedures, and the same training session and instructions (apart from the meditation instructions) were given to all the participants. Importantly, the Vipassana meditators in this study were from the International Buddhist Center in Nepal, enabling us to compare Theravada and Vajrayana (Rig-pa) meditations in a similar environment. As Kasina is not practiced in Nepal, this data was collected in Thailand.The Heart Rate Variability results are summarized in For Vajrayana meditation, the analysis demonstrated a marginally significant Condition  effect for HF, F = 3.19, p = 0.07. As we hypothesized that HF would decrease during Vajrayana meditations, we performed planned pairwise comparisons between Deity and Rest, and Rig-pa and Rest. HF was significantly decreased in Deity relative to Rest (p<0.05) and in Rig-pa relative to Rest (p<0.05). The post-hoc comparison between Deity and Rig-pa was not significant (p>0.8), see Furthermore, the between traditions comparison showed a significant Tradition  effect on HF, F = 7.02, p<0.05, so that HF was significantly decreased during Vajrayana in comparison to Theravada, see Overall, the results suggest that Theravada and Vajrayana meditative practices lead to very different patterns of HRV responses, exhibiting patterns that are consistent with a relaxation response for Theravada practices and arousal responses for Vajrayana practices.The statistical results for all the frequencies are summarized in For Theravada style of meditation, the analysis showed a significant main effect of Condition: F = 8.37, p<0.01, so that Delta power was reduced during meditation in comparison to Rest. However, posthoc comparisons using Bonferroni adjusted α levels of 0.017 per test (α = 0.05/3 = 0.017) did not reveal significant differences between Rest, Kasina, and Vipassana. The main effect of Location was significant: F  = 7.19, p<0.01, suggesting that Delta power was greater at the Center see Figure 5We also found a significant main effect of Condition for Vajrayana meditation: F = 5.11, p<0.05, indicating that Delta power was reduced during Vajrayana in comparison to Rest see Figure 5The comparison between traditions showed that the main effects of Attention, F<1, and Tradition, F = 1.97, p>0.1, were not significant, as well as the Attention X Tradition interaction, F = 1.48, p>0.2.The effect of Condition was not significant for either Theravada, F = 1.11, p>0.3 or Vajrayana styles of meditation, F = 2.5, p>0.1, as was the Condition X Location interaction – Theravada style: F = 1.9, p>0.1; Vajrayana style: F<1. We found a significant main effect of Location that was unrelated to meditation – Theravada style: F = 20.16, p<0.001; Vajrayana style: F = 3.5, p = 0.055 – suggesting that Theta power was higher at central scalp regions for both meditation and Rest.Although meditative states were often reported to produce an increase in Alpha power For Theravada styles of meditation, the analysis revealed a significant main effect of Condition, F = 6.84, p<0.01, indicating that Alpha power was reduced during meditation relative to Rest see Figure 5For Vajrayana types of meditation, in contrast to our predictions, there were no significant differences in Alpha power between Deity, Rig-pa, and Rest .The comparison between traditions showed that the main effects of Attention: F = 2.68, p>0.1, and Tradition: F = 1.86, p>0.1, were not significant, as well as the Attention X Tradition interaction (F<1). The main effect of Location was not significant (F<1), nor were there any significant interactions between Location and other factors .For Theravada styles of meditation, ANOVA showed a significant effect of Condition: F = 3.68, p<0.05, demonstrating that Beta power was reduced during meditation see Figure 5For Vajrayana style, there was also a significant main effect of Condition: F = 8.42, p<0.01, demonstrating that Beta power was reduced during meditation relative to Rest see Figure 5The between traditions analysis demonstrated a marginally significant main effect of Tradition, F = 3.69, p = 0.07, which suggests that Beta power was more decreased during Vajrayana than Theravada see Figure 5For meditations belonging to the Theravada tradition, although the main effects of Condition (F<1), and Location: F = 1.48, p>0.2 were not significant, we found a significant Condition X Location interaction: F = 3.09, p<0.05, and separate ANOVAs at each level of the Location factor showed a significant trend at the Left Location: F = 2.76, p = 0.09, but not the at the Right or Center (F<1 for both comparisons). Since previous studies found increases in Gamma during Theravada meditation As for Vajrayana, there was a significant main effect of Condition: F = 6.16, p<0.01, demonstrating a significant reduction in Gamma power during Deity and Rig-pa relative to Rest see Figure 5The differences in Gamma power between Theravada and Vajrayana were significant, as demonstrated by a significant Tradition main effect: F = 12.27, p<0.01. No other main effects or interactions were found in the between traditions analysis .Overall, the results show large EEG differences between Theravada and Vajrayana traditions. In particular, we observed a reduction in Alpha power for Theravada (both Kasina and Vipassana), but not Vajrayana practices. Furthermore, Gamma power was increased during Vipassana, but decreased during Vajrayana (both Deity and Rig-pa) practices. Interestingly, decreases in Beta power were observed in both Theravada and Vajrayana meditation, but they were more prominent during Vajrayana. On the other hand, we did not find any significant differences in EEG frequency power within traditions that could be explained through the FA-OM framework.The statistical results are shown in For Vajrayana style of meditation, Alpha Frontal Coherence also showed a marginally significant effect of Condition, F = 3.16, p = 0.07, suggesting that it is reduced during Vajrayana as well. In addition, for Vajrayana meditation, the analysis of Beta Fronto-Central Coherence revealed a marginally significant effect of Condition: F = 3.34, p = 0.06, suggesting that it was increased during Vajrayana meditation relative to Rest see Figure 6The comparison between traditions showed that for Alpha Frontal Coherence, although the main effects of Attention, p>0.2, and Tradition, F<1, were not significant, a significant Attention X Tradition interaction was observed: F = 4.98, p<0.05. This interaction shows that, whereas Alpha Frontal Coherence was greater for Rig-pa (OM) than Deity (FA) of the Vajrayana tradition, the opposite trend was observed for Theravada, so that more coherence was observed for Kasina (FA) than Vipassana (OM) see Figure 6In summary, the results of the coherence analysis support a tradition-based classification of meditations, but not the attention-based classification. While we found an increase in Beta Fronto-Central Coherence for Vajrayana practices relative to Rest, no such effect was found for Theravada meditative practices. Furthermore, we observed an increase of Alpha Frontal Coherence for Rig-pa (OM) relative to Deity (FA) in Vajrayana, but a decrease for Vipassana (OM) relative to Kasina (FA) during Theravada meditation, which is incompatible with the attention-based classification.The results of the study are summarized in As in The MRT results were analyzed through a 2 (Time: pretest vs. post-test) X 4 (Condition: Kasina/Vipassana/Deity/Rig-pa) ANOVA, which indicated a significant main effect of Time, F = 14.73, p<0.001. The effect of Condition was not significant, F<1. However, there was a significant interaction between Time and Condition, F = 9.52, p<0.001. Follow-up ANOVAs revealed a Time effect for Deity, F = 19.36, p<0.001, and Rig-pa, t(9) = 7.68, p<0.05, but not Kasina, F<1, and Vipassana, F<1 see Figure 7Similarly to the MRT results, VMT were analyzed through a 2 (Time: pretest vs. post-test) X 4 (Condition: Kasina/Vipassana/Deity/Rig-pa) ANOVA, which showed a significant main effect of Time, F = 20.73, p<0.001 (df = 45 as two Vipassana meditators did not perform the VMT). Again, the main effect of Condition was not significant, p>0.16, albeit a significant Time X Condition interaction was found, F = 8.57, p<0.001. Follow-up ANOVAs revealed a significant efficiency increase for Deity, F = 26.41, P<0.001, and Rig-pa, F = 19.46, p<0.01, but not Kasina, F<1, or Vipassana, F<1, see Overall, the results of Study 2 demonstrated a significant improvement in cognitive performance on two visual tasks, MRT and VMT, immediately after both Deity and Rig-pa Vajrayana styles of meditation, but not Theravada styles of meditation. Such dramatic improvements in cognitive performance in comparison with the baseline suggest enhanced phasic alertness takes place during Vajrayana meditation. The results are consistent with previous research on meditation Whereas previous research mostly emphasized the power of Theravada styles of meditation to induce a relaxation response, even after short practices (e.g. 20 minutes) hyperarousal) is a physiological reaction that occurs in response to a perceived harmful event, attack, or threat to survival It should be noted that although arousal and “fight-or-flight” or stress responses are related, since both result from the activation of the sympathetic system, they are not the same. Whereas arousal is “an energizing function” responsible for harnessing the body's resources for intense activity, fight-or-flight or the acute stress response  than OM (Vipassana) meditation for Theravada, but the opposite effect was observed for Vajrayana, where Alpha Coherence was larger for OM (Rig-pa) but not FA (Deity), inconsistently with the FA-OM classification. Considering that decrease in Alpha Coherence is associated with a more relaxed state Lastly, the difference in Beta Fronto-Central Coherence between Theravada and Vajrayana practices, manifested by an increase only during Vajrayana meditations, may be indicative of enhanced emotion evaluation and affective value choices Thus, based on our findings, we suggest that the categorization of meditations as either “focused attention” or “open monitoring” cannot fully accommodate the range of behaviors and neural processes that are involved during meditation. Indeed, the utilization of focused or distributed attention is not clear cut for the majority of, if not all, meditation techniques, and both attentional systems are probably active at some level in most types of meditations. On the other hand, the distinction between relaxation and arousal is dichotomous: something either induces relaxation or arousal (or neither), but cannot induce both. Our data demonstrate reliable and consistent differences between meditative techniques across traditions, and that meditative practices can be appropriately classified on the basis of whether they produce relaxation or arousal. Importantly, neither relaxation nor arousal are simple by-products of the meditative practice, but play an essential role in the process of attaining insight, and the possibility that the insight obtained would differ depending on whether a relaxation or arousal approach is chosen ought to be investigated in future studies. Whereas the elicitation of an arousal or relaxation response cannot provide a complete description of any type of meditation, the results of the current research provide evidence that it is possible to reliably categorize different types of meditation in this manner.The implications of our findings are important in several ways. First of all, the present research showed Vajrayana practices can lead to dramatic enhancement in cognitive performance, suggesting that Vajrayana practices can be useful in tasks where optimal performance is required. However, it is important to note that we did not assess long term (i.e. trait) effects of meditations in this research. While the improvements on cognitive tasks following Vajrayana meditation are immediate and dramatic, it is still to be investigated in further research whether they lead to long-term changes. At the same time, while such improvement were not observed after Theravada practices, there is evidence that Theravada meditations might lead to long-term improvement on attentional tasks Moreover, our results show that Theravada meditations produce relaxation responses, while Vajrayana types of meditation produce arousal, suggesting that Theravada meditations could be more appropriate for stress reduction than Vajrayana, while Vajrayana meditation could be more problematic in people with higher stress levels. However, it should be noted that our research was conducted on a sample of long-term practitioners. While previous research has shown that stress reduction can be achieved through Theravada types of meditation  would influence the level of arousal generated during Deity meditation. It is possible that wrathful Tantric Deities might generate higher levels of arousal in comparison to more peaceful Deities. In addition, since certain meditations utilize breathing specifically to alter the level of relaxation and arousal, it would be valuable for future studies to obtain concurrent respiration and EKG measures.Despite the limitations, we were able for the first time to show that Vajrayana and Theravada styles of meditation are correlated with different neurophysiological substrates. More generally, the current findings undermine the prevalent view that all meditation practices bring about the same results, of enhancing cognitive performance and reducing stress levels. Indeed, it shows that the physiological and cognitive influences that meditations induce can vary greatly between traditions. Even though the benefits that can follow from different types of meditations of different traditions are often similarly described, leading to the widespread belief that they are in fact highly similar and that the choice to practice one meditation over another would not greatly influence the outcome of the practice, the current research shows not only that this is a misconception, but also that it has greatly hindered the progress of the scientific study of meditation. Our research shows that the large body of research on Theravada meditation is not generalizable to Vajrayana meditation, and thus Vajrayana practices should receive a greater emphasis in future research. Indeed, we show that the term “meditation” is in many ways too general, and have taken a step toward establishing a terminology that can appropriately distinguish the various practices from different traditions.Table S1HRV Analysis.(DOCX)Click here for additional data file.Table S2Spectral Analysis.(DOCX)Click here for additional data file.Table S3Coherence Analysis.(DOCX)Click here for additional data file.Table S4MRT and VMT Analysis.(DOCX)Click here for additional data file.Supporting Information S1Brief Outline of Buddhist Traditions.(DOCX)Click here for additional data file.


We have shown that a fourth-generation telehealth program that analyzes and responds synchronously to data transferred from patients is associated with fewer hospitalizations and lower medical costs. Whether a fourth-generation telehealth program can reduce all-cause mortality has not yet been reported for patients with chronic cardiovascular disease.We conducted a clinical epidemiology study retrospectively to determine whether a fourth-generation telehealth program can reduce all-cause mortality for patients with chronic cardiovascular disease.We enrolled 576 patients who had joined a telehealth program and compared them with 1178 control patients. A Cox proportional hazards model was fitted to analyze the impact of risk predictors on all-cause mortality. The model adjusted for age, sex, and chronic comorbidities.P<.001; number needed to treat at 1 year=55.6, 95% CI 43.2-75.7 based on HR of telehealth program) for the telehealth program on all-cause mortality after adjusting for age, sex, and comorbidities. The time-varying interaction term in this analysis showed that the beneficial effect of telehealth would increase over time.There were 53 (9.3%) deaths in the telehealth group and 136 (11.54%) deaths in the control group. We found that the telehealth program violated the proportional hazards assumption by the Schoenfeld residual test. Thus, we fitted a Cox regression model with time-varying covariates. The results showed an estimated hazard ratio (HR) of 0.866 (95% CI 0.837-0.896, The results suggest that our fourth-generation telehealth program is associated with less all-cause mortality compared with usual care after adjusting for chronic comorbidities. Cardiovascular disease (CVD) is a major health burden worldwide ,2. To imBecause of the technologies adopted, different telehealth care programs provide different levels of care integration. Based on the integration of care, Anker and coworkers  classifiBased on our previous reports, we hypothesized that a fourth-generation telehealth program could reduce mortality in patients with chronic CVD. To test this hypothesis, we retrospectively analyzed the all-cause mortality data among 576 patients with chronic CVD who received the telehealth care program and 1175 patients who did not receive telehealth care.This was a single-center, clinical retrospective epidemiologic study and was approved by the Institutional Review Board of National Taiwan University Hospital, Taipei, Taiwan. All experiments in this study were performed in accordance with relevant guidelines and regulations. Informed consent was obtained from all participants.The study was conducted from December 2009 to April 2013 at the Telehealth Center of the hospital, and conducted by the Taiwan ELEctroHEALTH study group (TELEHEALTH study group). The original study method has been described previously . The floThe fourth-generation telehealth program at our telehealth center is a synchronized and integrated remote management program for chronic diseases. The Internet-based platform was developed by the Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taiwan. The details of this program have been reported previously . BrieflyPatients in the control group received the usual care provided by the primary care physicians at our cardiovascular center according to updated guidelines including, but not limited to, the American Heart Association’s guidelines for lifestyle modification and primary prevention to reduce cardiovascular risk, guidelines for the management of stable ischemic heart disease, and the American Diabetes Association’s guidelines for the management of diabetes. Patients made routine outpatient department visits (once every 3 months) to their primary care physicians. There was no contact between the telehealth center and patients receiving usual care.All demographic and clinical data were obtained from the electronic database of the hospital. The diagnosis of a chronic disease was based on the electronic database. The discharge diagnosis was used if the outpatient and discharge diagnoses disagreed.The primary outcome of this study was all-cause mortality. Mortality data were obtained from the death certification database in the Department of Statistics, Ministry of Health and Welfare, Taiwan.P value ≤.05 was considered statistically significant. The continuous variables are presented as mean (SD), whereas categorical variables are presented as frequency and percentage. In univariate analysis, the potential predictive factors of all-cause mortality were examined by the chi-square test, Fisher exact test, two-sample t test, or Wilcoxon rank sum test as appropriate for the data type. Next, multivariate analysis was conducted by fitting the Cox proportional hazards model to estimate the adjusted effects of predictive factors on time to all-cause mortality.Statistical analysis was performed using the R version 2.14.0 software . A two-sided P>.05 one at a time until all regression coefficients were significantly different from zero. Any discrepancy between the results of the univariate analysis and multivariate analysis was likely due to the confounding effects of uncontrolled covariates in univariate analysis or the masking effects of intermediate variables (or mediators) in the multivariate analysis.To ensure the quality of analysis, the model-fitting techniques for (1) variable selection, (2) goodness-of-fit assessment, and (3) regression diagnostics were used in our regression analyses. Specifically, the stepwise variable selection procedure (with iterations between the forward and backward steps) was applied to obtain the candidate final Cox proportional hazards model. All the univariate significant and nonsignificant relevant covariates listed in Finally, the statistical tools of regression diagnostics for verification of proportional hazards assumption, residual analysis, detection of influential cases, and check of multicollinearity were applied to discover any model or data problems. The required proportional hazards assumption was tested based on the scaled Schoenfeld residuals. We added interaction terms between time (days) and the covariates that violated the proportional hazards assumption into the Cox proportional hazards model to examine their time-varying effects on all-cause mortality in the stepwise variable selection procedure. Technically, the original wide-form survival data were reconstructed into a long-form data structure using the so-called counting process style of input for fitting such Cox regression models. Numbers needed to treat was estimated based on the hazard ratio of telehealth program .P=.07) were comparable between the two groups. In the telehealth group, however, there were more patients with CAD , heart failure , stroke , dementia, chronic obstructive pulmonary disease, diabetes, and peptic ulcer disease (P<.001) and emergency department visits  in the telehealth group compared with the control group. The outpatient visit times were comparable between the two study groups .A total of 1754 patients  were enrolled in this study . The basP=.81). Because the baseline comorbidities were heterogeneous and the follow-up durations differed between the two study groups, Cox proportional hazards analyses were performed. A proportional hazards assumption was tested for each variable using the Schoenfeld residuals test. The result showed the proportional hazards assumption was violated for the telehealth program (P<.001) for the telehealth program on all-cause mortality. The time-dependent interaction term in this Cox regression analysis indicated that the beneficial effect of the telehealth program on the HR would increase over time. Thus, the estimated numbers needed to treat for the telehealth program to prevent one death at 1, 2, and 3 years were 55.6, 40.5, and 27.7, respectively (There were 53/576 (9.3%) deaths in the telehealth group and 136/1178 (11.50%) deaths in the control group. The Kaplan-Meier survival curve is shown in  program . The timectively .P<.001) [The major finding of this study is that our fourth-generation telehealth program was associated with lower all-cause mortality after controlling for multiple comorbidities among patients with chronic cardiovascular disease. Prior studies on the effects of telehealth programs on all-cause mortality among patients with chronic diseases revealed mixed results -13. ThisP<.001) . Based oAmong patients with chronic heart failure, the beneficial effect of telehealth care on all-cause mortality has been repeatedly demonstrated in studies ,4. The eFirst, the telehealth program has changed over time. Early telemonitoring systems used asynchronous techniques to record and process the collected subjective symptoms and physiological data. A response to the data collected could take more than 1 day during the off hours. This newer system uses a synchronous technique to respond to the information received to act in a timely manner. Through quick communication, more accurate diagnoses and decisions can be made. Second, the age of the study participants differs. The mean ages in the studies were 80.3 years in the Mayo study, 70.3 years in the WSD study, and 64.5 years in our study. The potential barriers for elderly participants to effectively use a telehealth program include a lack of skill to operate a new device, psychological resistance to new technology, and the presence of more comorbidities. Third, the comorbidity profiles also differed. The reported chronic comorbidities were as follows: a mean Charlson score of 2.9 in the Mayo study, a mean number of chronic conditions of 1.8 in the WSD study, and a mean Charlson score of 1.3 in our study. In a meta-analysis on the effectiveness of telemonitoring for four chronic conditions, the results were more consistent for cardiac and pulmonary conditions compared with diabetes and hypertension . WhetherOur study found that the effect of the telehealth program on mortality was time dependent; namely, that the beneficial effect increased with longer follow-up durations. Although an increasing benefit on mortality has not previously been reported, an increasing benefit on other surrogate endpoints has been noted previously. In a study of telemedicine conducted with elderly Medicare patients, glycated hemoglobin (HbA1c) and blood pressure levels were lower after the follow-up for 5 years. The difference between the telemedicine and control groups increased further at 5 years . It is pThe paradoxical associations of CAD and PAD with lower all-cause mortality found in our data were unexpected. Plausible explanations of these survival paradoxes included chance or unmeasured residual confounding factors, especially effective treatment for CAD and PAD. In a recent large cohort of 102,023 patients with stable CAD, a history of percutaneous coronary intervention or coronary artery bypass graft in the past 6 months were associated with hazard ratios of 0.651 and 0.516, respectively, on all-cause mortality [Our study has some limitations. First, because our study was not a randomized study, unmeasured confounding factors might have influenced the results. Second, because our study compared the whole service program and not any single monitoring device or physiological parameter, the effect of each device or parameter on mortality cannot be assessed separately. Third, because all-cause mortality instead of mortality from specific causes was used in this study, we cannot draw a definite conclusion regarding the effects of telehealth monitoring on specific causes of death. Finally, the numbers needed to treat is estimated based on the hazard ratio of the telehealth program. This may lead to overestimating the numbers needed to treat.Our data suggest that a fourth-generation telehealth program is independently associated with lower all-cause mortality among patients with chronic CVD and multiple comorbidities.


Evidence is needed to develop effective educational programs for promoting evidence based practice (EBP) and knowledge translation (KT) in physical therapy. This study reports long-term outcomes from a feasibility assessment of an educational program designed to promote the integration of research evidence into physical therapist practice.Eighteen physical therapists participated in the 6-month Physical therapist-driven Education for Actionable Knowledge translation (PEAK) program. The participant-driven active learning program consisted of four consecutive, interdependent components: 1) acquiring managerial leadership support and electronic resources in three clinical practices, 2) a 2-day learner-centered EBP training workshop, 3) 5 months of guided small group work synthesizing research evidence into a locally relevant list of, actionable, evidence-based clinical behaviors for therapists treating persons with musculoskeletal lumbar conditions--the Best Practices List, and 4) review and revision of the Best Practices List, culminating in participant agreement to implement the behaviors in practice. Therapists’ EBP learning was assessed with standardized measures of EBP-related attitudes, self-efficacy, knowledge and skills, and self-reported behavior at baseline, immediately-post, and 6 months following conclusion of the program (long-term follow-up). Therapist adherence to the Best Practice List before and after the PEAK program was assessed through chart review.p < 0.001 and p = 0.002, respectively). EBP-related knowledge and skills showed a trend for improvement from baseline to long-term follow-up (p = 0.05) and a significant increase from immediate-post to long-term follow-up (p = 0.02). Positive attitudes at baseline were sustained throughout (p = 0.208). Eighty-nine charts were analyzed for therapist adherence to the Best Practices List. Six clinical behaviors had sufficient pre- and post-PEAK charts to justify analysis. Of those, one behavior showed a statistically significant increase in adherence, one had high pre- and post-PEAK adherence, and four were change resistant, starting with low adherence and showing no meaningful improvement.Sixteen therapists completed the long-term follow-up assessment. EBP self-efficacy and self-reported behaviors increased from baseline to long-term follow-up (This study supports the feasibility of the PEAK program to produce long-term improvements in physical therapists’ EBP-related self-efficacy and self-reported behavior. EBP knowledge and skills showed improvement from post-intervention to long-term follow-up and a trend toward long-term improvements. However, chart review of therapists’ adherence to the participant generated Best Practices List in day-to-day patient care indicates a need for additional support to facilitate behavior change. Future versions of the PEAK program and comparable multi-faceted EBP and KT educational programs should provide ongoing monitoring, feedback, and problem-solving to successfully promote behavior change for knowledge translation. Evidence based practice (EBP), the integration of research evidence, patient perspectives, and clinical expertise, has become a gold standard for physical therapist education and clinical practice around the world , 2. Know. found limited evidence to inform EBP education for allied health professionals [A recent systematic review by Dizon et alssionals . While sssionals . A systessionals . Yet, noThe Physical therapist-driven Education for Actionable Knowledge translation (PEAK) program is an educational program designed to promote physical therapists’ integration of research evidence into clinical decision-making . A mixedMost assessments of EBP education, including our own previous analysis of the PEAK program, have focused on EBP-related attitudes, self-efficacy, knowledge, skills, and self-reported engagement in EBP behaviors , 6; all A study to assess feasibility for implementing the PEAK program was conducted from 2010-2011 among physical therapists at the University of Southern California clinical practices. Previous reports describe the program and its theoretical underpinnings  and a miTwenty-five physical therapists practicing in three geographically dispersed USC patient care centers  were invited to participate through staff meetings and individual email. Therapists were required to have a minimum of 6 months clinical experience, be providing patient care at the University of Southern California physical therapy practices at least 20 h per week, be able to attend both days of an EBP knowledge and skills workshop, and be willing to commit to study activities at least 1 h per month for 6 months. The study was approved by the University of Southern California Health Science Campus Institutional Review Board (HS-10-00593). All participants consented to participate.The PEAK program is a multifaceted, learner-centered education program designed to promote physical therapists’ use of research evidence in clinical decision-making. Its theoretical foundations, described previously , are in All components of the PEAK program support a participant-driven learning experience – working as a group to generate a Best Practice List around a common, participant-selected clinical area. The Best Practices List is a locally generated list of evidence-based, actionable behaviors that participants agree (as a group) to implement in their clinical practice. Participants self-organized into small groups to review literature around their chosen topic of musculoskeletal lumbar conditions and generate evidence-based actionable behaviors. The actionable behaviors were reviewed and revised through a process of peer and expert review until all participants felt that they could implement the Best Practices List in practice . The finThe Classification Rubric for EBP Assessment Tools in Education (CREATE) model  providedStandardized measures of EBP learning were assessed at baseline, immediately-post PEAK program, and 6 months later for long-term follow-up Fig. .Fig. 3StAttitudes toward EBP were assessed using the attitudes items from the EBP Beliefs Scale. The 16-item EBP Beliefs Scale measures EBP attitudes and self-efficacy and has demonstrated construct and criterion validity among practicing nurses [g nurses . To exclSelf-efficacy for EBP was assessed using the Evidence-based Practice Confidence Scale. This measure has established face and content validity among healthcare professionals, including physical therapists [erapists . The EviKnowledge and skills for EBP were assessed with the 13-item modified Fresno Test which has demonstrated reliability and content and construct validity among physical therapists [erapists . The modbehavior was assessed using the EBP Implementation Scale which has demonstrated construct and criterion validity among nurses [Self-reported EBP g nurses . The 18-Diagnosis: The patient’s primary diagnosis for the episode of care was related to a musculoskeletal lumbar spine condition. Charts with the following ICD-9 codes as a primary diagnosis were reviewed for inclusion: 721.0–9 spondylosis and allied disorders; 722.0–9 intervertebral disc disorders; 724.0–9 other and unspecified disorders of back.Therapist: The therapist responsible for the majority (>50 %) of the patient’s care participated in the PEAK program.Date: Therapy ended in the 6 months prior to therapists participating in the PEAK program (pre-PEAK charts). Therapy began in the 6 months following the PEAK program (post-PEAK charts).Therapist adherence to the Best Practice List was assessed via medical chart review of therapists’ documented practice behaviors in the 6 months prior to and following the PEAK program Fig. . Raters For the two outpatient facilities, potential charts were identified for review through a single electronic database. Chart review was then conducted with paper charts. For the inpatient facility, potential charts were identified through a second database. The inpatient charts had been converted to electronic archives, but did not contain therapy evaluation and care notes. Without basic therapy information electonically, hard copy charts from among approximately 5000 patients needed to be individually retrieved from an archive center. Given that the return on this search was expected to be about 20 charts (0.4 %), it was not feasible to review the inpatient paper charts. Thus, inpatient charts were not included in the analysis.acute non-specific low back pain were recorded as ‘not applicable’ in the instance of a patient with chronic non-specific low back pain).Raters manually reviewed eligible charts for therapist adherence to behaviors listed in the Best Practices List. Behaviors from the Best Practices List sub-topic ‘outcome measurement’ were relevant to all charts. Behaviors from the remaining four sub-topics were only relevant when the appropriate diagnosis  was present. Adherence was recorded as either ‘behavior present’, ‘behavior not present’, or ‘not applicable’. ‘Not applicable’ was used when a therapist would not be expected to adhere to a behavior because the patient case did not fit pre-defined criteria for that behavior .Results of the four standardized measures of EBP learning for baseline, immediate-post, and long-term follow-up are detailed in Fig. p < 0.001) and self-reported EBP behaviors . Change for these two measures occurred between baseline and the immediate-post follow-up. No significant gain or loss was observed from immediate-post follow-up to long-term follow-up. EBP knowledge and skills showed a trend toward improvement from baseline to long-term follow-up . While change was not significant from baseline to immediate-post follow-up (p = 0.877), a significant improvement was noted from immediate-post to long-term follow-up (p = 0.022).Improvement from baseline to long-term follow-up was observed for EBP self-efficacy  of all eligible charts. Most charts reviewed were associated with patients with non-specific low back pain .One thousand one hundred ninety six potential charts were screened for inclusion Fig. . Of thosp < 0.001). The behavior involving ‘provision of a progressive home exercise program for persons with chronic LBP’ had high adherence pre-PEAK (92.7 %) that was sustained post-PEAK (87.5 %). The remaining four behaviors had <50 % adherence pre-PEAK that did not improve post-PEAK.Six of the 38 behaviors from the Best Practices List met the sample size criteria (≥14 charts in both the pre- and post-PEAK time period) and were assessed for change in therapist adherence (Table n = 8) was consistent with results observed in the full cohort of 16 therapists.An analysis of standardized measure performance restricted to the therapists whose charts contributed to the chart review data  fell short of the 25.7 point minimal detectable change derived for the modified Fresno Test . HoweverOur finding of consistently positive attitudes about EBP reflects a common finding among physical therapists , 21, 29.To our knowledge this is the first study to objectively assess physical therapists’ patient care behavior in response to a prolonged, multi-faceted program promoting general EBP and KT as opposed to a KT intervention specific to implementing a particular externally-generated clinical practice guideline , 5. Two Though it stands alone among the six behaviors analyzed, the substantial improvement observed in therapists’ adherence to conducting a depression screen can be explained by the influences of the PEAK program. The depression screen questions were part of an intake form that patients filled out before their first physical therapy visit. The intake form and associated procedures did not change during the study time period. However, our chart review showed that patients were inclined to leave the questions blank. It may be that as a result of developing the Best Practices List, therapists were more likely to follow-up with patients who left the questions blank thus resulting in a substantial increase in adherence to collecting this information.capability to change by increasing therapists’ EBP-related knowledge and skills for conducting the best practices. Further, our previous analysis [motivation by creating a group culture energized around the idea of improving patient care through EBP. However, the PEAK program likely fell short in addressing opportunity.Four of the six Best Practices List behaviors analyzed were change resistant, therapists had low pre- and post-PEAK adherence. The “behavior change wheel” developed by Michie and colleagues  providesanalysis  suggestsOpportunity refers to those factors that lie outside of the individual. While organizational support was carefully cultivated for the overall PEAK program, no specific organizational support was garnered to facilitate and sustain implementation of the Best Practices List. For example, therapists agreed to administer the modified Oswestry Disability Index  at the bIt is important to note that sustained low adherence to four of the six Best Practices List behaviors does not inherently mean that therapists somehow misrepresented their self-reported EBP behaviors. Based on our previous analysis, therapists reported increased behaviors associated with asking clinical questions, searching for and reading research evidence, and discussing their findings with patients and peers . This isThis study concludes evaluation of the PEAK program, a theoretically driven, evidence-based educational intervention to promote EBP and KT among physical therapists practicing in a geographically dispersed academic medical center. The feasibility nature of the study called for a small sample size of therapist participants in the educational program. This fact combined with a first attempt to monitor therapists’ adherence to the participant-generated Best Practices List revealed a number of challenges. Lack of efficiently searchable electronic records made the hospital charts with therapists’ adherence data inaccessible. Additionally, although lumbar spine conditions in general represent about 25 % of ambulatory visits to physical therapists , our parPreviously identified limitations  that warThis study supports the feasibility of the PEAK program to produce long-term improvements in physical therapists’ EBP-related self-efficacy and self-reported behavior. EBP knowledge and skills showed improvement from post-intervention to long-term follow-up and a trend toward long-term improvements. However, chart review of therapists’ adherence to the participant-generated Best Practices List in day-to-day patient care indicated a need for additional support to facilitate behavior change. Future versions of the PEAK program and comparable multi-faceted EBP and KT educational programs should include monitoring, feedback, and problem solving, to promote therapists’ adherence to best practices in patient care.The study was approved by the University of Southern California Health Science Campus Institutional Review Board (HS-10-00593). All participants consented to participate.Not applicable.All data is available through the first author of the manuscript.