The objectives of this study were to examine the feasibility of implementation in practice (primary) and the feasibility of study methods and potential effectiveness (secondary) of the Aging, Community and Health—Community Partnership Program, a new 6-month interprofessional, nurse-led program to promote diabetes self-management in older adults  and attended a median of three group wellness sessions provided by the CDEs in partnership with a community-based seniors’ association. The primary outcome was the feasibility of the program . Secondary outcomes included the feasibility of the study methods  and potential effectiveness of the program based on 6-month changes in self-reported outcomes including self-management behavior , health status , and costs of service use. Analysis of feasibility outcomes was primarily based on descriptive statistics. The potential effectiveness of the program was explored using different tests, with the results expressed using descriptive statistics and effect estimates .In total, 45 (88 %) of 51 eligible persons consented to participate. Of these, 37 (82 %) completed the 6-month follow-up. Participants and providers viewed the program as acceptable and feasible. Participants had a higher SF-12 physical component summary score at 6 months compared with baseline . Median costs for diabetes care increased over 6 months (reflecting inclusion of program costs), while other service costs either decreased or remained unchanged.This study offers preliminary evidence that the program was feasible to deliver and acceptable to participants and providers. Initial results suggest that the program may improve physical functioning. A randomized controlled trial is feasible, with some adaptations to the program and study methods that were identified from this feasibility study.NCT01880476Clinicaltrials.gov identifier: The online version of this article (doi:10.1186/s40814-016-0063-1) contains supplementary material, which is available to authorized users. Diabetes is a rising global health concern. An estimated 150 million people worldwide were diagnosed with diabetes in the year 2000, which rose to 371 million in 2012 and is projected to reach 552 million by 2030 . DevelopThe studies in these reviews have typically omitted older adults with multiple chronic conditions (MCC) . The omiPrevious studies pertain primarily to interventions focused on treating biological factors rather than the full range of health conditions and contextual factors affecting diabetes self-management  . SimilarEmerging evidence suggests that group-based programs implemented in community settings and involving partnerships with diabetes care providers are feasible and effective and may better address the complex interplay of contextual factors , 29–31. A community-based program of diabetes self-management for older adults with T2DM and MCC that results in efficient use of resources remains elusive . New andThe overarching goal of this feasibility study was to investigate the feasibility of a larger RCT that will examine the effectiveness of the Aging, Community and Health (ACHRU)—Community Partnership Program, an interprofessional, nurse-led program for community-living older adults with T2DM and MCC. Primary and secondary study objectives were designed to achieve this goal. The primary objective was to determine the feasibility of implementation of this program in practice. The secondary objectives were to (1) determine the feasibility of the study methods used to evaluate this program, (2) obtain emergent evidence of the potential effectiveness of this program based on changes over 6 months in self-management behavior, health status, and costs of use of health and social services, and (3) determine the most appropriate primary outcome measure for the larger RCT.preliminary evidence of potential program effectiveness.Because of the complexity of evaluating health service interventions, a mixed-method design  was used to examine the interaction between the community care context, program implementation, and outcomes . The feaCommon threats in pre-test/post-test designs of intervention studies include the placebo effect, history, statistical regression to the mean, and confounding with usual care. Methods were employed to minimize as many of these threats as possible. To minimize the placebo effect, participants were permitted to choose the number of in-home visits and group sessions, which reinforced the perception that individual needs were different and more was not necessarily better. Also, informed consent stressed that usual care would remain in place, because it was not clear that there were effects beyond those associated with usual care (hence the need for the study). Threats posed by history were minimized by using an intervention period of 6 months (longer time periods increase the likelihood of other changes occurring) and ensuring that post-intervention assessments were completed within 2 weeks of the end of the intervention. Statistical regression to the mean effects were reduced because participants were chosen on the basis of inclusive criteria considered representative of the broader target population (older adults with diabetes and multiple chronic conditions), rather than chosen on the basis of extreme instrument scores (thus representing a restrictive sub-group of the target population).This was a collaborative project between the Aging, Community and Health Research Unit (ACHRU) at McMaster University  and managers and practitioners in a seniors’ association and a specialized diabetes clinic located in southcentral Ontario, Canada. The goal of ACHRU is to promote optimal aging at home for older adults with MCC and to support their family caregivers. ACHRU is mandated by its funders to design, evaluate, and translate new and innovative interprofessional community-based programs to improve access to healthcare, health-related quality of life, and health outcomes in this population, while reducing costs. The study location was a city of moderate size , where older adults represented 13 % of the total population. The Diabetes Education Centre (DEC) was part of a larger primary healthcare practice. The DEC recruited study participants and provided the trained diabetes educators who partnered with representatives from a community-based seniors association to deliver the program.Study participants were 65 years or older, enrolled in the DEC or receiving diabetes-related services from a family health team  within the previous 24 months, diagnosed with ≥2 chronic conditions in addition to T2DM, competent in English (or with an interpreter available), and not planning to move away from the community within 6 months of study enrollment.>20 on the Montreal Cognitive Assessment (MoCA) [Recruitment took place between July and December, 2013. Trained DEC staff identified potential participants based on the inclusion criteria and then telephoned them to obtain verbal consent to be contacted by a research assistant from ACHRU. A research assistant conducted an in-home interview to obtain written informed consent and complete the baseline questionnaires. Older adults were deemed to be mentally competent and thus eligible for the study if they scored t (MoCA) . All eliThis 6-month program was complex and consisted of several interacting components including (1) home visits by a registered nurse (RN) and registered dietitian (RD) from the DEC, (2) monthly group sessions for participants, hosted by the seniors’ association in partnership with the DEC, (3) monthly nurse-led case conferences for team members, and (4) nurse-led care coordination. The combination of a RN and RD aligned well with usual care, as both were already delivering diabetes services at the DEC. Community nurses are in an ideal position to lead an interprofessional team given their scope of practice. A number of RCTs also show the effectiveness of interprofessional, nurse-led interventions involving community-dwelling older adults with MCC . Nurse-lParticipants could decline any number of home visits or group sessions, and all participants continued to have access to the programs and services normally offered by the DEC and the seniors’ association . The seniors’ association and its volunteer network was an excellent foundation for the program, given their exceptional reach into the community and history of implementing a wide variety of successful programs for seniors, including the long-established diabetes support group. The DEC was an equally capable partner, with certified diabetes educators (CDEs) already delivering a diabetes self-management education (DSME) program aimed at supporting informed decision-making, self-care, and problem-solving to improve clinical outcomes, health status, and quality of life.The program protocol was developed using the guidelines for developing complex interventions . It was The program also consisted of several components not normally included in usual care. One such component was the coordination of community-based services. The program was provided by CDEs from a specialized diabetes clinic in partnership with a program coordinator and physical activity leader from a seniors’ association. Three peer support volunteers recruited by the seniors’ association assisted with delivery of the group session component of the program. Another key component was holistic, client-centered care, facilitated by home visits to more fully understand the participant’s socio-personal context. Each participant was offered four in-home visits by the RN and RD over 6 months; the number of visits was based on previous research  and feasThe program emphasized team communication and collaboration. Monthly, the RN, RD, program coordinator, and physical activity leader met for a case conference to develop a client-centered and evidence-based plan of care for each participant. Case conferences provided an opportunity to share observations about participants’ strengths, challenges, and goals related to diabetes self-management; identify needs for other health professionals or community services; and prepare for upcoming group sessions. The RN provided care coordination; facilitated access to services and supports across the care continuum; and coordinated communication among the participant, caregiver, program team, and primary care providers.The program was implemented using a multifaceted approach. First, ACHRU investigators held an 8-h workshop with the RN, RD, physical activity leader and program coordinator together. Then, separate 8-h workshops were held for two groups: (1) the RN and RD and (2) the physical activity leader and program coordinator. The three peer support volunteers attended a 4-h workshop. To support program fidelity, a manual was prepared describing the program, and all team members were trained in the methods and content of the program. To monitor implementation and discuss challenges, the principal investigator and/or research coordinator met with the program team at monthly “outreach” meetings.Table Qualitative feedback was obtained at 6 months from providers, peer support volunteers, and participants regarding program acceptability and implementation barriers/facilitators. The 6-month focus group for providers was attended by the RN and RD from the DEC and the program coordinator and physical activity leader from the seniors’ association. The 6-month focus group for peer support volunteers was attended by the three volunteers. Six-month exit interviews were held with all participants that completed the program. All three groups were asked open-ended questions about the program regarding its perceived benefits, how it should be changed, what they liked and did not like, and implementation barriers and facilitators. Sessions were audio-taped and transcribed verbatim. Two quantitative measures were used to assess the program acceptability to participants: (1) percentage of participants that did not die or transfer to long-term care who completed the program; (2) percentage of completers who had at least one home visit and group session (“engagement rate”).A recent systematic review found that program fidelity for diabetes self-management education (DSME) programs remains largely under-investigated ; therefoEligibility was defined as the percentage of clients screened that were eligible to participate in the study. Our target was ≥50 %, based on the assumptions that 67 % of T2DM clients would have two or more other chronic conditions rate observed in recent study of Ontario older adults with diabetes, unpublished report by Griffith et al. 2015 and 75 % of these would be deemed eligible. Recruitment was defined as the percentage of eligible clients that enrolled in the study. We set a (somewhat arbitrary) target of ≥50 % for this outcome. Retention was defined as the percentage of enrolled clients that completed the 6-month program. We set a target of ≥80 % for the retention rate, based on the common view that bias is a concern if attrition exceeds 20 % . RepreseQuestionnaires, administered by trained interviewers, were used to collect data at baseline and 6 months. Inter-rater reliability was established prior to data collection. At baseline, we also collected sociodemographic data and medical history. The research assistants provided feedback on interview length, clarity and acceptability of interview questions, applicability of questions to participants, and ease of collecting data. Researchers reviewed the data collected, explored the reasons for missing or inconsistent responses, and reviewed the results from the focus groups and interviews for indications of important issues relating to data collection or analysis.Self-management behavior was measured using the Summary of Diabetes Self-Care Activities (SDSCA) scale . The SDSHealth-related quality of life (HRQoL) was measured using the SF-12 . The SF-Depressive symptoms were measured using the original 20-item CES-D scale . Total sThe two measures of metabolic control included in our study were glycated hemoglobin (HbA1C) and the frequency of hypoglycemic episodes. HbA1C serves as a marker of the average glucose concentration in the blood over a period of 2–3 months and can be expressed as a percentage or as a value in millimoles per mole (our results are expressed as a percentage) . To measWe compared the use of all diabetes medications before and after the program, to explore the effects of changes in self-management behavior. The effects could be increased use of medications as a result of increased compliance or decreased use of medications as a result of improvements in other behavioral practices . This was captured by comparing the proportion of participants before and after the program who increased, decreased, or did not change their use of diabetes medications.The costs of use of health and social services were determined using the Health and Social Services Utilization Index (HSSUI) . The HSSUI assumes a societal perspective, has been previously assessed for reliability and validity , 74, andThe candidate measures for the primary outcome in the larger RCT were the SDSCA, PCS from the SF-12, and HbA1C level. The criteria used to evaluate these measures included their applicability and relevance to the older adult study participants, face validity, and ease of data collection. Research assistants provided feedback on these criteria. Researchers also reviewed the data collected for each outcome measure, explored reasons for missing or inconsistent responses, and considered the responsiveness of each measure over the 6 months.The primary objective of this feasibility study was to determine the feasibility of the program, thus we focused on determining the number of participants that we could recruit over the 6 months at the study site, to provide information on the number of sites and time needed to recruit the sample required for the RCT. We also thought the 6-month time frame would generate a sample of between 20 and 40 participants, the size that Hertzog  found suThe last column of Table This study was conducted in accordance with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans . Ethics Baseline characteristics of the participants are displayed in Table Table 6  providesn = 37) was 97 % for home visits (36/37) and 76 % for group sessions (28/37). Engagement rates were slightly lower for females than for males, with rates of 95 % versus 100 % for home visits and 75 % versus 81 % for group sessions.Feedback from participants mirrored these positive comments. Participants noted that the providers were competent, knowledgeable, and empathetic. They mentioned the motivational aspects of the group sessions and the value of home visits for both the providers and themselves. They, too, commented on the benefit of having a close family member or friend attend the group sessions. Further evidence of the acceptability of the program to participants is provided by data on the uptake of the program components . Three participants died or transferred to long-term care, leaving 42 participants in the study that had the choice to remain in or drop out. Thirty-seven participants completed the 6-month interviews, including one participant who refused all components of the program. Therefore, 36 of the 42 participants chose to receive the program and we viewed this as the best indicator of acceptability, which resulted in an acceptability rate of 86 % (36/42). The engagement rate for study completers  issues and encourage participation by all members, and ensuring that the physical exercise component of group sessions is suitable for all participants and integrated with other program components. All three groups indicated that 3 h was sufficient or perhaps too long for the group sessions.The potential facilitators and barriers of program implementation were identified from the feedback received from the three groups. Important facilitators included adequate support for administrative activities, the option of home or clinic visits for participants, the motivational and facilitation characteristics of providers, flexibility and appropriate length for group sessions, maintaining a group  focus at group sessions, and attendance of a close family member or friend at the group sessions. Important barriers included group sessions in excess of 3 h, group sessions that were dominated by a small number of participants, physical exercises that could not be adapted to individual capabilities, and lack of administrative support. There was low uptake of transportation services offered by the program, suggesting that this was not a significant barrier to participation.The feedback obtained from the focus group sessions and interviews was instrumental in identifying modifications to the program that would facilitate its successful implementation in a RCT. The last column of  Table 6 potential effectiveness of the program (used in judging treatment enactment), significant changes in the outcome measures over 6 months were not expected because the feasibility study was underpowered and the program time frame was relatively short. The significant increase in HRQoL (PCS) observed in the feasibility study (see below) was unexpected and taken as a preliminary yet promising indication of the potential effectiveness of the program.Training protocols, manuals, and workshops were delivered to all providers, recruiters, and research assistants. The program was tailored so participants had the option of declining some or the entire program; however, only one participant declined all program components. Clients received a median of 3 home visits  and attended a median of 3 group sessions . The engagement rate was 97 % for the home visits and 76 % for the group sessions. Regarding the Although modifications to the program components were identified from the feedback received from providers, volunteers, and participants, the program was delivered as intended and was well received by all three groups. The variation in dose received by participants was appropriate for a tailored, client-driven program. The overall conclusion was that the program was delivered as planned.The measures used to evaluate the feasibility of the study methods include the eligibility, recruitment, and retention rates, derived from the CONSORT flow diagram Fig. . Forty-sOne of the participants who completed the 6-month interview did not receive the program. Because 6-month outcome measures were available for this participant, she was included in the analysis. One participant was excluded from the analysis because he misinterpreted the self-management instrument.live alone (58 % versus 0 %);have higher household incomes ;take fewer diabetes medications (8 % took 3 diabetes medications versus 87 %); andhave fewer strokes or transient ischemic attacks (6 % versus 38 %).We compared completers and non-completers on baseline sociodemographic characteristics, diabetes history, MCC, number of diabetes and total medications, self-management behavior, and health status. Some differences were observed; specifically, completers were more likely toFinally, we examined feedback from the research assistants and researchers on the data collection and analysis procedures. Table 7  providesTable Most of the 95 % CIs for the mean score differences included 0, indicating that the changes in the measures from baseline to 6 months were not significant Table . The excWe also examined hypoglycemic events and diabetes medication use and found that the majority of participants did not experience changes in these parameters. For 64 % of the sample, there was no change in hypoglycemic events, 8 % experienced a decrease, 11 % experienced an increase, and 17 % were not sure. For 70 % of the sample, there was no change in the use of diabetes medications, 17 % increased use, and 14 % decreased use. At both baseline and 6 months, 36 % of the samples were not taking any diabetes medications.The total median costs of the program were $499.00 (Q1–Q3 356.50–602.00) per study participant  or the lack of applicability of certain questions . We also found that the questions relating to glucose monitoring did not apply to a large number of clients, perhaps because they were newly diagnosed with diabetes and glucose monitoring had not yet been recommended to them.HbA1C was also considered as a potential primary outcome. This measure showed promise in that a reduction approaching clinical significance was observed over the 6 months. While we found that the timing of the measurements relative to the baseline and 6-month benchmarks varied considerably and fell outside a 1–2-week window for some clients, this was due in part to the use of existing client records to obtain these measures . The overriding concern with this measure was the evidence indicating its poor connection with patient-relevant issues .Finally, we considered the PCS as a primary outcome. This measure appeared more promising, in that participants in our study did not experience difficulty interpreting the SF-12 questions, the summary scores generated from the SF-12 instrument (PCS and MCS) represent well-validated measures of HRQoL, published norms exist for comparison with the Canadian general population, and the PCS score captures physical functional ability which appears to be an important outcome for patients . A recenThe overarching goal of this feasibility study was to determine the feasibility of conducting a definitive RCT to evaluate an innovative, interprofessional, nurse-led, community-based program to promote increased diabetes self-management in older adults with T2DM and MCC. To address this goal, our primary objective assessed the feasibility of implementing the program in practice. Secondary objectives focused on assessing the feasibility of the study methods, exploring the 6-month change in outcome measures for preliminary evidence of potential effects, and selecting a primary outcome for the RCT.and to the healthcare providers. There was recognition that the program provided an improved understanding of the client’s health status and context that was attributed to the combined effect of interprofessional collaboration, synergy among program components, and the unique insights gained from home visits. Further evidence of the acceptability of the program to participants was provided by the high level of engagement for home/clinic visits and group session attendance (97 % for home visits and 76 % for group sessions). Providers and participants requested increased family caregiver involvement, which is supported by research showing that goal alignment  leads to increased functional independence and improved symptom management [The feasibility of the program was confirmed by the acceptability of the program to providers, peer support volunteers, and participants. There was evidence of “buy in” from all three groups. For example, it was encouraging that participants saw value in the home visits, both to themselves nagement . We showWe noted that there were some differences between people who completed the program and those who dropped out. Participants who dropped out were more likely to be living with a spouse or someone else, have lower incomes, and be taking more diabetes medications. The latter characteristic may reflect the fact that non-completers had been living with diabetes longer or that their diabetes was more severe or less controlled compared with those who completed the program. This issue will be examined more fully in the RCT.The PCS score increased from baseline to 6 months. Our results for HbA1C are within the range of small positive effects (0.24–0.44 % decrease over 6 months) reported in two recent reviews of self-management interventions for people with T2DM , 17. OurWe observed no substantial changes in self-management behavior or mental health , whereas the existing evidence shows small positive effects for these variables , 17, 84.We evaluated the performance of the SDSCA, PCS, and HbA1C level to determine the most appropriate primary outcome for the RCT. The SF-12 assessment, which provides the PCS, was well received by participants and more reliable and easier to administer, compared with the other measures. Broader support for the PCS exists in a recent systematic review, which found that the PCS was among the most common primary outcomes in interventions similar to ours that were aimed at enhancing self-management of long-term or chronic conditions .Program administration: The administrative role in the program is considerable, particularly at the beginning, because of the lack of experience with this model of care. There needs to be sufficient support for the administrative role via the provision of an administrative assistant or sharing administrative tasks with other members of the program team.Program synergies: The potential for synergy across program components is high. All three groups indicated this, either by observing the synergies or recommending ways to enhance them. As a result, even though face-to-face contact with clients at home visits was fairly limited (3 h on average over the 6-month program), this was augmented by continuity of the providers over the program period and by multiple points of contact within the program. Both of these features enhanced team collaboration and client relationships and aided in developing a better understanding of the health status and context of all clients. Therefore, efforts should be made to preserve these features of the program in the full RCT, to capitalize on the potential for synergy. These efforts include having all providers present for the entire group session, to ensure consistency in messaging and goal setting. Efforts to shorten the group sessions  should be carefully planned, to maintain the maximum effect of the program. Efforts should also include having all providers trained in key program components, such as the physical exercise element, so that the objectives of these components can be reinforced at all client encounters. Methods of standardizing provider training will be particularly crucial in moving to the larger, multi-site RCT. As in this pilot study, multiple methods will be used to standardize training across sites in the larger RCT, including provider workshops, detailed training manuals, and regular outreach sessions with researchers to identify and resolve challenges in delivering the intervention and ensure that methods of addressing issues are consistent across sites.Peer support volunteers: The need for peer support volunteers may depend on the dynamics of the group sessions. In the feasibility study, peer support volunteers functioned more as participants and less as client supports. Study participants, on the other hand, assumed the role of peer support volunteer as they gained experience with the group sessions. Therefore, the role of peer support volunteer may be unnecessary at sites where participants assume this role or if a close family member or friend attends the group sessions (as suggested by both providers and participants).Case conferences: Case conferences were used primarily to plan the group sessions rather than to discuss client goals and progress. Increased efforts should be made to focus on client goals in all of the program settings, including case conferences, home visits, and the group program.Diabetes within the context of MCC: Although the RN and RD were instructed to focus not only on diabetes care but also on the prevention and management of other chronic conditions, their approach ultimately emphasized diabetes. It is critical to maintain a high level of diabetes care but equally important to move beyond the single-disease focus of the current clinical practice guidelines. The training of diabetes educators should be supplemented with an understanding of the common comorbidities experienced by older adults with T2DM, how these affect diabetes self-management, and self-management strategies that take comorbidity into account. Therefore, the training program for the full RCT and the monthly team meetings should provide more education to providers on resources and self-management strategies appropriate for clients with T2DM within the context of MCC.Medications: The feasibility study considered prescription medications only, yet non-prescription medications can have an important influence on health status, self-management ability, and program effectiveness. Therefore, the full RCT will consider total medications, including over-the-counter medications.Evaluation of program: This feasibility study involved the evaluation of a program implemented in a real-world community-based setting. It included consideration of the acceptability of the program, program fidelity, implementation barriers and facilitators, feasibility of study methods, and a range of potential effects. There were many components to the evaluation, but what seemed to be missing was an overall framework that tied all the pieces together. We reviewed the literature to identify potential conceptual models, with the RE-AIM framework being among the most comprehensive and applicable to our program. The RE-AIM framework guides the measurement of health effects and implementation barriers and facilitators, has been used to measure the pragmatic implementation of healthcare interventions in a variety of real-world settings, and includes the following five dimensions: reach, effectiveness, adoption, implementation, and maintenance . We inteMechanisms underlying the program: The feasibility study did not explore the mechanisms underlying the program, because the small sample size limited the ability to meaningfully explore these mechanisms and because of the need to focus on the more fundamental issue of whether it was feasible to move ahead with a definitive trial. However, our intention is to explore the mechanisms underlying the program in the RCT. Self-efficacy is an important mechanism, according to the social cognitive theory underpinning the program, and the program components were designed to affect different sources of self-efficacy . We plan to include a 6-item scale to measure self-efficacy  in the RSubgroup analyses: The small sample size limited our ability to explore differences across subgroups, although the feasibility study provides some initial evidence of characteristics that may influence the effectiveness of the program. For example, there were gender differences in self-management behavior and engagement rates. Providers thought the program would particularly benefit people living alone, and we observed a significant difference in the living status of completers versus non-completers . In the RCT, we intend to conduct a comprehensive subgroup analysis to understand who may benefit more from the program. This analysis will consider characteristics including gender, age, social vulnerability, duration with diabetes, and MCC.The feedback from providers, peer support volunteers, and participants was instrumental in identifying proposed changes to the program to ensure its successful implementation in the definitive RCT. The proposed changes were mainly at the operational level and did not change fundamental assumptions underlying the program. There were several important observations made and understandings acquired during the feasibility study that will affect how we implement and evaluate the program in the RCT, includingA particular strength of this study is its focus on a program that is well grounded in theory. Theory is an important consideration in the development of complex interventions, and it enables us to identify several hypotheses that can be tested in the RCT. Face validity of the program was achieved through the involvement of T2DM client and community providers in the design and evaluation of the program. Another strength of this study is that it was undertaken in a real-world setting within the existing healthcare system and using existing resources. As a result, the facilitators and barriers to implementation identified in this study are likely to be indicative of what would occur if the program was implemented in a real practice setting. This study also considered the costs of use of health and social services, which many intervention studies either omit entirely or approach less rigorously.preliminary/emergent, not definitive, evidence of the potential effectiveness of the program. Second, the study was a single-arm, pre-test/post-test design, which is less rigorous than a RCT. A number of measures were taken in the study to address the common threats to internal validity . Confounding with usual care was difficult to address, because usual care was in place in addition to the intervention and these services could account for some or all the changes observed between baseline and 6 months. However, many participants discontinued their regular diabetes clinic visits while receiving the intervention, so it is unlikely that a substantial portion of the effects observed are attributable to usual care. Third, a complete case analysis was conducted, which can result in biased estimates of the results. In the RCT, more sophisticated methods  will be used to address missing data. Fourth, while the instruments used in the study have been validated in many populations, this work often excludes complex patient groups such as older adults with MCC. However, the instruments appear to be performing as expected in this study . Fifth, we were unable to explore the mechanism through which the program improved HRQoL (PCS). We also did not explore the impact of participant differences, such as distinguishing between people with incident versus long exposure to T2DM or with higher versus lower levels of social vulnerability. These and other differences can result in different risk profiles and management strategies and can impact the effectiveness of the program. In the RCT, we will be conducting a subgroup analysis to explore the differential effectiveness of the program, measuring self-efficacy, and exploring how self-efficacy relates to self-management and the PCS. Sixth, the feasibility study involved a single site. Sites may differ on characteristics that can affect implementation of the program. For example, staffing is known to vary across DECs, with some having an RN and RD (as at the study site) and others having one healthcare professional (such as a pharmacist or RD) [We should also acknowledge a number of limitations. First, the sample size was intentionally small to allow us to focus on the primary objective, the feasibility of the program. However, this small sample limits the reliability of the statistical analyses and means that the results offer t or RD) . The RCTThis study provides the first evidence of the feasibility of implementing in practice an innovative, interprofessional, nurse-led, community-based program for older adults with T2DM and MCC. Based on the results of this feasibility study, a definitive trial to determine the effectiveness of the program would be feasible in the Canadian population of older adults with T2DM and MCC. Some adaptations to the program and study methods were identified from feedback from the providers, peer support volunteers, and participants. This paper also identified several key lessons learned from the feasibility study that will be carried forward to the RCT.


Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is the endoscopic method of choice for confirming lung cancer metastasis to mediastinal lymph nodes. Precision is crucial for correct staging and clinical decision-making. Navigation and multimodal imaging can potentially improve EBUS-TBNA efficiency.To demonstrate the feasibility of a multimodal image guiding system using electromagnetic navigation for ultrasound bronchoschopy in humans.Four patients referred for lung cancer diagnosis and staging with EBUS-TBNA were enrolled in the study. Target lymph nodes were predefined from the preoperative computed tomography (CT) images. A prototype convex probe ultrasound bronchoscope with an attached sensor for position tracking was used for EBUS-TBNA. Electromagnetic tracking of the ultrasound bronchoscope and ultrasound images allowed fusion of preoperative CT and intraoperative ultrasound in the navigation software. Navigated EBUS-TBNA was used to guide target lymph node localization and sampling. Navigation system accuracy was calculated, measured by the deviation between lymph node position in ultrasound and CT in three planes. Procedure time, diagnostic yield and adverse events were recorded.Preoperative CT and real-time ultrasound images were successfully fused and displayed in the navigation software during the procedures. Overall navigation accuracy (11 measurements) was 10.0 ± 3.8 mm, maximum 17.6 mm, minimum 4.5 mm. An adequate sample was obtained in 6/6 (100%) of targeted lymph nodes. No adverse events were registered.Electromagnetic navigated EBUS-TBNA was feasible, safe and easy in this human pilot study. The clinical usefulness was clearly demonstrated. Fusion of real-time ultrasound, preoperative CT and electromagnetic navigational bronchoscopy provided a controlled guiding to level of target, intraoperative overview and procedure documentation. Lung cancer is the most frequent cancer type in the world. The overall prognosis is poor . Early aRecent lung cancer guidelines suggest endobronchial ultrasound transbronchial needle aspiration (EBUS–TBNA) as the method of choice for detecting mediastinal lymph node metastasis . EBUS-TBThe EBUS bronchoscope used in lung cancer staging has a convex ultrasound (US) probe at the tip that scans a 60° image sector parallel to the bronchoscope shaft. The US signal can detect lymph nodes several centimeters outside the airway wall. Endoscopic view is used for airway orientation while advancing towards the region of interest. The US probe is then used for exact localization and visualization of the target, and real-time sampling guidance. A transbronchial needle system is inserted through the working channel of the bronchoscope, and used to aspirate a transbronchial specimen by intermittent suction and agitation of the needle. EBUS-TBNA has a good diagnostic rate –6. DespiAnother challenge is that mediastinal lymph nodes are organized in closely positioned lymph node stations , separatImprovement of EBUS-TBNA has been explored by using advanced image-guiding technology, such as electromagnetic navigated bronchoscopy (ENB) , 10. ENBCombined EBUS and ENB has also been explored with commercial systems, but only using radial array US probes that are designed primarily for the peripheral airways. The improvement in diagnostic yield has not been enough to justify adoption of combined radial probe EBUS/ENB technology , 14. TheThe study was performed with approval from the Regional Committees for Medical and Health Research Ethics , in compliance with ethical practices, according to the principles expressed in the Declaration of Helsinki, and recorded in the ClinicalTrials.gov Registry .www.custusx.org). Shortly after the current study was initiated, a simplified navigation software tailor-made for bronchoscopy was released . . 22]. ThAll patient investigations were according to the national lung cancer guidelines, using a simple, reproducible OR set-up in a realistic, clinical setting . The cliOur image guiding system has previously proved reliable , 16, 39.Improving success rates for EBUS-TBNA might be challenging . HoweverOur navigation system makes new visualization techniques possible. EMN allows both 3D EBUS and incorporation of modern image modalities such as PET-CT and PET-MRI , 45. FutThere are a few study limitations. A complete mediastinal mapping was considered futile in patients 1–3, probably reducing procedure duration. The specific contribution of multimodal image guiding to the clinical outcomes could not be concluded. Still, the supplement of EMN could be of importance for the yield and efficiency of EBUS-TBNA . The navThe feasibility of EM navigated EBUS-TBNA was successfully demonstrated in four lung cancer patients with respect to predefined outcomes involving technical functionality, accuracy, procedure time, safety and sample adequacy. The new navigation system offers a fast and precise guiding to the level of target, procedure overview and documentation. Navigated EBUS has a great potential for further image quality refinement, accuracy improvement and fusion of additional image modalities. Larger studies are required to assess the effect of addition of EM navigation on EBUS-TBNA efficacy, and extended human pilot studies are underway.


After completion of the Tier 2 Program of the Project P.A.T.H.S. , 8,489 participants in 196 schools responded to the Subjective Outcome Evaluation Form (Form C) to assess their views of the program, program workers, and perceived effectiveness of the program. Four major program elements were identified, including programs based on the adventure-based counseling approach (n = 48), programs concentrated on volunteer training and services (n = 44), programs with both the adventure-based counseling approach and volunteer training activities (n = 63), and other programs with different foci (n = 41). Descriptive statistics showed that the respondents had positive perceptions of the program, workers, and benefits of the program. Perceived qualities of the program and the program workers were positively associated with perceived effectiveness of the program. Multiple regression analysis revealed that perceived qualities of the program, but not the program workers, predicted perceived effectiveness of the program. The theoretical and practical implications of the findings are discussed.


The damage of buildings and manmade structures, where most of human activities occur, is the major cause of casualties of from earthquakes. In this paper, an improved technique, Earthquake Damage Visualization (EDV) is presented for the rapid detection of earthquake damage using the Synthetic Aperture Radar (SAR) data. The EDV is based on the pre-seismic and co-seismic coherence change method. The normalized difference between the pre-seismic and co-seismic coherences, and vice versa, are used to calculate the forward (from pre-seismic to co-seismic) and backward (from co-seismic to pre-seismic) change parameters, respectively. The backward change parameter is added to visualize the retrospective changes caused by factors other than the earthquake. The third change-free parameter uses the average values of the pre-seismic and co-seismic coherence maps. These three change parameters were ultimately merged into the EDV as an RGB  composite imagery. The EDV could visualize the earthquake damage efficiently using Horizontal transmit and Horizontal receive (HH), and Horizontal transmit and Vertical receive (HV) polarizations data from the Advanced Land Observing Satellite-2 (ALOS-2). Its performance was evaluated in the Kathmandu Valley, which was hit severely by the 2015 Nepal Earthquake. The cross-validation results showed that the EDV is more sensitive to the damaged buildings than the existing method. The EDV could be used for building damage detection in other earthquakes as well. Earthquake-resistant buildings and infrastructures, and emergency services during disasters are vital for protecting against earthquake damage. However, mass deaths and injuries caused by earthquakes over the past decades undermine the present situation. While urbanization is inevitable as a cost of the rising population, damage reduction strategies, particularly in vulnerable fault zones, are mandatory. Satellite remote sensing is an important technology for the monitoring of disasters.Earthquakes are one of the most catastrophic natural disasters. More than 23 million deaths have been caused by earthquakes during the period of 1902–2011 alone globally  for rapid detection of earthquake induced damage. The EDV technique builds on the existing NDPM method by using additional polarization and more change parameters. The performance of the EDV technique is demonstrated in the case of the 2015 Nepal Earthquake using the ALOS-2 SAR data and compared it to the existing NDPM method.http://earthquake.usgs.gov, last accessed 15 September 2016) are also plotted in This research was carried out in the urban areas of the Kathmandu Valley, which was severely hit by a 7.8 Mw earthquake on 25 April 2015. The Kathmandu Valley is a bowl-shaped valley standing at 1425 m above sea level, and surrounded by mountainous ranges. The location map of the study area is displayed in The EDV is based on estimates of the coherence changes between pre-seismic and co-seismic timings. A pair of before earthquake (pre-seismic) images are used to calculate the pre-seismic coherence; whereas a pair of before and after earthquake (co-seismic) images are used to calculate the co-seismic coherence. A coherence map shows similarity (cross-correlation) between two radar images pixel by pixel. High coherence values means that the ground objects remained the same between the two timings of the radar image acquisition, whereas low coherence means that the objects changed during that time. The pre-seismic and co-seismic coherence maps are then used to calculate forward (from pre-seismic to co-seismic) change, backward (from co-seismic to pre-seismic) change, and no change (between pre-seismic and co-seismic) parameters. The normalized difference between the pre-seismic and co-seismic coherences, and vice versa, are calculated to derive the forward and backward change parameters, respectively. The backward change parameter is added to see the retrospective changes caused by factors other than the earthquake. The average values of the pre-seismic and co-seismic coherences are calculated as the third change-free parameter. These three change parameters are ultimately merged as the RGB (Red Green and Blue) color composite imagery, called EDV.Advanced Land Observing Satellite-2 (ALOS-2) based L-band Single Look Complex (SLC) SAR images available from the Japan Aerospace Exploration Agency (JAXA) were used in the research. A pair of pre-seismic (4 October 2014 and 21 February 2015) images and another pair of co-seismic (21 February 2015 and 2 May 2015) images were used to calculate pre-seismic and co-seismic coherences, respectively. The pre-seismic and co-seismic coherences were calculated separately for the Horizontal transmit and Horizontal receive (HH), and Horizontal transmit and Vertical receive (HV) polarizations and averaged together for creating the EDV. The procedure of calculating the EDV for a single polarization is described in http://opencv.org)—an optimized C/C++ programming library for computer vision, machine learning and robotics—for in-depth description of the supervised classifiers used.The performance of the EDV was evaluated by using the k-fold cross-validation method. The k-fold method divides all the samples into k groups of samples, called folds. The k-1 folds are used for learning, whereas the remaining one fold is used for the validation. The total number of folds used in this validation was 10, so it is called the 10- fold cross-validation method. Four commonly used supervised classifiers  were tested for the cross-validation. Readers are referred to the OpenCV . The EMhttp://aria-share.jpl.nasa.gov/events/20150425-Nepal_EQ/DPM/ (last accessed 15 September 2016). Cross-validation of the EDV and NDPM methods were carried out based on 90 ground truth polygons available for each class . The ground truth polygons belonging to two classes  were laid over the raster images (EDV or NDPM), and the pixels delineated by a polygon were extracted and their median values were calculated. The number of pixels falling inside a polygon varies according to the size of building block. The median pixel data calculated for each layer of the EDV and NDPM images were used for the cross-validation. The EDV has three layers, whereas the NDPM has a single layer. Google Earth based time-lapse images were used to visualize performance of the EDV and NDPM images.The performance of the EDV was compared to the NASA Damage Proxy Map (NDPM) using the ground truth polygons. The NDPM map is available online for downloading from The EDV created from the ALOS-2 SAR data over the Kathmandu Valley is displayed in The performance of the EDV is demonstrated in a number of highly damaged  locations . The redIt should be noted that the red pixels of the EDV imagery  are not The performance of the NDPM in a number of locations is demonstrated in Following the visual performance in previous sections, the performance of the EDV was compared to the NDPM quantitatively by using all ground truth polygons (90 for each class) prepared. The overall accuracy (kappa coefficient) of EDV and NDPM calculated from 10-fold cross-validation method using four supervised classifiers  are shown in Among the supervised classifiers tested, the EDV performed better than the NDPM in terms of overall accuracy and kappa coefficient. Out of four classifiers, Gaussian Naïve Bayes showed the best performance for both the EDV  and NDPM  followed by the k-Nearest Neighbors and Random Forests.There is a significant difference between the performance of EDV and NDPM; the highest kappa coefficient achieved with the Gaussian Naïve Bayes is 0.41 in the case of NDPM, whereas the EDV achieved 0.71 kappa coefficient using the same classifier. The NDPM used only the HH polarization (single band information) based pre-seismic and co-seismic coherence change method. On the contrary, the EDV deployed both the HH and HV polarizations; normalized differences of the pre-seismic and co-seismic coherences, and vice versa, as well as the third change-free parameter. The accuracy metrics, overall accuracy (kappa coefficient) based on different supervised classifiers: k-Nearest Neighbors, Gaussian Naïve Bayes, Random Forests, and Support Vector Machine were 0.69 (0.39), 0.77 (0.53), 0.61 (0.22), and 0.71 (0.41), respectively, using a single HH polarization based forward change parameter as in the case of NDPM. The overall accuracy (Kappa coefficient) obtained from a single HH polarization based forward change parameter is significantly lower than the overall accuracy (Kappa coefficient) obtained from the EDV. The EDV provides improved detection of the building damage by adding additional polarization and more change parameters over the NDPM.An improved technique, the EDV was proposed in the research for visualizing the earthquake-induced building damage. The EDV consists of the forward (from pre-seismic to co-seismic), backward (from co-seismic to pre-seismic), and change-free (between pre-seismic and co-seismic) parameters. The performance of the EDV was assessed in the Kathmandu Valley, which was severely shaken by the 2015 Nepal Earthquake. The cross-validation results showed that the EDV is more sensitive to the building damage than the existing NDPM method. The improvement was achieved by using an additional polarization (HV) and more change parameters. False detection of the buildings damage in forested areas due to growth of trees over the time was observed. Forested areas could be masked out in advance or the false detection could be minimized if the short time span images are available.The earthquake induced hazards such as ground shaking/displacement, soil liquefaction, flooding/tsunami, and fires can damage buildings and man-made structures. The major cause of casualties of the earthquake is the damage of buildings and man-made structures where most of the human activities occur. Therefore, detection of building/structure damage is important for identifying the location of trapped victims during the immediate post-disaster period, and assisting the deployment of emergency services in the trapped houses. Though EDV provides better and rapid damage information based on coherence change measures using multiple SAR polarizations, tracking the individual damaged buildings is very challenging. Availability of sub-meter resolution SAR data is expected in the future to overcome the challenge. However, the availability of near-real time SAR data cannot be assured. For instance, a post-earthquake ALOS-2 SAR image was captured on 2 May, which is seven days after the strike of the 2015 Nepal Earthquake. This limits the usefulness of the satellite data in terms of detecting damage and saving life, as the best time has already passed. Moreover, planning the orbit of satellite to capture earthquake damage is difficult due to the uncertain nature of the earthquakes. Near real-time observations of the earthquake-prone fault zones using geostationary satellites or satellites with rapid revisits are suggested. Airborne lidar imaging can also be a promising technique in this kind of situation. Nevertheless, development of local telecommunication technology is inevitable for saving lives during the disaster. On the other hand, better building damage information obtained from the EDV is expected to provide new insights into disaster-preparedness planning such as updating building codes in the vulnerable fault zones, and allocating open spaces and evacuation zones.


Stroke is a major cause of disability worldwide and different types of impairments can affect the individual’s ability to manage everyday activities such as travel that is essential for participation in society. The purpose of this study was to investigate the feasibility of a new self-management intervention (BUS TRIPS) focusing on travelling by bus, and potential contributions to an improved ability to travel by bus for people with cognitive impairments after stroke. This is a pilot study of five individuals, utilizing a multiple case study design with a mixed methods approach. Assessments  were performed before, two weeks after, and three months after the program. The data collection also comprised reflection notes from the group leaders , a semi-structured group interview and an individual phone survey. The feasibility of the intervention was presented in four sub-categories: (1) appreciated group format despite too short sessions; (2) the importance of skilled leaders and motivated participants; (3) session material adequate but needs minor revision to fit the target group; and (4) homework is valuable but reflective group discussions must be supported. The narratives of each case showed that all participants made some progress related to travelling by bus, but the overall positive results could not be verified by all of the quantitative assessments. We conclude that the BUS TRIPS intervention is feasible and can potentially contribute to an improved ability to travel by bus for the target group. Future studies is called for, and should focus on recruitment challenges, to clarify assessments that would be suitable to use in larger scale clinical trials and during subsequent implementation in clinical practice. Stroke is a major cause of disability worldwide, causing different types of impairments that can affect the individual’s ability to manage everyday activities and reintegration in the community ,2. BarriThere are very few studies addressing rehabilitation interventions focusing on public transport and outdoor mobility, for people with stroke. Logan et al.  showed hOne way to address, e.g., aspects of confidence, is to use self-management strategies (SMs) when delivering the intervention. SMs make participants more active and involved throughout the intervention, with the intention to increase their self-efficacy at the core. Typically, this type of method is used in health care to support people with disabilities to learn different skills to be applied in everyday life activities . SM inteWe developed a new program: BUS TRIPS (BUS Travel for Improved Participation in Stroke survivors) based on previous knowledge gained from SM interventions targeting people with CIs in Multiple Sclerosis ,24 and rWhen developing BUS TRIPS, we presented a draft of the program to people with stroke, their family members, rehabilitation professionals, and researchers and used their comments to refine the program prior to the study.BUS TRIPS used in this study consisted of seven 2 h sessions , performed once per week, led by an occupational therapist and a physiotherapist. During the first session, each participant identified self-perceived problems in relation to activities linked to travelling by bus that s/he wanted to participate in. All smaller parts, that is, tasks of activities in a travel chain perspective , were coParticipants were recruited from a local part of the national quality register of stroke incidents in Sweden (Riks-Stroke), based on the following criteria: stroke onset 6–12 months ago, age ≥ 55 years, self-reported independent mobility indoors and outdoors at the three-month post stroke evaluation, agreement to participate in a screening of CIs, and an interest in travelling by local public transport. Fifty-nine potential participants were contacted by phone by the first author (EC), a registered nurse with experience in data collection with people with stroke, who posed questions about experienced difficulties when travelling with local buses. This resulted in 11 possible participants. However, five of those had no time to participate, leaving us with six persons who were screened for and/or stated self-perceived CIs. Since one of these withdrew before starting the program due to a lack of energy, five participants  completed the program. The intervention was performed during spring, and at a location in the south of Sweden. All participants had access to local busses and lived in urban or sub-rural areas. For an overview of their profiles, see This study has a multiple case study design  with a mData were collected through different sources: (1) demographics, (2) baseline data, (3) three quantitative assessments, measured before and two weeks after program completion, and at a three-month follow-up , (4–5) group leaders’ qualitative reflection notes , (6) a qualitative semi-structured group interview (performed during last group session), and (7) an individual phone survey (performed one week after program completion). For an overview see . All datTo investigate the feasibility of BUS TRIPS, we used three data sources: the leaders’ reflection notes (from the group sessions), the semi-structured group interview, and the individual phone survey. The data from the leader’s reflection notes included, for example, attendance, time distribution, how the lecture material worked, and any issues/uncertainties arising during the sessions. The semi-structured group interview was performed in the end of the last group session, led by EC and an observer. This audiotaped interview lasted 80 min and was transcribed verbatim. The interview included questions about the program such as “How did you experience the homework?” Last, an individual phone survey was performed where each participant answered questions such as “Could the leaders present the course material in a way you understood?” Each question was answered on a seventh grade scale . All data sources are presented in To describe each participants’ possible improved ability to travel by bus, we used five data sources: demographics, baseline data, the three assessments, the leaders’ reflection notes , the semi-structured group interview, and the individual phone survey . The basThe first author (Emma Carlstedt) performed all analysis in an interactive process involving all co-authors.A cross case analysis  was usedA within case analysis  was condEach of the two main categories (program delivery and program content) comprised two sub-categories . In addiThe group format was very valuable for the participants because it made it possible for them to meet and share experiences with others with the same difficulties. One participant said: “It is social and you can exchange thoughts and give each other tips” (Kent). Four of the participants were present at all sessions. The fifth could not attend the last group session. They wanted to have the sessions closer to home, but at the same time said the frequency (one session per week) was just right, “It is just what you can set aside time for” (Carl).Both leaders were present all sessions except from one when one of the leaders fell ill. Both emphasized the need of being two to be able to cover the content as planned. Although the participants did not seem to mind, the leaders experienced that the time for the sessions was overall too short to catch all content as planned and at the same time make room for breaks. They argued that sessions should be extended to three hours but that individual sessions should be reduced to one, since only one had been used during the program. The occupational therapist leader said: “It is really difficult to make enough time. We probably need three hours for every session to make room for a break.” They also suggested changing orders between some sessions: “The communication session should be placed earlier in the schedule. It is a bit strange to place it after they have finished their individual tasks” .Due to the phone survey, the participants felt the leaders had the right skills and explained the course material using simple language . They apThe leaders expressed the importance of revising the recruitment process, as not all participants were motivated to travel by bus or expressed no problems when travelling by bus during the program, although all participants stated such interests prior to participation in the intervention. “For some participants it was not obvious that they needed to practice travelling by bus. They experienced they could travel in other ways which worked well” (Physiotherapist leader).Participants ranked the quality of the material as good to very good during the phone survey . They thStill, leaders claimed that the participants needed much support to understand some of the material. They also meant that, preferably, defining activity problems and goal setting should be performed individually prior to the program since this was difficult to pursue within the group during the program.In turn, participants emphasized that some presentations were superfluous, and already well known: “The lecture of the travel planner and cell phone did not give much, because I knew it since before” (Elisabeth). Instead, they lacked information about, for example, whether they were allowed to bring an accompanying person for free. Such knowledge would make them feel more secure. They also suggested including practical use of mobility devices; they wanted to touch, try out, and evaluate them.Both participants and leaders recommended an adaption of the program material to participants’ needs, for example, printing in larger font size suitable to also those with visual impairments. The participants appreciated the homework and ranked it highly at the phone survey . It was Elisabeth is living with her husband in a single-family house. She is a slow walker and uses a rollator  for outdoor mobility. She does not drive a car but travels with her husband. Before the stroke, she went by bus on a daily basis. At baseline, Elisabeth expressed how the design of buildings and surroundings affected her participation. She complained of getting tired and losing concentration faster than she did pre-stroke. She also found it difficult to plan ahead and to stay attentive. Elisabeth reported several depressive symptoms .According to the physiotherapist leader’s reflection notes during the individual session with Elisabeth, her goal was to overcome the fear of travelling by bus, and to be able to travel independently. She identified problems with getting on and off the bus, and not getting a seat. She suggested alternative solutions, for example, avoiding travelling during rush hours and asking the driver to wait to drive off until she was seated. During the practice trip, Elisabeth managed to use a cane instead of a rollator. This had been an obstacle but after the successful ride, the physiotherapist leader considered Elisabeth to be secure enough to try it again with her husband and later on by herself.Directly after the program Elisabeth felt more self-confident, less scared and uncertain: “The fear and the uncertainty has decreased now and it is quite important that you get some self-confidence” (Elisabeth). Due to the phone survey , she staElisabeth felt the stroke had affected her societal participation, particularly in leisure activities at all three data collections, according to SIS. She rated her general self-efficacy lower after, than before the program, but at the three-month follow-up, ratings were back to baseline. Regarding life satisfaction in general, she felt quite satisfied with life at baseline, but this decreased over time .Viola is living with her husband in an apartment. She is a slow walker using a rollator outdoors. She has no access to a car. Pre-stroke she traveled by bus several times per week but expressed that access to transport and the environment as such affected her societal participation. She described difficulties related to CIs, for example, tiredness, loss of concentration, and difficulties with attention, expression, and remembering things. She reported several depressive symptoms .One of the problems Viola expressed when travelling by bus was that because both she and her husband used rollators, sometimes they were not able to travel together as the buses only accepted two rollators onboard. According to the physiotherapist’s reflection notes from the individual session with Viola, she needed support during goal setting and to find solutions to her travel difficulties. Still, during the practice trip Viola used different strategies to solve problems, for example asking other people for help. Although Viola was an experienced bus traveler already, she expressed that the program had helped her to become a more established bus traveler: “I don’t think much anymore, that I am taking the bus. For now, it has become habit” (Viola). She also said during the phone survey  that theViola perceived the stroke had affected her participation, which decreased from baseline to follow-up, according to SIS. Her general self-efficacy increased at follow-up as well as her life satisfaction in general (from quite satisfied at baseline and after program to satisfied at follow-up) .Lennart is living with his wife in a single-family house. He does not use any mobility device but is a slow walker. He does not drive himself but travels in the car with his wife. He rarely traveled by bus. Lennart did not express any environmental barriers influencing participation. He reported some CIs such as getting tired easily, losing concentration, having attention deficit, and difficulty understanding other people. He did not report any depressive symptoms .During the individual session, the occupational therapist leader noted that Lennart did most activities together with his wife, except from participating in a board meeting once a month. His goal was to walk to that meeting on his own, since it was close to home. After recommendations from the occupational therapist leader, he used walking sticks to prevent falls, and successfully fulfilled his goal. During the individual phone survey, Lennart expressed that the program had been helpful and increased his participation in activities outside home, and the leaders had motivated him to try out new strategies .Lennart perceived less impact of the stroke on participation before BUS TRIPS than after, according to SIS but it had decreased at follow-up. At baseline, he scored maximum general self-efficacy, which decreased at the following assessments. He was satisfied with life in general throughout, but even more at follow-up .Carl is living with his wife in a single-family home. He walks slowly and uses a rollator in- and outdoors. He has access to a car but had been advised not to drive. Before the stroke, he travelled by bus about once a month. Carl identified that access to transport and the design of the environment affected his societal participation. Carl scored below normal cognition, but did not report any such impairments subjectively. He had no depressive symptoms .Although Carl stated that he was interested in travelling by bus before BIS TRIPS, during the program he seemed to change his mind and did not try to travel. He said: “I don’t think I have the need of it” (Carl). He expressed it was difficult to change buses, and due to prior experiences he did not have confidence in the drivers. During the program, the occupational therapist leader noted that Carl needed repeated information of its purpose, and that due to lack of insight and motivation he should not have been admitted. Although Carl did not practice travelling by bus during BUS TRIPS, he expressed that the program had motivated him to try out new strategies and helped him to come closer to travel by bus . For exaPre-program, Carl expressed that his stroke affected his participation in society, mostly during activities together with others due to SIS. At discharge, this impact had increased, but decreased again at follow-up. His general self-efficacy increased from baseline to after program completion, but decreased below baseline at follow-up. Throughout, Carl felt quite satisfied with life in general at baseline, which increased to satisfied after the program and at the follow-up . Kent is living with his wife in an apartment. He is a very slow walker and uses mobility devices in- and outdoors. He does not have access to a car. He seldom travelled by bus prior to the stroke. Kent said access to transportation and the environment affected his participation in society. Subjectively, he reported faster tiredness, loss of concentration, and attention and memory deficits. He also reported some depressive symptoms . Kent was determined to travel by bus again, as pre-stroke when he had managed on his own: “I will have that as a goal, to go out again and take the bus down town” (Kent). According to the occupational therapist leader that traveled with him, Kent was concerned about his self-efficacy when travelling. His goal was to walk from home to the bus stop, to travel to the city center. Kent managed the practice trip himself, according to his plans. Afterwards, he formulated a new goal: to take the trip independently to get a haircut. Kent was satisfied with the support during the program, and expressed it had meant a lot to him and made him feel more secure: “It (the program) has given me incredibly much. I feel much stronger now” (Kent). He expressed how the leader who had traveled with him  was skilled, and had a personality that made him feel secure: “She feels so knowledgeable and sends out an aura of security which I love and need” (Kent). It was important for him to feel self-confident to travel again—an ability he now mastered: “It’s about overcoming the fear, that I don’t have to be afraid” (Kent). The program had made him travel more by bus by himself and participate more in activities outside home, due to the individual phone survey . He feltKent perceived the stroke had affected his societal participation at all three data collections, especially during active leisure activities according to SIS. His general self-efficacy was higher at discharge and follow-up than at baseline. He was very satisfied with life in general throughout, except from a small decrease after the program completion .This study examined an intervention targeting travelling by bus for people with CIs after stroke, an area where there is a lack of research. Our study shows that the new intervention BUS TRIPS is feasible, and the five participants improved their ability to travel by bus, although this could not be conclusively verified by the assessments. Moreover, as highlighted by the results, there are challenges in relation to participant recruitment to consider. The participants appreciated the program, and especially valued the group format, confirming previous studies showing benefits of social support in such programs . They alTwo of the participants (Elisabeth and Kent) were especially motivated to travel, able to formulate clear realistic goals, and ready for the action stage, including the whole travel chain. Since the same two persons who objectively (according to MoCa) did not qualify for moderate or severe CIs, it is worth considering if BUS TRIPS in its current form is best suited for those with no moderate or severe CIs. Some of the other participants did not travel by bus at all during BUS TRIPS. However, some made other progresses; for example, one saw benefits of travelling by bus and another reached a goal of walking independently to a meeting, which in the long run is a skill required to catch a bus. It is not always the tasks related to the bus as such that are perceived as challenging, but other links in the travel chain such as walking to the bus stops. Considering the stages of Prochaska’s and DiClemente’s change model , our resAlthough no statistical conclusions can be drawn from our small sample, a limitation of this study is that, unlike the results of the semi-structured group interview and the individual phone survey data, the assessments  could not conclusively verify any improvements post-program. A noteworthy finding is that four of the five participants scored lower on the SIS  after prThe finding that general self-efficacy in our sample was slightly lower than in a general stroke sample  and did Focusing on meaningful activities is important for people with strokes’ ability to adapt to their new situation . We usedAll participants in this study lived together with a spouse, but we did not ask them about what role their spouse played in their attempts to travel by bus. This might be a limitation of this study, since research has shown both encouraging and restrictive influences of family and friends when it comes to outdoor mobility and travelling ,15. It iOther study limitations include challenges regarding the recruitment of participants leaving us with a very small sample. Since measurements of restrictions in cognition and reintegration in societal participation are not included in the national stroke register in Sweden, such information was not available during the recruitment to our study. Thus, we could not direct our recruitment to only people with CIs and difficulties related to travelling by bus, but our recruitment had to be from a broader spectrum. On the other hand, previous stroke research has shown that recruiting participants with narrow inclusion criteria is a difficult task , and oftFurther challenges relate to those who actually attended the program. Some of the participants were not motivated to fulfill the tasks in the program, and little insight as to their CIs was another potential barrier for participation. These aspects influenced the program but reflected the complexity when addressing people with stroke with various types of impairments. Recruitment issues are not unique to this study, and people with stroke can be particularly vulnerable and difficult to recruit . There iOne strength of our study is the mixed methods approach including different perspectives , types of data, and analyses. This gave detailed information as to program feasibility and as to how the program might contribute to an improved readiness to travel by bus in the target group. This knowledge will be used to improve BUS TRIPS in future studies.The BUS TRIPS program is feasible and has potential to contribute to a readiness to travel by bus for people with stroke and CIs. All participants in our pilot study made some progress, e.g., overcame the fear of travelling by bus or saw advantages some travelling by bus, although not all assessments captured the improvements. Future studies should focus on recruitment challenges, larger scale clinical trials and subsequent implementation in clinical practice.


Latin America and the Caribbean (LAC) has long been associated with the production and export of a diverse range of agricultural commodities. Due to its strategic geographic location, which encompasses a wide range of climates, it is possible to produce almost any crop. The climate diversity in LAC is a major factor in its agricultural potential but this also means climate change represents a real threat to the region. Therefore, LAC farming must prepare and quickly adapt to an environment that is likely to feature long periods of drought, excessive rainfall and extreme temperatures. With the aim of moving toward a more resilient agriculture, LAC scientists have created the Latin American Plant Phenomics Network (LatPPN) which focuses on LAC's economically important crops. LatPPN's key strategies to achieve its main goal are: (1) training of LAC members on plant phenomics and phenotyping, (2) establish international and multidisciplinary collaborations, (3) develop standards for data exchange and research protocols, (4) share equipment and infrastructure, (5) disseminate data and research results, (6) identify funding opportunities and (7) develop strategies to guarantee LatPPN's relevance and sustainability across time. Despite the challenges ahead, LatPPN represents a big step forward toward the consolidation of a common mind-set in the field of plant phenotyping and phenomics in LAC. In the past decades, climatic variations related to El Niño or La Niña phenomena have brought serious challenges to the agricultural sector in LAC. While drought is the main threat to food production associated to La Niña, El Niño can cause heavy rains, flooding or extremely hot or cold weather , Food and Agriculture COST Action FA1306, the International Plant Phenotyping Network (IPPN), the Australian Phenomics Network (APN), the German Plant Phenotyping Network (DPPN) and the U.K. Plant Phenomics Network (UKPPN). In Asia, the 1st Asia-Pacific Plant Phenotyping will be held in Beijing, China in October 2016 and the 3rd International Plant Phenotyping Symposium was held in Chennai, India in 2014. More recently in North America, the United States of America recently launched the North American Plant Phenotyping Network (NAPPN).http://www.unep-wcmc.org), six are in Latin American, namely Brazil, Colombia, Ecuador, Mexico, Peru, and Venezuela. Furthermore, from the eight primary centers of origin and diversity, numbers VII  and VIII  are based in the region . The region is highly heterogeneous in terms of climate, ecosystems, human population distribution, politics, economy and incomes, and cultural traditions. Out of a total of 17 megadiverse countries identified by the World Conservation Monitoring Centre  is completely different to that of LAC. According to the World Bank, around 37% of the LAC population lives under poverty or extreme poverty  is almost absent . This event had three main goals: (1) bring to Latin American researchers and students, international keynote speakers and plant breeding companies from around the world, to present their ongoing work on plant phenomics and phenotyping for plant breeding; (2) perform a workshop to train Latin American scientists and postgraduate students in the use of key plant phenotyping tools, the analysis of data and the mapping of traits to the genome; and (3) set up the Latin American Plant Phenomics Network (LatPPN), conceived to facilitate the training on high-throughput phenotyping and pre-breeding methodologies, scientific exchange of young/senior researchers and students, and to improve access to resources and research facilities.The potential of recent advances in phenomics encouraged the Plant Breeding and Phenomic Center  and the National Plant Phenomics Centre  to organize the First Latin American Conference on Plant Phenotyping and Phenomics for Plant Breeding , and data handling and manipulation.rd day of the conference. Representatives from LAC  and from other countries  got together to discuss what LAC's breeding programs needed to do to become more efficiency in terms of plant phenotyping and phenomics. They also discussed the differences between phenotyping and the more complex concept of phenomics. This discussion helped to define where LAC currently stands (more focused on the phenotyping of few traits and low number of genotypes) and where it needs to be in the future . For example, the wheat breeding program of INIA Chile, used to consider a classical approximation where the numbers of traits evaluated increases insofar the number of generation progresses: ~9 traits at F2–F5: susceptibility to Puccinia triticina, P. graminis, and P. striiformis, plant height, tillering capacity, type of spike, grain color, type of grain, and black point or other grain defects; ~16 at F6–F8: previous ones plus heading date, grain yield, and some grain characteristics such as test weight, protein and gluten content, sedimentation, and seed hardiness; and ~19 at F9–F10 where less than 5% of the original crosses are evaluated: previous ones plus some other required by millers such as W flour value, falling number, and some bakery aptitudes. Today, using spectrometry and thermography, this breeding program is aimed to predict some of these traits but also to consider other 30 morpho-physiological and physico-chemical characters (some examples covered in next section), screening ~800 genotypes per day.The LatPPN, which is chaired for two years by Chile (Dr. Gustavo A. Lobos) and Colombia (Dr. Anyela Camargo), had it first reunion during the 3Due to resources' availability such as equipment, skills and infrastructure, LAC has mainly focused on plant phenotyping. Although phenomics in LAC has not yet had a proper expansion, there are some good examples of institutions focusing on it: (i) The International Maize and Wheat Improvement Center (CIMMYT—Mexico) routinely uses remote sensing and high spec sensor technologies to screen for wheat and maize's responses to biotic and abiotic stresses, among them yield and its components, biomass, senescence (stay-green), water stress, and water use efficiency, canopy cover, photosynthetic capacity and activity  The International Centre for Tropical Agriculture (CIAT—Colombia) is screening root architecture to identify markers associated to drought stress tolerance in beans and grasses  develop LatPPN's own tailored identity: there is not a common crop but rather a wide diversity of them, from grasses to forest species. As previously mentioned, plant phenotyping and phenomics has been developed almost exclusively on cereal improvement, however LatPPN needs to focus on other breeding programs that are important for particular countries. For example: blueberries for Chile , potato for Peru (production was estimated to be 4.5 million tons for 2015), tangerines for Uruguay (production was ~6000 tons in 2014), pineapple for Costa Rica  and Coffee for Colombia  and Brazil (exports account for ~2.6 million tons in 2014). The production of these cash crops will face serious challenges  in the coming decades due to the sensitivity of them to water shortages and heat stress. In this meeting, it was also highlighted: (ii) training on plant phenomics and phenotyping using strategies that allow the participation of several countries at the same time. We are aiming at finding resources to implement distance-training courses using currently available technologies such as webinars and teleconferences; (iii) learn from experienced researchers and current plant phenotyping and phenomics initiatives. In order to facilitate the interaction between researchers and institution, senior researchers on plant phenotyping and phenomics were invited to participate in the first meeting; (iv) since high-throughput phenotyping requires a broad range of capabilities , is important to promote interdisciplinary work between researchers; (v) identify the state of art of plant phenotyping and phenomics in LAC. In order to identify strengths, opportunities and weaknesses and develop targeted strategies, key information such as breeding programs, researchers, equipment and infrastructure, regional and local financial sources, and capabilities should be surveyed. All this information should be included on the future LatPPN webpage; (vi) distribute efforts on common goals , it will be necessary to standardize measurements and protocols; (vii) sharing of equipment and infrastructure; and (viii) LatPPN visibility and presence. To avoid early disenchantment, LatPPN needs to carry out activities to promote the network .In relation to weaknesses, the lack of a permanent budget to run network activities is one of LatPPN's main concerns. Currently, the Director and Co-Director, the executive committee (Dr. Paulo Hermann from EMBRAPA—Brazil and Dr. Gustavo Pereyra from INTA-CONICET—Argentina), and the representative members  devote part of their time and resources to consolidate the network. However, they are looking into sources of support within LAC and worldwide. At the country level, there are a number of countries that have access to grants provided by their own governments. At regional level, there are a number of organizations such as PROCISUR and PROCITROPICOS, which provide regular grant support for agricultural research initiatives. At international level, there are several organizations such as FAO , EU (the European Union), and IBS (the Inter-American Development Bank) who support agricultural research in LAC.Another weakness is LAC's low publication rate and the lack of accessibility of LAC institutions to main bibliographic databases. According to the World Bank, the number of publications produced by the most important economies in LAC in 2012 was 48,622 from Brazil, 13,112 from Mexico, 8,053 from Argentina, 5,158 from Chile and 4,456 from Colombia. Brazil is the only country whose output is equivalent to high-income countries where phenomics have been developing in the last 10 years; U.S.A. , Germany , U.K. , France , Spain , and Australia  , CSIRO , IBERS (U.K.), Universidad de Barcelona (Spain), the Julich Plant Phenomics Centre (German), and the James Hutton Institute (U.K.).The establishment of LatPPN represented a big step forward toward the consolidation of a common mind-set in the field of plant phenotyping and phenomics across LAC. Clearly there are more opportunities than disadvantages, and each weakness needs to be addressed having in mind a regional approach.Phenomics can complement the potential of new molecular/genotyping technologies, and together with agronomy and plant breeding efforts would be a real contribution to develop new strategies to help mitigate the impact of climate change in agriculture. There are major opportunities for phenomics in LAC, not only because it has been adopted in isolated initiatives, but also as worldwide development has focused mainly on grain breeding programs. LAC researchers have identified the need to collaborate to exploit the opportunities and gathered together to organize the Latin American Plant Phenomics Network (LatPPN). Currently, LatPPN has prioritized the work on several fronts to consolidate the network  and planning a second regional conference organized by EMBRAPA during 2017, drafting of LatPPN's survey, drafting of LatPPN's white paper, and construction of LatPPN's webpage). What follows next is the development of strategies leading to the sustainability of the network. We are aware of the work ahead of us and know that the collaboration within LatPPN members and with other networks will be crucial to build on the foundations laid.Both authors contributed equally.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.


A total of 52 schools (n = 8679 students) participated in the experimental implementation phase of the Project P.A.T.H.S. . After completion of the Tier 1 Program, 344 instructors completed the Subjective Outcome Evaluation Form (Form B) to assess their views of the program, instructors, and perceived effectiveness of the program. Based on the consolidated reports submitted by the schools to the funding body, the research team aggregated the consolidated data to form a “reconstructed” overall profile on the perceptions of the program implementers. Results showed that high proportions of the workers had positive perceptions of the program and their own performance, and roughly 90% of the workers regarded the program as helpful to the program participants. The present study provides additional support for the effectiveness of the Tier 1 Program of the P.A.T.H.S. Project in Hong Kong.