Secondly, the basal levels of the Mapela terraces and hilltop contain élite solid dhaka (adobe) floors associated with K2 pottery and glass beads. Thirdly, with a hilltop and flat area occupation since the 11th century CE, Mapela exhibits evidence of class distinction and sacred leadership earlier than K2 and Mapungubwe, the supposed propagators of the Zimbabwe culture. Fourthly, Mapungubwe material culture only appeared later in the Mapela sequence and therefore post-dates the earliest appearance of stone walling and dhaka floors at the site. Since stone walls, dhaka floors and class distinction are the essence of the Zimbabwe culture, their earlier appearance at Mapela suggests that Mapungubwe can no longer be regarded as the sole cradle of the Zimbabwe culture. This demands not just fresh ways of accounting for the rise of socio-political complexity in southern Africa, but also significant adjustments to existing models.Across the globe, the emergence of complex societies excites intense academic debate in archaeology and allied disciplines. Not surprisingly, in southern Africa the traditional assumption that the evolution of socio-political complexity began with ideological transformations from K2 to Mapungubwe between CE1200 and 1220 is clouded in controversy. It is believed that the K2−Mapungubwe transitions crystallised class distinction and sacred leadership, thought to be the key elements of the Zimbabwe culture on Mapungubwe Hill long before they emerged anywhere else. From Mapungubwe (CE1220–1290), the Zimbabwe culture was expressed at Great Zimbabwe (CE1300–1450) and eventually Khami (CE1450–1820). However, new fieldwork at Mapela Hill, when coupled with a Bayesian chronology, offers tremendous fresh insights which refute this orthodoxy. Firstly, Mapela possesses enormous prestige stone-walled terraces whose initial construction date from the 11 For over a century, the origin and evolution of this complex society continues to ignite the imagination of enthusiasts, scholars and the public in different parts of the world , Great Zimbabwe (Zimbabwe culture) and Khami (Zimbabwe culture). As such, archaeologically well-explored places became the theatres of innovation, thereby editing out of historical significance the many sites that chronologically overlap with the so-called capitals. In fact, sites such as Mapela  were, wiet al. dhaka floors and participated in long-distance trade . Furthermore, there are numerous Leopard's Kopje sites such as Mapela . Furthermore, it contained prestige stone walls and evidence of class distinction, which suggest that the Zimbabwe culture was expressed earlier at Mapela than at K2 and Mapungubwe. Finally, a polycentric model informed by Actor Network theory, historical data, material culture patterning and modelled Bayesian dates was developed.Mapela was naturally attractive because it contains substantial terrace walls, abundant local pottery, solid Mapela  is the ndhaka, or earthen floors, with curved kerbs typical of Great Zimbabwe and related sites. Garlake  Excavation Area 1 on the flats . It was succeeded by yet another event associated with burning. A mixture of wood charcoal, grass and sorghum seeds was recovered in this level 13. The recovery of sorghum seeds suggests that the circular stone feature that continued from the layer above, on the northern side of the trench, was a grain bin foundation. Below this was another floor underlaid by a layer comprising of broken dhaka fragments, pottery and charcoal. This was followed by a midden which accumulated on top of a floor, and covered one side of the trench. The southern corner of the trench contained charcoal, ash and burnt dhaka in level 16. It seems that this material collected on top of a floor (levels 17 and 18) which sealed a very thin midden that contained K2 pottery, charcoal and three glass beads (levels 18 and 19). Because of the depth and integrity of this stratigraphy, nine samples of carbonaceous materials from levels 7, 9, and 13 to 19 were submitted for radiocarbon dating.Terrace Excavation Trench 1 yielded an authoritatively informative stratigraphy . A very Lower Summit Trench 1 was just over half a metre deep. However, the stratigraphy was complex, comprising alternating layers of midden and floors. Initially, a 2×1-metre trench was excavated but this was abandoned after 20 centimetres when an intact floor was encountered. A decision was made to extend the trench by one metre (Extension A) and to excavate that to bedrock . Only fodhaka.When combined, the excavations produced a number of significant finds ranging from domestic pottery, spindle whorls, ferrous metal objects, copper-based ornaments, glass beads, fauna, fish bone, carbonised seeds to fragments of Only domestic pottery and glass beads were typologically and stratigraphically analysed to determine the sequence of occupation and the identity of the inhabitants of Mapela. Since the ceramic and bead sequences in southern Africa are reasonably well dated and are reproducible, it is easy to cross-date new sites by comparing their ceramics and beads to established types et al. The glass beads from Mapela were placed within a chronological and typological framework established by Robertshaw The earliest bead series from the terrace excavation belonged to the K2 series. These were followed by Mapungubwe series glass beads. Apart from being chronological markers, glass beads are also seen as status markers The pottery and glass bead typology indicated that Mapela contains both Leopard's Kopje Phases I and II, or early Zimbabwe culture traits on the terraces, flats and hilltop. However, samples of carbonised seeds and charcoal were radiocarbon dated using AMS and conventional radiocarbon dating techniques to develop an absolute and independent chronology.Samples for radiocarbon dating were obtained from charcoal and short-lived samples, such as carbonised seeds and twigs. The dates were modelled following Bayesian techniques in the software OxCal version 4.2.3 at Oxford University's Research Laboratory for the History of Archaeology and Art. Bayesian models are conditional probabilities which allow for pre-existing information to be incorporated into the current data, to permit the development of an integrated interpretation process th century. The lack of dates from the top section of the trench was considered unimportant in view of the need to provide a tight sequence relating to the K2, Transitional K2 and Mapungubwe intervals. The dates from Garlake At the 95% confidence interval, the start of K2 phase was estimated to be from 1055 to 1219 cal CE while the K2/Transitional K2 phase was estimated at between 1163 and 1224 cal CE. The Transitional K2/Mapungubwe boundary has been estimated to between 1223 and 1272 cal CE. The end of the sequence, based on the dates available up to level 7, is between 1225 and 1317 cal CE (95%). The presence of Mapungubwe pottery and glass beads in levels 1 to 6 suggests that the sequence extends to the 14th century cal CE, K2 people were established on the and that in the 12th century, Transitional K2 pottery was being produced, with Mapungubwe material appearing towards the middle of the 13th century cal CE.The modelled dates authoritatively show that by the late 11Class distinction and sacred leadership characterised the Zimbabwe culture, the most complex society in precolonial southern Africa. This complex society evolved between AD 1000 and 1300 at the sites of K2 and Mapungubwe in the Shashe-Limpopo Valley”  pattern th century, endorses Robinson's conclusion et al.dhaka floors with curved kerbs, dispelling the notion that they appeared first on Mapungubwe Hill before anywhere else in the region. Huffman dhaka structures represent the earliest Zimbabwe culture expression. Evidence from south-western Zimbabwe shows that everything that makes up the Zimbabwe culture at Mapungubwe appeared earlier at Mapela, making Mapela one of the most important sites with secure evidence of the evolution of the Zimbabwe culture.The construction of dry stone walls during K2 times is hardly surprising given that Robinson th century CE. Mapungubwe therefore exhibits cultural practices that were already on the landscape, showing continuity in tradition through interaction, copying, and other means.Historically and ethnographically, one of the features of élite Zimbabwe culture is the ideology of class distinction crystallised on the ground through building élite dwellings on raised ground and commoner dwellings on the flats th and early 20th centuries when virtually all the stone-walled sites were looted for their gold. Even today, the ghost of past plundering rears its ugly head in the form of multiple illicit trenches in parts of Mapela with evidence of metallurgical slags. Herbert Mapela furthermore possesses thousands of glass beads suggesting that it was a major player in the Indian Ocean trade system th century CE. Specifically, it is argued that before the 13th century CE, rainmaking took place in the natural environment, away from homesteads. However, this practice changed during the Transitional K2 period when certain individuals appropriated rainmaking control on Mapungubwe Hill and used it as springboard to political power. The signature of rainmaking includes steep-sided hills difficult to access, as well as infrastructure such as rock tanks and artificial cupules. Huffman et al. Recently, the cultural practice of rainmaking has been placed deep within the debate about early state formation in southern Africa. Murimbika Having demonstrated the presence of élite Zimbabwe culture attributes from the K2 period onwards, emphasis now shifts to the Mapungubwe occupation. Just as Mapela was much larger than K2, it was also bigger than Mapungubwe. et al. dhaka floors singly and in combination are widespread in south-western Zimbabwe and adjacent regions. The distances between Taba Zika Mambo in the Zimbabwean Midlands, Mapungubwe in the Shashe-Limpopo and Jahunda in south-western Zimbabwe, where all these features are expressed, makes it difficult to understand how given the logistical limitations of the time, any one of these entities could have dominated the whole landscape politically and economically , was exploited to account for the rise of socio-political complexity in southern Africa. ANT simultaneously considers the human aspects as well as ideology and relationships between multiple entities on the landscape. In ANT, actors are combinations of symbolically invested things, identities, relations, inscriptions, and networks capable of nesting within other diverse networks et al. Because of the existence of many widely separated but chronologically overlapping Leopard's Kopje communities in south-western Zimbabwe, south-central Zimbabwe, north-eastern Botswana and northern South Africa   it is prFurthermore, the similarity in glass beads over time and the almost identical frequency suggests that all the actors participated in the network with no single entity monopolising the trade. To use Renfrew and Cherry's Unlike the traditional model, which ignores all these networks and unnecessarily robs the region's past of dynamism, ANT places these entities at the centre of societal change. The result is that southern Africa around CE1000 had multiple socio-politically complex entities that competed, conflicted and interacted with one another This interpretation is adequately supported by Shona historical and anthropological data which demonstrate the existence of robust networks at various levels, from the small- to the large-scale dhaka floors, and the first rainmaking hill. Rather, it is possible to see a network of actors who exhibit shared cultural traits occasioned by various forms of interaction.It is prudent to pose the question of why these innovations in socio-political organisation are associated with the Leopard's Kopje period after CE900 onwards. The overarching influence of demography is one critical variable that has been overlooked in studies of the Iron Age of southern Africa. Shennan From a comparative perspective, it is important to briefly consider the emergence of socio-political complexity in the world. In the Middle East around 4000 BCE various city states of Sumer were actors or peers who networked and often competed with one another On the basis of the evidence presented in this paper, it is clear that Mapela occupies an important space in debates on early state formation in southern Africa. Fundamentally, the ceramics, glass beads, chronometric and architectural evidence suggest that Mapela had fully developed attributes of the Zimbabwe culture during K2 times. Furthermore, the ideology of class distinction and sacred leadership at Mapela antedates that at K2 and Mapungubwe. On this evidence neither K2 nor Mapungubwe qualify to be the region's incipient Zimbabwe culture centres. Of course Mapungubwe has yielded an impressive array of gold objects which are yet to be found at Mapela. However, on the basis of cultural precedence, Mapela had a fully developed Zimbabwe culture much earlier than Mapungubwe. The thousands of glass beads found at Mapela show that it was a principal player in long-distance trade. Mapela has also been shown to be considerably larger than Mapungubwe. Therefore, it would be unreasonable to conclude that a later site with far fewer dry stone walls is more important than one with more, if both the sites are within the formation of the Zimbabwe culture period.A combination of historical evidence with Actor−network theory and its variants such as peer polity interaction, suggests that towards the early second millennium CE, various Shona communities resident in the region bound by the Indian Ocean to the east and the Kalahari to the north underwent a series of transformations ideologically, culturally, economically and politically. The seeds of these transformations were sowed during the Leopard's Kopje Phase I and were elaborated during the Zimbabwe culture period. The presence of various actors exposes markedly the undesirability of models which fix the birth of early state formation at single points in time. It is far more prudent to argue that various communities exhibiting identical cultural practices all contributed and participated in early state formation. As such, early state formation did not start at Mapungubwe; neither did it start at Great Zimbabwe or Khami. Instead, it started with the many Leopard's Kopje sites which show evidence of the expression of Zimbabwe culture in south-western Zimbabwe and adjacent regions. The thinking that the evolution of the Zimbabwe culture started at Mapungubwe through Great Zimbabwe to Khami must now surely be revised. This is because as elsewhere, it is impossible to pinpoint the start of an innovation which is widely expressed across a vast stretch of land by using only a few sites. Certainly the Zimbabwe culture started with the Leopard's Kopje, which evolved into the Zimbabwe, but the mechanisms of such continuity and change are unknown. Huffman : 49 has


Anorexia nervosa (AN) is particularly dangerous for adolescent sufferers, as the potential for long term damage is heightened during this critical developmental period. Hospitalisation is necessary for many adolescents with AN, and in Australia, around 90% of such admissions are to public hospitals. Given the high costs associated with this treatment modality, the economic impact on public health systems is substantial. In 2013, a new adolescent eating disorder program was introduced in a large public paediatric unit. Informed by the Maudsley Model, the program had the dual aim of improving patient outcomes and managing service demand. We evaluated the program's success in terms of its impact on admission rates and duration, and on patient outcomes. Despite an increased demand for inpatient services since the new program commenced, it has achieved significant reductions in occupied bed days without compromising patient outcomes. Weight gain and decreases in eating psychopathology were maintained at 3-month follow-up. This presentation will detail the results of the evaluation, and discuss its implications for other services facing similar challenges. We will also discuss the implications of this research for informing improvements in the provision of effective inpatient treatment for adolescent AN.


Three hundred and seventy-six middle school students in Wenchuan County were assessed three and one-half years after the Wenchuan earthquake to examine the effects of rumination on posttraumatic stress disorder (PTSD) and posttraumatic growth (PTG). The results revealed that recent intrusive ruminations partly mediated the relationship between intrusive rumination soon after the earthquake with PTSD but not with PTG. Recent deliberate rumination partly mediated the relationship between intrusive rumination soon after the earthquake and PTG but not PTSD. Moreover, recent deliberate rumination also partly mediated the relationship between recent intrusive rumination with PTG but not with PTSD. Overall, intrusive rumination soon after the earthquake had an effect on PTSD but not on PTG through recent intrusive rumination and affected PTG but not PTSD through deliberate recent rumination. Furthermore, intrusive rumination soon after the earthquake affected PTG but not PTSD by recent deliberate rumination following recent intrusive rumination. More importantly, the present study also found that PTSD exhibited no relation to PTG. These results suggest that PTSD and PTG are influenced by different mechanisms, which further indicates that PTSD and PTG represent two separate dimensions of experience after adversity. Traumatic events are notably common worldwide  and inclThe shattered world assumption of For most people, intrusive ruminations tend to occur soon after the traumatic event . Soon afMore importantly, engaging in intrusive rumination soon after a traumatic event can occur a long time after the traumatic event . In the Continued intrusive and deliberate thoughts play different roles in influencing the outcomes that follow a highly stressful experience . Event-rWhile the theoretically expected co-existence of PTSD and PTG has been verified by empirical studies , it remaThe 2008 Wenchuan earthquake was the most devastating earthquake in China since 1976 and resulted in more than 69,000 deaths and 370,000 injuries, the majority of which involved adolescents. Compared to adults, adolescents are generally more vulnerable when they are exposed to trauma, and therefore, they often exhibit traumatic reactions following disasters . The preThe present data were collected as part of a longitudinal study of psychological adjustment amongst the child survivors of the Wenchuan earthquake. For the present study, 376 adolescent survivors were randomly selected from several classes at the only two high schools in the county of Wenchuan in Nov, 2011. All the participants personally experienced this earthquake. On average, these participants were 15.98 years of age (SD = 1.64) with a range of 13–19 years old. One hundred ninety-eight of the participants (52.7%) were girls.This study was approved by the Research Ethics Committee of Beijing Normal University and conducted according to the principals of the participating schools. In the selected classes, everyone who attended school on the date of the survey was recruited to participate. There were no exclusion criteria. Compensation was not provided. The purpose of the study and the voluntary nature of the students’ participation were highlighted before the survey, and written consent forms that emphasized the right of each participant to withdraw from the survey at any time were provided to participants and their parents. The researchers administered the questionnaire packets in a classroom setting without the presence of the teachers. The participants were initially asked to provide demographic information that included sex, age and ethnic group. They were asked to complete the remaining measures that assessed core belief challenge, rumination, PTG and PTSD. After the questionnaire packets were completed, the participants were told that school psychologists or teachers were available to provide any psychological/counseling services that they might need.not at all) to 5 . The original Event-Related Rumination Inventory was developed by  and recent rumination .The modified Event-Related Rumination Inventory was used to measure intrusive and deliberate rumination . The iteloped by  and consloped by . The parno change) to 5 (very great degree of change). The PTGI has good internal consistency and good construct, convergent, and discriminate validities (α = 0.90), and the fit indices from a confirmatory factor analysis were acceptable .Posttraumatic growth was measured using a modified version of the Post-Traumatic Growth Inventory . The orilidities . The revα = 0.86), and the fit indices from a confirmatory factor analysis were good .Posttraumatic stress disorder symptom levels were assessed using the Child PTSD Symptom Scale  as appliDescriptive analyses were conducted for all of the measures administered. Pearson correlations were calculated to examine the associations between the major variables.The statistical analyses were conducted using Mplus 6.0 software . BecauseAdditionally, to evaluate the model fit, we used chi-square values, the comparative fit index (CFI), the Tucker–Lewis index (TLI), the root mean square error of approximation (RMSEA), and the standardized root mean residual (SRMR). A non-significant chi-square indicates good model-data fit. The general cutoffs for accepting a model are equal to or greater than 0.90 for the CFI and TLI and equal to or less than 0.08 for the RMSEA and SRMR .We built SEM to examine the effects of intrusive rumination soon after the earthquake, recent intrusive rumination, recent deliberate rumination on PTSD and PTG. SEM models have two basic elements: a measurement component (“measurement model”), and a structural component . Although both the measurement and structural components can be evaluated simultaneously in SEM  stronglyNext, according to mediating effects test procedures , we applTo describe the study sample, the means and standard deviations of the measures are presented in Table χ2(8) = 16.001, CFI = 0.992, TLI = 0.984, RMSEA (90% CI) = 0.052(0.009–0.088), SRMR = 0.032]. The results indicated that the measurement model was good and applicable to the analysis of the SEM.We built a measurement model that included the two latent variable constructs of PTSD and PTG. Next, the PTSD latent variable was evaluated according to the scores for the CPSS subscales of Intrusion, Avoidance and Hyper-arousal , whereasχ2(11) = 19.34, CFI = 0.992, TLI = 0.985, RMSEA (90% CI) = 0.045 (0.000–0.077), SRMR = 0.027]. The path analysis revealed that there were significant direct effects of the intrusive rumination soon after the earthquake on PTSD and PTG, and the relation between PTSD and PTG was marginally significant (p = 0.051).In this phase, we formulated two structural models using the measurement model mentioned above. First, we built a direct effects model (M1), which demonstrated that intrusive rumination soon after the event had direct effects on PTSD and PTG. The model fit the data well [Pearson correlations observed in the present data, we added a path from recent intrusive rumination to recent deliberate rumination and established a multiple indirect effects model  = 36.07, CFI = 0.989, TLI = 0.976, RMSEA (90% CI) = 0.056 (0.030–0.082), SRMR = 0.029. These results indicated that the M2 was acceptable.Second, based on the direct effects model, we added recent intrusive and deliberate rumination to the relationships of intrusive rumination soon after the earthquake with both PTSD and PTG. Moreover, based on the PTG model of  and the n = 376) using random samples with replacement. Model 2 was conducted 5000 times with these samples to yield 5000 estimations of each indirect path coefficient. If the 95% confidence interval for the estimate of indirect path coefficient does not include 0, it could be concluded that the indirect path coefficient is significant.Next, to evaluate the significance levels of the indirect effects in M2, we conducted bias-corrected bootstrap tests with a 95% confidence interval to determine the significance of the indirect effects . First, Table In this study, we constructed a multiple indirect effects model to examine the relationships between intrusive rumination soon after traumatic events, recent intrusive rumination, recent deliberate rumination, PTSD and PTG in a sample of adolescent survivors of the Wenchuan earthquake. The adolescents’ intrusive ruminations soon after the earthquake positively predicted PTSD; i.e., the adolescents who experienced more intrusive rumination soon after the earthquake exhibited more severe PTSD symptoms, which is consistent with the results of Inconsistent with previous studies , the preOther interesting findings of this study were that recent deliberate rumination have a positive and significant effect on PTSD, which be inconsistent with previous studies . Here, wIn SEM, we found that intrusive rumination soon after the earthquake had a positive and significant effect on PTSD via recent deliberate rumination. We further used bias-corrected bootstrap test with a 95% confidence interval to determine whether the indirect effect was truly significant. However, the result showed that this indirect path was non-significant, indicating that intrusive rumination soon after the earthquake could not predict PTSD via recent deliberate rumination. Here, the traumatized adolescents who engaged in deliberate rumination indicated that they had been continuing to struggle with and to understand the trauma . During Soon after traumatic events, trauma survivors always engage in intrusive rumination, which has important effects on subsequent cognitive activities, particularly recent intrusive and deliberate rumination that, in turn predict PTSD or PTG. The present study found that intrusive rumination soon after the earthquake led to both PTSD and PTG, and recent intrusive rumination played a role in the former, while recent deliberate rumination played a role in the latter. These findings further support the assumption of  that theAlthough most of this study’s theoretically derived predictions were supported, several major design and measurement limitations must be acknowledged. One major limitation is the cross-sectional design, which means that the findings do not indicate causality or a temporal sequence. A second limitation is that the reports by the participants about their ruminations “soon after the event” and “recently” might have been biased by the inability to accurately recall the thought processes that occurred in the past . In addiDespite these limitations, to our knowledge, this study is among the first to examine the cognitive processing differences between PTSD and PTG. Furthermore, this study contributes new knowledge to previous theoretical and empirical studies of the relationship between PTSD and PTG that have indicated that PTSD and PTG can independently co-exist in traumatized adolescents. From the intervention and health-enhancement perspectives, this study also highlights important implications for adolescent survivors of the Wenchuan earthquake. Substantial growth can still occur even in the face of distressing symptoms, and treating the latter should not impede the former. Clinical efforts should focus on the enhancement of recent deliberate rumination even as intrusive rumination soon after the earthquake and recently are decreased.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Introduction: In the design of educational programs, much attention has been paid to teaching methods, needs assessment, an important part of the development of educational programs, generally is neglected. Another important aspect in educational program design is assessing effectiveness. The aims of this study were to design a formal needs assessment program to define the core contents of a faculty development program, and to determine whether participation in the faculty development program reinforced new teaching skills.Methods: A teacher-training program was designed at Shiraz University of Medical Sciences to help medical instructors boost their teaching skills. Needs assessment was done with nominal group technique followed by a 5-point Likert scale questionnaire. The program, imparted in workshop format, covered effective teaching methods, feedback, assessing knowledge and time management. Instruction was in the form of lectures, group discussions, case simulations, video presentations and role-plays. The program was evaluated in several phases using data triangulation and multi-item assessments of overall program quality in three major dimensions: Kirkpatrick program evaluation model, evaluation of the educational environment and qualitative analysis with open-ended questions. All participants in the study belonged to the academic staff of Shiraz University of Medical Sciences (n=396).Results: Seven main categories were derived from nominal group techniques and questionnaires. After the program, participants rated the quality of the program highly. They felt that the educational intervention was appropriate and had a positive impact on their knowledge of effective teaching methods, feedback, knowledge assessment and time management. Assessment of the effectiveness of the program showed that participants reported significant improvements in their teaching abilities.Conclusions: Our faculty development program  have a significant positive effect on medical university teaching staff members’ competencies. Further research is needed to investigate whether the faculty development program actually results in improved teaching performance. Faculty members of medical schools play a strategic role in the training and instruction of medical practitioners. Teachers are expected to address a wide variety of educational goals as they work with medical school students. Due to the complexity of effective teaching, medical teachers need to be able to deploy many teaching skills. Planned activities to enhance faculty members’ teaching, administrative and education research skills are known collectively as faculty development .In response to the need for better trained faculty members and with the aim of improving their teaching skills in Iran and the Eastern Mediterranean area, the World Health Organization (WHO) designed an international teacher training program in 1969. Eight centers were selected to train teachers in their own setting. In 1972, the Teacher Training Center at Shiraz University was established and selected as a regional teacher training center  developed a needs assessment procedure for use in designing a faculty development module. The faculty development program, which has been running since 2008, comprises a variety of educational methods. The present study aimed to define the process of needs assessment, implementation and evaluation of the effectiveness of the program with a triangulation design. Needs AssessmentThis study was prepared in three main stages during 2008: needs assessment, implementation and analysis. The first stage was begun by forming a panel of 20 experts in medical education, and using Nominal Group Technique  to deter1) definitely should not be included in the program;2) probably should not be included in the program;uncertain as to whether it should be included in the program;3)4) important and probably should be included in the program; 5) very important and definitely should be included in the program.All topics that obtained a mean score higher than 4 were selected for inclusion in the faculty development program.Implementation, awards for presenters, accommodations for invited lecturers and refreshments.In the second stage, announcements about the program were sent to different departments as posters, banners and information on the university website. Faculty members were also sent emails and sms about the program. To ensure quality, a well-equipped hall with audiovisual support was made available. A budget was considered for the program to cover printing costs, soft and hard copies of medical education journals A workshop format was used for most of the program. The flexibility provided by workshops can encourage skill acquisition in faculty development programs and prepare faculty members for new curricular contents , and can to help participants familiarize themselves with a new teaching environments .The Education Development Center of SUMS developed the workshops for academic staff as 1-month medical education programs, called the Medical Education Fellowship. The workshops were held four times per academic year. A core group of faculty provided half-day sessions on topics such as effective teaching skills, curriculum planning, evidence-based medicine, computer and statistical skills, leadership, faculty responsibilities, communication skills, professionalism, interprofessional education, evaluation and feedback, scientific writing, problem-based education, and educational scholarship. The methods of instruction used in the program consisted of lectures which were learner-centered and experiential, with small-group discussion and a problem-based approach. Group discussions were a part of almost every session. Furthermore, video presentations and role-play were used to help participants apply new contents. We tried to provide a friendly environment by creating opportunities for participants to enjoy refreshments and socialize. We offered one credit valid toward academic promotion opportunities for assistant and associate professors, and the program was free of charge. A total of 396 faculty member of SUMS from 2008 to 2012 took part in the workshops, of whom 221 (56%) were male and 175 (44%) were female. %52 of the participants were from clinical science faculties and 42% were from basic science faculties. Mean age of the participants was 39 years (range 29-62 years). Program Evaluation The program was evaluated in several phases using data triangulation and multi-item assessments of overall program quality in three major dimensions as described below. 1. First Dimension . The questionnaire had 10 items that were scored on a 5-point Likert scale (5 = excellent to 1 = very weak) that evaluated the quality of course organization, training materials, program and time management, attainment of course objectives, group interaction, quality of instructors’ presentation style, scientific content, communication with learners and use of educational technology. The questionnaires were distributed to participants at the end of each week.The impact of participation on teaching and professional abilities was assessed in three of the four outcome levels  defined by Kirkpatrick . To eval In the second level (K2), the effect of the program on participants’ learning was evaluated. The changes in participants’ knowledge were studied with 20-item instructor-administered tests in which each correct response was scored as 1. The tests were given before the training program began. The test instrument covered essential medical education topics taught during the program. The results of this evaluation were compared to those in a control group of faculty members who did not participate in the fellowship program.In the third level (K3), the participants’ behavioral changes were measured. For this purpose, participants’ teaching style as evaluated by their under- and postgraduate trainees  were compared before and after they attended the program with evaluation forms that were designed by the faculty evaluation unit. This evaluation is part of our medical school’s routine quality assurance procedures. Mean scores on this evaluation instrument were compared between participants and a control group.The fourth level (K4) involved evaluation of the program’s long-term impact on the learners’ career. This evaluation was not done because data collection proved to be complex, time-consuming and costly.2. Second Dimension The educational environment was investigated with a Dundee Ready Education Environment Measure (DREEM) questionnaire in which the items were tailored to the workshop presentations in Persian. The validity and reliability of this 43-item questionnaire were verified previously, and all items were scored on a scale from 0 (strongly disagree) to 4 (strongly agree) . The max3. Third Dimension The effect of the program on educational capacities was assessed from participants’ answers to 3 open-ended questions on their general views and feelings about the program, the educational environment, the teachers, and participants’ suggestions for the future. The evaluation methods and tools used are summarized in AnalysisTo analyze the K1 dimension, we used descriptive statistics (mean and standard deviation). If the mean of any item was more than 60% of the maximum score , this was considered to indicate an acceptable level of satisfaction. t-tests for paired samples were used to compare pretest and posttest results, and t-tests for independent samples were used to compare the results between participants and a control group. For K3, t-tests for paired samples were used to compare the mean scores from the evaluation forms before and after the program, and t-tests for independent samples were used to compare the results between participants and a control group. Analysis of the modified DREEM questionnaire was based on the mean score calculated for each of the five categories. The participants’ answers to open-ended questions were categorized by grouping similar comments for each question.For the second and third dimensions (K2 and K3), SPSS 14 software was used for the statistical analysis. The Kolmogorov-Smirnov test was used to verify normality of the data, and if the resulting p value was >0.05, we used parametric statistics. For K2, The study proposal was approved by the ethics committee of the Shiraz Education Development Center, and all participants completed an informed consent form. The names of the participants were masked throughout the study. The results of the needs assessment exercise are summarized in The examples of the some of the important sessions highlighting the key messages are the following:Bedside and ambulatory teaching: Subjects discussed in these sessions are: optimizing teaching at the bedside and in the ambulatory setting; teaching a multi-level group, e.g. students, interns, resident and fellows; We made video recordings of examples of good and immoral bedside and ambulatory teaching and asked faculties to role play good and bad bedside and ambulatory teaching in role play sessions.Presentation abilities and giving good lectures: The skills required for teaching in large groups and interactive lectures are covered in this session. A video sample of an effective lecturer is displayed and after that participants were asked to give a 10 min lecture on topic of their choice. Conversation on the presentations and feedback was done by tutors and participants.Evidence based medicine:In this module the importance of evidence in making decision, the format of a question, searching strategies, critical appraisal of different articles and decision making was discussed by tutors and was done practically by participants in small group session.Clinical reasoning skills:At the start of this session, a medical case with goat disease is used to demonstrate the hypothetico-deductive reasoning to reach a diagnosis. Emphasis is on how to involve learners in the analysis of clinical data rather than just recall. After that each of clinical reasoning tests was explained by tutors and a sample of a good clinical reasoning test was shown to participants.After needs assessment and implementation, fourteen groups of participants took part in the eight, 1-month programs at our center from 2008 to 2012. A total of 396 persons  attended the program. The results of the K1 analysis showed participants’ overall' satisfaction with the workshops was high .SD=Standard deviationWhen we compared pre- and posttest scores in the intervention group to assess changes in knowledge , we found a significant increase in participants’ cognitive knowledge . The mean posttest score increased significantly in the intervention group (p<0.001), which was evidence of the positive impact of the intervention. Comparison of the posttest scores in the intervention and control groups showed that the difference between groups was statistically significant (p<0.001). Our comparison of baseline characteristics between participants and nonparticipants detected no significant differences in the pretest scores between the control and intervention groups (p>0.05). To assess behavioral changes and the application of learning in the workplace (K3), we compared participants’ and nonparticipants’ ratings by their under- and postgraduate trainees before and after the program. A total of 2500 trainees rated 396 participants in the intervention group and 360 faculty members in the control group. There was no significant difference between the under- and postgraduate trainees’ evaluation of teaching effectiveness between the participant and control groups before the intervention (p=0.78). The mean rating for faculty members who participated in the program (18.76 out of 20) was significantly higher (p<0.001) than their rating before the course (17.68 out of 20). No such improvement was seen in the control group’s rating, indicating the positive impact of the program on teaching effectiveness Evaluation of the educational atmosphere with the DREEM questionnaire yielded a mean score of 156.51 (90.9%) out of a possible total of 172 across five educational subscales. This was evidence of the excellent educational climate during the program sessions. The mean score on the perception of learning subscale was 46.2±7.55 out of a maximum score of 48 (teaching highly thought of), and mean score on the course organizer subscale was 35.69±7.02 out of a maximum of 40 (model course organizer). For the perception of atmosphere, the mean score was 25.66±5.62 out of 32 . On the academic self-perception subscale, the mean score was 22.87±5.02 out of 24 (confident), and on the social self-perception subscale, the mean score was 23.23±4.88 out of 28 . The mean scores for each subscale are summarized in Our analysis of the participants’ responses to open-ended questions showed that most participants thought the overall course quality was good. According to most participants the program increased their motivation to acquire teaching and communication skills. Some of their free comments on the program’s strengths noted that there was good communication between them and the instructors, the program objectives were clear, and that group work and interactions were satisfactory. Some of them noted that they enjoyed of the program and appreciated the friendly climate. Academic vitality is dependent on faculty members’ expertise, and faculty development plays an important role in promoting academic excellence. However, faculty development programs needs to be systematic, and require coordination and planning, implementation and assessment, 13. InvNeeds assessment is vital before changes are undertaken in teaching content or educational strategies. In descriptions of adult education, Knowles assumed that adult learners desired to sense a need to learn, and identifying one’s personal learning requirements was an important part of self-directed learning . The preThe primary assumption of faculty development is that it will eventually serve the critical goals of medical education, i.e. improving patient and community care by educating qualified medical practitioners. The outcomes of faculty development are an important issue; despite several decades of reported success with faculty development programs, little has been published on their outcomes . The litOur assessment of the results for the K1 dimension showed that participants reported high satisfaction with both specific topics and the overall program. The results of a systematic review of 53 faculty development programs found that such programs resulted in high levels of satisfaction and changes in attitudes, knowledge, skills, and teacher behaviors .In the K2 dimension, the pretest and posttest results showed that there were significant increases in participants’ knowledge, and significant differences between the case and control groups. Gains in knowledge and skills were also reported in 53 other faculty development programs .In the K3 dimension, we obtained students’ evaluations of teachers before and after participation in our program, and compared both evaluations to those students provided for nonparticipants. The results were positive and showed statistically significant improvements in participants’ teaching and evaluation skills, but no such improvements in nonparticipants, as judged by under- and postgraduate trainees. This result is evidence of the positive impact of the program on teacher effectiveness. The educational environment of our program was rated favorably by participants in a modified DREEM questionnaire. This result suggests that careful preparation of the teaching sessions, appropriate feedback from instructors and the creation of a suitable environment can improve the quality of teacher training programs. The World Federation for Medical Education has indicated that the learning environment is one of the targets for the assessment of educational programs . The DREIn qualitative, open-ended questions the quality of our program was rated well by participants. A positive attitude, beliefs and motivations were, as noted above, areas of concern for our program managers. According to the education literature, motivation influences the learning process and outcomes . Our proBecause the work schedule of our participants changed during the training period, we faced challenges in ensuring faculty members’ participation, and this led to an element of resistance among some participants—an issue that should be addressed by the program managers. Some participants could not attend certain sections of the program and commented on specific items for inclusion in the program. In these cases we tried to accommodate their requests by organizing additional sections which could be implemented by small-group teaching. However, the most important aspect of managing these instances of minor resistance was our emphasis on motivating participants and using new educational techniques.According to all dimensions we evaluated, the program had a positive impact on teaching abilities. The results of the present study support the findings of previous studies that examined faculty development programs , 22, 23.Taken as a whole, our findings demonstrate that a faculty development program can improve teaching skills. The approach we used was informative, and aimed to determine course strengths and weaknesses as well as to develop practical recommendations for improvement.Study limitationsWe were unable to analyze the fourth level of effectiveness due to time and administrative constraints. Participants took part in the fellowship program voluntarily, but their motivation may have been influenced by the potential competing interest of credit gained toward academic promotion. This factor is sometimes considered an element that “obliges” faculty members to participate in workshops, although enrolment in the study was completely voluntary and none of the attendees refused to participate in the present analysis. Longitudinal and cohort studies are recommended to measure to long-term impact of faculty development programs. This study presents evidence of the efficacy and usefulness of a faculty development program designed to increase teachers’ knowledge of the principles and philosophy of education based on a well designed needs assessment process and careful implementation. We show that there was a statistically significant improvement in teaching effectiveness, with a positive, medium-term gain in skills as a result of our faculty development program. Nevertheless, retention of the new teaching skills acquired through the program decreased with time. Further studies are needed to determine whether booster programs might help faculty members maintain appropriate teaching skills in the medium and long term. Clearly, faculty development is an important aspect of medical education. We concur that faculty development will promote the professionalization of teaching and must be an essential aspect of every medical school; therefore it is our duty to design formal approaches to achieve our goals in this area.


To reproduce and report a bioinformatics analysis, it is important to be able to determine the environment in which a program was run. It can also be valuable when trying to debug why different executions are giving unexpectedly different results.Log::ProgramInfo is a Perl module that writes a log file at the termination of execution of the enclosing program, to document useful execution characteristics. This log file can be used to re-create the environment in order to reproduce an earlier execution. It can also be used to compare the environments of two executions to determine whether there were any differences that might affect (or explain) their operation.http://search.cpan.org/~boutroslb/Log-ProgramInfo/).The source is available on CPAN (Macdonald and Boutros, Log-ProgramInfo. Using Log::ProgramInfo in programs creating result data for publishable research, and including the Log::ProgramInfo output log as part of the publication of that research is a valuable method to assist others to duplicate the programming environment as a precursor to validating and/or extending that research. So, simply providing access to the code used is not a complete solution. It is necessary, but not sufficient.Reproducibility is a major concern in science as a whole, and computational biology in particular. For reproducibility, it is not sufficient to provide access to the raw data—it is ever more critical to also provide access to the program code used to analyse those data . But theThe need for reproducibility is growing because our pipelines are getting increasingly complex: a typical sequencing pipeline might involve a chain of a dozen unique tools . But repUnique identifiers and version numbers for programs and libraries;The values of parameters used to generate any given output; andThe names and version numbers of programs  used to generate those outputs.Among the best practices for scientific computing (e.g. ) is listA large fraction of pipelines for bioinformatics are written in the Perl programming language (e.g. BioPerl ). HoweveTo resolve this issue, we introduce here the module Log::ProgramInfo to facilitate run-time logging of Perl-based pipelines, thereby directly improving the reproducibility of modern bioinformatic analyses.A further advantage to such tracking information is the ability to test an analsis using later versions of the component tools to determine whether they provide different results .A search found some programs for related processes but nothing that served the same purposes.There are some programs available to collect and document the computing process - by recording the steps invoved, including command lines and arguments during the actual data processing. Such a program could work well together with the described module but addresses a different aspect of the reproducibility issue. In our lab, when the workflow of the data analysis was sufficiently complex to require such a description, we instead write a program to encapsulate that process, so there is no long list of manual processing steps to document.In particular, the program (ReproZip)  was capahttp://search.cpan.org/~boutroslb/Log-ProgramInfo/is available as open source, and has been distributed on CPAN .The Log::ProgramInfo module Macdonald and Boutros, Log-ProgramInfo. use statement. Since its effect is global to the program, it should be enabled directly from the main program, or from a utility module that contains global configuration settings for a suite of programs.Log::ProgramInfo is enabled simply by being included with a Perl Any desired setting of non-default values for the options can be provided either through environment variables, or as “import” list options.- An END block is created. It will be executed when the program terminates, to write out the log information.- Signal handlers are installed for catcheable signals - if one of them occurs, the log information will be printed out before the program terminates.- options are set to their default values- any env variables to control options are saved- a copy is made of the original command line arguments for eventual logging- the start time is recorded for eventual logging-... When the module is used for the first time, the loading process carries out a number of actions for its operation: after the initialization steps described above.)Every time the Log::ProgramInfo module is used, the import list is processed and any values in it are used to update the option values. . This allows changing the option settings for individual runs so that the log can be suppressed, enabled, or redirected for a single run of the program.The code that prints the log information ensures that it only executes once .If the main body of the program changes a signal handler after Log::ProgramInfo has set it up, that will usually not interfere with Log::ProgramInfo. Usually, the program will catch signals and handle them in a way that allows it continue to operate, or to terminate with an exception. It is only if the program resets a signal handler to its default  that Log::ProgramInfo’s log will not be written. That is not a problem for publication - if the program is being killed by some signal then it is not yet running successfully, and thus not yet ready for publication. However, it does mean that the log might not be available as a diagnostic aid in such situations.For most cases, that is the only interaction between the program and Log::ProgramInfo.The one additional interaction that might occur is if there is information unique to the program that is desired to be logged. The functionLog::ProgramInfo::add_extra_logger can be called by the program to specify a callable function that will write additional information to the log. (See the program documentation for precise details.)Parameters are available to control the logging process: whether  a log is to be written. Choosing the location where the log is written allows collecting and managing this important information in a way that co-ordinates with the entire set of computational activity carried out for a research project (or an entire organisation’s collection of research projects). The default name used for the log file includes the name of the program that is being reported upon as well as a time-stamp to distinguish separate runs—you might choose to override the name or directory path to provide more complete organisation of logged results. Suppressing log output can be useful for runs that are not intended to generate reproducible results, such as while the software is being developed. However, even in such cases, it might turn out to be useful to have this log output to assist diagnosing problems with system configuration changes—to confirm that the environment being used is the one that was intended and that updates have actually occurred, etc.There is an additional parameter that permits the logged information to be sent to a separate logging mechanism, such as a Log4Perl log. This would allow the information to be collected with the other logged information from the program. The output to such logs is mixed with the other logged output from the program, and is also usually reformatted to some extent. Such logs cannot be processed by the Log::ProgramInfo parser provided with the package; hence the normal action for Log::ProgramInfo is to still write its own log file as well.MODULE – Name, version, file location, and checksum for each perl library module used by the program.INC – The search path used to find modules.UNAME – Operating system information.PROCn – Specific information for each processor PERL – The perl interpretor pathname.PERLVer – The perl interpretor version.PERLSum – Checksum of the perl interpretor binary.libc – The version of libc used by the perl interpretor.libcSUM – Checksum of the libc library used by the perl interpretor.User – The user ID  running the program.Group – The group IDs  running the program.ProgDir – The directory containing the program.Program – The program name.Version – The program’s version.ProgSUM – Checksum of the program file.Args – The number and values of the command line arguments provided to the program.Start – The time the program started running.End – The time the program stopped running.Elapsed – The elapsed time while the program was running.EndStat – The program’s exit status.program-specified – Any additional info provided by program-specified callback functions.The output created by Log::ProgramInfo contains the following information: The format of the log file is designed to be easily parsed. A parsing subroutine is provided in the package. You could call that subroutine from a program that analyses logs according to your needs. See the program documentation for details. If you have written the log info using a logging module such as Log4Perl, you will have to separately extract the bare ProgramInfo log information out of that log, separating it from any other logging by the program, and removing any line decorations added by the log module.Here is an example of using Log::ProgramInfo. Assume a simple program, called simple.pl.When you run it, you get two lines of output.The first line is the expected output from the program, the second line comes from Log::ProgramInfo to tell you that a log file was created, and where.lines beginning with a plus sign are wrapped to fit the page widthlines wrapped in angle brackets describe text that has been omitted for brevityNow, take a look at the log file: Now that you have a log file, you still have to make use of it. Typically, you would treat this log file as one of the output files of your processing activities. So, if you normally discard the output files (e.g. for a test run while developing the pipeline), you will likely also discard the log. On the other hand, for significant runs, you would collect the log file along with the other output files, labelling and storing them as appropriate for reference. The log file would be available as a synopsis of how the output data was created, ready to be used for publication, or reproducing the process .The C environment is not well built for program introspection activities such as determining which static and/or dynamic libraries have been linked into the program’s executable image. This module lists the version of libc that was build into the perl binary - but that information can be out of date. A future release may try to get info about other libraries beyond libc.Another major problem is that even if a perl module is downloaded from CPAN (which would be one way of ensuring that other people could get the same version), the install process that puts it into the library path for perl programs can be done in may ways, and often is not even done on the same computer as the one that is running the perl program. So, it is not easy to do any sort of detailed validation - the downloaded package bundle is not accessible in any determinable way  to the program itself (and thus to Log::ProgramInfo). While it would be possible to compute checksums for every library module that has been loaded, that would take a significant amount of time and is not currently being done. It may be added as an option that could request it explicitly.Module Log::ProgramInfo provides a convenient way of logging information about the way a program is run. Adding it to existing programs is as easy as adding one line to the program or any module the program already includes.Log::ProgramInfo’s output file can be easily included in the published results along with the actual source code (or references to where it can be found). With this log output, other researchers have information necessary to any meaningful attempt to reproduce the original research, either in the process of validating or extending that research.Log::ProgramInfo is a good candidate for inclusion in modules intended to mandate standards, and may find use well beyond the field of bioinformatics.Project name: LogProgramInfoProject Home Page:http://search.cpan.org/search?query=Log%3A%3AProgramInfo&mode=allOperating System(s): Linux, Unix, Mac OS X (untested), Windows (untested)Programming Language: Perl 5Other Requirements: noneLicense: Perl 5 License (Artistic 1 & GPL 1)


Little is known about the frequency and locations in which emergency physicians (EPs) are bystanders to an accident or emergency; equally uncertain is which contents of an “emergency kit” may be useful during such events. The aim of this study was to describe the frequency and locations of Good Samaritan acts by EPs and also determine which emergency kit supplies and medications were most commonly used by Good Samaritans.We conducted an electronic survey among a convenience sample of EPs in Colorado.Respondents reported a median frequency of 2.0 Good Samaritan acts per five years of practice, with the most common locations being sports and entertainment events (25%), road traffic accidents (21%), and wilderness settings (19%). Of those who had acted as Good Samaritans, 86% reported that at least one supply would have been useful during the most recent event, and 66% reported at least one medication would have been useful. The most useful supplies were gloves (54%), dressings (34%), and a stethoscope (20%), while the most useful medications were oxygen (19%), intravenous fluids (17%), and epinephrine (14%).The majority of EPs can expect to provide Good Samaritan care during their careers and would be better prepared by carrying a kit with common supplies and medications where they are most likely to use them. Off-duty emergency physicians (EPs) may be called upon to provide care as bystanders to accidents and emergencies outside of the hospital.4Anecdotes of EPs providing care outside of their official roles can be heard from the break room to popular emergency medicine podcasts. With the exception of Good Samaritan events on airplanes and in schools, little is known about how often or in which locations these events occur.6Anticipating that most EPs will be bystanders to an emergency in their lifetime, several organizations worldwide have recommended carrying an emergency kit.Describe the (a) frequency and (b) locations of out-of-hospital emergencies in which EPs are called upon to provide Good Samaritan care.Determine which supplies and medications are most frequently useful to EPs during Good Samaritan acts.We emailed a link to an electronic survey to a convenience sample of board-certified and board-eligible EPs and pediatric EPs at five emergency departments along the Front Range of Colorado in April 2015. After obtaining written consent, the respondents were asked a total of eight multiple choice and fill-in-the-blank questions. Comments and anecdotes were welcomed at the end of the survey.Survey responses were aggregated in Microsoft Excel  and analyzed with simple descriptive statistics. The survey was approved by the Colorado Multiple Institutional Review Board.A total of 90 responses were returned from the 167 invitations sent (response rate: 54%). During their careers as EPs, 78% (n=70) reported having provided Good Samaritan care. The median reported number of Good Samaritan acts was 2.0 events per five years in practice (IQR 0.5 to 4.2). Several outliers reporting very high numbers of Good Samaritan acts were noted .The locations of Good Samaritan events are reported in Of the 70 respondents who reported previous experience as Good Samaritans, 86% (n=60) reported that at least one emergency kit supply would have been useful during their most recent Good Samaritan event, and 66% n=46) reported that at least one medication would have been useful. The utility of supplies and medications is reported in 6 reporteThe vast majority of surveyed EPs have performed Good Samaritan acts during their careers. Many of the respondents reported that at least one supply and one medication would have been useful. The high frequency of Good Samaritan acts and the reported utility of supplies and medications support the idea that EPs should be prepared in the event that they are bystanders to an accident or emergency.One strategy to improve preparedness would be to carry a kit with commonly used supplies and medications while in the locations where Good Samaritan events most frequently occur. In this way, keeping an emergency kit in one’s car—which is often within reach of the EP at the scene of road traffic accidents or sports and entertainment events—would maximize access to useful supplies and medications in times of need.This survey was limited by its retrospective nature. The reported frequency, locations, and utility of supplies and medications were all dependent on the EPs’ ability to recall events. Also, respondents eager to share their Good Samaritan experiences may have been more likely to complete the survey than those who did not have any experience. Validity outside of the state of Colorado would also need to be further assessed, especially regarding locations of Good Samaritan events.In analyzing several of the extreme outliers, comments left at the end of the survey suggest that these respondents included events that were outside of the scope of Good Samaritan acts defined in the survey . This likely over-reports the median frequency of Good Samaritan acts.Although commonly desired supplies and medications should influence the composition of an emergency kit, there are other factors that must be considered. Supplies geared toward airway protection  and bleeding control  may be infrequently used but have significant life-saving utility in certain circumstances. Cost, perishability, and environmental-specific factors should also influence emergency kit composition.The prepared emergency physician can expect to provide Good Samaritan care multiple times during a career. Many physicians report utility of supplies and medications during these events. Keeping this in mind, EPs may benefit from carrying a kit containing commonly used supplies and medications in situations where they are most likely to be called upon as Good Samaritans.


High attrition is a common problem for weight loss programs and directly affects program effectiveness. Since 2006, the Veterans Health Administration (VHA) has offered obesity treatment to its beneficiaries through the MOVE! Weight Management Program for Veterans (MOVE!). An early evaluation of this program showed that attrition rate was high. The present study examines how individual, facility, and program factors relate to retention for participants in the on-site MOVE! group program.Data for all visits to MOVE! group treatment sessions were extracted from the VHA outpatient database. Participants were classified into three groups by their frequency of visits to the group program during a six month period after enrollment: early dropouts (1 – 3 visits), late dropouts (4 – 5 visits), and completers (6 or more visits). A generalized ordered logit model was used to examine individual, facility, and program factors associated with retention.More than 60% of participants were early dropouts and 11% were late dropouts. Factors associated with retention were older age, presence of one or more comorbidities, higher body mass index at baseline, lack of co-payment requirement, geographic proximity to VA facility, addition of individual consultation to group treatment, greater program staffing, and regular, on-site physical activity programming. A non-completion rate of 74% for on-site group obesity treatment poses a major challenge to reducing the population prevalence of obesity within the VHA.Greater attention to individualized consultation, accessibility to the program, and facility factors including staffing and physical activity resources may improve retention. High attrition is a common problem for weight-loss programs ,2 and exThe Veterans Health Administration’s (VHA) nationwide MOVE! Weight Management Program represents a model system for population-level obesity management. General program guidelines align with the U.S. Preventive Services Task Force’s (USPSTF) directives which provide a Class B recommendation (fair evidence of benefit) for intensive or recurrent behavioral intervention for all obese adults . USPSTF 2) or overweight (BMI 25 – 30 kg/m2) if they have elevated waist circumference or with an obesity-related condition such as diabetes and hypertension. By 2008, nearly all VHA facilities (98.7%) offered MOVE! and more than 100,000 individuals had participated in MOVE!  = 1.32 – 1.55; ORlong-term = 1.53, 95% CI = 1.40 – 1.68). Those 75 years or older were at least 58% more likely to stay in the program .Compared to individuals with age < 55, those between ages 55–64 years were at least 43% more likely to stay in the program . Compared to overweight individuals, obese individuals were 22% more likely  and morbidly obese persons were 47% more likely  to remain in the program.For both short- and long-term retention, a greater geographic distance to the clinic was associated with lower retention. Compared to those living within 10 miles of the clinic, those who lived 10 or more miles away had a 25% lower likelihood of retention . Those who lived 20–30 miles away had a 34% lower likelihood of retention . Retention for those living more than 30 miles from the clinic was similar to those living 20–30 miles away.Offering individual consultation to group participants was uniformly associated with both short-term and long-term retention. Individual consultation was associated with increased retention regardless of when it was received. Compared to participants who did not receive it, those who received individual consultation on the same day or before starting MOVE! were 68% more likely  and those who received it after the index date were 72% more likely  to complete the program.Facilities that offered self-management support through visits or by telephone had only half the retention of those without it . Providing access to bariatric surgical services was not associated with short-term retention but was associated with 35% greater long-term retention .Compared to sites with low MOVE! staffing , sites with high staffing (7.61 or more FTEs) were almost twice as likely  to retain patients in the program.Among 10 common weight loss strategies we examined, only two were associated with retention. Regular on-site physical activity program was associated with 51% greater retention  and use of incentives/rewards was associated with 44% greater retention .Only one-fourth (26%) of all participants in the MOVE! group weight loss program attended six or more sessions during a six-month follow-up in 2008. More than 60% of all participants dropped out before the fourth session and 46% of the participants dropped out after attending just one treatment session.Although high attrition is a common problem for weight management programs, MOVE! attrition rates appear to be higher than most. Tsai and Wadden  reportedBecause high attrition diminishes the effectiveness of weight management programs ,3-6, ourPrevious research on factors that affect attrition from weight loss treatment is limited. Honas et al. 2003) examined data from a single medical weight management program and found that female sex, divorced status, African American race, and ages <50 were associated with higher attrition  or used 003 examiOur results were largely consistent with previous findings, except for marital status and comorbid depression which showed no significant association with attrition in our study (data not shown). Noticeably absent from the literature is information about how variations in accessibility, program features, and provider characteristics affect attrition. This is the first study to examine facility, program, and patient characteristics conjointly as potential factors affecting attrition in medical weight management programs.A recent study of MOVE! best practices at 22 sites  identifiOur results have several national and local policy implications. Geographic access is often a barrier to retention when MOVE! groups are held on-site. Electronic or telephone delivery of treatment offers potential solutions. Research on the effectiveness of Internet intervention has shown mixed results ,25-28 buOur findings suggest that more extensive use of individual consultation with specialists is warranted as an adjunct to group treatment early in the MOVE! program. Although we still do not clearly understand the extent to which effective obesity intervention requires in-person contact , our results as well as the “best practices” evaluation study  highlighOf the program factors we examined, regular on-site physical activity was the only strategy associated with increased retention. Currently, many sites do not have adequate resources for providing regular physical activity. According to the NCP Annual Report, 67% of facilities reported that indoor physical activities were barely or not at all sufficient for MOVE! program needs and 37% reported that outdoor physical activity facilities were insufficient.Based on these results, we suggest that the VHA consider adopting a measure of MOVE! treatment retention as a facility performance or quality indicator. Current MOVE!-related measures focus on screening for obesity and participation in at least one treatment visit, but they do not recognize or reward facilities for better retention. In 2011, the VHA introduced retention as a pilot indicator of site performance. Future research should examine the effect of this indicator on attrition and, ultimately, on patient weight loss.Major strengths of our study were its large sample and simultaneous modeling of individual, facility, and program characteristics associated with retention in an evidence-based group obesity treatment program. A limitation is that data for facility and program characteristics were drawn from the NCP Annual Report that is primarily used to monitor accountability within the healthcare system. This required report is completed by each facility’s MOVE! coordinator, and the fidelity with which facilities implemented each program strategy has not been validated. Also, because our study design was observational, causal inferences cannot be drawn.We found a number of individual, facility, and program characteristics to be associated with retention in the MOVE! group treatment program. Individual attributes such as older age, more comorbidities, and higher BMI were associated with greater retention, whereas male sex, non-Hispanic black race, and living a greater distance from the MOVE! facility were associated with lower retention. Facility factors including offering of individual consultation and more MOVE! staff per participant were associated with higher retention. Among the program characteristics we examined, holding a regular on-site physical activity sessions and offering incentives/rewards were associated with higher retention.Recognizing that certain characteristics place patients at heightened risk for drop-out may help in identifying those who need targeted outreach to retain them in treatment. Optimal targeted retention strategies for at risk demographic groups still need to be developed, as do those more personally tailored for individuals. As an example of targeting, offering TeleMOVE! or telephone treatment to those who live at a greater distance from the treatment facility might prove warranted. The findings also suggest that to the extent possible given a facility’s resource constraints, optimizing facility level factors so as to offer individual consultation and a higher provider to patient staffing ratio may help foster retention. At the level of staff decisions about obesity program design, investment in onsite exercise programming and incorporation of incentives into program design warrant additional study as ways to improve retention.Although greater attention to these factors may help improve treatment retention and weight loss outcomes, a non-completion rate of 74% for in-person group obesity treatment poses a major challenge to reducing the population prevalence of obesity within the VHA. In the future, supplementing the VA’s in-person group treatment with connective technology offers hope for improved weight loss . Purely VHA: Veterans Health Administration; USPSTF: United States Preventive Services Task Force; NIH: National Institutes of Health; ADUSH: Assistant Deputy Under Secretary of Health; NCP: VA National Center for Health Promotion and Disease Prevention; BMI: Body Mass Index; CDW: Corporate Data Warehouse.The authors declare that they have no competing interests.BS, MS, SL, SH, LK and FW participated in the conception and design of the study, critical review of the manuscript, and interpretation of results; MS acquired the data and conducted statistical analysis; MS and SL drafted the manuscript; All authors approved the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/14/363/prepub


Given the increasing emphasis on the community management of spinal cord injury (SCI), strategies that could be developed and implemented in order to empower and engage individuals with SCI in promoting their health and minimizing the risk of health conditions are required. A self-management program could be one approach to address these complex needs, including secondary complications. Thus, the objective of this study was to determine the importance attributed to the components of a self-management program by individuals with traumatic SCI and explore their views/opinions about the delivery of such a program.Individuals with SCI were recruited by email via the Rick Hansen Institute  as well as an outpatient hospital spinal clinic. Data were collected by self-report using an on-line survey.n= 53; 53.5%), nutrition , pain management , information/education on aging with a SCI , communicating with health care professionals , problem solving , transitioning from rehabilitation to the community , and confidence . Overall, 74.7% (n= 74) of the sample rated the overall importance of the development of a self-management program for individuals with traumatic SCI as “very important” or “important”. Almost 40% (n= 39) of the sample indicated that an internet-based self-management program would be the best delivery format. The highest proportion of participants indicated that the program should have individuals of a similar level of injury ; having individuals of a similar age  was also noted. Over one-quarter of the sample (n= 24) had a depression score consistent with significant symptoms of depression.The final sample size was 99 individuals with traumatic SCI. The components of a self-management program that were rated as “very important” by the greatest proportion of participants included: exercise  contains supplementary material, which is available to authorized users. The trend of decreasing length of stay in rehabilitation facilities has led to individuals with spinal cord injury (SCI) entering the community with fewer self-care skills to prevent secondary complications ,2. FamilHirsche and colleagues  conducteA national, cross-sectional study was conducted including individuals with traumatic SCI living in the community in Canada. Research ethics approval was obtained from the University of Toronto (Protocol Reference #26429). All participants provided informed consent prior to completing the survey.Eligible participants included individuals who 1) had experienced a traumatic SCI ; 2) were 18 years of age or older; and, 3) were fluent in English. Participants were recruited by email via the Rick Hansen Institute (RHI) and included individuals who had agreed to be contacted for research purposes. RHI is a Canadian-based not-for-profit organization “committed to accelerating the translation of discoveries and best practices into improved treatments for people with SCI” . AdditioData were collected by self-report surveys using on-line software, FluidSurveys®. The complete survey is included in Additional file Participants were asked to rate the importance of various content modules as well as the overall importance of a self-management program for individuals with traumatic SCI on a Likert-type scale with five response options . These modules were based on the themes from our previous, qualitative research on the perceived facilitators and barriers to and meaning of self-management in traumatic SCI  ; as welStandardized questionnaires were also used to capture the qualitative themes generated from the first phase of the study  as wellThe HADS is a brief, self-report measure that was designed to detect the presence and severity of relatively mild degrees of mood disorder in non-psychiatric, hospital outpatients. It provides separate scores for anxiety and depression. The HADS has 14 items (seven for anxiety and seven for depression) and has established validity and reliability  . Scores The PAM is designed to assess an individual’s knowledge, skill, and confidence in managing his or her own health care ,18. The The MSES was developed to measure an individual’s confidence in performing functional, social, leisure, and vocational activities post-SCI. Participants rate their confidence in their ability to complete the 16 tasks on a seven-point Likert scale . The total scale score is obtained by summing the individual item responses and range from 16 to 112. Higher scores indicate higher perceived self-efficacy. Results have confirmed that the MSES is a valid instrument that is sensitive to real-life changes post-SCI .The PMS measures global sense of personal control. It consists of seven items and participants respond to a five-point Likert scale about the extent to which they agree (5= strongly agree) or disagree (1= strongly disagree) with the various statements. A PMS score ranges from 7 to 35, with a higher score reflecting greater mastery .In addition, socio-demographic and injury-related variables were documented including age, sex, marital status, level of education, level of injury, and time since injury. Multiple iterations of the survey instrument were produced and reviewed by the research team for flow and content.t-test and Chi-Square test, or Mann–Whitney U-test. This was to determine whether the “completion” group was representative of the larger group of eligible individuals identified for the study. The importance of the various content modules of a self-management program, the views related to the delivery, format, construction of program components, follow-up periods, program leader(s), program organizer(s), as well as the overall importance of developing a self-management program have been reported as proportions. To assess how these ratings might relate to the duration of the SCI  Chi-Square tests were conducted. Statistics were calculated using the Statistical Package for the Social Sciences software . Wellness/health promotion interventions  are resources that allow the individual to choose behaviours to enhance and sustain quality of life within the context of living with a chronic disabling condition , and thuApproximately 40% of the current sample indicated that a module on increasing confidence was “extremely important”, a finding which is consistent with the importance/centrality of self-efficacy in the CDSMP ,10. We aA module on “information/education on aging with a SCI” was also rated as an important module. As progress in health care and rehabilitation treatment has improved, individuals with more complex needs, including chronic conditions such as diabetes and heart disease, are surviving . Indeed,The greatest proportion of participants thought that an internet-based self-management program would be best. Internet-based applications/tools are recognized as having the potential to overcome barriers to self-management skills including cost and access  . We prevAlmost one third of participants thought that a one-on-one format  would be best, which may reflect a need/desire for more intensive/individualized support given the potential physical  and emotional complexities of living with a SCI. At the same time, group programs include the benefit of peer support and opportunities for interaction . Almost The current study acknowledges some limitations, especially with respect to the generalizability of our study findings. Although the sampling frame was national, the resulting sample was small and may not be representative of the population of people with traumatic SCI in Canada. Thus, it is likely that it was not representative of the broader group of individuals with traumatic SCI. Instead the current sample likely represented a more engaged and healthier group of individuals with traumatic SCI . The generalizability of the study findings to individuals with non-traumatic SCI is unknown, although the study findings may be limited to individuals with traumatic SCI as individuals with non-traumatic SCI tend to be older and include more females . Thus, tThe current study is, to the best of our knowledge, the first of its kind, in Canada or elsewhere, to determine the importance attributed to components of a self-management program by individuals with traumatic SCI. Many of the modules of a self-management program that were rated as important were existing modules of the CDSMP. At the same time, the importance assigned to the modules on exercise and nutrition is in line with our previous, qualitative research and a wellness/health promotion approach for self-management in this population e.g., . Various