The family physician program was launched in 2005 in rural areas of Iran and then piloted in 2012 in the cities of Fars and Mazandaran provinces due to insufficient health coverage in these cities. However, despite its pivotal role in the health system, this program has not progressed according to the policies. This study aimed to explain the underlying factors and challenges of implementing the urban family physician program in Iran.This qualitative study was conducted on 44 policy-makers and managers at national and provincial levels selected via snowball and purposive sampling with maximum variation. The data were managed in MAXQDA 2020 and analyzed by directed content analysis. A triangulation method was adopted for this purpose.A total of 10 categories, 18 sub-categories, and 29 codes were formed. Most challenges related to underlying factors included precipitancy, economic sanctions, belief in traditional medicine, belief in the expertise of previous physicians, and global ranking of countries. For program implementation, most challenges included a diversity of insurance organizations, budget allocation, referral system, electronic file, educational system, and culture building.The major challenges pertaining to underlying factors included international pressure for reforms and precipitancy in program implementation due to management changes. The challenges associated with program implementation included budget provision and interaction with insurance organizations. Therefore, to expand this program to other provinces in Iran, the identified factors should be carefully considered so that sufficient confidence and commitment can be guaranteed for all stakeholders. According to the recommendations of the World Health Organization (WHO), the implementation of family physician programs is an effective strategy to improve service delivery, reduce costs, and establish equity in healthcare delivery . The famDespite many discussions about the success –9 and prAlidosti Alidosti et al. referred to the role of literacy as a key underlying factor and considered information sharing and education of low-literacy people as major factors in the implementation of the family physician program . Chaman There are many international studies on family physician programs. Still, in these countries, there is no distinction between urban and rural family physician programs . Sans-CoThe present study aimed to evaluate the implementation of the Iranian urban family physician program with a new approach to examine the underlying factors and challenges of program implementation. The results can provide suitable strategies for planning and improving the referral system.This qualitative study using the directed content analysis was conducted in Kerman, southeastern Iran, in 2021. Semi-structured in-depth interviews were conducted from September 2015 to March 2017, with 44 policy-makers and managers at national and provincial levels enrolled via snowball and purposive sampling with maximum variation. The participants’ demographic characteristics are shown in Table The interviewees were contacted in person or via phone or email. The participants were informed about the topic of the study, its objectives, and reasons for conducting it. If they accepted to participate, the interviews were conducted at the interviewee’s office or any places agreed upon by them . The intDirected content analysis was adopted to analyze the data, and a triangulation method was used for this purpose . The datTo ensure the trustworthiness and quality of the findings, the criteria proposed by Lincon and Guba were used . To ensuThe findings are presented on two dimensions of underlying factors and challenges of implementing the urban family physician program in Iran. The underlying factors were classified into four categories: situational, structural, cultural, and external factors, with nine sub-categories and 15 codes Table . The chaPrecipitancy in decision-making means that a decision is made before the necessary tools are provided and is implemented before being practically possible. This was evident in the participants’ statements."Unfortunately, in Iran, the family physician has fallen victim to the precipitancy of governments. At the end of the eighth government, the family physician program began in villages without proper infrastructure. Also, at the end of the tenth government, the program was planned to expand all over the country. The result of these hasty actions is what we now see in Fars and Mazandaran provinces" (M 4).Change of governments: The healthcare programs in Iran are affected by the change of governments and ministers. With the departure of each government, a new minister takes the office and launches a new plan regardless of previous efforts. This has been more prominent in the family physician program, especially at its outset.“A problem in our country is that governments are formed and ended every four years. In the first year, people are novice and begin to learn about issues. They start to work in the second and third years, and in the fourth year, they leave the office. In such a system, it is not possible to implement a longitudinal and time-consuming program such as the family physician program” (M 3).Sanction on medication: According to the respondents, the impact of political and economic sanctions on the health sector has been more prominent in the pharmaceutical sector and medical equipment."I think we implemented this plan when we had a drug crisis in the country. I have been the Vice-Chancellor for Food and Medicine at the university for about 10 years now, and I can safely say that things have never been worse than the past 10 years. That means that people have been faced with a new plan, and when they wanted to get a prescription, they constantly heard that the drug was unavailable. We are under sanctions. This has had a negative effect" (M 14).Economic sanctions: Sanctions imposed on Iran’s economy by the international community have directed the financial and economic resources of social programs to areas with greater priority. The lack of funding for the program has affected its implementation."Of course, the government is also dealing with financial problems... The government now runs the country with taxes, and most of the oil revenue is not available" (M 5)."The issue of payments, medicine, salaries of executive staff and assistants, and the physician per capita have significant and direct relationships with the sanctions" (M 25).Inflation: Iran experienced the highest inflation rate in the early years of the program implementation."If the family physician program is implemented properly, it will be economically beneficial for people; now, they pay 10% of the visit fee, but they used to pay 30%. The medicine is also free; but if there is inflation, it affects everything, not just health" (M 23).Politicization means the removal and selection of ministers and officials by political-factional motives, and ignoring the principle of selecting people with the right expertise and appropriate characteristics in all areas, even non-political areas such as social service and economy."Authorities should not have a political view in the social service sector so that, when the governments change, they won't replace everyone due to their political views" (M 5).Change of policy-makers: In addition to a change of governments as a transient factor  contributing to the family physician program, changing policy-makers and ministers and health system unsustainability  have forced plans and programs to be implemented in a short time."Unfortunately, after the revolution, no health minister has been in the office for two consecutive terms, and this in itself is a major factor motivating ministers to look for programs with quick returns which make everyone miss the details... Experience has shown that working on a structure while reforming a sector will yield more sustainable results" (M 7).Employment and immigration of graduates: A large population of young and educated people is an economic capital; however, it is also considered a serious and potential threat in Iran. The low employment rate of medical graduates impacts the process of planning and implementing employment programs."If the family physician program is implemented, medical graduates will not be unemployed" (S 2)."In principle, the identity of GPs has been questioned. So, they either immigrate or choose other jobs, and that is their fate. Unfortunately, many GPs are unemployed" (M 12).Material motives: Contrary to the approach of older physicians in providing services to the people, the formation of some kind of material motive among physicians has damaged the health system programs. The interviewees believed that this has led to discrimination and affected the urban family physician program."It has become difficult to meet the expectations of physicians, whether GPs or specialists. Nowadays, it takes much more to fill the mouths of physicians." (M 5)Lack of a plan: The health system does not have a well-considered plan for health, treatment, and health education."How were the health reform program or family physician program formed? Did top-level authorities make decisions about them? It was not a matter of sitting down, developing a program, determining the status quo and the standards, or covering the gaps in these programs" (M 7)"The lack of a master plan  has made our education system fail to adapt to the concept of family physician. In this situation, physicians graduate without being prepared for such programs" (M 4).Gender differences: According to the interviewees, religion did not considerably affect the referrals to family physicians, and the role of religion was mostly observed in the gender differences among family physicians. Some female patients who had a male physician preferred to see a female physician."Many of our physicians are men. Some people, whether women or their spouses, do not want the family physician to be in the midst of their family problems, so we had a series of challenges in this regard. Some solutions were also proposed. For instance, the assistant of a male physician must be a woman . Another challenge is that many people do not believe in midwives or nurses, but the interesting thing is that they still do not allow a male physician to visit them" (M 35).Belief in traditional medicine:Some people believe in traditional medicine and do not visit family physicians, which posed many barriers to the program."We have people in our target population who visit our colleagues who are traditional medicine specialists. Well, they have to pay all the costs out of their own pocket" (M 40).Belief in the expertise of previous physicians:"Unfortunately, the biggest cause of dissatisfaction among clients is that some physicians may have an effective treatment method or more experience, and almost all clients only believe in these few physicians" (M 38).People’s belief in the status of family physicians: Another cultural issue is the status of family physicians  among people. Iranian people prefer to consult specialists for most diseases and, as such, it is difficult for them to accept that they must consult a GP (in the form of a family physician) for most conditions."When physicians do not have power and authority within a society, people do not accept or trust them" (M 5).Before the implementation of the urban family physician program, people were free to visit any physician they chose. Changing physicians created some problems by limiting the population covered.The global ranking of countries: External factors can impact health programs and systems even from outside the organization or country. An external factor emphasized by the interviewees was Iran’s ranking in the region and the world in terms of health indicators."Iran ranks low in the region and has a long way to go to realize the goals set by national policies suggesting that it must rank first in the region in terms of health indicators. The implementation of the family physician program has been an important effort of policy-makers to fill in the gap and reform the health system" (S 10).With regards to establishing and implementing the family physician program, six categories, nine sub-categories, and 14 codes were extracted from the participants’ statements Table .Diversity of insurance organizations: Diverse insurance organizations in Iran, different policies of these insurance organizations , and various insurances such as the oil industry, banks, and other companies presented obstacles to the implementation of the family physician program out the outset."The family physician program has been implemented mainly in countries that either followed the NHS system or had integrated insurance funds. In countries that have different funds with different policies, implementing a family physician program is very concerning" (M 5).Interaction between the health system and insurance organizations: A barrier to the implementation of the urban family physician program is related to the health system’s interaction with insurance organizations. According to the experts and provincial documents obtained from the coordination meetings of the officials in these areas, contrary to the beginning of program implementation, coordination was later made between family physicians and insurance companies at least at the provincial and lower levels, so that the physicians were accepting the insurance cover of these companies."In my opinion, this coordination was great both at the provincial and the national level. The problem was that enough credit was not given to the program" (M 23).Payment and service purchase system: Payment to the providers of urban family physician program has been defined for family physicians and their teams as “per capita”, and for levels 2 and 3 as “single payment”."The family physician's fee is paid as per capita. The basic per capita payment for the physician and his/her team increases per person according to special cases. However, the specialist or subspecialist's fee for inpatient services is paid as per hour" (S 1)."If a family physician, for any reason, refers one of his/her patients to a specialist, he/she will receive 90% of the private visit fee and 100% of the public visit fee from insurance companies if the patient goes to the private sector; he/she will receive the fee for 3 public visits from insurance companies if the patients go to the public sector" (S 1).Budget provision: According to the senior managers of the Ministry of Health and Medical Education, the financing of this program greatly fluctuated, thereby impacting the realization of its objectives. According to the reviewed documents, the budget required for the urban family physician program was foreseen and approved in the budget law, but was not paid for years due to various reasons (including a change of ministers and governments)."Providing resources is another issue in this area. For example, the family physician program was planned to start in 2011 but there was no budget then" (M 5).Budget allocation: The allocation and use of the budget guarantee the implementation of the urban family physician program in the two provinces. This requires the efforts of authorities of the program, which has been absent for years impacted the program.th government that came to power did not have a plan to allocate budget to the program, and this was practically postponed until the end of the year" (M 6)."The 11- Referral system: In the urban family physician program, an effective referral system ensures close communication between all three levels of the health system, including family physicians, specialists, and subspecialists. It also helps people receive the best possible care in the nearest location."Providing level 2 and level 3 infrastructures is very important. If level 2 refers to a specialist who is sitting in his/her office, then we must admit that the infrastructure is not ready yet" (M 24).Another issue is the effective communication between various levels of the referral system."We are only referring to the second and third levels, but unfortunately we don't receive valuable feedback. I don't remember the exact number, but when I've been referring patients, I referred only five or six patients who gave me valuable feedback, which had an educational advantage for me" (M 37).According to the family physicians, the coordination between family physicians at the first level and specialists at the second level was limited to a referral sheet, and there was no other communication."Specialists have virtually no communication with family physicians; they only know that the referral sheet consists of two pages, with one side filled out by the family physician and the other by them in response to the family physician" (M 38).Inter- and intra-sectoral communication: Inter- and intra-organizational coordination at different levels is of particular importance. At the urban and provincial levels, the coordination between various deputies in medical universities, and between the family physician’s team and other departments to ensure the proper implementation of the referral system greatly helps advance the process."The dean of the university was definitely in the meetings that they were holding, and if he wasn’t, he would have asked some else to represent him. But the reason for the lack of coordination was that the therapists thought that it is the responsibility of the health system, which was not the case. Some coordination between us was good, though" (M 22).Advanced healthcare systems in the world are equipped with powerful and advanced information systems. Information technology is useful for the family physician and is also essential for access to an advanced healthcare system.Electronic files: Urban family physicians need information recording software. This software provides physicians with patients’ information centrally, and provides program managers with more comprehensive information such as the medication and equipment, the type of services provided to the client, and his communication with different levels."A big problem of the program was the software, as the Iranians’ health software was also the software of the program. We entered the patients' information, medical history, and national ID number, and we were online. The big drawback was that the software was being upgraded, which meant that we didn't have the upgraded software when starting the program. We were saying, let’s start the program. However, when we started the program, four months later, we found out that we need this and that in the system, which was not even ready for six months. After six months when the system was finally ready, we found that the system is wrong here or does not work there." (M 23)A lack of strong information technology infrastructure was another serious obstacle to the urban family physician, which needed to be resolved at the highest levels of the healthcare system."Completing and strengthening the IT infrastructure in the country is, doubtless, very important for electronic files, copying, electronic referrals, etc., and with the improvement of this system, works will be much easier" (M 12).Internet: The existence of software and electronic records requires access to the Internet in both public clinics and private offices. The participants believed that:"At the urban level, we had no problem in terms of hardware infrastructure in the public sector as we had prepared all these facilities before the official implementation of the program. But in the private sector, this infrastructure was not ready, and even to this day, some physicians have not done their work in their office" (M 22).The required human resources for the urban family physician program include the family physician specialist and his/her team.A family physician is a specialty with a generally preventive and health-oriented rather than therapeutic approach.Education system: From the outset, the medical education system in Iran has trained GPs with an emphasis on the centralized treatment approach; therefore, it cannot easily cope with the family physician’s health-oriented approach and achieve the goals of the program."One of our problems is that physicians are not family physicians. We trained them to be physicians who treat, and this is not their fault. So, both the science we taught them and their role model were different. We all earn money from treatment, not health and prevention. These physicians have had no proper education on health and prevention, no proper observation of models, and even no income from health and prevention, so they just sit in their office and write prescriptions" (M 1).Motivation"It would be much better if, from time to time, some meetings were held for family physicians to express their problems and offer solutions. Unfortunately, this does not happen at all" (M 40).Experience of ministers: The policy-makers of the family physician program have not had enough experience and expertise to manage the healthcare system and, consequently, the urban family physician program. Since it takes at least a few months for a minister to take the office, it takes him/her a while to figure out what the program means and what the plans are. Therefore, the lack of experience of people who are appointed as ministers can negatively affect the implementation of the program." Except for Dr. Pezeshkian who was the Deputy Minister, among the five Ministers of Health that we've had during the implementation of the program, no one had any experience with the country’s senior management" (M 5).The implementation of the family physician program partly relies on information sharing and culture building. In this regard, culture building for the program among people and service providers is essential.Culture building: To implement the urban family physician program, culture building should be actively done to orient the public’s mentality towards the program. The increased dissatisfaction and complaints about the urban family physician program may partly be related to this problem."If this program had been well explained to people, we would have created a good culture. If we had spent a few years explaining this program to people, we might not have faced the problems we are dealing with now" .Information sharing: Insufficient sharing of information before the implementation of the program has caused many problems for the program providers, e.g., the large number of people visiting family physicians at the beginning of the program, disruption of the patient referral process, and patients’ dissatisfaction."Except for television, and especially the provincial television, the media did not advertise the program. Newspapers were less involved with the program. Television aired a weekly interview and presented the report or provided guidance" (M 23).According to the program implementers, the physical space, facilities, and equipment necessary for the implementation of the program were set in place, especially in the public sector and before program implementation."We had no problem with the hardware … There was no problem with the location and physical space" (M 23)."We had no problem at the urban level in terms of hardware infrastructure in the governmental sector … We easily prepared these facilities even before the official implementation of the program” (M 22).The family physician policy to establish a referral system has been the second major pivotal reform in the Iranian healthcare system. According to the findings, despite the positive steps taken to strengthen the service leveling system, this program still faces challenges that can be classified into two main categories of underlying/contextual factors, and challenges of program establishment and implementation.According to Grindle and Thomas, underlying factors play a limiting or facilitating role in the development, implementation, and expansion of the urban family physician program . The preThe economic condition in the early years of program implementation was another influential situational factor. Due to sanctions, the priority of family physician program in the health system was undermined; still, like other studies conducted in Iran that have addressed the impact of sanctions on the pharmaceutical market , the impThe findings related to structural factors suggest that developmental plans and programs drawn up by one government and submitted to the parliament for approval may not be accepted; even with the approval, their implementation depends on the next government’s political view. This problem has previously been reported by an Iranian study . In thisThe effects of cultural factors on health policies and their prominent role have been widely reported , 38. As Iran’s average position in the global ranking has put pressure on health authorities and policy-makers to solve the problems, and this impact on the family physician program in Iran has also been reported in other studies .The results concerning program establishment and implementation revealed that the program was implemented without complete provision of information sharing, cultural infrastructure, and communications. The common perception was that some of these problems would be resolved after program implementation . The proBefore program implementation, sufficient coordination had been made between different levels of the referral system, but the communication between these levels was not well-established during implementation. The use of low-level capabilities of the health system to achieve its goals, such as improving the quality of services, has been reported in previous studies .While launching and expanding the program, the software infrastructure for creating electronic health records was not ready, and this problem persisted for the first 3 years of this study. This problem was noted by previous studies as well . A natioThe establishment and implementation of the program have been affected by the education and training of treatment-oriented GPs by the education system who find it difficult to understand the concept of family physician principles . The lack of material motives for physicians was also mentioned. Family physicians’ lack of involvement in decisions related to the program is caused by this lack of motives .The results concerning information sharing and culture building indicated that, in the previous system, people used to refer directly to specialists for any disease which formed a wrong culture. Factors such as the lack of trust in the family physician, excessive referral to the family physician, and dissatisfaction with the referral system are the consequences of this culture. This dissatisfaction with the urban family physician program reported in previous studies  and hereThe findings demonstrated that the required physical space, facilities, and equipment were ready for the establishment and implementation of the program. The readiness of the PHC infrastructure in the public sector and the significant participation of the private sector in cities seem to have been the main reasons for this success.Researchers had difficulties in getting access to policy makers and program managers. Sometimes they had to wait up to one or 2 months to do an interview or request an interview by frequent visits to their offices. This problem was partially resolved by coordination with officials and policy makers as well as corporation of president of Kerman university.However, this issue was not considerable when there were meetings or gatherings. As in these meetings researchers could meet managers and conduct an interview or set a timer for interviews.Conclusion.Some managers and policy makers who attended an interview gave politically acceptable answers, considering their role and job responsibilities. They expressed speeches from a political point of view rather than scientific view. However, an attempt was made to reduce the problem by explaining the objectives of the research to the interviewees. Various underlying factors affected the piloting of the urban family physician and caused the program to experience many ups and downs. The program has continued to this day despite the impact of underlying factors, but it is still limited to two provinces of Fars and Mazandaran and there is no plan to expand it to other provinces. Based on the findings, numerous underlying factors and challenges have impacted the urban family physician program implementation. As for underlying factors, globalization and international pressure for reform to improve Iran’s position in the global ranking, precipitancy, a change of policy-makers and programs, and sanction-induced economic conditions were influential factors on the implementation and continuation of the program. In terms of establishing and implementing the program, budget provision, interaction with insurance organizations, referral system, communication between different levels, and electronic health records were the effective factors. To expand the program to other provinces, policy-makers and planners are recommended to focus more on the above-mentioned factors and reformulate the program accordingly.


As the COVID-19 pandemic spread, the Japanese government declared a state of emergency on April 7, 2020 for seven prefectures, and on April 16, 2020 for all prefectures. The Japanese Prime Minister and governors requested people to adopt self-restraint behaviors, including working from home and refraining from visiting nightlife spots. However, the effectiveness of the mobility change due to such requests in reducing the spread of COVID-19 has been little investigated. The present study examined the association of the mobility change in working, nightlife, and residential places and the COVID-19 outbreaks in Tokyo, Osaka, and Nagoya metropolitan areas in Japan.First, we calculated the daily mobility change in working, nightlife, and residential places compared to the mobility before the outbreak using mobile device data. Second, we estimated the sensitivity of mobility changes to the reproduction number by generalized least squares.Mobility change had already started in March, 2020. However, mobility reduction in nightlife places was particularly significant due to the state of emergency declaration. Although the mobility in each place type was associated with the COVID-19 outbreak, the mobility changes in nightlife places were more significantly associated with the outbreak than those in the other place types. There were regional differences in intensity of sensitivity among each metropolitan area.Our findings indicated the effectiveness of the mobility changes, particularly in nightlife places, in reducing the outbreak of COVID-19. The present study aimed to examine the mobility changes in work, nightlife, and residential places in Japan based on mobile device data and to clarify the association of mobility change at these places with COVID-19 incidences.With the global spread of the novel coronavirus disease COVID-19), many countries have implemented non-pharmaceutical interventions, including lockdowns and travel restrictions, to control the pandemic.9, many cWe observed the mobility changes resulting from the outbreak of COVID-19 in three major metropolitan areas—Tokyo, Osaka, and Nagoya—from March 1 to July 31, 2020. Although there are multiple definitions of metropolitan areas in Japan, in this study, Tokyo, Kanagawa, Saitama, and Chiba Prefectures were defined as the Tokyo metropolitan area; Osaka, Kyoto, Hyogo, Shiga, Nara, and Wakayama Prefectures were defined as the Osaka metropolitan area; and Aichi, Gifu, and Mie Prefectures were defined as the Nagoya metropolitan area.12 were employed as the mobility data. We classified the grids into work, nightlife, or residential place based on the median of population at specific times  of each weekday from January 3 to February 6, 2020. When the median of daytime population was 10,000 or more and twice as large as the median of midnight population, the corresponding grid was designated as a “workplace”. When the median of nighttime population was 10,000 or more and twice as large as the median of midnight population, the grid was designated as a “nightlife place”. When the median of midnight population was 100 or more and smaller than the median of daytime population, the grid was set as a “residential place”.“Mobile Spatial Statistics” , which provide the estimated hourly population in a 500-m-square grid based on mobile device locations,m of each specific place type p on day t is as follows:pPop,t is the total hourly population in p at specific times  on day t. The baseline in each place type (pB) was defined according to the median of the total hourly population at the corresponding time on a day, from January 3 to February 6, 2020. In the statistical analysis described below, we employed a 7-day moving average to exclude the day-of-the-week effects on the daily mobility change index, m. The moving average M of each specific place type p on the day t is as follows:For the mobility change index of each place type, we determined the ratio of the daily population to the baseline population in each grid from March to July 2020. Specifically, the mobility change index 13 which summarizes the press releases of confirmed cases published by local governments. We counted the number of daily positive cases, excluding re-positive cases, by each metropolitan area based on the confirmed date (or reported date if confirmed date of the case is unknown).For obtaining the daily counts of positively confirmed cases, we used the open-source epidemiological data provided by J.A.G JAPAN Corp,t, ty:α, β0, β1, and ρ are parameters to be estimated through generalized least squares. The response variable, ty, is defined as:ic is the number of daily confirmed cases on day i. In the model, the coefficient, tβ, is the increasing rate of the 7-day cumulative cases, ty, compared to the earlier 7 days  by each specific place type and metropolitan area. In addition, with the independent and identically distributed white noise, tω ∼ iidN, we used the first-order autoregressive error, tε, to adjust the temporal dependency caused by unknown factors, where ρ is the so-called autocorrelation parameter; E(tε) = 0, Var(tε) = σ2/(1 − ρ2), and Cov = ρσ2/(1 − ρ2).To evaluate the relationship between mobility changes and COVID-19 incidences, we employed the following model (model 1) to predict the cumulative number of confirmed cases in the last 7 days beginning from day tβ is simultaneously dependent on the mobility change indices of all place types to improve the predictive accuracy of the model (model 2). In this model, tβ is as follows:p (pL), we substituted the optimal value for each place type determined through the results of model 1 in the respective metropolitan areas.We also considered the model in which Although the mobility change indices in workplaces and nightlife places had already declined slightly as of early March, it showed a drastic downward trend in all regions from late March, before SOE was declared Figure B. Becausβ1 and the optimal lag period of the models with the single mobility change index (model 1), the mobility changes in workplaces and nightlife places were positively associated with the incidence after 8 to 16 days in all metropolitan areas, and the residential places’ mobility was negatively associated  slightly improved the accuracy of predicting the number of new positive cases, their results also indicate that the mobility changes in nightlife places were more significantly associated with the outbreak than those in workplaces and residential places in each metropolitan area . Moreover, the models with all mobility change variables (model 2) showed that the mobility changes in residential places were slightly related to the outbreak only in the Nagoya metropolitan area, but those in the Tokyo and Osaka metropolitan areas were not. These findings suggest that there may still be various opportunities having risks of infection  in largely populated regions, such as the Tokyo and Osaka metropolitan areas, even though mobility was reduced in highly-sensitive places, and the stay-at-home population increased.Our study has several limitations. First, we used the confirmed date to compile the incidence data, because several local governments have not disclosed their onset date, but ideally the date of illness onset would more properly reflect the epidemic dynamics. The differences in the optimal lag periods among the metropolitan areas could possibly be explained by regional differences in the period from onset to diagnosis/reporting, due to the testing system. Second, the choice of “place” we analyzed was defined only by the ratio of population during a specific time, and there is a possibility that some places might have been wrongly identified as nightlife places. However, we manually ascertained that the primary business/nightlife districts are correctly included in workplaces/nightlife places that we defined . Third, Our study’s findings can be used for designing future public health and social measures against COVID-19. The results indicate that mobility reduction, particularly in nightlife places, may contribute to reducing the transmission of infectious diseases. This will help in implementing mobility reduction at appropriate places in the future.


Oxidative stress in the rostral ventrolateral medulla (RVLM), a key region for blood pressure (BP) regulation, has been demonstrated to be responsible for the overactivity of the sympathetic nervous system in hypertension and heart failure. Nuclear factor-erythroid-2-related factor 2 (Nrf2) is a key transcription factor that maintains redox homeostasis by governing a broad array of antioxidant genes in response to oxidative stress. β-Arrestin1 is a multifunctional scaffold protein with the ability to interact with diverse signaling molecules independent of G protein-coupled receptors (GPCRs), and its overexpression in the RVLM could reduce BP and renal sympathetic nerve activity (RSNA) in spontaneously hypertensive rats (SHR). The goal of this study was to investigate whether Nrf2-mediated antioxidative stress is involved in the antihypertensive effect of β-arrestin1 in the RVLM. It was found that the activation level of Nrf2 in the RVLM of SHR was significantly reduced, compared with normotensive Wistar-Kyoko (WKY) rats. Overexpression of β-arrestin1 in the RVLM significantly decreased ROS production and facilitated the Nrf2 activation in the RVLM of SHR, accompanied by upregulating the expression of HO-1 and NQO-1. However, Nrf2 knockdown attenuated the antioxidant effect of β-arrestin1 overexpression in the RVLM by downregulating HO-1 and NQO-1 expression levels. In conclusion, the current results suggested that the antihypertensive effect of β-arrestin1 overexpression in the RVLM is mediated by decreased ROS production, which is associated with Nrf2 activation. Oxidative stress occurs when the balance between the oxidation and antioxidant systems is broken, which results in the accumulation of reactive oxygen species (ROS) . Oxidatiβ-Arrestin is a key regulatory protein of G protein-coupled receptor (GPCR), including β-arrestin1 and β-arrestin2. β-Arrestin plays a negative role in regulating GPCR by regulating desensitization and endocytosis and mediating cell signal transduction . Recent in vivo (in vitro and in vivo phosphorylation of Nrf2 on Ser40 by protein kinase C facilitates the dissociation of Nrf2 from the Keap1 complex. Phosphorylated Nrf2 (p-Nrf2) is involved in the nuclear translocation and antioxidant response element (ARE) transactivation of Nrf2 (Recent studies have reported that nuclear factor-erythroid-2-related factor 2 (Nrf2), a key transcription factor, is involved in the regulation of the antioxidant system in vivo . It has  of Nrf2 . Accumul of Nrf2 . It is r of Nrf2 . Convers of Nrf2 . Taken tAccordingly, the present study is designed to investigate whether the Nrf2 pathway contributes to reduce oxidative stress in the RVLM and mediate the antihypertensive effect of β-arrestin1. Two main aims in this study need to determine (1) if β-arrestin1 in the RVLM exerts antihypertensive effects by attenuating the level of oxidative stress and (2) if Nrf2 mediates the antihypertensive effects of β-arrestin1 by regulating oxidative stress.ad libitum.A total of 70 male SHR and 40 male WKY rats were used in the experiment. The rats weighing 250–350 g were 16 weeks old and purchased from Vital River Laboratory Animal Technology Co. Ltd. . All procedures obtained approval from the Institutional Animal Care and Use Committee of Naval Medical University, and all experimental operations involving the use of animals in the present study strictly complied with the requirements in the Guide for the Care and Use of Laboratory Animals published by the US National Institutes of Health. Experimental rats were kept in a 12-h light and 12-h dark animal room, and they were allowed access to food and water NM_012910) (AAV-Arrb1). The control AAV contained all sequences except the Arrb1 gene and was labeled by green fluorescence protein (AAV-GFP). The final infectious titer of AAVs for β-arrestin1 was 1.2 × 109 transducing units/ml.In brief, as described previously , the oveThe rats were anesthetized by inhaling 3% isoflurane and fixed in the stereotaxic frame. As previously described , brieflyTM-in vivo kit was purchased from Engreen Biosystem Co, Ltd . According to the operation manual, the transfection complex was composed of siRNA, EntransterTM-in vivo, and DEPC water according to the ratio of 2:1:1, and the final concentration of siRNA in the transfection complex was 500 μM. To verify the efficiency of Nrf2 knockdown, the Nrf2 siRNA transfection complex (1 μl) was injected bilateral into the RVLM of WKY rats, and the rats were sacrificed at 24, 48, and 72 h after injection. Nrf2 protein expression was detected by Western blot to determine the most appropriate time for Nrf2 knockdown. Two weeks after overexpression of β-arrestin1 in the RVLM, SHRs were anesthetized and 1 μl transfection complex was microinjected bilaterally into the RVLM. The rat was anesthetized, and the brain was quickly removed 24 h later. SHRs were divided into four groups as follows, for different treatments: GFP-NC, GFP-Nrf2 siRNA, Arrb1-NC, and Arrb1-Nrf2 siRNA.The siRNA that specifically interferes with the expression of Nrf2 protein was designed and synthesized by Shanghai Gene Pharmaceutical Co., Ltd. . The sequence of the specific siRNA against Nrf2 was as follows: sense (5′–3′) UUUGAGUCUAAGGAGUUCAGCUGGC, antisense (5′–′3) GCCAGCUGAACUCCUUAGACUCAAA, and the scramble sequence was used as the negative control (NC). As described previously , the traAs described in our previous study , the BP 2) concentration was monitored by a CO2 analyzer  and kept at the level of ∼4%. The right femoral artery was catheterized for BP and HR recording with the PowerLab system . MAP and HR were obtained from the BP pulse.Before the rats were sacrificed, the BP and HR in the anesthetized rats  were recorded through femoral artery cannulation. In brief, the trachea of anesthetized rats was cannulated to facilitate respiration with a ventilator . The end-tidal carbon dioxide , a ROS-sensitive fluorescent dye. DHE was dehydrogenated by ROS to produce ethidium. Ethidium binds to RNA or DNA to produce a red fluorescence. According to our previous study , the braAccording to our previous study , rats weThe protocols of immunofluorescence were described previously . In briet-test was used. BP is expressed by mean arterial pressure. The BP monitored continuously on conscious rats were analyzed by repeated-measures ANOVA. In the Nrf2 siRNA knockdown efficiency test experiment, the expression difference of Nrf2 was analyzed by one-way ANOVA followed by Bonferroni’s post hoc test. All the other value differences were analyzed by two-way ANOVA followed by Turkey’s post hoc test. All the data were analyzed by GraphPad Prism 6.0 . P-values of <0.05 were considered statistically significant.All data were examined as mean ± SE. When only two groups of data, SHR and WKY, were compared, the unpaired Student’s Consistent with our previous results , compareAs shown in At first, the expression of p-Nrf2 in the RVLM was significantly decreased in SHR than that in WKY rats. Meanwhile, the expressions of HO-1 and NQO-1, both downstream antioxidant proteins of p-Nrf2, were also significantly reduced in SHR compared with WKY rats. However, the expression levels of Nrf2 and Keap1 were not changed significantly .After overexpression of β-arrestin1, the level of p-Nrf2 expression in the RVLM of the AAV-Arrb1 group was markedly increased compared with the AAV-GFP group in SHR, accompanied by upregulation of the expression of HO-1 and NQO-1 , while tIn order to verify the efficiency of Nrf2 knockdown, Western blot was used to detect the protein expressions of Nrf2 at 24, 48, and 72 h after Nrf2 siRNA injection into the RVLM. Compared with the NC group, the protein expressions of Nrf2 at 24, 48, and 72 h after siRNA injection were significantly reduced, and there was no significant difference between the three groups . TherefoThe present study reveals the effect of β-arrestin1 on oxidative stress and confirms that β-arrestin1 exerts an antihypertensive effect mediated by Nrf2 activation. In this study, the major findings are that (1) overexpression of β-arrestin1 improved the cardiovascular dysfunction in SHR by decreasing the level of ROS in the RVLM and (2) overexpression of β-arrestin1 facilitated the Nrf2 activation in the RVLM of SHR, while Nrf2 knockdown reversed the antioxidant stress effect of overexpression of β-arrestin1. Based on our findings, it is indicated that the overexpression of β-arrestin1 decreases the BP as a result of its antioxidant effect mediated by facilitating Nrf2 in hypertension.in vivo and in vitro. Combining with the results of our previous and current in vivo experiments, it is suggested that overexpression of β-arrestin1 in the RVLM exerts antihypertensive effects, which is mediated not only by reducing the expression of AT1R but also by reducing oxidative stress. These findings suggest that β-arrestin1 in the RVLM is involved in the neural regulation of cardiovascular function through multiple mechanisms.β-Arrestin1 in the RVLM is involved in the neural regulation of BP and has the effect of improving the cardiovascular function of SHR, but its detailed mechanism is still unclear. Our previous studies have confirmed that overexpression of β-arrestin1 in the RVLM reduces BP and sympathetic outflow in hypertension by downregulating the expression of angiotensin type I receptors (AT1R) and revealed that this effect is mediated through the enhancement of interaction β-arrestin1 and IκB-α . ConversA large amount of research evidence has shown that increased levels of oxidative stress in the RVLM contributes to sympathetic output and increases BP, and abnormal enhancement of the renin–angiotensin system (RAS) in the RVLM promotes oxidative stress . Our preExcessive generation of ROS is an important aspect of oxidative stress. The increased activities of NADPH oxidase, myeloperoxidase, and cytochrome P450 monooxygenase; nitric oxide synthase uncoupling; and mitochondrial respiratory chain dysfunction contribute to the ROS production . On the In the light of the research results of our and other teams , knockdoAlthough the present study confirms the relationship between β-arrestin1’s anti-hypertension and oxidative stress, there are also some limitations. First, this study has not carried out further exploratory experiments on the specific pathway through which β-arrestin1 promotes the activation of Nrf2. It has been reported that thrombin can activate the PI3K/Akt signaling pathway mediated by Gα and β-arrestin1 in IIC9 cells . Under tIn conclusion, we have demonstrated that the overexpression of β-arrestin1 in the RVLM exerts an antihypertensive effect mediated by a decrease in ROS production, which is associated with Nrf2 activation . These fThe datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/The animal study was reviewed and approved by the Institutional Animal Care and Use Committee of Naval Medical University.XT, P-LJ, and J-CS contributed to conduct the experiments. WW, PY, and Y-QL collected and analyzed the data of the study. XT drafted the initial version of the manuscript. Y-KW and W-ZW provided revisions on the manuscript. All authors have read and approved the final version of the manuscript for publication.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.


Evidence indicates family caregivers of individuals living with dementia (ILwD) are at risk for diminished physical and mental health; which may decrease their quality of life and directly impact their ability to provide care. An interdisciplinary approach to self-care and skill-building for caregivers is provided in a virtual support group offered by Council on Aging in Sonoma County, CA. As part of the nonprofit’s Adult Day Program, the group is offered to client caregivers and has two goals: First, creating a community-based, long-term support system for ILwD who are aging-in-place; second, fostering a safe and supportive community for family caregivers, by providing opportunities to collaborate with peers and an interdisciplinary team that includes a Marriage and Family Therapist (MFT), an Occupational Therapist (OT), and a Recreation Therapist (the day program manager). The closed group model established through eight weekly sessions builds trusting relationships in a frame that combines: the OT client-centered and collaborative approach to problem-solving everyday challenges of caregiving, the MFT skills of creating a safe space for discussion and deeper exploration, and program staff insights regarding the ILwD’s current interests and abilities exhibited during Day Program activities. Sessions include an emotional check-in by group members; a brief overview of best-practices and common caregiving concerns related to a weekly topic; and an opportunity for caregivers to explore the integration of best-practices into daily routines, while also attending to their well-being as caregivers. Program evaluation and results related to the program’s effectiveness and implications for scalability will be discussed.


Complex healthcare systems increasingly demand influential nurse leaders adept at managing changes in unstable environments. The doctor of nursing practice (DNP) prepares the nurses for the most advanced level of clinical practice. The aim of this study was to explore the necessity of establishing a DNP program in Iran from experts’ views.The study used a qualitative descriptive approach. The participants consisted of 13 faculty members and Ph.D. candidates selected using purposive sampling. Data were collected through focus group and semi-structured interviews, and analyzed using qualitative content analysis.The content analysis led to the extraction of two main categories: “providing infrastructures” and “DNP as an opportunity to make positive outcomes.“It is concluded that it is not necessary to establish a DNP program for Iran’s nursing education system. Supplying infrastructures is a crucial component to establishing a new program in Iran. Although DNP, as an opportunity to drive positive changes, is recommended, in the current situation, using alternative solutions may yield better outcomes than establishing a DNP program.The online version contains supplementary material available at 10.1186/s12909-021-02758-w. Healthcare systems are rapidly evolving. Complex healthcare landscapes increasingly demand influential nurse leaders adept at managing changes in unstable environments . A nursiGenerally, there are two kinds of terminal degrees in the nursing profession: the Doctor of Philosophy (Ph.D.) and the Doctor of Nursing Practice (DNP). The focus of the Ph.D. degree is on research and knowledge generation, aiming at advancing the theoretical foundations of the profession, while the DNP degree is a practice-focused doctorate. The scope of DNP programs is varied, but “specialty competencies” are the core of all advanced practice roles .DNP is a powerful strategy to prepare nurses for the most advanced clinical nursing practice level, i.e. “providing leadership for evidence-based practice” . It focuIn 2004, the American Association of Colleges of Nursing (AACN) members endorsed the DNP degree for advanced practice registered nurses to better align nursing with other health professionals by 2015 . The NatThe combined knowledge and skills of both DNP and Ph.D. nurses can decrease the gap between theory and practice. Collaboration among nurses with DNP and Ph.D. degrees to advance the knowledge and translate the research into practice provides educational opportunities, facilitates healthcare delivery, and improves desired outcomes .In Iran, nursing education is a university-based program and includes the Bachelor of Science, the Master of Science, and Ph.D. in nursing. A bachelor’s degree is required for registered nurses, and it is the basic nursing program at the academic level. This program lasts for four years and requires students to complete at least 130 credits of coursework and training. Clinical training starts from the second semester simultaneously with theoretical courses and ends at the end of the sixth semester, and the curriculum is completed in a full-time internship period , 10.MSN programs are 2 to 3 years in length and involve 30 to 44 credits, depending on each university’s policies. Usually, in the third semester, four to six modules are assigned to the dissertation project. An MSN curriculum content focuses on theoretical knowledge, research, statistical analysis, and, to a lesser extent, clinical courses. Although MSN programs aim to develop registered nurses’ knowledge and clinical competency, most of these programs focus on theoretical knowledge rather than practical skills. The greatest incentive for registered nurses to participate in MS programs is financial advantages followed by leaving clinical settings for educational environments  due to pThe first Ph.D. program was launched at the Tabriz University of Medical Sciences, Iran, in 1992. It lasted 4–5 years, and Ph.D. candidates completed 45credits, including 20 credits of dissertation. The program included two courses on education and research .In recent years, the nursing profession in Iran has made significant advancements in various nursing practices, such as hospital-based practice, critical care nursing, primary healthcare, community-based care , spirituIn Iran, doctoral programs in nursing are limited to a Ph.D. degree, and large numbers of nurse educators and Ph.D. candidates seek a doctoral degree for attaining tenure and promotion in universities. There are few clinical positions for Ph.D. graduates and those preferring academic and research roles . In compDNP programs initially started in the United States, Canada, and the United Kingdom. Healthcare systems’ complexity in South and South-East Asian Countries has led to changes in these programs . There iIn 2013, AACN reported that 241 colleges and universities across the United States offered DNP degrees . DespiteThere is no consensus on whether DNP programs are required in Iran’s nursing education system; an issue that should be explored by specialists. Due to differences in the social, political, economic, and cultural contexts of the healthcare system in Iran, this qualitative study aimed to explore the necessity of establishing a DNP program in Iran from experts’ views.The study used qualitative content analysis with a naturalistic paradigm. The paradigm includes beliefs and values forming a conceptual and theoretical framework to answer research questions . NaturalThe participants consisted of 13 faculty members and Ph.D. candidates selected using purposive sampling . We seleAt first, we collected data using focus group discussion with 11 of the participants. Then, we conducted individual semi-structured face-to-face interviews with two professors in nursing education, who were members of the Iranian Board of Nursing from March 2016 to June 2017. The synergistic nature of focus group discussion and its social interactions motivate participants to speak up, producing rich data . The intThe researchers carefully developed the focus group and had an interest and insight into the research topic. Author 3 facilitated the group discussion. Managing the focus group session included delivering a prepared introduction, welcoming the interviewees, overviewing the topic, answering questions, and beginning the discussion by asking an open-ended question. In the focus group interview, the interviewers were familiar with the participants. In healthcare studies, familiarity between researchers and participants can be helpful because the ‘warm up’ time is short and thus the interview can be started rapidly. The interviews continued until data saturation, i.e. “sampling to redundancy” . In our Data analysis was carried out simultaneously with data collection  using thWe applied four criteria proposed by Lincoln and Guba to evaluate trustworthiness, including credibility, dependability, conformability, and transferability . TrianguThe participants included 11 women and 2 men. Demographic characteristics of the participants are summarized in Table Most of the participants considered the adequate provision of infrastructure resources essential before establishing DNP. This theme yielded the two following categories:1–1. “Basic infrastructures”.Insufficient basic infrastructures were considered among the significant concerns for transition to DNP and included the following subcategories: need assessment in different levels, adequate resources , role/position definition, salary, evaluation factors facilitating or inhibiting this transition using DNP executive countries’ experiences, and cultural adaptations.In this regard, the participants stated:“I think infrastructure must first be provided. The roles of DNP nurses should be clearly defined; otherwise, it can lead to a big challenge” (# 4).“We require the need assessment program at colleges, hospitals, and the community levels” (# 11).“The DNP setup should be based on the needs and context of the Iranian community.” (# 10).“At present, Ph.D. graduates do not have a suitable passion in clinical settings. Definition of the new program is ambiguous….” I do not think the DNP launch will be successful. Even cultural adaptation is important”. (# 3)“The fact that the DNP program exists only in developed countries is not a sufficient reason for the establishment of the DNP program in Iran. The proliferation of DNP degree programs in some developed countries has created a series of challenges and confusions …” (# 5).1–2. “Challenges of developing a DNP program without providing infrastructures”.From the participants’ views, graduates’ frustration after unsuccessful DNP performance, waste time and costs, a lack of guarantees for promoting patient outcomes, inadequate support for promoting the profession, the burden on the healthcare system, and blind imitation of western countries formed subcategories.“The DNP is not a certain solution for ensuring the quality of care, and the unsuccessful implementation will lead to the graduates’ frustration”. (# 9)“The unplanned implementation of the DNP will lead to wasting costs and time” (# 2).The second theme yielded the two following categories:2.1. “DNP to meet the patients’ newly emerging needs”.Application of knowledge to practice, development of clinical nursing practice, technological advances, patients’ changing needs, and healthcare systems’ complexity are critical factors in improving specialized care. Weaknesses of Ph.D. programs in improving clinical competency in graduates were another critical concern among the participants.“Nurses need to achieve a more significant role in the clinical settings and policies. One of the weaknesses of the Ph.D. program is a theory-based curriculum. Graduates increase their distance from the clinical settings by upgrading their degree.” (# 13).“I believe nurses with practice doctorate can apply knowledge in a practice to solve the problems.” (#6).2–2. “Improvement of patient outcomes”.This category included three subcategories: evidence-based practice development, decrease in the theory–practice gap, and advancement of nurses’ roles. Evidence-based practice is the gold standard for safe care provision. This approach has a significant role in improving patient outcomes and reducing the theory-practice gap.“Evidence-based nursing can bridge the gap between research findings and clinical practice.” (# 12).“…No doubt, we need the DNP because one of the major challenges in nursing education is the theory-practice gap. Maybe, this strategy helps to improve quality of care” (# 1).This study explored experts’ views on the necessity of establishing a DNP program in Iran. Although DNP-prepared nurses may promote the profession at the leadership level and improve the quality of care and patient safety, they have an evident concern about their management and organization in clinical settings. Our findings revealed that insufficient infrastructures were essential obstacles to establishing a DNP program in Iran. Insufficient infrastructures were mainly related to need assessment, resources , role/position definition, salary, cultural adaptation. The Iranian Medical Education Context is physician-centered, and nurses do not have enough authority to drive positive changes in healthcare settings. This finding is similar to that of the study conducted by Vahedian-Azimi et al. . The resAmbiguity in DNP graduates’ role was another significant concern. The findings are consistent with those of Udlis and Mancuso . MultiplTransition to a practice doctorate level will be expensive regarding resources and other factors. McCauley et al.  stated tIn contrast, recommending the DNP degree without focusing on research is not applicable, which is a challenge for DNP executive countries. It is essential to equip DNP students with clinical research skills, quality advancement competencies, and opportunities to apply knowledge in the practice of desirable healthcare delivery . TherefoOn the other hand, failure to apply the knowledge generated by Ph.D. graduates and improve care quality has been the motive to fill this gap. Brown and Crabtree  noted thMurphy et al.  believedDue to the qualitative design of the study with purposive sampling, generalization of research findings to the larger population is limited.It is concluded that it is not necessary to establish a DNP program for Iran’s nursing education system. Supplying infrastructures is a crucial component to establishing a DNP program in Iran. Inadequate resources, as well as cultural, social, economic, and political differences in developing countries, especially Iran, compared to developed countries, are significant limitations in implementing DNP. Therefore, a new program should be developed more carefully based on the health system’s needs, the society’s requirements, and doctoral candidates’ expectations. Before shifting to a new paradigm, its advantages and disadvantages should be carefully evaluated and criticized in each society’s cultural context. Although DNP, as an opportunity to drive positive changes, is recommended in nursing education, in the current situation, using alternative solutions may yield better outcomes than establishing a DNP program. In this regard, revising the curriculum, developing MSN levels, and modifying and refining the Ph.D. program, such as creating fellowship programs with a focus on clinical practice, may improve patient outcomes and decrease the theory-practice gap.Currently, the COVID-19 pandemic has highlighted the valuable role of physicians and healthcare providers, especially front-line nurses, in saving patients’ lives in Iran and around the world. In developed countries, DNP nurses may play an essential role in resolving this global crisis through evidence-based practice, critical thinking, resource management, health economics, health technology, and leadership at the national and international levels. Therefore, due to insufficient evidence on this issue, it is recommended to address DNP nurses’ specialized role with respect to the novel coronavirus in future studies.Additional file 1.


Traditional understanding of urban income segregation is largely based on static coarse-grained residential patterns. However, these do not capture the income segregation experience implied by the rich social interactions that happen in places that may relate to individual choices, opportunities, and mobility behavior. Using a large-scale high-resolution mobility data set of 4.5 million mobile phone users and 1.1 million places in 11 large American cities, we show that income segregation experienced in places and by individuals can differ greatly even within close spatial proximity. To further understand these fine-grained income segregation patterns, we introduce a Schelling extension of a well-known mobility model, and show that experienced income segregation is associated with an individual’s tendency to explore new places (place exploration) as well as places with visitors from different income groups . Interestingly, while the latter is more strongly associated with demographic characteristics, the former is more strongly associated with mobility behavioral variables. Our results suggest that mobility behavior plays an important role in experienced income segregation of individuals. To measure this form of income segregation, urban researchers should take into account mobility behavior and not only residential patterns. Urban income segregation is often discussed in terms of where people live. Here, the authors show that the way people experience income segregation is also associated with their mobility patterns and the places they visit. These two forces can erode the urban social fabric, dramatically affecting economic, social, and health outcomes of people living in urban areas. In particular, income segregation has been shown to impact access to important urban resources, such as housing2, community facilities3, health services4, and clean environment5. Recently, residential income segregation has been shown to have a significant effect on the economic outcome of children6.In a world of increasing urbanization, migration, and mobility, cities are becoming the epicenter of our social life. Diverse populations and social cohesion are crucial for sustainable urban development, but cities are facing rising segregation and inequality8. Because it is difficult to measure actual interactions between individuals in the real world, many studies instead quantify the potential opportunities people have to interact with others from different economic backgrounds. This is often measured as the amount of physical exposure to different income groups in one’s daily lives11, and income segregation is understood as a result of restrictions to contact with other groups12. However, most city-dwellers spend much of their time outside home14 and, interactions and encounters between people happen in specific places, not at the level of large neighborhoods or census areas. Income segregation actively experienced by people is indeed different from traditional measures of residential income segregation, and it varies by both the type of places visited and the time of the day19. Understanding the income segregation experience of individuals requires a more thorough understanding of behavior and mobility beyond residence, including individual motivation for visiting different places and encountering other groups of people.To quantify income segregation, researchers often measure or approximate actual social interactions or exposure between different income groups in cities22, explainable by urban mobility models25, and can be grouped into collective mobility behaviors26. These results suggest that experienced income segregation in the social fabric of cities might be partly encoded in universal behavior and mathematical models that explain the urban mobility patterns of people.The daily mobility of individuals in urban areas is now a well-studied subject. Research that uses call detail records or GPS locations at the city- and country-scale to measure high-resolution human movement has shown that individual mobility patterns are highly predictableUsing a large collection of micro-scale mobility data, we address how individual mobility behavior contributes to people’s experience of income segregation. Specifically, we analyze income segregation at the level of individual places in cities, and identify the main urban, behavioral, residential and mobility features associated with reduced or increased social connection and experienced income segregation in cities. Our main data source is from Cuebiq, who supplied 6-month long records of anonymized and high-resolution mobile location pings for 4.5 million devices across 11 U.S. census core-based statistical areas (CBSAs). Our second data source is a collection of ~1.1 million verified venues across all CBSAs, obtained via the Foursquare API (see Methods).27 level using their most common location between 10 p.m. and 6 a.m. Individuals are then grouped in four equally sized quantiles of SES according to the median household income of their home area  proxy. We first infer the home area of each individual at the U.S. Census Block Groupα in the city, we compute the proportion of total time spent at that place by each income quartile  when the total time across all individuals spent at the venue is split evenly among the four income quartiles. By contrast, a venue with Sα = 1 is one that is visited exclusively by a single income group, hence a higher level of segregation (see the Methods section). To define income segregation at the level of individual experience, we compute the amount of time they spend in each place and, using the place income segregation measure, calculate the relative exposure of an individual i to each income quartile q in the city . We have examined extensively that our results are robust against the specific choice of segregation metric or groups of income , for each of the cities in our data set. Surprisingly, P(Sα) is strikingly similar across a diverse array of US metro areas. These results show that the neighborhood or census area in which a place is located does not predict its income segregation profile: most areas in cities are home to both highly integrated and highly segregated places.Income segregation measured at the level of places is heterogeneous across places see Fig. e; more i28, which typically span about 20 km and contain a residential population of 150 thousand people. Figure catchment range. Place categories with lower catchment range (higher average travel distance to them) tend to be less segregated than categories that are highly accessible . We also include the average distance users need to travel from their home census block group in order to visit a place, the number of other places in the immediate area, and the median income of the block group in which a place is located. Finally, to compensate for the difference between areas within the same city, we include geographical fixed effects at the level of Public Use Microdata Areas (PUMAs)The fine-grained structure of place income segregation and the fact that individuals move much longer distance than home census areas challenges the notion that experienced income segregation in cities is driven by residential neighborhoods or well-described by census areas. As shown in Fig. ρ = − 0.173 ± 0.002) with the income of the area where the individual lives. Even individuals who live near one another can have very different income segregation experiences; as we can see in Fig. As we can see in Fig. 23, visitation patterns of individuals are rather uneven, and time spent in different places is heavy-tailed  visit and spend time in many different places while others (returners) spend most of their time in few important locations. Thus the set of important places is larger for explorers than for returners. Remarkably, we find that this exploration/exploitation behavior emerges in many other cities and geographies and is correlated with experienced income segregation: if we denote ST the total number of places visited, then returners  are found to be more segregated than explorers (with a large ST). Specifically, the correlation between experienced income segregation for individuals and the total number of places visited is high . As is well knownsee Fig. . This susee Fig. . Even ifρ = 0.579 ± 0.001), suggesting that individuals visit places of similar income segregation level to their own overall experience (see Supplementary Note ρ = 0.754 ± 0.001). This suggests that individuals tend to visit places with a given income segregation pattern throughout the city, and that there is a strong association of that pattern with the final experience of income segregation individuals have.We also find that, in general, segregated individuals visit similarly segregated places. In principle, it could be possible that an integrated (nonsegregated) individual flits between segregated places that are dominated by different income groups. However, the correlation between individual experienced income segregation and the average income segregation of visited places is high  and preferential return   model30, which quantifies whether the majority of a place’s visitors are from the same income group as the user. More specifically, we characterize each individual by their Schelling parameter or social exploration rate, σs, which is defined as their probability of visiting a new place where their income group is a minority . However, we observed in general that top places are slightly (~14%) more segregated than the rest  with observed ones  they are visited. People with a small σp (returners) spend most of their time in a small number of places that are likely near their neighborhoods, and their experienced income segregation is primarily predicted by how segregated those places are. Since top places are slightly (~14%) more segregated than the rest, this means that in general returners are more segregated than explorers, even if their σs is large. Only people with both large σs and σp, who have high rates of both social exploration and place exploration, are economically integrated and have equal exposure to all the income groups in the city. Indeed, it is important to note that individual experienced income segregation is not just driven by σs: while the results of our social-EPR model are correlated with the empirical data (ρ = 0.777 ± 0.001), the correlation between individual income segregation and σs is only moderate (ρ = −0.538 ± 0.002). Finally, both aspects of exploration seem to be largely independent from each other with only a moderate correlation . These results reinforce the idea that experienced individual income segregation depends on both the visitation patterns and the income segregation of the places where individuals spend their time. The only way to be economically integrated is to be a social and place explorer at the same time.Note that individual experienced income segregation is not explained merely by σs), and place exploration (measured by σp). What predicts an individual’s social and place exploration patterns? Traditional ways of understanding income segregation have tried to answer this question by looking at the different demographic characteristics of residential neighborhoods or workplaces. However, as we have already seen, the way we move around the city and the places we visit are important factors associated with individual experienced income segregation.The proposed social-EPR model suggests that experienced income segregation for individuals is largely described by two characteristics: social exploration  and residential variables  liσp is mostly influenced by mobility behavioral variables, i.e., types of places an individual visits and in a minor way by their geographical mobility. This result is in line with recent studies31 which report insignificant relationship between place exploration behavior and socio-economic variables. Our results indicate that place explorers can be found in any area, mostly independent of their demographics, and that the key ingredient to understand place exploration is the lifestyles of individuals. For example, knowing that an individual frequently visits Movie Theaters, Exhibits, Coffee Shops or certain types of Restaurants  can tell us more about whether an individual is a place explorer (high σp) than knowing the income level of the individual  are those that have lifestyles that include visits to Entertainment, Food and Shopping places, but not many visits to places associated with Education and certain Work places like Factory or Warehouse  predicted by the residential characteristics of a user’s neighborhood, especially education level, employment, race composition, mode of transportation, and poverty level  factors account for the remaining 45%  might also depend on individual social and place exploration. Our model thus provides a new venue to understand the nuances of how income segregation is experienced in cities, and may provide further opportunities to investigate its relation to other important aspects of city life.We demonstrate that a simple Schelling extension to a classic model of individual mobility can be used to accurately model income segregation experienced by individuals. The proposed social-EPR model provides a bridge between computational studies of human mobility34, alleviating experienced income segregation may help create more diverse and robust societies in the future.Our findings have implications for our understanding of how income segregation is experienced in cities. While income segregation is often studied in terms of neighborhoods, areas, and residences, our results show that the income segregation experienced by individuals is related to their visitation patterns and mobility behaviors. To better understand how income segregation manifests itself in cities, understanding of residential segregation should be complemented with how urban interventions and design impact both social and place exploration, i.e., where residents spend their time well beyond their neighborhoods, and with diverse groups of people. For example, transit routes, commercial development strategies and zoning, and prioritizing certain types of amenities may all affect the lifestyles of city residents, at which venues they may spend time, and by extension, with whom they have the opportunity to encounter. Our results suggest how further analysis of those interventions  may help understand the causal effect on experienced income segregation. Since spatial proximity still plays an important role in creating social relationships35. Our results therefore serve as a proxy and bound for the potential income segregation in cities. Our study focuses on income (economic) segregation and not segregation in other dimensions such as race, wealth, or ethnicity, which might be correlated but nevertheless different from income segregation. Finally, although our results are descriptive and do not imply causal relations, we believe that our findings point to important factors whose causal effect may be further tested through carefully designed experiments and interventions.Our study has several limitations. We select individuals for whom we could identify home locations during the 6-month period, and therefore exclude those who do not have a stable residence or have nonnormative work shifts . Similarly, the venues we consider are limited to those available via the Foursquare API, which might be biased towards certain types of places. We are also not able to differentiate between encounters of different nature, e.g., a casual conversation between two strangers in a coffee shop, or a financial transaction between a service worker and a high-finance bankerOur geo-location data come from Cuebiq, a location intelligence company that curates, creates and analyzes high-resolution location data from applications of opted-in users in an anonymized way. The data set consists of anonymized records of GPS locations (“pings”) from users that opted-in to share the data anonymously through a General Data Protection Regulation and California Consumer Privacy Act compliant framework. Data was shared in 2017 under a strict contract with Cuebiq through their Data for Good program where they provide access to de-identified and privacy-enhanced mobility data for academic research and humanitarian initiatives only. All researchers were contractually obligated not to share data further or attempt to de-identify data. Ethical oversight: Additionally, we obtained IRB exemption to use the mobility data from the MIT IRB office through protocols #1812635835 and its extension #E-2962.36 between Oct 2016 and March 2017  in the Schelling model is not arbitrary. As we show in section Supplementary Note σp and σs. While σs controls the segregated nature of the places a person visits, σp describes how often (or not) they are visited.The proposed social-EPR model is an extension of the EPR model with an additional parameter. Specifically, when individuals decide to explore a new place (as in the EPR model), with probability S, σ ~ {Ri} + {Pi} + {Mi}  and residential variables {Ri}. Mobility variables are related to the extent of the city covered by individuals, i.e., radius of gyration and total distance traveled. Lifestyle variables are given by a vector {Pi} whose entries correspond to the fraction of time user i has spent in each of the categories included in Fig. Ri} of about 30 residential (census) variables that account for the income, education levels, employment characteristics, race composition, poverty ratios, transportation modes, etc. of each census block group (see Supplementary Table To understand the relative importance of each group of variables and maintain explainability, we use a simple linear regression model Further information on research design is available in the Supplementary InformationReporting Summary


Beat It—a community-based exercise and lifestyle intervention—in improving anthropometric and physical fitness outcomes in older adults with type 2 diabetes mellitus (T2DM). Methods: Australians with T2DM who were aged 60 years or older were included. These individuals were enrolled in Beat It, a twice-weekly supervised group exercise and education program conducted over 8 weeks. Anthropometric measurements and physical fitness parameters were assessed at baseline and completion. Physical fitness measures were then compared to validated criterion standards of fitness levels required by older adults to remain physically independent into later life. Results: A total of 588 individuals were included in the study. At baseline, a substantial proportion of the cohort had physical fitness measures that were below the standard for healthy independent living for their gender and age. Significant improvements in waist circumference and physical fitness were observed post program and resulted in an increase in the number of participants who met the standard for healthy independent living. Conclusions: Participation in Beat It improved important health outcomes in older adults with T2DM. A longer-term follow-up is needed to determine whether these positive changes were maintained beyond the delivery of the program.Background: The aim of this study was to assess the efficacy of  Diabetes is a chronic condition characterised by high blood glucose levels and is one of the fastest-growing and most serious health conditions globally . In AustPhysical activity is considered a cornerstone in the management of T2DM  and refeTargeted exercise prescriptions provide significant clinical benefits . HoweverEffective exercise interventions in adults with T2DM have utilised four intervention components that include (1) personalised exercise prescription, (2) supervision by an exercise professional, (3) fitness testing, and (4) group delivery . HoweverBeat It is a community-based exercise and lifestyle program established by Diabetes NSW and ACT in 2010 and supported by the National Diabetes Services Scheme (NDSS) since 2015. This program is an example of translational research, the application of research knowledge into practical ‘real-world’ settings [Beat It has been running in its current format since 2015 and is an eight-week program that focuses on supporting individuals in improving their diabetes self-management through group exercise and education sessions. The current study aimed to assess whether Beat It, a scaled-up exercise intervention, was effective in improving anthropometric, physical fitness, and psychological outcomes in older adults with T2DM.settings . Beat ItBeat It involves twice-weekly group-based exercise sessions including moderate-intensity aerobic, resistance, flexibility, and balance-based exercises, as well as education sessions on diabetes self-management. Accredited Exercise Physiologists (AEPs) (n = 53) delivered the programs at 67 separate locations within New South Wales (NSW) and the Australian Capital Territory (ACT). Participants attended a one-on-one initial consultation with an AEP which involved completing a pre-exercise screening, baseline measurements, fitness testing, and motivational interviewing to establish program goals. Information obtained from this consult was used to devise a personalised exercise program for the participant accounting for physical capabilities, the current level of fitness, as well as co-morbidities or injuries that may be impacted by exercise. Each exercise program included a dynamic warm-up and cool-down, aerobic , resistance , balance , and flexibility exercises . During the group exercise sessions, participants completed their exercise program under the supervision of an AEP, who was able to advance or regress exercises in accordance with the participant’s progress. These exercise sessions were held in a variety of settings, dependent on location and availability, including public gyms, community halls, and private clinics. All AEPs completed a specialised facilitator training program called ‘Beat It Trainer’ to ensure consistent and effective delivery of the program. This accredited continuing professional development training course consisted of online learning and a one-day practical workshop. To maintain this certification, Beat It trainers were also required to complete a refresher course within 2 years of completing the initial training.Participants were recruited between July 2017 and April 2019 via the NDSS database or through advertising on the Diabetes NSW and ACT website. Prior to commencing, participants were required to provide evidence of medical clearance to exercise from their general practitioner and were then eligible to attend their initial health and fitness assessment with their designated trainer. The number of participants per group session was limited to 15 to enable individuals to receive suitable supervision and support from their AEP. At the completion of the eight weeks, a final health and fitness assessment was undertaken. For inclusion into the current study, participants had to be 60 years of age or over, and have a clinical diagnosis of T2DM. The Macquarie University Human Ethics Committee approved the study, protocol number 5201950887424.Beat It. Sociodemographic variables including gender, date of birth, and residential postcode, were collected. Postcodes were used to determine Socioeconomic Indexes for Areas (SEIFA) and Accessibility and Remoteness Index of Australia (ARIA) [This study employed a pre–post evaluation design where participants completed in-person physical assessment sessions at baseline and at eight weeks after completion of a (ARIA) , as an aa (ARIA) . IRSAD wa (ARIA)  and cateHeight and weight were used to calculate body mass index (BMI), and BMI was then categorised as healthy, overweight, or obese according to the WHO . Waist cDASS-21 is the short-form of Lovibond and Lovibond’s 42-item self-report which measures the negative emotional states of depression, anxiety, and stress . ParticiParticipants were asked to evaluate the efficacy of the program on their knowledge of physical activity and identify the facilitators and barriers to being physically active. Information including country of birth, language spoken at home, and Indigenous status was collected. Participant perspectives around physical activity and diabetes, confidence to incorporate physical activity into diabetes management, and perceived barriers to engaging with physical activity were collected where participants used a five-point Likert scale to indicate to what extent they agreed with statements. Participants were also asked to list any benefits they had gained through engaging in the program and rate how likely they would be to recommend the program. These questions were developed by Diabetes NSW and ACT with the specific intent of evaluating the program and therefore are not validated tools .Beat It program on anthropometric and physical fitness assessments was examined using paired T-tests for continuous variables, stratified by gender. For categorical ordinal variables , the paired Wilcoxon signed-rank test was used to compare pre- and post-program effects. For dichotomous variables  the paired sample McNemar test was utilised to compare pre- and post-program effects. A Bonferroni corrected p < 0.001 was considered significant to account for multiple testing.Data analysis was performed using SPSS version 24 . Descriptive statistics: mean, median, and standard deviations (SD) were calculated for continuous variables and frequencies and percentages for categorical variables. The effectiveness of the t-test, power of 0.80, one-sided α-error 0.05, based on the primary outcome waist circumference effect size 0.15. The effect size used is based on the literature for older (+60 years) overweight adults participating in randomised clinical trial physical activity interventions between 3 and 9 months [The required sample size was calculated with G*Power (Version 3.1.9.2) . The sam9 months . In totaBeat It program at one of 67 locations. Of this cohort, 286 (48.6%) were male, and age ranged from 60 to 84 years old with a mean age 69.8 ± 5.6 years. Over one-third (36.1%) of participants were from lower socioeconomic regions, and 47.4% resided outside of major cities. A total of 588 individuals were included in the study. These individuals were aged 60 years and over, had reported a diagnosis of T2DM, and had participated in the At recruitment, 89% of the cohort had a BMI that placed them in the overweight or obese category, while for 95% of the cohort their waist circumference measures put them at higher risk of chronic disease . The resNon-significant improvements in weight and resting heart rate were observed post program. Significant improvements in waist circumference, aerobic capacity, strength, flexibility, and balance were observed post program  and wereAll participants were asked to evaluate the efficacy of the program on their knowledge of physical activity, and their confidence in managing their diabetes. Analysis was undertaken on pre- and post-program evaluation questionnaires from 97 participants. Of this group, 44.3% were male, age ranged from 60 to 82 years old, with a mean age 69.6 ± 5.7 years, 74.2% were born in Australia and 97.9% had English as their first language. Within this group, two participants (1.8%) identified as Australian Aboriginal, and 40.2% of participants were from lower socioeconomic areas.p < 0.001).Significant improvements in knowledge around the amount of physical activity required to maintain optimal health were observed, with a 13.2% improvement following completion of the program (57.9% vs. 71.1%). These participants also reported a significant increase in their confidence to undertake exercise ; knowledge to exercise safely ; and of social support . Participants were also asked to record any benefits that they experienced due to participating in the program. Reported benefits included improved blood glucose levels (38%); social support (37%); energy (68%); and increased motivation to exercise (96.2%). Participants were also highly likely to recommend Beat It to other people with a net promoter score of 87 (range −100 to 100).Participants were asked to rate barriers to engaging in regular physical activity. Significant reductions in perceived barriers were observed regarding motivation (−3.8, This translational study demonstrates that community-based group exercise and lifestyle programs can achieve important health outcomes in deconditioned older adults with T2DM. This research supports previous smaller-scale studies ,24,25 thWith an ageing population, there is a need to adopt initiatives that assist in maintaining an individual’s functional fitness, which, in turn, will reduce the risk of falls and enable independent living. Loss of independence is a significant contributor to reduced quality of life. Research suggests that for individuals managing T2DM, their main health goal is to maintain their independence and activities of daily living .Beat It can improve physical fitness in older adults with T2DM, who may otherwise have been at risk of losing their independence.In the current study, a substantial proportion of the cohort at baseline had physical fitness measures that were below the standard for healthy independent living for their gender and age. The improvements in aerobic capacity, strength, flexibility, and balance observed in this study demonstrated that Beat It, have a valuable role in supporting older adults in making lifestyle changes to remain healthy and independent into older age.Physical fitness plays a key role in the health of people with T2DM, as increases in physical fitness can predict improvements in cardiovascular risk factors and insulin sensitivity . In thisBeat It, there was a significant reduction in waist circumference. Waist circumference is a surrogate marker for abdominal visceral fat [On completion of eral fat  and redueral fat . Signifieral fat . For oneeral fat . Studieseral fat , which iA reduction in depression, anxiety, and stress symptoms was observed in a sub-sample of participants post program. T2DM is known to be an ongoing source of stress, and depression and anxiety can intensify diabetes severity, contributing to poor glycaemic control and decreased ability to maintain medical and behavioural regimens . ParticiBeat It program works in practice, although the operational nature of the dataset resulted in some issues with data matching between the in-person assessments and evaluation questionnaires. The pre- and post-survey questions were developed by Diabetes NSW and ACT with the specific intent of evaluating the program and therefore are not yet validated tools. This limits the generalisability of the findings. Information regarding the length of time since a participants’ diabetes diagnosis and insulin dependence was not available. Lastly, this study only evaluated the short-term effectiveness of the program; a longer-term follow-up is needed to ascertain if these positive health outcomes were maintained over time.Other benefits reported by participants include significantly increased confidence in managing their diabetes and significant reductions in self-perceived barriers to physical activity which included motivation, energy, and knowledge of exercise. The delivery of the program to higher and lower socioeconomic populations in both metropolitan and regional areas should be noted as a strength. A limitation of this study is that it employed a pre–post evaluation with no comparison group, a common design for translational community-based programs . This stBeat It program, with improvements observed in physical fitness, mental health, and general approach to diabetes management. The success of this program supports the feasibility of larger-scale community-based supervised group exercise programs in the management of T2DM. A longer-term follow-up is needed to determine whether these positive changes were maintained beyond the delivery of the program.This study revealed that older adults with T2DM can benefit from the eight-week combined exercise and lifestyle