The total estimated cost reduction of absenteeism is 427,896€ over a year. ROI was equal to 27.66€. BEA indicated that the break-even point was reached by implementing the program on 3.27 HCWs. The program evaluation demonstrated the particular effectiveness of the implemented WDMP model, acting positively on the variables that affect productivity and the limitation to work.The progressive ageing of the working population and the increase in related chronic diseases tend to affect working capacity. The aim of this study was to evaluate a Workplace Disability Management Program (WDMP) within a pediatric hospital. Absenteeism due to healthcare workers’ (HCWs) pre- and post- WDMP and the related costs were used for the program evaluation. The Return on Investment (ROI), the Break-Even Analysis (BEA) and the value of the average annual productivity of HCWs who took advantage of the Disability Management (DM) interventions to assess the economic impact of the program, were also used. The HCWs enrolled in the program were 131 , of which 89.7% females and with an average age of 50.4 years (SD ± 8.99). Sick leave days of the HCWs involved decreased by 66.6% in the year following the end of WDMP compared to the previous one ( The progressive ageing of the population and the increase in related chronic diseases tend to affect healthcare workers’ (HCWs) levels of autonomy and working capacity ,2,3,4,5.In relation to this scenario worldwide, for about 40 years, Workplace Disability Management Program (WDMP) models have been developed with the aim of matching the productive interests of the company with the needs of disabled or sick workers to find a job that satisfies them, not only in economic terms but also on a human and social level . WDMPs iWDMP, in fact, has been established for the multidisciplinary management of the needs of HCWs suffering from mental or physical disabilities. Disability Management (DM) intervention was defined as a systematic and constructive method to ensure job-retention and job-reintegration in competitive employment for individuals with (temporary) disabilities . ThroughThe term DM refers to a model theorized in the 1980s, initially developed in North America and Europe ,14,15,16Currently, several companies all over the world apply WDMP programs with a high variability of methods difficult to reconduct to useful models for drawing-up operational protocols based on efficacy evidence ,31,32,33Conversely, in North America, the following is privileged: evaluation of the investors’ role in DM programs ,47,48,49In recent years, several systematic reviews ,31,32,33This pilot study aims at evaluating the effectiveness of a WDMP implemented since 2017 within an Italian pediatric hospital.Internal reorganization of work duties, keeping destination and job assignment unchanged.Proposal to the company management for environmental, ergonomic, structural and technological improvement measures.Paths of psychological support and/or health promotion interventions.Change of working destination or, ultimately, change of job.In 2017, the hospital management started a WDMP program as part of the three-year strategic plan of the company’s Workplace Health Promotion (WHP). The program aimed at reducing the impact of a possible disability  on the individual’s working capacity. In this context, the distribution of work restrictions by risk factor highlights how the main causes are the ergonomic factors and the organizational risks, on which the main preventive actions have been focused. In fact, the improvement actions have concentrated on limiting the risk from biomechanical overload/manual patient movement (MPM) and on the activities necessary for the organizational well-being. Furthermore, in 2011 an ad hoc Working Group (WG) was set-up with the aim of managing of the so-called “difficult suitability,” thus replacing the cases with limitation and, at the same time, identifying the “full” suitability for the assigned task. The WG, coordinated by the Head of Occupational Medicine, is constituted by competent physicians, members of Human Resources (HR) Department and Health Directorate; it meets periodically on a monthly basis. There are three main reasons for entering the HCWs in the program: intra or extra work psychological distress ; musculoskeletal disorders; other pathologies, especially neoplastic diseases. These are the main reasons that impact on the work capacity of the HCW who very often manifests discomfort, an altered health condition and/or is often absent from work. The paths that are proposed by the WG are personalized and mainly concern four types of intervention:The assessment of each case is carried out during the WG meetings and the decisions on the adequate intervention to be implemented or changed along the way are discussed and agreed with the HCW and his/her supervisors. The path can last several months, on average. It is closed when the criticalities detected at the entrance have found the appropriate solution. The various steps of the path are ratified within the monthly WG meetings.The supervisors and staff responsible of the wards and departments were involved in all the phases of the program from the evaluation of the case to the decision regarding the objective of the personal program of the HCWs and, necessarily in the phase of the modification effort and personal support to the HCW.A retrospective observational study was conducted on a set of objective and economic indicators on the casuistry of HCWs included in the WDMP between July 2017 and December 2019. The data used for the survey were taken from the monthly reports of the WG meetings. The development of a database allowed to trace the path of all the HCWs included in the WDMP. As an indicator of the program efficacy, we measured illness-related absences recorded during six months and one year before, six months and one year after participation in the WDMP in order to define an objective assessment of the path according to the criteria used in WDMP evaluation studies ,29,30,81The study was carried out in a large research pediatric hospital with more than 600 settled-bed, located in Rome, Italy, accredited since 2007 by the International Joint Commission. The hospital is regarded as the reference pediatric hospital in central and southern Italy. The total number of ward admissions in 2019 was 29,432. Additionally, more than one million and a half clinical procedures were performed in the outpatient clinics. Finally, about 89,000 patients were admitted to the Emergency and First Aid Department. In the hospital HCWs are about 3300 with a large prevalence of nurses and females. During the period considered, those with problems of internal or external psychological pathologies connected with work related stress, musculoskeletal pathologies or other diseases at risk for limitations and/or disabilities were included in the WDMP.The participation in the program is voluntary and starts from the request of the HCW or after the proposal of the occupational physician who can recognize the eligibility of the HCW for the program. The percentage of refusals to undertake the program, as well as the percentage of abandonments, is very low (1–2%), because the enrolment process takes place through a very accurate evaluation phase carried out with the participation of the HCW concerned and his/her supervisors.In order to evaluate the costs associated with the days of absence, using the information provided by the hospital’s HR Department, the average cost of the working day was calculated to define the direct costs of the day of absence of each HCW, which is equal to 169.80 Euros. By multiplying the average cost of the day of absence by the number of days saved after six months and one year from the end of the program, the total savings determined by obtained with the program have been defined. The economic evaluation of the one-year total absenteeism savings was also used for the definition of ROI  as grossAs impact measurement of the WDMP economic effectiveness, the value connected to the productivity recovery of HCWs who undertook the WDMP process, defined in terms of average per-capita annual productivity, was also evaluated. For this computation, on the basis of the calculation of the annual average value of the per-capita productivity at national level according to ISTAT methodology , the aveSocio-demographic and work-related variables related to the study population ;Management variables related to the program carried out , of which 89.7% women, with an average age of 50.4 years (SD ± 8.99) and an average working seniority of 25.3 years (SD ± 12.09) . The totWork and extra-work discomfort, mainly of a psychological nature, linked to conditions of work-related stress (29.8% of cases);Musculoskeletal pathology due to biomechanical overload in personnel exposed to the risk of MPM (35.1%);Other problems related to the presence of serious pathologies, especially neoplasms (35.1%).In accordance with the case studies relative to occupational disease complaints, the ones examined concerned three categories:Internal reorganization of work duties, keeping destination and job assignment unchanged (tool: interviews with personnel responsible for the area in order to relieve HCWs from activities too heavy for their pathology): 31.7%Proposal to the company management for environmental, ergonomic, structural and technological improvement measures: 24%Paths of psychological support and/or health promotion interventions: 16.4%Change of working destination or, ultimately, change of job: 27.9%.The type of interventions implemented for the HCWs involved was:A first evaluation of the program effectiveness was carried out by verifying the number of job limitations registered among the hospital HCWs from the systematic monitoring of health surveillance data collected between 2017 and 2019 after the WDMP introduction. The job limitations are lower (5.5% of personnel) compared to the national benchmark relative to healthcare facilities (11.8%).p < 0.001) in the 6 months following the final date of WDMP compared to the 6 months preceding the start of the program  and 66.6% in the course of a subsequent year (p < 0.001) . The estimated savings associated with the reduction of sick leave absence due to the WDMP are a total of 324,657.60€ over the six months following the conclusion of WDMP and 427,896€ over a year with a per-capita saving of 2898.73€ at 6 months and 4975.53€ at one year , the days of illness-related absences decreased by 73.3%  and one-year rate from 41.5 days to 14.6 days . These data compared with the company absenteeism rate calculated for the same time frame  and the same periods of time  show after WDMP an absenteeism rate slightly higher than average company rates .males (−79.3%)older age group 51–65 (−71.5%)technicians (−88.3%)belonging to the Specialist Pediatrics Department (−89.5%)affected by chronic-degenerative diseases (−79.6%)recipients of DM interventions that have foreseen the internal reorganization of the work tasks, keeping destination and work task unchanged combined with environmental, ergonomic, structural and technological improvement measures (−98.3%)The stratification of absenteeism for the variables considered in the study shows a higher reduction of absences after participation in the WDMP of HCWs subdivided into the following categories:The investment cost calculated on the total working hours of the company WG described in the Methods, On the basis of the investment cost and gross profit obtained by calculating the savings generated by the reduction in days of absence after 1 year from the conclusion of WDMP, a ROI of 27.66€ was calculated for each euro invested. As for BEA, the break-even point is reached by implementing the program at 3.27 HCWs .The recovery value in terms of average per-capita annual productivity of the 84 HCWs who completed the WDMP is 12,183.89€ for a total value of recovered productivity for the hospital of 1,023,446.26€ . AssuminThe study has allowed to insert the hospital WDMP among the programs reported in literature that provide for interventions centered on a preventive approach, management of disabilities and permanence at work of HCWs both with limitations (SAW) and on RTW. The case studies examined  confirms a higher impact of musculoskeletal problematic conditions and connected to other pathologies, especially neoplastic, in a working population with a high average age and mainly characterized by female subjects and with a qualification as nurse. The study records also the importance of the management and prevention of psychological discomforts of HCWs determined by work related stress in a healthcare setting. The program impact highlights its effectiveness in terms of a statistically significant reduction in illness-related absences and work limitations compared to the company and national data.The economic evaluation of the program, not so frequently reported in the literature on the evaluation of similar programs ,22,80,81The significant amount of the detected recovery in productivity appears to be connected to the high competence and value of the workforce of a health reality, represented in the study by the higher annual average per-capita gross productivity of the hospital compared to the parameters provided by Istituto Nazionale di Statistica (ISTAT) on a national basis . The valThis survey confirms and broadens the studies published in literature, especially in recent systematic reviews, on the classification of WDMP models and their evaluation of efficacy, mainly in terms of proactive case management, changes of workplace or equipment, work design and organization, work environment, stakeholder communication ,12,13,16The program is in fact included in a network of structured services and interventions within the hospital organization as part of a multi-year WHP plan, governed by a set of WGs interconnected and collaborating with each other with the objective of guaranteeing and promoting interventions for the health and well-being of HCWs, who have showed the particular convenience of the adopted prevention strategies ,92,93,94Compared to this proactive approach to early identification and as much as possible based on the prevention of the condition of disability and removal from work, it is evident that a late approach, such as the one activated exclusively by reporting long periods of absence and activation of RTW, does not allow any risk prevention and minimization intervention. Moreover, very often the programs in literature defined as preventive, in practice are applied during illness-related absences and not in the previous phase ,49,51,52In this first experience, a top-down approach was preferred for some advantages  that this type of approach may ensure. However, the authors are aware of the usefulness of a participatory, bottom-up approach, which may help to collect and analyze the contribution of workers and can help achieve more stable results over time ,96,97. AA specific strength of the study is that it has been conducted in a health facility where rarely similar analyses had been conducted. This study presents a few limitations related to some conditions not measured in the analysis conducted. Mainly, the impossibility of referring to the measurement, as recommended in literature, although there are few studies that report data first on job satisfaction of WCWS’ after being included in the WDMP and of the service manager, as well as measurement of physical and mental health indicators before and after the intervention.Only a part of the workers who were the subject of this analysis could be studied with questionnaires that measure quality of life and psychological well-being [ and the Goldberg’s General Health Questionnaire (GHQ12)] at the beginning and end of the observation period, that showed a very significant improvement of their general health and quality of life. A desirable development of this study may consider an analysis of the variations of these health parameters and their association with treatment.Beyond the indirect measurement of these conditions connected to the conclusion of the path proposed by the WG and approved by the HCW, measurement of subjective parameters of health and working well-being and connected to job satisfaction, can be implemented within the analyzed WDMP to verify, also from a subjective point of view, the positive conclusion of the path.Moreover, this study was a retrospective analysis of records from a company-sponsored proprietary program to improve RTW rates and this may undoubtedly bias the results. Furthermore, for ethical reasons the offer of disability program has been extended to all the workers of the company and this prevents having a control group. However, the favorable results obtained in the area of disability management provide a reasonable starting point for extending the experience to other companies; in particular, the collaboration of the doctors of the Catholic University and the Gemelli Polyclinic will allow the realization of multicentric studies in the future, which will be able to overcome the problems present in this experience and will provide a non-randomized analysis of pre- and post-outcomes.The evaluation of the program carried out through this study seems to demonstrate the effectiveness of the implemented WDMP model, acting positively on the variables that influence productivity  and allowing to restrict limitations within the hospital.The originality of our study consists in the use and connection of different methods of analysis for the evaluation of the program effectiveness and efficiency. The analysis connects, in fact, through the use of two objectives indicators (absenteeism and limitations) with a complex economic analysis conducted through the use of several parameters  used separately in other studies reported in the literature.The study contributes to deepen the knowledge on the importance of implementing an integrated WDMP in a specific structure, such as a hospital, where health promotion and wellbeing of HCWs constitute a critical issue. The study mainly aims at demonstrating the program effectiveness in terms of reduction of absenteeism and limitations of the hospital personnel and the efficiency of the investment defining the power of the experience. Moreover, the definition of return to productivity of the HCWs involved represents the added value of the study, providing the right dimension of the power of such a preventive approach to disability and aging of the working population.The experience carried out over the years within the hospital will lead to the development of a protocol, structured according to the WDMP model, with the management’s consent as a “company good practice.” Redefinition and recoding of the key steps of the DM process and evaluation of the results achieved, also through the analysis of key indicators, such as pre-post-illness-related absences, is contributing to the implementation of the model. This will allow a review of the WDMP model to be proposed within the Italian healthcare organizations. A further development of the protocol should include the possible introduction of the professional profile of the Disability Manager as responsible for the entire program.In future multicenter investigations, a qualitative analysis may be included, seeking to understand the reasons, arguments and attitudes relevant to understanding the factors that facilitate productivity, health and well-being of employees.


Background: Extracorporeal membrane oxygenation (ECMO) is a complex life-saving support for acute cardio-respiratory failure, unresponsive to medical treatment. Starting a new ECMO program requires synergizing different aspects of organizational infrastructures and appropriate extensive training of core team members to deliver the care successfully and safely.Objectives: To describe the process of establishing a new neonatal ECMO program and to evaluate the program by benchmarking the ECMO respiratory outcomes and mechanical complications to the well-established Extracorporeal Life Support Organization (ELSO) registry data.Materials and Methods: We reviewed the processes and steps involved in planning and setting up the new ECMO program. To assess the success of the ECMO implementation program, we retrospectively reviewed data of clinical outcomes and technical complications for the first 11 patients who have received ECMO therapy for respiratory indications since program activation (July 2018–May 2020). We analyzed mechanical complications as a tool to measure infrastructures and our effective training for the core team of ECMO specialists. We also looked at all clinical complications and benchmarked these numbers with the last 10 years of ELSO registry data (2009–2019) in the corresponding categories for comparison. Chi-square test was used to compare, and outcomes are presented in percentage; a p-value of <0.05 is considered significant.Results: A total of 27 patients underwent ECMO in the hospital, out of which 11  patients had acute respiratory failure treated with venovenous (VV) ECMO or veno-arterial (VA) ECMO over a 22-month period. We had a total of 3,360 h of ECMO run with a range from 1 day to 7 weeks on ECMO. Clinical outcomes and mechanical complications are comparable to ELSO registry data (no significant difference); there were no pump failure, oxygenator failure, or pump clots.Conclusions: Establishing the ECMO program involved a multisystem approach with particular attention to the training of ECMO team members. The unified protocols, equipment, and multistep ECMO team training increased staff knowledge, technical skills, and teamwork, allowing the successful development of a neonatal respiratory ECMO program with minimal mechanical complications during ECMO runs, showing a comparable patient flow and mechanical complications. Extracorporeal life support (ECLS) or extracorporeal membrane oxygenation (ECMO) is a modern rescue modality used to support critically sick newborn infants with cardiorespiratory dysfunction when conventional therapies have failed . The ExtSidra Medicine (Sidra) hospital is built to be a beacon of learning, innovation, and exceptional care. This new hospital is built to be one of the finest and most technologically advanced hospitals in the world. Sidra is also part of a dynamic research and education environment in Qatar, and through strong partnerships with leading institutions around the world, Sidra is creating an intellectual ecosystem to help advance scientific discovery through investment in medical research.P < 0.001) in Qatar's neonatal mortality rate from 26.27/1,000 in 1974 to 4.4/1,000 in 2008  following cardiac surgery. There was a huge need for this program in Qatar and the region. The ECMO program was built in Sidra medicine with rigorous planning and execution over 1 year 2017–2018) and was activated in June 2018. Setting up a new sophisticated technology into the new clinical environment was a challenging process, especially when used in high-intensity settings and high-risk situations, and the potential risks are magnified. This process of establishing a new ECMO program involved tremendous effort and faced many challenges as it was developed over a completely new Greenfield site hospital , pediatric ICU ECMO physicians, perfusion, and ECMO nurses. Other allied health, pharmacy, radiology, blood bank, laboratory, and different pediatrics subspecialties were also required for the ECMO services as well as key individuals from the hospital administration to support the ongoing efforts. The ECMO program steering committee mission is to enhance the science of pediatric and adult critical care while providing advanced care to patients. There was a Medical ECMO Director as well as an ECMO coordinator who directed these efforts.The scope of practice of the ECMO program steering committee included the following:The needs assessment to define the scope and role of the program at Sidra and within Qatar and the Middle East region, as well as identifying the patient population and the demand for the service, both immediate and in the future.Evaluation of necessary equipment and consumables.Identifying issues, addressing risks, and coordinating activities and timelines as well as operational planning needed for initiation of the clinical operations of the ECMO Service.Developing, implementing, and evaluating protocols, formalizing policies, and procedures in collaboration between its members, to facilitate evidence-based practices.Developing a multidisciplinary team to deliver, in a collaborative effort, the best family-centered patient care.Setting up and maintaining of ECMO to critically ill patients at Sidra Medicine within its vision for world-class service.The scopes of practice also included the setup and maintenance of Continuous Renal Replacement Therapy (CRRT) via the ECMO circuit at Sidra Medicine.Developing a robust advanced training and educational center for ECMO for not only the region but also internationally.Ensuring that patient statistics will be reported to the ELSO and compared to other international ECMO programs for benchmarking and improving quality.An essential step before setting up a new program was to assess its need and viability, which depends on the appropriate patient population, identifiable both clinically and geographically. The United Kingdom (UK) Collaborative ECMO Trial Group provided rigorous evidence of the cost-effectiveness of neonatal ECMO at 4 years for mature infants with severe but potentially reversible respiratory failure . As of JTo measure the demand and need for this service locally, we reviewed the healthcare records and data from the existing neonatal ICU  in the country. There are 26,000 deliveries per year in Qatar. We looked at newborn infants who were admitted to the NICU who met the criteria to undergo ECMO therapy. The average number per year was identified to be between 12 and 16 per year. Of those, there was 8–10 severe diaphragmatic hernia per year, which required high-frequency oscillation and nitric oxide therapy. These cases in the past only have conventional treatment available and had a very high mortality rate, more than 80%.ex-utero intrapartum treatment (EXIT) procedures  in the NICU, PICU, and CICU.ECMO-trained physicians and surgeons formed a core group of ECMO program along with the bedside treating team of intensive care physicians . The team had a working knowledge and understanding of ECMO support and the technical ability for emergency troubleshooting and circuit intervention.It was envisaged that policies, procedures, as well as clinical guidelines will be synchronized between all critical care units at Sidra Medicine. This will enable patients to receive the same level of service and evaluated by the same protocols and standards, irrespective of the physical location of their care.ECMO “Specialist” is the technical specialist with strong critical care background trained to manage the ECMO equipment and also the clinical needs of the patient on ECMO under the direction and supervision of an ECMO-trained physician , 20. TheThe ECMO specialist-based model is shown in SIDRA recruited physicians and nurses with prior ECMO training from their previous workplace; however, among the team members, experience varied, and there was a need to build up a bigger team. To become clinically proficient, a comprehensive ECMO educational curriculum was developed to train subspecialty physicians, nurses, perfusionists, and RTs with minimal to no prior pediatric ECLS experience. The focus of this training was to provide an opportunity for dedicated practice of individual skills and separately to build and improve performance across multiple domains of expertise. Twenty ICU nurses from CICU/NICU and 10 RTs were chosen to undergo training. Of the 20 ICU nurses, 15 were novices and 5 had variable experience. Ten RTs had ECMO experience that varied from novice to advance. Neonatologists without much prior ECMO experience were trained gradually to be part of an ECMO team managed and led by a neonatologist with good prior ECMO experience. Both neonatal and cardiac ICU teams were trained simultaneously in the same training schedule; however, neonatal respiratory ECMO patients were decided to be managed separately in the neonatal ICU, necessitating establishment of a separate team.Once the equipment was procured, intense training sessions for a week by the ELSO team were followed by a 3-day Sophia Children's Hospital, Rotterdam visit to see Xenios machines in action to learn practical challenges. This hospital was established in 1863, and their ECMO program was commenced in 1996 so the services and teams were extremely experienced. Their protocols and workflows were reviewed, and troubleshooting was discussed. Moreover, the Xenios 3-day workshop from Germany was conducted for team training.For new ECMO programs to achieve the designation as an ELSO center of excellence, they have to begin their journey with the path to excellence in life support. A pillar of attaining the quality care required for this is the presence of an established and institutionally supported ECMO education program.A multistep educational program was delivered over 2 years to 30 ECMO team members, based on guidelines from the ELSO , 20. In The framework adopted by ELSO is the one that uses Miller's triangle. This is a framework for clinical assessment. It is a process of assessing clinical skills, competence, and performance.ELSO recommends that each center develops training programs that accomplish the first three steps of Miller's triangle to allow for a successful implementation of the “Does” phase.The ECMO Medical Director and Coordinator/Manager were responsible for the training of the team, ensuring that:Ongoing competency is maintainedEstablished guidelines and standards are defined in institutional policies and proceduresThe course content was planned to provide a consistent, effective multidisciplinary content with all providers exposed to a single curriculum for initial ECMO Training.Additional training needs to be tailored to the specific needs of individual learners.The ELSO-based educational program can be divided into three categories  oxygenator This ECMO equipment was approved recently by the FDA in the United States. Altogether, the different components built a very compact and easy-to-handle device with a weight of 5 kg. The system is entirely heparin-coated (Reoparine Medos AG) and has a priming volume of 275–600 ml depending on the oxygenator size. A recent study from seven European pediatric centers looked at their patient's outcomes on this device . They exWe developed protocols and procedures for:Technical backup, storage, and space.Equipment safety and monitoring.Maintenance and upkeep of point-of-care devices.Robust methods of ensuring adequate supplies while avoiding the expiration of infrequently.ECMO activation procedure.An extensive review of the literature was conducted, and visits to some of the hospitals that use the same equipment were conducted. We also leveraged the vast experience of our ECMO group; we drafted our protocols, which were reviewed by the members of our ECMO team including physicians, surgeons, nursing staff, ECMO specialists, perfusionists, and pharmacy. After every stakeholder input was incorporated, protocols were finalized.We also have developed few programs embedded in our ECMO services including (a) neurocritical monitoring in collaboration with our neurology department, (b) CRRT therapy in collaboration with our nephrology department, (c) anticoagulation therapy in partnership with our hematology department, (d) ventilation management during ECMO, and (e) quality program, overseen by our quality department, and report to the ELSO. Medical management guidelines and protocols were written, and workflows for multidisciplinary team management were put in place.Our ECMO program was activated in May of 2018 and first baby was referred for ECMO in June 2018 . MultiplThe program is continuously monitored by the ECMO leadership team and our ECMO quality team. Meetings were scheduled monthly to discuss issues and review cases. Each case is discussed in detail with a goal to improve the quality of care.As the ECMO program was getting established, both the NICU and PICU teams were trained simultaneously. Initially, a NICU ECMO specialist managed pediatric patients in the PICU as part of training and new neonatal ECMO physicians also participated in the care for these patients in PICU.To evaluate the success of the program and for benchmarking, the ECMO database of Sidra Medicine Hospital was queried for all patients who received ECMO since activation (July 2018 to June 2019). All patients undergoing respiratory ECMO  were included in this study.We followed the ELSO guidelines and developed a set of criteria based on a consensus process.Consider and discuss ECMO in any near-term neonate: if unable to adequately oxygenate and/or ventilate despite maximal ventilator and cardiac support with reversible respiratory and/or cardiac failure. Any ECMO referral is channeled to a multidisciplinary team and evaluated by the intensivist, medical director, and specialists .The following Neonatal General inclusion and exclusion criteriawere followed:Gestational age, 34 weeks, or birth weight 2,000 gNo significant coagulopathy or uncontrolled bleedingNo major intracranial hemorrhage, Grade II or greater intraventricular hemorrhageReversible lung disease with the length of mechanical ventilation <10–14 daysNo uncorrectable congenital heart diseaseNo lethal congenital anomaliesNo evidence of irreversible brain damageNo evidence of irreversible multiple organ damage.Neonates with severe respiratory failure, refractory to extensive medical management, with a potentially reversible etiology:This may be indicated by:Oxygenation Index >40 for >4 hOxygenation Index >20 with lack of improvement despite prolonged (>24 h) maximal medical therapy or persistent episodes of decompensation2 <40) unresponsive to interventionSevere hypoxic respiratory failure with acute decompensation  in the corresponding categories for comparison. Chi-square test was used to compare the categorical variables, and outcomes are presented in percentage, and Data were collected from the Sidra Medicine ECMO registry between July 2018 and May 2020 and also from the ELSO registry. A total of 27 patients have undergone ECMO therapy at Sidra Medicine in the first 22 months after establishing the program (July 2018 to May 2020), of which 11 patients (six newborn and five pediatric) who had respiratory indications were reviewed. The remaining patients had either cardiac indications or extracorporeal cardiopulmonary resuscitation (ECPR).Six male and five female patients were treated with ECMO. Demographics data and pre-ECMO clinical status markers, which are also indications for ECMO, are described in There were only two mechanical complications noted in these 11 ECMO runs, which include one canula issue (clot) and one circuit component clot, but zero pump failure, oxygenator failure, or pump clots .In the newborn group, there were two neurological complications and one renal failure needing renal replacement therapy, as listed in This original paper is the first ever to investigate the process of activation and success of a first regional neonatal ECMO program in the Middle East. There are existing adults and pediatric ECMO services in the other countries in the Middle East region and even in Qatar; however, these services were underutilized for the neonatal respiratory ECMO and were mainly limited to Cardiac ECMO. As per our knowledge, there is no such similar program in the Middle Eastern region which is led and managed by neonatologists. The demography and social structure of the Middle Eastern population are different as compared to other parts of the world. The growing population may create a need for the future establishment of more ECMO programs in the Middle Eastern region, and this experience may help them. This was an ECMO specialist-driven program that was executed in a very planned manner over a period of time with rapid ramping up once the hospital was opened. The key feature of the success of program implementation was outcomes comparable to  the ELSO registry despite setting it up on a Greenfield site. This can be attributed to careful planning with systematic execution, collaborating available experience, and extensive training of ECMO staff before activation. Although the number for comparison was small, the clinical outcomes were also comparable to the ELSO registry, including the percentage of babies discharged from the hospital. There were no patient complications that occurred during transport, demonstrating that adequate training and proper protocols can execute safe transport in a new system.We have excellent outcomes in this group when compared to other low-volume center data. We appreciate that we had two clot complications in 11 patients we reported, which may seem high compared to ESLO . We have reviewed and discussed our anti-coagulation protocol among all multidisciplinary teams including hematology, and we are regularly auditing this so that these complications will not occur in the future. Clinical complications were less difficult to conclude due to the small number size, and we shall evaluate this regularly.There were particular challenges faced during ECMO activation, which were as follows:Sidra ECMO program was initially built with combined teams from NICU and PICU but eventually separated into two independent programs; one is offering neonatal respiratory ECMO in the NICU. Getting ECMO specialists, staffing the team, and ensuring ECMO competency of the novice nurses were very challenging. Also, ECMO physicians had mixed experience, with some having extensive training and others with limited experience. Due to the high demand for in-house physician cover, extra commitment was needed to get trained and improve skills for ECMO physicians. A separate ECMO roster was putting other neonatologists in the NICU team under pressure and it needed their flexibility to support the increasing needs of the program.Allocation of time during the training to train people from different specialties was also a challenge.Although ECMO experienced staff were recruited, new machines, different terminologies, and unfamiliarity with new pumps resulted in a slow learning curve, with pumps failing twice during training sessions with even breakdown of the circuit. So, getting everyone aligned on the same process was an ongoing challenge, which was tackled with bedside one-to-one teaching to ECMO specialists.Laboratory support running ECMO coagulation parameters in the lab is not a usual practice for non-ECMO centers. Our hematology department developed and standardized all the ECMO critical testing required, including anti-X essays.ECMO transport program—transferring a baby on ECMO from a referring hospital and also for procedures like CT scanning—had a lot of logistical challenges with extra training needed for the staff in the radiology department and the ECMO team. Now, with training additional staff, our ECMO transport team covers the whole Qatar region and aspires to do international transport very shortly.The article summarizes the process and evaluation of setting up a new ECMO program on a Greenfield hospital site. It can be a guide for future hospitals trying to establish a similar program. The development of neonatal ECMO programs was desperately needed in the Middle East region and was achieved successfully. Although we have minimal patient data, the number was achieved in a short duration of 18 months, and the complication rates were lower than or comparable to ELSO data, assuring a successful implementation. The number of patients is a limitation in this study and no real conclusions can be drawn regarding patient outcomes. However, the key components in building a successful ECMO program appear to be institutional commitment, multidisciplinary leadership, and organized training. Using consistent and continuous training is the key to the success of the ECMO specialist's model.The datasets generated for this study are available on request to the corresponding author.Written informed consent was obtained from the individuals for the publication of any potentially identifiable images or data included in this article.ME conceptualized and drafted the manuscript. KM extracted ECMO data and edited and finalized the manuscript. SY helped in reviewing and analyzing data. DA made substantial role in developing, running this new ECMO program with active role in managing patients on ECMO. He has taken over ECMO lead position and reviewed and corrected the revised manuscript before submission. All authors contributed to the article and approved the submitted version.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.


The purpose of this study was to evaluate the implementation and effectiveness of a novel care management program for low income older adults in Chicago. Older adults (n=200) who had annual income below $31,225 but about the state level for home and community based services were received care management. Program participants completed a battery of assessments  at initial assessment and 1-year follow-up. We also conducted interviews with clients and care managers. We used a t-test to evaluate participant outcomes and coded qualitative data to identify themes. Results showed no significant differences between baseline and 1 year follow-up indicating that this care management program kept participants stable. Only 5 of 200 (2.5%) of clients transitioned to a nursing home. This study contributes important results on a novel program to sustain vulnerable older adults in the community.


At present, the earthquake-risk perception research in Aceh only focuses on the general public. Limited research examines earthquake-risk perceptions amongst students. This exploratory study is focused on geography education students because this study programme has integrated disaster education into its curriculum. This study aims to find the extent to which earthquake knowledge and fatalism beliefs affect earthquake-risk perception. The survey was conducted on 210 students using questionnaires. Using the Spearman correlation test, the results of this study revealed that there was a positive and significant relationship between earthquake knowledge and risk perception with coefficients (0.200) and significance (0.004). Meanwhile, fatalism beliefs have a negative and significant relationship to the perception of earthquake risk with correlation coefficient (−0.224) and significance (0.001). This means that the higher the fatalism attitude of students towards disasters, the lower the perception of earthquake risk. It is feared that fatalism will have an impact on the lack of disaster preparedness. Fatalism beliefs are complex issues that require joint efforts from governments, religious leaders, educational institutions and the media to reduce them. Aceh region (located in Indonesia) is an earthquake-prone area. With regard to its geological location, Aceh is in a subduction zone. From 1990 to November 2004, Aceh had experienced more than 2200 earthquakes with powers above 6 in the Mw : There is a positive and significant relationship between earthquake knowledge and earthquake-risk perception.Hypothesis 2 (H2): There is a negative and significant relationship between fatalistic beliefs and earthquake-risk perception.The study of the relationship between knowledge and fatalism-related earthquake-risk perception is important because disaster is the relationship between natural events, natural risk and physical and social vulnerability  developed by Lindell and Perry , knowledAccording to the cultural theory of risk based on Thompson et al. , fatalisConfidence in external factors makes a person less likely to care about risk . The results of normality measurements show the value of the Shapiro–Wilk coefficient of 0.000 . From thMeanwhile, Spearman correlation test results  indicateThe students’ average score of knowledge on earthquakes is relatively high. The five items of knowledge of earthquake questions have a mean of 0.83 on a 1-point scale. The high knowledge of earthquakes because of disaster education has been integrated into the geography education curriculum at Syiah Kuala University and Samudra University. Through geology, geomorphology and disaster geography, students were taught about earthquakes.The high knowledge of earthquakes has a positive impact on risk perception (significance = 0.004). It supports the opinion expressed by Yari et al.  that knoThe findings of this study are consistent with the cognitive learning theory developed by Ormrod  that an The findings of this study provide empirical evidence that it is important to strengthen the knowledge of future earthquakes. Knowledge of earthquakes is believed to influence people in making decisions at the time of a disaster. According to the theory of PADM, knowledge is one of the most influential components in retrieval decisions when a disaster occurs . The average value of the statement ‘no action can be taken to reduce the impact of damage and destruction from an earthquake’ . This number indicates that most respondents agreed that there were not many ways to reduce the impact of the earthquake disaster. The findings of this study reinforce the cultural theory of risk developed by Thompson et al.  that fatThe high fatalism attitude of Acehnese students was allegedly because of the influence of the message conveyed by religious leaders. After the 2004 Indian Ocean earthquake and tsunami, most religious leaders in Aceh interpreted the disaster as a form of punishment from God for human sins. The message conveyed by religious leaders allegedly influenced the perception of earthquake risk amongst students. The findings of this study proved the risk perception model developed by Renn and Rohrmann , which sThe high belief in the fatalism of Acehnese students has a negative relationship with risk perception . The data explained that the higher attitude of the fatalism of students towards disasters resulted in lower perception of earthquake risk. This finding corroborates several studies in the field of psychology, which show that empirical fatalism beliefs have a negative effect on decision-making and human behaviour (Rashwan & Jenkins Therefore, joint efforts are needed in reducing fatalism beliefs. The government, religious leaders and the media are expected to play a role in reducing fatalism beliefs. The role of religious leaders is very important to reduce fatalism beliefs. According to Ghafory-Ashtiany , fatalisIn addition, the media also plays a role in reducing fatalism beliefs. The way the media presents disaster damage information will affect public perception. For example, the information conveyed that damage from an earthquake cannot be prevented but will increase fatalism beliefs amongst the people (McClure et al. The main objective of this study is to assess the relationship between knowledge and fatalism beliefs on earthquake perceptions amongst students. The results showed that knowledge has a positive and significant relationship affecting the perception of earthquake risk. The higher knowledge of earthquakes significantly increases the risk perception. This finding provides empirical evidence regarding the importance of increasing knowledge about disaster risk reduction. Comprehensive knowledge about disasters will increase risk perception. In the end, it will help in making the right decision when a disaster occurs.Other findings of this study indicate that geography students have a high belief in fatalism during disasters. The high belief in fatalism has a negative relationship with the perception of earthquake risk. The higher belief in fatalism will cause low perception of earthquake risk. Therefore, this study suggests the need for joint efforts from the government, religious leaders and the media to reduce fatalism beliefs amongst students.


This research aims to explore the life experiences of relocated earthquake survivors with PTSD and develop a conceptual framework for understanding their life experiences.Interviews were conducted with twenty-three participants. The participant selection, data collection and analysis were based on grounded theory methodology. A theoretical model called “loss of homeland” was developed.Loss of homeland was the most important condition that influenced the relocated participants’ self-identity, social connections, and meaning system. These aspects were categorized into existential changes, lost connections, and changes in identity. Post-disaster relocation threatens individuals’ sense of meaning, integrity of self, and sense of belonging, affects every aspect of everyday life and shatters their inner and outer harmony.Further research guided by this theoretical model is needed to inform post-disaster mental health services and relocation policy. Mental health professionals and policy makers can make more informed decisions in terms of disaster relocation policy and manage post-disaster psychological disturbances by focusing on both places and people. The victims of the devastating Sichuan earthquake on May 12, 2008 have yet to fully process their extreme life experience. Their psychosocial pain is still evident and has not diminished over time, even many years after the earthquake , 4. The Health must be understood not only in terms of individual characteristics but also in relation to locales , 18. DisThe cultural meaning of relocation and how relocation leads to psychological disturbances among Sichuan earthquake survivors have not been addressed in the academic literature. A qualitative, survivor-centered approach could provide a deep understanding “beyond measures and numbers” and is an important complement of quantitative research .Our current study attempts to explore relocated survivors’ perspectives of relevant processes and contexts and the interplay among relocation, mental health vulnerability, and the cultural expression of symptoms among Sichuan earthquake survivors; this approach may offer a deeper understanding and valuable information that advances theory building and culturally sensitive trauma-informed care.This study aims to explore the life experiences of relocated earthquake survivors with PTSD. A grounded study design, which is a suitable method when new areas are investigated in an exploratory manner, was adopted.The eligible participants were earthquake survivors who screened positive for PTSD and were relocated to other communities. The participants had previously lived in villages, many of which were destroyed by the earthquake. Entire communities were destroyed by the earthquake and could not be rebuilt in their original places; accordingly, these people were relocated to newly built towns or communities. Our participants were survivors who had moved from a village to a town or new community.Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for current PTSD, and the severity of the participants’ PTSD symptoms was determined by administering the Clinician-Administered PTSD Scale (CAPS) [The participants were recruited through referrals from local physicians and posters displayed throughout the affected communities. The initial screenings for PTSD were conducted by using the PTSD Checklist-Civilian Version (PCL-C), which is a reliable and valid assessment of PTSD . A PCL-Ce (CAPS) . All parIn-depth semi-structured interviews were used for the data collection. A face-to-face, semi-structured interview was conducted with each participant at the local community medical center from 2016 to 2017. The participants were interviewed after the PTSD diagnosis was made by psychiatrists. The interviews were conducted by the first author. The first author had previously worked as a psychologist at a hospital and had been involved in another qualitative research project. Each interview was individually organized but usually began with open-ended questions, such as the following: Tell me about what happened to you after the earthquake. What did you feel? What did it mean to you? What are the changes to different aspects of your life? What are the changes in the different community? How has relocation affected your life? Complementary probing questions were added as needed that could relate to prior experiences with the disaster. The questions were developed based on previous interview data, and an ongoing analysis influenced the subsequent questions and the selection of the following participants. The interviews lasted between 30 and 60 min. The location of the interviews was quiet and private to protect the confidentiality and privacy of the participants.We followed the procedures for data management and analysis recommended by grounded theory , 26. AllThis study was approved by the Clinical Research Ethics Committee of Southwest Hospital. The aim and process of the study were explained verbally and in writing to the participants, and the participants signed a written permission of informed consent. The participants were informed that they could decline participation at any time during the study. Confidentiality was maintained throughout the data collection, interview recordings, and process of presenting the results. Our current study was based on a previous qualitative study that aimed to understand suffering and emotion in Chinese earthquake survivors. We followed this previous study to focus exclusively on relocated earthquake survivors.The emerging theory was inductively derived through the process of a constant comparative analysis. Figure Before the earthquake, I had a house with enough household appliances. Well, I also had land, and I could raise some pigs. This could help me make some money. After the earthquake, I had no house, no land. How could I make money? So, I had to do some part-time jobs to make a living. In the past, I had a house, and our family lived in the center of a big yard. I felt I was competent. After the earthquake, I became homeless, and I felt I was nobody all of a sudden. .Most relocated earthquake survivors lost their homeland due to the catastrophic earthquake. All participants presented the pain of a “loss of homeland”. The homeland is imbued with a range of meanings, feelings, experiences and a sense of belonging. The participants started their families in their homeland. The participants felt secure and protected in their homeland. One participant said the following:I don’t even dare to look at my ruined house. I feel so sad every time I look at it. My house collapsed. Sometimes, I recall where my living room and kitchen were… Now, they are all gone. The yard was over there, you know. I don’t want to look at it. Why would you want to take a look if you have no house there? If you look at it, you will recall where you put noodles and other things. In the earthquake, the pigs and cows were killed. I can find next to nothing in the house, and I feel so down. .House, land, and home define the participants’ identity and happiness. The devastating earthquake caused tremendous loss and suffering.I only found a fat pig of mine in the farmland. I don’t know how it survived. I had a house, and all my family lived in it. All of a sudden, my wife and my wife’s sister were buried in there. You know, the most painful part is that nearly all my family died in the earthquake. They are all gone. .Building a good home represents an enormous accomplishment. In turn, the loss of a home means the loss of identity. In China, home and person are considered an organic whole and cannot be separated. However, those who lost both their home and people suffered even more pain.Well—how can I say it?—I feel very lonely now. We only have six family members, and four of them died in that earthquake. This hurt me the most. You see, I have no sons and grandsons to accompany me now, and I feel so lonely in the house. Sometimes, I take the plow to do some farm work, and when I look around, no one is there around me. Basically, I have no house and no family members now. I was the head of my village, and we had more than one thousand people in the village before the earthquake. Only five hundred of them survived. In the past, I could have dinner with every family when I collected the agriculture tax in their house. But, now, the house is gone, and the people are gone. I even stopped walking there. .In their homeland, there were people who the participants loved and cared for, and they established a family in the community. The loss of their homeland represents not only the loss of their home but also the loss of their loved ones, family members, relatives, friends, acquaintances, and the people with whom they grew up.I told myself I need go to the mountain (the place where he lived before the earthquake) to take a look. I sat there and cried for a while. The whole community was gone; the village was gone. .Sometimes, the loss means not only the loss of the participants’ home and family members but also the loss of their community. Their entire communities define the participants’ self-identity and existence, and deep emotions bind them within the community.I did not like the new community. I got used to living in the mountains, and I felt good when I saw the mountains, rivers, and plants in my previous villages. I felt everything is strange to me in the new community. .Another participant reported the following:To a certain extent, a continuous longing for their hometown and home exists deep in the participants’ hearts. They understand that it is impossible to return to their hometown and their home again because the disaster destroyed everything. The participants are thus living with the pain of the loss of homeland.I have a life as long as my sons are alive. That’s what I mean. I take everything lightly now—unlike before, when different villages were fighting among themselves about the field boundaries. The problem does not exist anymore. As long as you are alive, what is the point of fighting for trivial things? Life is short. After I survived the earthquake, I adopted a different attitude toward many things in my life. .The wreckage left by the earthquake continues to evoke images of the disaster, loss, suffering, and death. The participants’ life experiences after the disaster make them ponder the existential problem, i.e., the meaning of life. The experience of suffering a catastrophic disaster can shatter one’s assumptive reality and sense of certainty in such a fundamental manner that survivors must not only cope with this loss but also rebuild their understanding of life. All participants presented changes in existential thinking after the disaster.I think I am more mature when viewing many things in my life. I think people should really treat friends well. After the earthquake, some of my friends died, and some left. We gradually lost contact with each other. I really adopt a more open attitude toward my life. In the past, I was not willing to spend money on eating and clothing. But, my attitudes have changed now. A person should eat and dress well in his or her life when he or she is alive. Nearly all my relatives have left, and I think I should try my best to help and keep in touch with the relatives who are still around me. .After experiencing a life or death situation, the participants began questioning the most important things in their lives.What makes me happy is very simple right now. My sons frequently visit me. I can make some money, and my grandsons have fun every day. That’s what makes me happy… this is what I want. .The participants attached more importance to interpersonal relationships and family relationships. After experiencing this pain, they begin to redefine their lives and themselves.The kids have grown up, and I want family members to be together all the time. I am this type of person. I feel better and important when we are all together. .Many participants worked outside the community before the earthquake. Some participants moved back to their home to find a job nearby and live with their family members after the earthquake.Some participants claimed to experience existential suffering that prompted them to answer the following question: What is the life that I want to live? They formed new understandings of life and meaning.I cannot find a person to talk to. I moved to this village after the earthquake. My good friends had moved away. Sometimes, it is so hard—so hard to find a friend to pour out my bitterness to. .Many participants claimed that most of their social connections were shattered after the earthquake. First, some participants said that the people with whom they lived had died in the earthquake or migrated to other places after the disaster. Second, most participants had to migrate to a new community, and they feel a loss of connection with the people and community with which they were familiar. Third, after the disaster, the participants became hypersensitive in their relationships.In the new community, I feel it is so hard to communicate with other people… I feel everything is not right. For example, when you make a call and your voice is really loud, I will come to you and ask what happened or ask whether something terrible happened. I will feel so down if you don’t tell me. After several times, I stop keeping in touch with them, and I don’t know why I became like this after the earthquake. .Many participants had to move to and settle in a new place. Losing contact with their friends was a consequence of the earthquake. In addition, the participants complained about experiencing oversensitivity in their social interactions.It feels like you and me. We are two strangers, and we feel good about each other, and we want to be friends. However, there is a voice inside telling you that you cannot do this because that person may hurt you (just like the people did in the earthquake). All relationships have changed. You are alone in an isolated land without any resources. After the earthquake, the participants became oversensitive to negative information and information from people with whom they are not familiar. As a result, they began to forge a distorted conception of themselves and their interpersonal relationships.I was afraid that the local people (people in the new community) would give me a weird look. After so many years, I walked away and lived alone after I had this feeling. My life circle is not as broad as before, and I don’t want to meet people. I spend more time in the house. .Due to this hypersensitivity towards interpersonal relationships and sense of inferiority after the earthquake, the participants proactively isolated themselves from other people. They stopped contacting other people simply out of self-protection.The participants tend toward self-protection or avoidance of interpersonal conflict in the new community, and they choose to isolate themselves, which adds to their suffering through a loss of connections.I feel I do not know who I am. The disaster really hurt me… I am not sure how the damn earthquake made me become a person like this: nervous, sensitive, suspicious… I also wonder whether I am crazy. Sometimes, I ask myself how you turn into a person like this—whether I am a human being or a ghost or neither. .For many of our participants, their sense of self was threatened by the disaster. Most participants reported that their sense of self was removed from the world that they actually inhabit. Many participants claimed to have a lower self-image and even self-alienation.I rarely look at myself in the mirror. Sometimes, when I look at myself, I feel so strange about myself in the mirror… and I also feel that I am inferior compared to other people. You have nothing that can compare with others. You are old. You cannot change anything… You cannot rebuild a house anymore. .The men’s sense of self was threatened, and they negatively responded to information from their surroundings and other people. Most participants claimed to experience major changes in their self-perception after the earthquake.Another man also claimed that he felt differently about himself. He felt that he had turned into a different person. He was also confused about why and how his personality changed. The integrity of self had been threatened and transformed by the traumatic experiences. The integrity of self was also deeply connected to their land, tradition, and community.I just cannot help recalling the whole scene. When I think about those terrible memories, I feel like I am having a mental breakdown. To be honest, everyone will feel scared in that situation. We are fortunate people because we did not die in that earthquake. What I feel terrified about is not the collapse of those houses but the death of so many people I knew. I am in my forties, and I just cannot help remembering those memories. .“Living on that day” implies a day-to-day life full of traumatic experiences and memories. It is a different type of life from the participants’ past, normal life experiences. The participants experience intrusive memory, fear, phobia, helplessness, and nightmares day and night. The participants attempt to live a life as normal as possible but struggle with these terrifying feelings. They become easily irritated, hyper-vigilant, and out of control and are preoccupied by the feeling of loss and hopelessness. All of these experiences are explained by the fact that they are in continuous pain.On that day, I invited my classmate’s son to help me carry the corn in from the land. My classmate’s son was killed by stones on his way to my house. Forty to fifty people died in my village, which is a huge stress for me. I cannot stop thinking about them. When I think, I just cry. .Many emotions, such as guilt and regret about the earthquake, do not fade over time. These emotions still linger and corrode their minds.I have so many negative thoughts, even when I see an acquaintance and I can remember how he treated me in the earthquake. I feel very reluctant to have these thoughts, but they just come up automatically. .Regardless of their attempts, the memories of that day constantly intrude upon their everyday lives.You did not see that scene, and I cried for a long time after I came back. Sometimes, I dreamed about those kids who were dug out from stones without hands and heads. Blood was everywhere. Some kids were not dead when they were found, but their hands and arms were gone, and blood was rushing. It felt so sad when you saw that. I do not want to live when I recall those scenes. .Nightmares followed. Many participants reported that all their dreams are related to that day.I run immediately whenever there is a small aftershock. Sometimes, I think about whether I need to find a place to put some water and food for an emergency in case an earthquake happens. I think all the time about what I should do if there is an earthquake again. When some aftershocks hit, I just run, even if it is a really small quake. It has been 8 years since the earthquake occurred, but the participants still live in the shadow of the earthquake and the pain that it caused. The participants are similar to a bird that frightens at the sight of a bow.“Living on that day” involves the survivors’ intrusively and uncontrollably recalling images of the disaster or pain caused by the earthquake.I had been under the stones for an hour in the earthquake. My chest became numb… After the earthquake, I always feel uncomfortable, and I feel faint all the time. My memory also became bad. I want to get something sometimes, and when I walk there, I remember nothing. .Physical uneasiness is a major complaint of survivors with PTSD. Survivors with PTSD believe that everything is related to their physical problem . All parI find I have a problem when I talk with people now. When I want to talk about something, I say other things. When I think of one name in my mind, I say a different name… Do you think my brain has some disease? There is another problem. I feel faint immediately when I am under pressure. In recent years, people have given me money a couple of times, and I count how much. If they ask me how much money, I just cannot remember. .Poor memory is a major complaint of all participants. Many participants attribute their poor memory to a physical disease, and they visited a hospital for evaluation. The symptoms disrupt their daily functions.Sometimes, I make a call, and after I dial the number, I do not remember who I called. I have to wait for the person to speak, and I can then remember who I called. I have had this problem several times recently. .Another participant expressed similar concerns as follows:Chinese people mainly describe their physical symptoms rather than mental problems or feelings. They experience memory and physical symptoms in their everyday lives, which causes many disturbances.In our model, we can observe the dynamic interplay among relocation, psychosocial vulnerability and the cultural expression of disease, which demands a new framework for understanding PTSD. Typically, the disaster impacted the relocated participants’ families, social relationships, communities, cultural integrity, beliefs and life stories. The significance of land for Chinese people has generally been ignored in the Western literature. However, because of its central role in identity construction, connection, and, in particular, a sense of belonging, the concept of land is important for understanding Chinese life experiences and feelings.Based on our model, we can observe that the homeland forms the foundation of safety, belonging, meaning, connection, identity, and integrity of the self and body. Attachment to land is a characteristic of rural society. In rural China, it is normal for farmers to settle in one place for generations; it would be abnormal for them to migrate. The sense of belonging to interpersonal relationships, the sense of self, and the well-being of individuals, family, and community are experienced and occur on the land. Relocation and the loss of homeland lead to problems with the sense of self, social connections, and meaning. Previous researchers have also claimed that people who perceive the environment as stable, consistent, predictable, manageable, and meaningful are more likely to have a sense of coherence and develop a better ability to cope with traumatic incidents and vice versa . WithoutIn our study, the participants’ experiences of loss of connections helped identify the impacts of traditional cultural values on Chinese patients’ experiences of suffering. Chinese society emphasizes interpersonal interrelatedness, which has become an important part of Chinese people’s personality , 30. GivIn the phenomenological research, the feeling that one becomes another person is an indicator of how one’s self-image and identity change after a disaster. Due to the loss of their homeland, community, and social connections, victims feel that they have become totally different people compared to their past selves, which contributes to avoidance, vigilance, and feelings of vulnerability. Furthermore, increased feelings of avoidance, vigilance, and vulnerability have been described as symptoms of PTSD. Previous research that simply describes the symptoms of PTSD may fail to understand victims’ experiences of the dis-integrity of self, which is the origin and core of their symptoms. Consistent with the literature, after a traumatic incident in life, without a stable holding environment, the integrity of self is usually threatened, which presents as low self-esteem and increased self-doubt , 35.As claimed by many relocated survivors, disaster is a powerful threat to the life of earthquake victims, and regular safety and certainty are not taken for granted. Traumatic events shatter one’s community and stable surroundings in which the individual’s meaning is embedded, which leads to a sense of meaninglessness, hopelessness, impotence, uncertainty, and lack of control in life. As mentioned by many existential psychologists and scholars, the threat evokes an existential exploration of what the most important things are in a person’s life and what he or she wants to live for , 37.Based on the participants’ narratives, traumatic memory is always “unforgotten” and relived in their everyday experiences. The biological foundation of the traumatic symptoms of PTSD have been well documented in different experiential, psychophysiological, and neurobiological studies. In addition to the biological understanding of the disease, based on our sociocultural model, we can clearly observe that without a safe and stable harbor, i.e., community, connections, cultural resources, etc., victims live in an unpredictable, unsafe, and overwhelming setting. They have no way to recover from the disaster. Without helping them rebuild connections, community, culture, and meaning, we simply label their symptoms, which does not help them recover from their trauma.Somatic changes and physical health complaints were often displayed, as bodily stories were experienced more by illustrating than by speaking. Chinese people do not verbally express their feelings or personal emotions. The major complaints of physical health changes rather than psychological disturbances indicate a confirmation of the personal history of their experiences. The close interrelatedness between psychic and physical states in the Chinese culture may suggest that unspeakable pain could facilitate a deeper cultural understanding of disaster survivors’ experiences . The meaPast quantitative research has provided one aspect of their experiences. Our current qualitative research forms another picture of the life experiences of relocated earthquake survivors with PTSD and can help in devising methods to boost survivors’ resilience by promoting social support and recovery in a resilient community. With better information regarding the dynamic interactions by which post-disaster relocation affects mental health, mental health professionals and policy makers can make more informed decisions in terms of disaster relocation policy and manage post-disaster psychological disturbances by focusing on both places and people.First, future mental health professionals and policy makers must understand how place relates to mental health, which is important for delivering effective “contextually sensitive” interventions and policies. Second, mental health professionals or policy makers can use the findings from this study to inform the development of comprehensive “land”-based programming that aims to increase the sense of belonging, recover community routines, build a sense of identity, decrease social exclusion, and promote inclusion in new communities. Third, the embodied experiences of somatization should be explored and considered to understand earthquake survivors’ inner suffering and pain. Future mental health services could focus on patients’ somatic complaints, which may reflect emotional distress, as the failure to incorporate somatic metaphors and Chinese conceptualizations of distress may lead to a failure in understanding posttraumatic psychological disturbances .Despite this study’s contributions, it has the following limitations. First, although we followed the theoretical sampling of grounded theory, our study group of participants who have experienced relocation to other communities represents a small share of the millions relocated due to the Sichuan earthquake; therefore, the theoretical soundness of this study is limited. Second, this study involved participants from several moderately to severely damaged communities, and most patients had low socioeconomic backgrounds. Therefore, our results may not be generalizable to populations with a higher socioeconomic background or from mildly damaged communities. Third, some patients suffered complicated grief and prolonged PTSD, and how relocation impacted their complicated grief and prolonged PTSD was not addressed in the current study.Chinese people’s self-identity is closely related to land, community, and social ties. The severe disaster shattered not only the homeland of the earthquake survivors but also their sense of belonging, security and self-identity associated with land, community and social relationships. Mental health services need to address the cultural factors that might shape survivors’ vulnerability to traumatic incidents. Future clinical workers must find a natural way to help earthquake survivors narrate their traumatic experiences in a more acceptable and indigenous manner, such as rituals, ceremonies, and traditional coping strategies to integrate unintegrated, fragmented, and fragile episodic memories into a semantic memory system to form a comprehensive and sequential autobiographical memory of their family, community culture, and homeland.


The Rx (prescription) for Addiction and Medication Safety (RAMS) program was developed during the 2017 through 2018 academic year to educate students from 6 selected Rhode Island public high schools about opioid misuse, overdose, and recovery. During 2016, 3 schools participated in the RAMS program and returned for RAMS-PEER in 2017; 3 schools were newly recruited in 2016. Tenth graders returned from schools that participated during RAMS in 2016, and all ninth graders were new. Our study’s aim was to evaluate the overall effect and spillover benefit of the RAMS-PEER intervention from tenth to ninth graders by surveying students both before and after the education program. Survey questions were modified from the 2015 Youth Risk Behavior Survey and the 2015 Ontario Study Survey. Student responses were matched for preintervention and postintervention analysis using a unique identifier. We observed an improvement in knowledge of opioid misuse; however, we found no evidence of a significant spillover benefit. Rhode Island adolescents had among the highest estimated prevalence rates of illicit drug use from 2015 to 2016.The Rx (prescription) for Addiction and Medication Safety program was developed to deliver opioid misuse education for Rhode Island public high schools to reverse the trend of illicit drug use. Results found student knowledge of opioid misuse and use disorder improved following a pharmacy-implemented intervention. However, spillover benefits were not observed, indicating that consistent program delivery may be needed.Our study provides evidence of an effective adolescent opioid misuse awareness program and, perhaps, a foundation for a statewide opioid misuse educational program within Rhode Island public schools.The United States is facing an unprecedented crisis of drug overdose. More than 70,200 people died from an overdose during 2017 alone. From the 70,200 deaths, 47,600 (68%) were overdoses from all opioids, and 17,029 (24%) were overdoses from prescription opioids  program. Developed by the University of Rhode Island (URI) College of Pharmacy, RAMS was an opioid misuse prevention education program delivered by trained pharmacy students for freshmen students at 8 public high schools in Rhode Island during the 2016 through 2017 academic year. Of students surveyed, 33 (7%) significantly improved their identification of opioid misuse, 19% improved knowledge of opioid withdrawal symptoms, 14% improved knowledge of the need for treatment referral, and 28% improved knowledge of naloxone administration  during the program’s implementation. Returning tenth graders who had received the RAMS curriculum in the first year were instructed to view videos either in school or in their spare time. A discussion led by high-school faculty was mandatory after each booster video. Once completed, URI pharmacy students delivered the primary RAMS program to ninth graders at both new and returning schools.RAMS is a 3-hour, on-site, school-based curriculum, providing 3 to 4 interactive educational sessions. Sessions include medication safety, signs, symptoms, and risk factors for opioid misuse and withdrawal; opioid overdose identification and response; and local treatment and recovery resources. Implementation of RAMS has been described previously . Before program delivery (preintervention), ninth graders completed a 20-minute survey that included risk and protective factors for substance misuse; past 30 days nonmedical use of opioids, alcohol use, and use of other substances; students’ perception of risk or harm from prescription drugs and prescription drug overdose; awareness of resources and treatment of substance misuse; proper disposal and storage of prescription medications; and how to obtain and administer naloxone. These items were modified from the 2015 Youth Risk Behavior Survey from the Centers for Disease Control and Prevention and the 2015 Ontario Study Survey from the Canadian Centre for Addiction and Mental Health and identical to surveys administered in the RAMS first-year program . The sur2 test to conduct cross-sectional and paired comparisons between outcomes at the 6 schools at preintervention and postintervention. Because the matched sample had missing values , a multiple imputation approach was used with discriminant function for categorical variables to impute missing values. We used the fully conditional specification method to impute the missing data. Multiple imputation was performed on combined preintervention and postintervention data to generate 30 data sets with complete information, assuming a multivariate normal distribution and that missing data depended only on observed covariates (P < .20) in the logistic model evaluating the association of school type on outcomes. Statistical analysis was completed using SAS Version 9.4 , and all tests were 2-sided at P < .05 significance.Descriptive statistics, including means and proportions, were used to report participant demographics and other characteristics. We used the χvariates ,11. CIs lues n = 9, 40%, aTo evaluate the possible spillover and peer education benefit from tenth to ninth graders in returning schools, we calculated the adjusted odds ratios (aORs) of correct responses or improvement in knowledge among ninth graders in returning schools versus ninth graders in new schools. Improvement in knowledge was defined as having correct answers in both the presurvey and the postsurvey, or having incorrect answers in presurvey and correct answers in the postsurvey. Of ninth grade students in 2017 through 2018, 1,030 participated in the preintervention survey, and 439 participated in the postintervention survey. We matched 321 students with both preintervention and postintervention surveys for the year. Most ninth graders from the 6 high schools were aged 14 or 15 years , 823 were white (79.9%), and 908 (88.2%) earned nearly all A and B grades. Of the 1,030 students, 715 (69.4%) reported good mental health status, with no feelings of worthlessness  or hopelessness . Additionally, 707 students found it difficult or did not know how to obtain pain relief medication (68.6%) or medication to treat attention deficit hyperactivity disorder without prescription  .After the RAMS-PEER program, during the 2017 through 2018 academic year, ninth grade student knowledge of opioid misuse improved. The percentage of correct answers increased significantly from preintervention to postintervention for questions on knowledge of opioid misuse (from 76.2% correct to 84.4% correct), and perceptions of people who use drugs (from 27.4% correct to 33.9% correct) .P = .01 (Improvement was observed among matched ninth graders (n = 321) regarding their knowledge that accepting a prescription medication from a friend was drug misuse. For Question 93, P = .01 . After rP = .01 . KnowledIn our assessment of an opioid misuse education program among ninth- and tenth-grade students in Rhode Island, we found that ninth-grade students had improved knowledge of opioid misuse and improved perceptions of people who use drugs after the education program during the 2017 through 2018 academic year, demonstrating effectiveness of the program. We also found a positive, although nonsignificant, spillover effect among ninth graders from the 3 returning schools. Although a more robust assessment of the spillover mechanism is needed, these findings indicate that an educational awareness and prevention program needs consistent delivery to provide beneficial outcomes.Our study has several limitations. Although each school administration approved survey implementation, the Rhode Island Department of Education halted it for several months before revoking the approval midstudy. Approval was again obtained after the department’s expanded review of the identical survey; however, critical time lost during the study negatively affected data collection and limited evaluation of spillover effects. We received 1,030 preintervention survey respondents from ninth graders; however, only 415 students completed the postsurvey, and we were only able to match 321 pre- and postrespondents. The preintervention survey had approximately 30% missing answers and the postintervention survey had approximately 20% missing. A low response rate to the postsurvey and missing outcomes limited our ability to detect improvements in knowledge. Another limitation was our use of a fully conditional specification, a semiparametric method that is flexibly suitable for this study. One known theoretical limitation of this study is its high sensitivity to imputing values, and this might have affected our results . To avoiFuture studies could use a randomized design, which might provide a more accurate evaluation of spillover effects of the RAMS-PEER intervention and offer additional insights into the intervention coverage levels needed to change and sustain norms around opioid misuse among adolescents.