Fidelity assessment tools can assess whether a program embraces a core set of principles and performs well. A quality fidelity tool with valid scales can be a feedback loop to identify areas that need further work to improve the program. Using data collected from 1816 correctional and reentry programs in the United States in the construction sample and 761 programs in the confirmation sample, this study examined the internal consistency of the Risk-Need-Responsivity (RNR) Program Tool, an online resource to capture information about structural features of a program.The study reports on reliability statistics and factor analyses to highlight individual subscales. Six scales emerged and had acceptable to excellent levels of internal consistency. These scales are staffing, reward-and-sanction, clinical standards for programs, coaching, program duration, and risk-need assessment.This article discusses fidelity scales from the RNR Program Tool and provides guidance on the importance of tool development processes to ensure accurate, valid, and reliable scales. The purpose of the RNR Program Tool is to create a modern, online tool integrating both the empirical (research) literature on effective practices and clinical standards on quality programming. This process minimizes the need for consultants by giving program administrators the ability to gather information on their programs, score them, and receive instant and targeted feedback with recommendations for improvement to assess their programs against empirical standards in the field. Furthermore, it provides a standardized tool that administrators can use to examine what type of individuals fare better in their programs. The provided targeted feedback can give the programs the ability to seek technical assistance or guidance in specific areas that can strategically strengthen their program. Higher quality programs deliver better client-level outcomes  the Correctional Program Assessment Inventory (CPAI), (2) the Correctional Program Checklist (CPC), and (3) the Standardized Program Evaluation Protocol (SPEP). Each tool assesses the quality of the programs but the tools vary in terms of the number and type of item, and sources of information. This section will describe the similarities and differences among the three tools.The CPAI was developed using Canadian programs to measure how well programs were adhering to Gendreau and Andrews’  principlThe CPC was developed on a sample of halfway house programs in Ohio by researchers at the University of Cincinnati  has been previously established for consultants . The goals are to use the diagnostic information to improve resource allocation, reduce inconsistencies in decision-making, structure intake interviews to capture similar important information, and improve the matching of individuals to programs  have been shown to reduce recidivism, and are the preferred style of providing therapeutic services  to psychometrically evaluate the scales of a new fidelity tool, the RNR Program Tool, (2) to utilize psychometric scale development to design the existing scales and improve their internal consistency, and (3) to provide guidance on the importance of psychometrics in tool and scale development. In addition, we report the findings on two sample sets of programs data to illustrate how the scores vary across types of programs. This study is intended to provide program administrators with knowledge about fidelity of their programs. Using data collected from 1816 correctional and reentry programs in the United States in the construction sample and 761 programs in the confirmation sample, this study examined the internal consistency of the RNR Program Tool. Exploratory factor analysis (EFA) and reliability analyses were performed on the construction sample to let the data determine underlying constructs for the measured variables. Then, confirmatory factor analysis (CFA) was performed on a different sample to test and confirm the structure of the identified factors. More details are explained below.The RNR Program Tool was developed in 2009–2011 to provide a self-administered instrument for a broader array of programming that is typically used for justice-involved individuals including cognitive behavioral groups, restorative justice, educational groups, and community services; the tool was designed to assess the fidelity of program components depending on the goal, purpose, and whether the program had a therapeutic orientation(s). The RNR Program Tool includes a number of built-in reliability checks. It does not require consultants to administer it but instead allows agencies and systems to use the tool to broadly examine the quality of their programs and services. Training and certification for the tool are provided by the Center for Advancing Correctional Excellence (ACE!) . Many of the programs were newly awarded grants from the Center for Substance Abuse Treatment  and/or Bureau of Justice Assistance (U.S. Department of Justice). Both granting agencies encouraged their grantees to use the tool to assess the quality of the program. Others are from select jurisdictions that requested the assistance of the ACE! to improve program fidelity. Program staffers completed the tool and agreed to allow the information to be used for research purposes. The data included a construction sample of 1816 correctional and reentry treatment programs in the construction sample and 761 programs in the confirmation sample. The tool involves a self-administered online survey that is stored in a secure database.Data were collected from programs across the United States that agreed to use the Program Tool as part of the RNR Simulation Tool package  estimator. The data were examined based on correlations among variables, parameter estimates, and the model’s fit to the observable data. Model fit was assessed by examining the relative chi-square (chi-square/degrees of freedom), root mean square error of approximation (RMSEA), probability RMSEA, standardized root mean square residual (SRMR), and comparative fit index (CFI) and Tucker Lewis index (TLI). Factor loadings of each item were expected to be 0.40 or greater  is recommended. KR-20 formula is equivalent to performing the split half methodology on all combinations of questions and is applicable when each question is either right or wrong (dichotomous). KR-20 coefficient was measured and reported below.The reliability of an instrument or questionnaire is concerned with the consistency, stability, and dependability of the scores  Program Tool scales established construct validity using EFA and CFA, and had good reliability, with KR-20 reliability coefficients of 0.60 to 0.90. All items were dichotomized to ensure the consistency of the items. The reliability measures can be found in Table Table Internal consistency across almost all factors was high. With the KR-20 coefficient, a score above .5 is usually considered reasonable. Good internal consistency means that the survey items tend to pull together. In other words, a participant who answers a survey item positively is more likely to answer other items in the survey positively Blunch, .The staffing factor consists of 8 items with a high reliability KR-20 coefficient of .90. The reward-and-sanction factor consists of 9 items with a high reliability KR-20 coefficient of .85. Four items loaded into factor 3, clinical standards for programs, with a reliability KR-20 coefficient of .71. Four items loaded together to create a coaching factor (4) with a reliability KR-20 coefficient at .60. Factor 5 has four items representing the program duration with a reliability coefficient of .63. Five items loaded together to create the use of risk-need tools factor with a reliability measure of .86 (factor 6). Total score has a reliability of .91 for the main sample of 1816 individuals and a comparable reliability of .90 for the test sample of 761, which was used for the CFA. Originally, we had expected to have 3 more factors , but they had low reliability, very few items with cross-factor loadings, and the CFA confirmed excluding them. Therefore, number of factors was reconsidered because very few items are insufficient to measure a construct Norton,  and itemCFA was conducted on the items on a different sample of 761 programs to test the hypotheses about the six theorized constructs achieved by EFA, which concurred with expert opinions and theoretical concerns. WLSMV estimator was used within CFA, which is specifically designed for binary, categorical, and ordinal data. As Li  shows, WModel fit was assessed and the results were satisfactory; the collective goodness-of-fit indices pointed to a good fit. Chi-Square Test of Model Fit was 1463.094 with 512 degrees of freedom. Just like the EFA, a large Chi-square value is expected for large sample sizes Brown, ; therefop-value) for the loadings of all six latent variables of the RNR scales. Figure Table Program fidelity is associated with better outcomes, and it is important to assist correctional and treatment organizations – either institutional or community-based – with the tools to understand the degree to which they are implementing quality programs to achieve key client benchmarks , five items for risk-need assessment, eight items for staffing, to nine items for reward and sanctions. Psychometric methods aid researchers to assess if the construct is unidimensional (measuring only one construct) or multidimensional (measuring more than one construct). Collectively, the advancement of rigous scales is an important contribution to the field.Future research is needed to examine the predictive validity for different program outcomes  for each domain and the overall tool score. Predictive validity will examine which of the domains are needed to deliver a high-quality program that contributes to positive client outcomes. We could not perform concurrent validity for this study because there are no other validated instruments that are related to the constructs measured in this study, and we are unaware of any tools that have such items. In another study, we explored how program- and individual-level factors impact the success of 848 drug court clients in nine courts in terms of: 1) graduation rates; and 2) not being arrested while participating in the court program. In this study, we found that three program level factors  predicted recidivism   literature on effective practices and clinical standards on quality programming. Administrators can gather information on their programs, score them, and receive instant and targeted feedback with recommendations for improvement. The targeted feedback can give the programs the ability to seek technical assistance or guidance in specific areas that can strategically strengthen their program. The tool provides an opportunity for administrators to learn aobut their operations and work on specific areas. While the tool has utility for administrators, consultants can also use the tool to provide a solid process for assessing program features. Facilitators or consultants are frequently needed for an agency to critically analyze operations, and in fact external facilitators typically help organizations achieve greater gains (Berta et al., Second, RNR Program Tool scales essentially describe core functions that are important to the program quality in terms of the clinical, management, and/or empirical literatures. And, these core features derive from a myriad of literature in correctional programs, substance use disorders, mental health disorders, educational programs, and social work services. This means that the tool and the resulting scale are valuable to different audiences including programs and services that are operated by other agencies outside of the correctional system. These include practices related to staffing, clinical standards, and use of rewards and sanctions. The scales disentangle the messiness of implementation fidelity into more manageable and targeted components given the goal is to provide administrators with feedback on how to improve their current program. That is, the feedback report will generate scores in each domain and then administrators can use this report to identify program features that need to be strengthened. Targeted feedback reports can be directive and point programs into specific directions for improving their fidelity. This self-administered approaches uses feedback reports as a means of helping administrators identify the aspect of the program that needs improvement.This study illustrates the importance of using accepted psychometrics in developing instruments for justice settings and/or programs that service justice clients. During the development of the RNR Program Tool, EFA and CFA assisted in clarifying the scales. It raised issues regarding the measurement of core variables, which resulted in harmonizing the underlying data to use dichotomous variables. This drove the selection of the KR-20 over the Cronbach’s alpha for measuring reliability. Developers of scales can learn lessons about creating subscales or domains that are empirically and theoretically sound through the use of better psychometric methods. This is important to both the science behind the instrument as well as its utility in the field. More emphasis should be placed on ensuring that instruments are reliable and valid.This study is motivated by the dearth of studies on scales for fidelity tools. Fidelity assessment tools can assess whether a program embraces a core set of principles and performs well. After covering the literature on what we know about fidelity in programming and program impact on client level outcomes, this article discusses the construction of scales for one fidelity tool, the RNR Program Tool, which integrates both research on effective practices and clinical standards on quality programming. This online process gives administrators and consultants the ability to collect information on their programs, score them, and receive instant and targeted feedback with suggestions for improvement in their programs and to evaluate them against empirical standards in the field.The importance of developing accurate, valid, and reliable scales while developing tools is highlighted in this study. A valid fidelity tool is invaluable since it ensures that the underlying scales represent objective items that are useful in assessing the process of a program. Good quality scales can provide a feedback loop to administrators on how to strengthen the program. Consequently, a quality fidelity tool with valid scales can offer an accurate picture of the functionality of a program with guidance on how to improve practice. Furthermore, it provides a standardized tool that administrators can use to examine what type of individuals fare better in their programs. The provided targeted feedback can give the programs the ability to seek technical assistance or guidance in specific areas that can strategically strengthen their program.


While adoption of machine perfusion technologies into clinical practice in the United States has been much slower than in Europe, recent changes in the transplant landscape as well as device availability following FDA approval have paved the way for rapid growth. Machine perfusion may provide one mechanism to maximize the utilization of potential donor liver grafts. Indeed, multiple studies have shown increased organ utilization with the implementation of technologies such as ex-situ normothermic machine perfusion (NMP), ex-situ hypothermic machine perfusion (HMP) and in-situ normothermic regional perfusion (NRP). The current review describes the history and development of machine perfusion utilization in the Unites States along with future directions. It also describes the differences in landscape between Europe and the United States and how this has shaped clinical application of these technologies. In the United States (USA), there continues to be a discrepancy between the number of patients awaiting liver transplantation and the number of available donor livers . As the Since the initial rise of liver transplantation, static cold storage (SCS) has remained the gold standard in preserving donor livers due to its low cost and simplicity. While this form of preservation has worked well for high-quality organs with relative short cold ischemic times, it has several limitations particularly when trying to expand the donor pool with donation after circulatory death (DCD) or other “marginal” livers. These limitations include: (I) sustained organ injury not being reversed; (II) further organ injury during storage; (III) organ viability cannot be assessed; and (IV) storage time is limited . Machinep < 0.0001). The effect was most pronounced in DCD livers, where the peak AST was reduced by 73.3% compared to 40.2% in donation after brain death (DBD) livers. In addition, there was a 50% lower organ discard rate and 54% longer mean preservation time in the NMP group.Initial studies from Europe have demonstrated encouraging results for NMP, HMP and NRP. The safety of NMP was initially demonstrated by the Oxford transplant group using the OrganOx metra device , after wp = 0.03).When looking at ex situ HMP, a multicenter study from transplant centers in Zurich and Birmingham compared DCD liver grafts treated with SCS, with livers treated with 1–2 h of hypothermic oxygenated perfusion (HOPE) after cold storage. In that study, graft loss was significantly less in HOPE-treated livers, despite longer donor warm ischemia times than SCS. . More reIn situ NRP represents a different technology to ex situ NMP and HMP. NRP provides oxygenated perfusion and the potential recovery of the organs in DCD donors where a mandatory period of warm ischemia has occurred during the withdrawal of life-sustaining therapy (WLST). Previous studies looking at in situ NRP have demonstrated reduced ischemic cholangiopathy (IC) and improved patient and graft survival compared to SCS . In addiWhile high-quality data from randomized trials demonstrating a clear benefit of machine perfusion technologies compared to SCS is still limited to a few trials, there is growing literature from non-randomized studies to suggest potential benefits, particularly for DCD and other “marginal” donor livers.The slower adoption of machine perfusion in the USA than Europe is multifactorial; however, the primary reason has been the lacking clinical availability until after U.S. Food and Drug Administration (FDA) approval. The first FDA approval for an ex situ perfusion device was on 28 September 2021 . Prior tEx situ machine perfusion devices have been approved for clinical use in Europe for some time. Many of the first machine perfusion platforms were developed in Europe. In addition, the medical device approval process has previously been shown to occur much more quickly in Europe than in the United States . The FDA2 compared to 0.09 million miles2 in the United Kingdom. As a result of this vast area, many organ procurements require plane flights, a situation that is even more pronounced when looking at marginal liver grafts [Another challenge to using machine perfusion in the USA has been the large land area over which organ procurement take place. The land area of the USA is 3.80 million milesr grafts . This rer grafts ,15,16,17Advancing American Kidney Health, by President Donald Trump, changes to the organ procurement system were sought to help the almost 109,000 people in the USA currently on the transplant list for a lifesaving organ [Organ Procurement Organizations (OPOs) are not-for-profit organizations responsible for recovering organs from deceased donors for transplantation in the USA. There are 57 OPOs, each mandated by federal law to perform this mission in the donation service area (DSA) assigned to them. As part of an executive order, ng organ . On Noveng organ . The goang organ ,3,4.In addition to the pressures on OPOs to increase organ utilization, there have also been significant changes to the liver allocation process that have increased the pursuit of “marginal” liver grafts by transplant centers. Following years of debate and legal challenges from all sides, a liver distribution system based on acuity circles went into effect on 4 February 2020 . This haOCS liver system (TransMedics): NMP, FDA approved.® System: NMP, FDA approved.OrganOx metraLifePort Liver Transporter (LLT) system: HMP, DHOPE, clinical trial complete with FDA approval pending.VitaSmart Liver Machine Perfusion System (Bridge to Life): HMP, HOPE via portal vein alone, clinical trial currently recruiting.The following are the NMP and HMP platforms that are either FDA approved for clinical use or currently in the clinical trial stage in the USA :OCS livep = 0.009). OCS use was also associated with a significant reduction in ischemic biliary complications at one year . Patient survival at one year was high, at 94% for both OCS and SCS control arms [Prior to September 2021, the utilization of NMP was only available for clinical use as part of a registered clinical trial. The Liver PROTECT trial compared livers treated on the OCS liver system (TransMedics) compared with SCS controls . This strol arms .A multicentered randomized control trial comparing the OrganOx NMP system with SCS was conducted between 9 October 2016 and 3 February 2020 at 15 US liver transplant programs . While dSeveral single-centered trials investigating NMP have been performed at Cleveland Clinic using their internally developed NMP platform . Data fr® System received FDA approval for clinical use on 9 December 2021. Since those dates, the clinical use of both platforms has increased. The OCS liver system (TransMedics) may be used directly by members of the transplant center or may be used as an “end-to-end” service through the National OCS Program run by TransMedics. The National OCS Program employs procurement surgeons that will procure and place the donor liver on NMP, then fully staff the device during transport until implantation of the liver at the recipient transplant center [® System is available for use by members of the transplant center. OrganOx does not offer a national program. The OrganOx metra® System is the only NMP device in the US that supports back-to-base usage, where the liver is procured and brought back to the transplant center using SCS and then placed on NMP.The OCS liver system (TransMedics) received FDA approval for clinical use on 28 September 2021, while the OrganOx metrat center . The trap < 0.001) [At the time of writing this manuscript, there have been no publications on the outcomes of NMP in the USA following FDA approval of the two aforementioned devices. There have been several publications using data from the Scientific Registry of Transplant Recipients (SRTR) that looked at NMP outcomes from liver transplants that were performed as part of clinical trials. The first study investigated N = 228 livers that underwent NMP (OCS or OrganOx) prior to liver transplant. The NMP group had a 3.5% discard rate versus 13.3% in the SCS group (< 0.001) . Surviva< 0.001) .p = 0.08). In a follow-up to that study, the same group published data from the registered trial: Hypothermic Machine Preservation-Phase 2 [p = 0.016). Mean hospital stay was significantly shorter in the HMP group . [Currently there are no HMP devices that are FDA approved for clinical use in the USA. HMP in the United States was initially carried out by Guarrera et al. at Columbia University . In this-Phase 2 . In that 0.001). .® with SCS was conducted between 3 April 2019 and 30 July 2022 at nine US liver transplant programs [A multicentered randomized control trial comparing the LifePort Liver Transporter (LLT) system using Vasosolprograms . Resultsprograms .When discussing NRP it is important to differentiate between Abdominal NRP (A-NRP) and Thoracoabdominal-NRP(TA-NRP). While these procurement techniques share the utilization of extracorporeal membrane oxygenation, they differ dramatically in their cannulation techniques, which organs are provided with in situ perfusion, and the re-initiation of cardiac activity. A-NRP provides in situ perfusion of the abdominal organs only via the infrarenal aorta and IVC  and does not involve the reinitiation of cardiac activity, while TA-NRP involves in situ perfusion of the thoracic and abdominal organs (via the aortic arch and right atrium) as well as the reinitiation of cardiac activity.The first group to publish their experience with A-NRP in the US was the University of Michigan. In that experience, the authors described 37 cases of A-NRP in which livers were used for transplantation in 13 cases . The MicThe use of NRP in the US was largely abandoned until 2020. As DCD heart transplantation started to gain support, select thoracic transplant programs began to pursue TA-NRP as an alternative to ex situ machine perfusion in establishing a viable means to procure hearts from DCD donors. An initial series of 15 cases of TA-NRP was published by a group from Vanderbilt and clinical trial protocols were listed from both NYU and University of Nebraska . These TThere is renewed interest in the establishment of A-NRP in the USA driven by abdominal transplant teams. At Mayo Clinic Florida, we began the development of an A-NRP program in January 2022. To date, we have performed a total of 10 liver transplants using A-NRP recovery in the donor. Six-month graft and patient survival are 100% and we have had no cases of IC. The rate of EAD has been 10% and the PRS has been 0%, compared to a rate of 33.6% and 26.0%, respectively, in our DCD LT undergoing SCS .Discussions surrounding the ethics of NRP in the United States has resulted in several individuals and groups wanting further conversation on the topic. These discussions have largely been in reference to TA-NRP where the heart is restarted, and the brachiocephalic vessels are clamped to prevent reperfusion of the brain. They have not been raised regarding A-NRP, where only the abdominal organs receive in situ perfusion. The most notable of these groups wanting further conversation on TA-NRP was a white paper by the American College of Physicians . SubsequPerfusion of the organs in the body: This is not autoresuscitation or resuscitation of the donor. The donor is dead before the initiation of NRP. NRP is mechanically assisted regional perfusion and oxygenation of organs for transplantation.Clamping the brachiocephalic vessels before the initiation of TA-NRP ensures that the brain is not reperfused. Circulatory death has already been determined under the UDDA and in accordance with accepted medical standards when the brachiocephalic vessels are clamped.Reperfusing the heart in the body on NRP is no different that restarting the heart outside of the body with machine perfusion. While this is optically different, in both cases, the heart is restarted with artificial machine assistance for the purpose of organ donation in a person who died intending to donate their organs. The heart would not continue to function within the donor without ventilatory support, so it is functioning only with mechanical assistance for the purposes of organ donation.The American Society of Transplant Surgeons (ASTS) released a statement addressing TA-NRP in DCD donors on 23 August 2022 . In thatIn addition to the above statement, the ASTS also released recommendations on best practices in DCD organ procurement, that was supportive of both TA-NRP and A-NRP .The interest in machine perfusion in the USA is strong, particularly as the utilization of DCD donors has continued to rise . As in ECost Report for all Medicare patients. This reimbursement is based on the percentage of Medicare and Medicaid patients receiving liver transplantation at the respective transplant program and that percentage of the total Cost Report is reimbursed. Previous authors have speculated that for Medicare and Medicaid patients, the costs of machine perfusion will be fully reimbursed under the organ acquisition Cost Report for all Medicare patients [For Medicare and Medicaid patients, reimbursement for organ acquisition costs (which would include the costs of machine perfusion) would fall under the patients . Many unWhile still in the experimental phase, it is possible that in the future machine perfusion protocols could employ gene therapy, nanoparticles, or liver defatting. These protocols could potentially allow for the more extensive reconditioning of damaged livers ,47.In conclusion, while adoption of machine perfusion technologies into clinical practice in the United States has been much slower than in Europe, recent changes in the transplant landscape as well as device availability following FDA approval have paved the way for rapid growth. The future of these technologies in the USA is exciting, as many are hopeful they will facilitate the maximal utilization of donor livers, thus honoring the wishes of the donor and the donor’s family to provide a lifesaving gift.


The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), ratified in 2006, states that the achievement of equal rights, empowerment, and social inclusion of people with disabilities requires comprehensive rehabilitation services involving educational, social, economic, and medical interventions, all dimensions of the World Health Organization Community based rehabilitation (CBR) matrix. CBR programs aim at achieving those goals. In the present study, we investigated whether a large scale CBR program is improving access to multiple services  and providing satisfactions (by measuring the reduction in unmet needs) of Afghans with disabilities. We enrolled in the study 1861 newly recruited CBR participants with disabilities from 169 villages between July 2012 and December 2013, and 1132 controls screened with disabilities randomly selected with a two-stage process within 6000 households from 100 villages in the same provinces as the CBR but outside its catchment area. Using propensity score matching (PSM) and difference in difference analysis, we estimated the differences in accessing services. There were statistically significant differences between participants and controls on the access of available services between the baseline and endline. Using PSM we also found that needs were more often met among CBR participants compared to the controls. Our study indicates that a CBR program may be an effective way to provide services for persons with disabilities even in a conflict context such as Afghanistan. It contributes to addressing the longstanding question whether CBR can actually improve the rehabilitation of persons with disabilities. Persons with disabilities in Low- and Middle-Income Countries (LMICs) have been marginalised, enduring a level of multipronged difficulties in all spheres of life that no other social group has encountered . ExistinIn LMICs, resources to fight poverty, provide equal opportunities to persons with disabilities, promote their rights, and encourage full participation in society are limited. Community Based Rehabilitation (CBR) was introduced by the World Health Organization WHO) following the Declaration of Alma-Ata in 1978 on primary healthcare coverage as an effective strategy to overcome limited resources and poor access to existing ones for persons with disabilities by offering local rehabilitation initiatives in LMICs. Such initiatives aimed at implementing part or all of the five components of the CBR matrix—health, education, livelihood, and social and empowerment components depending on local needs and priorities ,22. The During an international consultation to review CBR program principles organised by the WHO and other Un agencies in 2003 , severalThe evaluation of CBR effectiveness remains scarce in LMICs, making the adoption of evidence-based practices problematic to achieve . Many stThe access to services can be considered as a key indicator of the performance of the CBR programs. Measuring satisfaction with services as part of access is essential as the literature has shown that persons with disabilities often are confronted to situations where inappropriate services, particularly healthcare services, are offered or they face attitudinal, financial, or physical barriers to access ,45,46. SThe present study seeks to contribute to the literature by investigating the effectiveness of a wide range of services delivery—physiotherapy, assistive devices, employment services, education services, and advocacy—for participants of a CBR program in rural Afghanistan with various types of disabilities, including their level of satisfaction with the services received over time compared to treatment as usual through the basic package of health services for a random control group of persons with disabilities. We conducted a large quasi-randomized field experiment of a CBR program that has been implemented in 13 provinces of northern and eastern Afghanistan since 2004. The CBR is implemented in 13 provinces with four regional project offices based in Ghazni, Jalalabad (Nangharar province), Mazar-e-Sharif , and Takhar  See . As of 2mahals where recruited CBR workers live and from where the program expands progressively to include nearby villages until covering extensively each district of the 13 included provinces.We included all new 1680 CBR participants included in the CBR program between July 2012 and December 2013 living in one of the 169 urban or rural catchment areas of the CBR program and identified using a locally developed, tested, and validated questionnaire based on the World Health Organization guidelines for grassroot disability program . CatchmeWe also included during the same period a group of controls living in 100 randomly selected villages and urban centres of the same provinces but outside of the program catchment areas. At the second stage, 60 households were randomly selected from the social centre (a mosque or an open square) of each village/urban centre yielding a total of 6000 households. From the social centre, a random direction was defined using a spinner, direction in which all households were numbered. The first household was identified using a random number selected between 1 and 60. And all other 59 households were selected using the nearest front door method. A household was defined as a unit that shared a kitchen, an income, and occupied the same flat, house, or compound. Children and adults with disabilities were identified using a locally validated disability-screening tool composed of 34 items for adults (DSQ-34) and 35 for children (DSQ-35) . All study participants were interviewed with a locally developed and validated questionnaire that inquired about demographic characteristics, socioeconomic status, access to various CBR services from among the five domains of the CBR matrix  , individThis study assessed self-reported measures of availability of CBR program services and service recipient satisfaction. We first measured if study participants received any of five types of services—namely physical therapy, assistive devices, employment support, education support, advocacy—and then we asked about quality-of-life improvement of the services received. A dummy variable was created for each set and for each outcome . For access to services, we considered the use of services as a relevant proxy ,55 and wPhysical TherapyPhysical therapy (PT) is provided in 12 existing physiotherapy centers and at home for both children and adults with disabilities diagnosed with a condition that can be improved through PT. Mobility and assistive devicesMobility and assistive devices are made available free of costs to participants with disabilities with mobility limitations. Prosthesis and orthotics are locally manufactured in four regional workshops by Swedish Committee for Afghanistan and provided to people wounded by ammunitions, landmines, or explosive ordnance. Orthotics have been provided in some cases to children presenting conditions such as poliomyelitis and cerebral palsy. In case of paralysis or other walking limitations, locally built wheelchairs or three wheels bicycles with a system of hand pedals have been used. Similarly, crutches, walking frames, and walking sticks all locally fabricated have been made available for different conditions of mobility problems. Finally, special chairs are fabricated for children with cerebral palsy who need some support while sitting. Employment and livelihood supportThe employment and livelihood support program has been offering increased services to persons with disabilities since the beginning of the present study. Such services include vocational training , business management training, small loans, in-kind support, establishing saving groups and producer groups engaged in sectors such as dairy, garments, and soap making to launch or support businesses. Education supportThe CBR program promotes early educational intervention through home-based education for children with disabilities. Following a period of home-based education, children are transferred to a Community Rehabilitation Development Centre, where they are introduced to formal literacy and numeracy for two to three years before transitioning to a mainstream school. Advocacy and community mobilizationShurah about the rights of people with disabilities aiming at fighting stigma and discrimination in the public sphere. Another important activity is awareness raising about the benefits of inclusion in education among school principals, teachers, and parents of both disabled and non-disabled children to promote open and welcoming schools. Similarly, targeted awareness towards employers to promote inclusion of persons with disabilities in employment is an important dimension of advocacy. Such definition was shared with CBR participants who were asked to acknowledge if any advocacy and community mobilizations activity has been conducted by the CBR program to address problems of discrimination they faced in their community.A variety of activities are included in the generic appellation of “advocacy and community mobilization” as we found through discussion with CBR workers and activity observation during the present study. In practice, advocacy and community mobilizations include a combination of disability sensitization and awareness raising interventions by CBR workers among community members. A major activity is general training and lecturing for families, village elders, and members of the local community called Service recipient satisfaction was measured with the following question: “What are the remaining needs you have that the program did not cover?”, from those who received a given service. Participants identified a list of nine possible needs: Education and training, housing, healthcare, income, job opportunity, disability pension, respect from family, respect from community, getting married. The present study measures exposure to CBR program services delivered to participants compared to a group of controls that received usual services offered by the State either directly or through the subcontracting to Non-Governmental Organizations (NGOs), in particular, the basic package of health services . We asseSeveral covariates were included in the calculation of the propensity score. We included study participants characteristics at baseline, including gender , age (continuous), disability type , cause of disability , ethnicity  education level , and level of wealth measured by a welfare index using polychoric principal component analysis based on a list of durable goods  owned by the household . We also included community-level variables such as availability of electricity (availability or not in the village), distance to the closest school (continuous), and to the closest healthcare facility (continuous). We did not include age and disability type in the calculation of the propensity score. The age range difference between participants and controls was very narrow. There was potential collinearity between cause and type of disability, therefore we used cause of disability for the calculation of the propensity score and for the adjustment of the model.t tests compare demographic and socioeconomic characteristics, and village characteristics and outcomes of interest (access to and satisfaction for CBR services) between CBR participants and non-participants.Descriptive statistics provide the distribution, and chi-squared tests and For obvious ethical reasons of NGO commitment to make the CBR program available to all persons with disabilities in its catchment area, we could not randomly select participants in the two arms of the study. In absence of meeting all the conditions for an experiment, and to reduce selection bias, we examined the change overtime on the outcomes of interest comparing CBR participants and non-participants using a difference in difference model after propensity score matching (PSM) . We usedWe estimated a propensity score for each individual representing their probability of receiving the mentioned five types of services, conditional on a set of observed covariates that are recognized to predict both treatment assignment and outcomes of interest (Models 1 to 5). Propensity score matching allows to reduce selection bias linked to the choice of a quasi-experimental study design by controlling for selection on observables that might influence the probability of being in the CBR program intervention or control group . SimilarIn both set of models (access to and satisfaction with services), we controlled in the analysis for personal characteristics that might have an effect on the impact of the programme  and because all those who are eligible within a catchment area are included in the programme we made the reasonable assumption that participant and control groups have similar characteristics overall ,65.ATE) and the average treatment effect on the treated (ATT) of the CBR program through its interventions can be estimated using the following formulas:E[Y0||D = 1] nor E[Y1||D = 0] can be observed, since we did not observe what would have happened to the controls had they received the program, or what would have happened to the treatments had they not received it. We estimated these two counterfactuals by matching each CRB participant with one or more controls that were similar in key characteristics. In mathematical terms, the average treatment effect (ATT) can be obtained by:To overcome the possible selection bias of non-random choice of participants and controls and the absence of independence between the effect variable and the treatment variable, we introduced an assumption of conditional independence. We assumed that we observed all the variables  we assumed the existence of common support, which implies that only CBR participants that have a probability of being treated also found in any of the controls were included in the analysis. Similarly, controls with an extremely low probability of being treated were not included either. This method has the advantage of not requiring any assumption on whether the program has homogeneous or heterogeneous effects on the model errors and by being non-parametric it can be combined with other methods in order to yield more precise impact measures .We combined PSM with the difference in difference (DD) approach in the case of access to services only when two points in time (bles (X) . We idenATT):We used a logistic regression of the likelihood to access the program based on baseline variables  of having unmet health needs and male while being a Pashto significantly increased the risk of having unmet educational and pension needs. Other minority ethnicities were more likely to have a remaining need to find a life partner than Pashto. Not surprisingly, unmet needs for income and pension increased with age, while educational and social (respect and marriage) needs were less likely to be unmet with aging. Conversely, people with intellectual and associated disabilities compared to persons with a physical disability as well as those disabled at birth compared to those disabled from a known cause such as war violence, a disease, or an accident, were more likely to lack family and community respect, a noticeable indication of the stigma associated to certain types and causes of disability. Uneducated people were also more at risk of unmet needs for respect. Finally, the poorest were more likely to have unmet needs in all domains. Our study offers several contributions to the literature on the impact of CBR programs in LMICs. First, we provide insights into the effectiveness of in the delivery of health and rehabilitation, employment support, access to school and advocacy, and community mobilization services of a CBR program in Afghanistan using a quasi-experiment approach. Our results revealed an overall significant impact of the CBR program on the access to physical therapy, assistive technology, employment, education and advocacy, and community mobilization, indicating that CBR programs can bring closer needed services to persons with disabilities in LMICs. Second, we established participants’ satisfaction with the program coverage by investigating the level of uncovered remaining needs—health, education, housing, employment, income, pension, family and community respect, and marriage—that belong to various components of the WHO CBR matrix . Third, The CBR program had a differential impact in terms of access to services. The highest positive effect was on the access to physical therapy services. After 3 years on average in the program, the estimated marginal effect is a considerable 105.8%. The large gap between treated and controls is the result of a long-standing offering of physical therapy services but also assistive technology devices, both at the origin of the CBR program in Afghanistan, a country where decades of conflict have generated a large number of people physically disabled by violence and in need of such services . These skismet), or black magic. The latter are designed by the use of a derogative term ‘mayub’ in Dari and Pashto, the two major languages in use [The improvement in access to services is not uniform across the sample of participants. In particular, the gap in the benefit of assistive technology between males and females is partially explained by the lower number of females who lost limbs or were injured due to the conflict. The program put an emphasis on intervening earlier in life and/or at the onset of disability to try and minimize the negative impact of the impairment explaining an early intervention for education. The program also aims at supporting those who are most stigmatized. This probably explains why people disabled due to the conflict were less likely to receive employment support compared to those disabled at birth. Literature has shown that in Afghanistan, persons who were disabled due to conflict are highly recognized in Afghan society and often benefit from socioeconomic advantages, in particular in terms of job opportunities. It is probably why the recipients of physical therapy and assistive technology are more likely to be found among the richest 20%. Conversely, persons who were disabled at birth or from an unknown cause, are stigmatized against and considered disabled as the consequence of a curse of God, spirits, jinn, fate  of program participants compared to the controls. We did not find such a gap in reducing unmet needs for disability pension. A possible explanation for the absence of a significant reduction in the need for a pension is the small amount of the existing disability pension scheme unlikely to cover basic capabilities, combined with the eligibility rules that favor persons wounded or killed at war (‘martyrs’), excluding de facto many persons with disabilities from its benefit. But the otherwise reduction in unmet needs is extremely important considering that a growing body of literature has demonstrated a higher level of deprivation of people with disabilities not only in terms of income and material wealth but also in terms of basic needs, compared to the rest of the population in LMICs ,82,83,84The impact of the CBR program on the level of respect from family and the community as well as access to marriage is an important finding with far-reaching consequences. First, building family and community respect has proven effective in reducing internalized stigma, low self-esteem , and menPashtunwali code that determines that men are the breadwinners while women should not participate in social and economic life and access public areas, including healthcare facilities, unless accompanied by a mahram, a male close relative, but instead fulfill a role of house wife and mother [There is notable variation in unmet needs according to people with disability characteristics. Poorer disabled people remained more likely to have unmet needs than wealthier disabled people. This finding is supported by the available evidence showing that the material deprivation of persons with disabilities is associated with the deprivation of other basic capabilities such as employment, healthcare, education, and social and political participation ,93,94 amd mother . It is od mother ,98. Liked mother .Our study presents some limitations. First, the quasi-experiment approach we had to adopt does not ensure random assignment to either the treatment or the control arm, presenting a risk of selection bias. Elderly people and people with associated disabilities were significantly less likely to participate in the program (53). Similarly, the program coverage area included villages that seemed less remote than the control villages when considering better electricity coverage and less distance to the closest school and healthcare facility. To reduce the risk of selection on non-observable variables, we included multiple control variables to calculate the propensity score. We also used a difference in difference model to increase the likelihood of unbiased estimates of the CBR program effect. Baseline information shows that CBR participants started worse off than their counterparts, reducing the chance that observed impacts were due to initial differences favoring CBR participants. Similarly, services sometimes started immediately, in particular for physical therapy, showing a high proportion of CBR participants already receiving services at baseline. Providing treatment and services came first, the study came second. Therefore, we observed a vast majority of people with mobility limitations who already started receiving physiotherapy from the program at the time of their first interview. There is also a risk of information bias as data collection was carried out by CBR workers for security reasons. This might have encouraged a social desirability bias as CBR workers might have been tempted to show a positive impact of their program. We conducted a close supervision of data collection, random re-interviews, and multiple consistency checks to reduce the risk of bias. This empirical study has shown that a CBR program could contribute to improve the livelihood of persons with disabilities, lessen the costs of living with a disability, promote their participation in family and community life, escape stigma and prejudice, and reduce the level of unmet needs by effectively ensuring access to various CBR services from among the five domains of the CBR matrix  in Afghanistan, a country characterized by over four decades of turmoil. A key message arising from this study is that CBR programs can effectively improve the social and economic life of persons with disabilities and their families, even in a crisis context. Consequently, CBR programs can also improve the mental wellbeing of persons with disabilities by reducing the impact of the multiple daily stressors they endure ,99. Thes


The program has an effect on lower limb endurance (p > 0.05). Gains in balance were correlated to the diminution of fear of falling (p < 0.05). An 8-week multicomponent physical exercise program based on balance is efficient to reduce fall risk and fear of falling among the elderly.In older populations, falls are responsible for decrease autonomy and increased pain and injuries. With aging, fall risk is multifactorial and associated with sarcopenia, impaired balance, falls themselves and psychological factors such as fear of falling. The objectives of the present study were: (a) to test the effects of a short multicomponent physical exercise program on fall risk and fear of falling; and (b) to analyze the relationship between fall risk and fear of falling. The participants were thirty-five older persons who were engaged in an eight-session physical exercise program. Balance , lower-limb endurance  and fear of falling were measured before and after the multicomponent physical exercise program. Results indicated an increase in balance and a diminution of fear of falling after the end of the physical exercise program ( Among the elderly, fall risk is associated with a reduction in quality of life and mobility ,2. IndeeTo date, several strategies have been proposed to prevent fall risk and functional decline of the body with aging. These strategies include muscular reinforcement with resistance exercises, balance exercises, blood flow restriction and neuromuscular electrical stimulation or vibrations ,18,19,20However, physical condition is not the only factor that influences fall risk. Psychological factors and especially fear of falling seems to be an important predictor of falls among the elderly. Indeed, a study by Lavedán and collaborators showed that fear of falling is a cause and a consequence of falls . AuthorsThus, beyond muscular reinforcement and balance, the evaluation of fear of falling seems to be an important measure in fall risk prevention among the elderly . Indeed,Of the seventy-three initial subjects, only thirty-five of them completed. Subjects were 66 to 89 years of age (76.3 ± 7.9 years old) and were engaged in the program. Dropouts were due to medical  and personal reasons (family). Subject were recruited in the Nîmes Sport-Santé association, France, that proposes adapted physical activities and sensitization programs. To participate, subjects had to be member of the association, have a good autonomy, living at home, aged >65 years old and signed informed consent. The exclusion criteria were residential care and terminal illness. Authors of the present study had the written authorization of both participants and Nîmes Sport-Santé association to use the data collected by the association.The program was composed by 8, one-hour weekly morning sessions supervised by an adapted physical activity teacher. Subjects were divided into two groups of 5–15 people. The content was specific to each session. In sessions 1 and 3, subjects realized balance exercises. Sessions 2 and 5 consisted of upper and lower limb muscle strengthening exercises. Sessions 4 and 6 focused on gesture and posture. During session 7, the subjects worked on proprioception. Session 8 was reserved for a general review of the exercises covered in previous sessions and to give advice and tools for independent practice. The program is fully detailed in Pre and post balance and fall risk assessments were completed before and after the intervention program by using a combination of balance and physical tests.Equilibration level was measured with the one-leg balance test, which has been shown to be an important predictor of falls among older adults . It consThe wall-sit test is a test of lower body muscular strength and endurance. The test requires the subject to hold a sitting position while leaning back against a wall with their knee bent at 90° and time was recorded.Functional reach test (FRT) is a clinical measure, defined as the maximum distance one can reach, forward beyond arm’s length. It is used to evaluate elderly subjects at risk of recurrent falls and measure dynamic balance ability clinically. Forward distance was typically between 16 and 35 cm .Fear of falling was evaluated by participants answering a question “are you afraid of falling?” on a one-to-ten Likert-scale. One being the lowest fear of falling and ten the maximum. Participants reported their fear of falling on the analogic scale twice, during the first and the last session of the intervention program. Thus, 22 subjects were retained for the evaluation of fear of falling.p < 0.05.Variable data normality was checked using the Shapiro–Wilk test and homogeneity of variance with the F-test. Given that the studied variables displayed a deviation from normality, effects were analyzed by non-parametric tests. Thus, the paired-sample Wilcoxon test was used to compare pre- and post-evaluations. Pearson correlation was performed to test the association between the reduction of fear of falling and the amelioration of static balance before and after the intervention program. Analyses were performed using GraphPad Prism software . Data are presented as means ± SD. Significance was set at p > 0.05)  .p < 0.001).Subjects performed the functional reach test during the first and the last session. Analysis of results showed a significant increase in the forward distance subjects could reach beyond arm’s length. p = 0.01) and increased by 24.8% with left foot on the floor, i.e., 13.9. ± 2.0 s vs. 17.3 ± 2.0 s before and after the program, respectively (p = 0.026). In the condition with eyes closed, the maximal time subjects could hold in a standing position increased by 98.6 % with the right foot on the floor, i.e., 3.2 ± 0.2 s vs. 6.3 ± 1.2 s before and after the program, respectively, (p < 0.001) and increased by 179.6% with the left foot on the floor, i.e., 2.4 ± 0.4 s vs. 6.7 ± 1.1 s before and after the program, respectively (p < 0.001).One-leg balance test was improved by the program whatever the condition, i.e., with eyes open and closed. Indeed, in the condition with eyes open, the maximal time subjects could hold in a standing position increased by 39.2% with the right foot on the floor, i.e., 16.2 ± 2.0 s vs. 22.3 ± 1.8 s before and after the program, respectively (p = 0.036).p = 0.026 and p = 0.039, respectively). Other balance indicators are not significantly correlated to the reduction of fear of falling (p > 0.05).A correlation has been performed to check the association between the reduction of fear of falling and balance indicators, i.e., amelioration of functional reach test and one-leg balance test (eyes open and closed) between the beginning and the end of the program. To this end, gains in balance indicators and reduction of fear of falling have been calculated from the difference of values between the end and the beginning of the program. Results are presented in In this study, we test whether an eight-session multicomponent physical exercise program based on balance and muscular reinforcement could reduce fall risk and fear of falling among the elderly. Several results generated from this study are worthy of discussion.With aging, more and more people are likely to fall. Prevalence of fear of falling is between 20–39% among community-dwelling older adults ,34,35. Tp > 0.05). Here, balance gains could not be explained by skeletal muscle adaptation. These data underline the interaction between balance and fear of falling observed our study and confirmed by Pearson’s correlation. Thus, in our conditions, balance gains could be explained by psychological aspects, i.e., reduction of fear of falling, suggesting that fear of falling is a predictor of balance among the elderly.Many studies focusing on the prevention of falls among the elderly have examined effects of physical activity programs on balance. Indeed, it has been shown that a balance-based physical activity program was associated to a reduction of fall risk ,43,44. QSubjects were asked to be more active in daily life. However, physical activity performed between sessions was not evaluated. An increased physical activity level between sessions could have explained, at least in part, the observed gain in balance in the present study.Balance gains and decreased fear of falling should be interpreted carefully. We do not have any information on long-term effects. In order to strengthen our hypotheses, it would have been interesting to have a measure of fear of falling and balance several weeks after the end of the physical exercise program. It is possible that psychological benefits decrease over time if no follow-up is done. Under these conditions, several investigations are needed to find out the long-term effects of an eight-session multicomponent physical exercise program on balance and fear of fall among the elderly. Moreover, the use of the FES-I questionnaire to evaluate fear of falling would have been interesting as it use among the elderly and includes environmental factors . NeverthThis study showed that an 8-week multicomponent physical exercise program could increase balance and decrease fear of falling but was insufficient to improve muscle strength. Increased balance was therefore associated with decreased fear of fall rather than with muscle strengthening. Thus, psychological factors may have benefits on balance. Longer interventions should be proposed to include muscle function improvement. A global approach including both physical, psychological and environmental factors is recommended to prevent fall risk among the elderly.


We describe the clinical implementation in North America of Teen Online Problem Solving (TOPS), a 10+ session, evidence-based telehealth intervention providing training in problem-solving, emotion regulation, and communication skills.Twelve children's hospitals and three rehabilitation hospitals participated, agreeing to train a minimum of five therapists to deliver the program and to enroll two patients with traumatic brain injuries (TBI) per month. Barriers to reach and adoption were addressed during monthly calls, resulting in expansion of the program to other neurological conditions and extending training to speech therapists.Over 26 months, 381 patients were enrolled , and 101 completed the program. A total of 307 therapists were trained, and 58 went on to deliver the program. Institutional, provider, and patient barriers and strategies to address them are discussed.The TOPS implementation process highlights the challenges of implementing complex pediatric neurorehabilitation programs while underscoring potential avenues for improving reach and adoption. However, a gap exists between the identification of promising evidence-based practices (EBP) validated through randomized controlled clinical trials and their introduction into clinical care. Evidence suggests that the vast majority of EBPs never move beyond peer-reviewed publications into everyday clinical practice . This soPediatric neurorehabilitation suffers from both a dearth of EBPs and unique challenges around efforts to clinically implement them. Most children with behavioral health care needs following traumatic (TBI) or other acquired brain injuries (ABI), such as stroke or brain tumors, fail to receive behavioral health treatments of any type , 4. FactRecent evidence-based guidelines for pediatric ABI  have idereach, defined as the number of patients screened, referred, and treated, and adoption, defined as the number of therapists trained and delivering the program  sought to examine the clinical implementation of the TOPS program content in these three modalities, considering patient choice, insurance coverage for behavioral health care, and the availability of therapists and broad-band internet access. The RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) framework was utilized to examine the numerous facets of implementation. Specifically for the purposes of this investigation, the focus was on characterizing  program . Our Reareach and adoption data, considering the unique context of COVID-19; (2) characterize barriers to reach and adoption, as well as strategies for overcoming those barriers; and (3) report changes in reach and adoption over time. In doing so, we hope to promote and inform further efforts to implement EBPs in pediatric rehabilitation.Our objectives here are to: (1) describe the process of implementation over the initial 26 months including 2.2.1.The TOPS program includes ten core sessions addressing cognitive reframing, metacognitive strategies, self-regulation, and communication skills in a collaborative problem-solving framework. Adolescents and caregivers were encouraged to complete the program together. However, therapists had the option of working with adolescents individually, depending on family circumstances and parental availability , 18. ForIn 2019, ten sites, including eight large children's hospitals and two rehabilitation hospitals were identified as initial implementation sites based on their patient volume and interest in providing active neurorehabilitation to their patients. Investigators at these sites actively solicited therapists at their sites who were interested in receiving training and delivering the program. In February 2020, therapists across sites began training, and in May 2020 began using the TOPS program with patients and families (details about the training process are provided separately below).To expand reach, we created a parallel transdiagnostic version of the website that could be used with other acquired brain injuries  and brain conditions  that were associated with substantial executive dysfunction). We used a multistep interactive process for the transdiagnostic website. In August of 2020, therapists began using the existing TOPS program for TBI with adolescents with diagnoses other than TBI and provided feedback regarding the appropriateness of various content and needed modifications. Between July 2020 and January 2021, we conducted key informant interviews with patients and families with a range of neurological conditions  who suggested changes to the website. Between January 2021 and March 2021, we also conducted a survey of medical providers regarding the frequency of neurocognitive and socioemotional concerns across diagnoses. This 31 item survey contained 7 items pertaining to physical symptoms ; 7 items pertaining to cognitive-communication symptoms ; 8 items pertaining to behavioral or emotional symptoms ; and 7 items pertaining to social and family functioning . Ninety-seven providers began the survey and 34 completed it. Responses indicated substantial overlap in concerns across conditions, including high levels of attention problems, executive dysfunction, and school difficulties, with some differences in the profiles of most problematic concerns for each diagnosis .Together, feedback from therapists delivering the existing program, data from the key informant interviews, and provider surveys informed modifications to the website and program delivery. Improvements to the transdiagnostic website included referring to “brain conditions” rather than “brain injuries”, removing references to “before your injury”, incorporating videos of adolescents and young adults with non-TBI neurological diagnoses, adding an alternate core session on managing fears and worries to address anxiety , and creating additional supplemental modules. New supplemental content focused on making choices, self-advocacy, initiation, managing medications, and coping with visible and invisible disabilities.Clinicians also proposed modifications to patient-eligibility criteria to further support successful program use in their setting . Thus, a2.2.Therapists were trained during a 7-hour training delivered either in a single, day-long session or two half days. Training was supported by a detailed therapist's manual and therapist's training website. We sought to train a minimum of five therapists at each site to deliver the program. Initial therapists included pediatric psychologists, neuropsychologists, and psychology interns and fellows. Three therapist trainings were held in person and the remaining trainings were conducted virtually due to the pandemic. Training at all ten original implementation sites was completed in spring 2020. Five additional sites were added and trained in fall 2020, with 15 sites enrolling patients beginning in 2021.To further expand reach, we developed a multiprong strategy for increasing therapist capacity that was tailored to the site. At sites with active psychology or neuropsychology training programs, we developed processes for integrating TOPS into existing clinical rotations for predoctoral interns and postdoctoral fellows, or creating a distinct TOPS rotation. When successful, this process has provided a pipeline of available therapists for TOPS referrals and allowed closer integration of neuropsychological assessment and treatment.Secondly, we began training speech language pathologists (SLPs) to deliver the program in the Fall of 2020. As described elsewhere , prior to training SLPs, the PI worked with a team of SLPs to revise the manual and training materials to reframe emotion regulation issues in the context of cognitive communication challenges and develop resources for knowing when substantial mental health or family concerns might necessitate consultation or referral to a mental health provider.Finally, in areas with few psychologists/neuropsychologists, training was extended to master's level clinicians in social work and other disciplines. Although this approach expanded therapist availability at these sites, it raised additional challenges about finding time in their schedules to receive consultation/supervision around the neurological underpinnings of the child's behavioral health concerns and how to tailor treatment accordingly.2.3.As noted above, we initiated implementation at eight tertiary care children's hospitals and two rehabilitation hospitals. Additional funding from PCORI supported expansion to four additional children's hospitals and one additional pediatric rehabilitation hospital in fall 2020. Initial meetings with each site mapped processes for identifying, screening, and referring patients to the program. We conducted monthly cross-site meetings to discuss barriers and highlight successful implementation strategies beginning in March 2020. These monthly “All Teach All Learn” meetings . Adoption was defined as the number of therapists trained and the number who went on to deliver the program (target five therapists per site trained to deliver the program). We report data regarding program enrollment (TBI or transdiagnostic), treatment condition (self-guided vs. therapist-supported), and therapist metrics .3.3.1.3.2.We projected enrolling two patients per site per month with TBI, and two patients per site per month with other diagnoses, following expansion to other diagnoses in Fall 2020. New sites joined the TOPS program in January of 2021 and began enrolling patients. As depicted in 3.3.n = 94; 46%) were actively enrolled. Of the 176 families enrolled in the therapist-guided treatment through June 2022, 94 (∼53%) completed the program by finishing at least five sessions. 52 (29.5%) ended treatment before completing five sessions, and 30 (17%) were still actively involved in the treatment.Adherence varied between the self-guided and therapist-guided programs. Of the 205 families enrolled in the self-guided treatment through June 2022, 10 (∼5%) completed the program by finishing at least five sessions. 101 (∼49%) completed no sessions over a six-month period. The remainder  to deliver the program. From February 2020 to spring 2022, 307 providers were trained to deliver the TOPS program at implementation sites. Provider backgrounds included clinical psychologists, neuropsychologists, and varying levels of psychology and neuropsychology trainees. After extending training to SLPs who worked with this population, 38 SLPs completed training through Spring 2022. 3.5.Of the 307 individuals trained, 66 therapists, including 25 clinical psychologists, 14 neuropsychologists, 13 SLPs, 3 social workers, 2 master's level counselors, and 9 psychology trainees, delivered the program to patients. Reasons for not delivering the program after completing training included: (1) completed the training for other purposes , (2) moved to a different role or position before having an opportunity to deliver the program, and (3) plan to deliver the program but have not yet had the opportunity. Of note, therapists at non-supported sites often experienced considerable lags gaining institutional approval and support that would allow them to deliver the program.3.6.3.6.1.Quarterly meetings with implementation teams at each site identified a range of potential barriers including: (1) lack of a medical home or established follow-up clinics for many of the patients with conditions of interest, (2) lack of behavioral health care providers for these populations, (3) lack of communication among subspecialties treating these children about neurobehavioral concerns and associated failure to generate referrals, and (4) lack of broader institutional support/reliance on a single champion. Fragmented follow-up care made patient identification challenging, and this was especially true for rural patients who may be less likely to receive follow-up care at all. Additional potential barriers arose from the age range and severity of patients treated; this was particularly evident at the participating rehabilitation hospitals where substantial numbers of patients were extremely low functioning and unable to engage with the program. Catchment areas that crossed state boundaries posed additional barriers to offering the therapist-guided option of the program, because therapists were most often not licensed in multiple states.via telehealth. Sites without existing infrastructure for these services had to establish procedures and identify personnel who could perform those tasks.Developing a workflow to integrate TOPS into existing clinical care and getting buy-in from administrative staff to schedule appointments that were seen as different and required different steps  from typical psychotherapy appointments posed challenges at some sites. At some institutions, the videoconferencing platform that they used for telehealth did not support screen sharing, requiring additional problem-solving around program delivery. Staff/administrative infrastructure to determine insurance coverage, schedule appointments, and process billing was necessary to support families working with TOPS therapists, either face to face or Awareness of the program was a key issue identified across sites, and this was a particular issue when there was not an established follow-up clinic for these patients, but rather follow-up across various subspeciality clinics without embedded TOPS-trained providers. Potential referral sources also had difficulty recognizing who was eligible and determining who was appropriate to refer, particularly if there were significant comorbid mental health concerns. In the latter situation, anecdotal feedback indicated that they were more likely to use traditional mental health referrals, rather than refer to a novel program with which their institution lacked experience.•Establish strategies for routinely screening clinic schedules and flagging potentially eligible patients at sites with existing follow-up clinics, including use of EMR search features.•Promote outreach (including TOPS training) for behavioral health providers embedded in these clinics so that they could support enrollment.•Identify a coordinator who could screen clinic schedules and flag potentially eligible patients based on age and diagnoses supported this process, although this took time to implement and was not possible at all sites.•Identify site-specific procedures for streamlining the process of delivering the program and minimizing additional administrative burdens.•Engage leadership to support broader marketing initiatives to reach out to patients who may not be receiving follow-up care.Given these Institutional barriers, the following strategies were identified:3.6.2.Although substantial numbers of potential providers received the TOPS training at each site, most did not plan to deliver the program because it was not part of their current workflow or role at the site . Since most of the patients with TBI/ABI were not currently receiving behavioral health services, offering care to them would require additional providers, which was not planned at most sites. COVID-19, and the mental health challenges arising from it, further exacerbated therapist shortages due to increased demand for services and fewer providers due to illness, resignation, or furlough.Lack of provider buy-in or reluctance to refer patients to something new was also noted. This reluctance was characterized by one provider as follows: “To use a shopping analogy, our goal is to get great bread. We have multiple options we know and trust in our region. A newer brand may come on the market, and it might be tasty indeed, but if the barriers to getting it are basically the same, why switch?” Additionally, some providers expressed reluctance to refer patients to a self-guided program, and wanted to limit referrals to the therapist-involved options. Associated factors included perceptions that the program duplicated existing services or that the program wouldn't work in their setting because it was developed elsewhere. Remembering how to refer appropriate patients and finding time during a relatively brief outpatient visit to describe the program and make the referral constituted additional barriers. Specifically, although families expressed greater interest in the program when the provider had the opportunity to log on and demonstrate it to them, this was often precluded by tightly scheduled visits. Finally, providers often lacked the ability to follow-up and determine whether the family engaged with the program and to understand reasons for nonengagement.•Develop brief presentations and informative fliers that site champions shared with brain injury and other subspecialty clinics, as well as other providers who were likely to come into contact with eligible patients.•Tailor treatment delivery modes to further address barriers to care such as insurance coverage, therapist availability, and out-of-state residence.Given these Provider barriers, the following strategies were identified:3.6.3.Reasons families cited for declining treatment included the adolescent not wanting to identify as having issues related to their TBI/brain condition or the desire to prioritize another area . In some cases, these reasons may reflect the ongoing stigma associated with mental health treatment. For other families, general stressors  took precedence over the brain condition or the child was already receiving treatment from community providers, and the family was reluctant to start an additional program, even if it was self-directed. The family focus of the treatment also led some families to decline due to high levels of family conflict, lack of parental time, or the desire to focus the treatment on the child. Some families expressed discomfort with the technical aspects of navigating the website or lacked broadband access; whereas others preferred a treatment that did not involve screens or that was more customized to their needs. Although traditional, face-to-face treatment was an option at all sites once pandemic restrictions relaxed, distance and available therapists continued to pose barriers. Families who wanted to work with a therapist were often deterred by therapist unavailability and long wait times for a first appointment. Limitations of insurance coverage, and out-of-state residence posed further barriers to obtaining either of the therapist options. For patients with a specific concern , there was reluctance to engage in a more comprehensive program that addressed issues in addition to their concern. Finally, although there was a Spanish language version of the TOPS website, adolescents with Spanish-speaking parents preferred the English version and primary languages other than English or Spanish were not supported.Approximately one quarter of families who expressed interest in the program failed to follow through by creating a username and password, or received a username and password, but never accessed the program. Barriers identified by referral sources included lost log in information and difficulties updating their password, fatigue with screens/videoconferencing, and being overwhelmed by multiple stressors.•Increase patient awareness and linkages to the program through presentations to stakeholder organizations, such as brain injury and brain tumor support groups. Some sites worked to more closely integrate TOPS delivery into existing programs, making it a step-down program following initial outpatient rehabilitation.•Link TOPS referrals to neuropsychological evaluations and feedback sessions to establish TOPS as a complement, rather than competitor, to existing services through increased education and collaboration with providers across subspecialties.•Establish procedures for directly enrolling families during the child's clinic visit, thereby eliminating the gap between agreeing to enroll and creating a login/password. When time permitted, enrolling providers also previewed the sessions and showed parents and adolescents some of the skills they would learn.•Tailor program delivery to address patient concerns. In practice, this meant shifting the order of session content to maximize relevance. For example, therapists could address emotion regulation or communication before working on executive functioning skills, for example, if that corresponded to patient and family concerns.Given these Patient/Family barriers, the following strategies were identified:4.Our implementation of TOPS led to the development of solutions to overcome challenges at the institutional, provider, and patient/family level; such solutions may be relevant to others seeking to implement EBPs for patients with low-incidence conditions and for those interested in providing a complex eHealth treatment program into clinical practice. To our knowledge, this is the first pediatric rehabilitation intervention to be broadly implemented, although efforts have been made to implement other evidence-based pediatric interventions such as Bright IDEAS . Our choThe COVID pandemic, which coincided with our implementation efforts, has offered unprecedented barriers and unique opportunities. Outpatient clinics were cancelled for a period of time and at some sites, the individuals who were trained to deliver the program were temporarily furloughed due to low patient volume. Institutions, providers, and patients faced demands and financial strains that made the introduction of a new program challenging and often unwelcome. However, the expansion of telehealth and Medicaid waivers to support provision of telehealth across state boundaries in some regions served as a catalyst for the provision of telehealth services at institutions that were previously resistant to such initiatives. Patient and family enthusiasm and engagement with telehealth waxed and waned over the course of the first two years of the pandemic. Although families initially embraced telehealth visits, therapists reported greater family fatigue with videoconferencing over time, particularly when both school and outpatient medical visits/therapies were virtual. As a consequence, some patients embraced the opportunity to resume in-person therapy sessions when restrictions were relaxed. Hybrid delivery models that included some virtual and some in-person visits also improved uptake. As challenges arising from the pandemic continued to evolve, we sought to adapt our approach to address these challenges. For example, we retrained therapists who were trained early in the pandemic and were subsequently furloughed before they could deliver the program and continued to explore program tailoring options to improve patient engagement . Ultimately, it is not possible to fully disentangle the positive  and negative impacts  of the COVID pandemic or the ultimate effectiveness of our responses.During our initial two years of implementation, our reach was substantially lower than the two patients per site per month with TBI that was initially anticipated. Although COVID resulted in a number of unanticipated challenges and delays in ramping up, implementation within large, complex medical systems required considerable time to establish pathways and procedures before successfully enrolling patients. Inclusion of other neurological conditions with similar neurobehavioral consequences allowed us to substantially expand our reach, nearly doubling the numbers enrolled, and extend evidence-based practices to historically under-served patient populations. Consistent with other multisite implementations there continues to be considerable variability across sites suggesting the possibility to further extend reach as we more broadly implement the outreach strategies that we have identified .Efforts to expand therapist adoption of the program (training and program delivery) have been more successful. As sites have established procedures for screening patients for appropriateness and referring them to the program, newly trained therapists can be more readily connected with patients on the waiting list. Thus, we are less likely to lose potential therapists to moves/completion of training before they have an opportunity to deliver the program or lose patients due to a lack of available TOPS-trained therapists. Positive preliminary feedback from SLPs who have successfully delivered the TOPS program suggests that this may be another avenue for extending program adoption. At another level, the first cohort of fellows who were trained in TOPS have recently begun jobs, potentially supporting further program spread. Although promising, it will take a few years to determine whether those who delivered the program during fellowship continue to use it in their new roles.Implementation through large children's hospitals that are part of broader academic networks has afforded unique opportunities to extend the program to adolescents with a range of low-incidence conditions. However, it also posed challenges due to the complex and varied systems for tracking and managing children with ABI and other neurological conditions and the multiple subspecialties involved in their care. Heterogeneity across sites necessitated tailoring solutions to the institution, rather than relying on a one-size-fits-all approach. Thus, although successful solutions could be shared through our monthly All Teach All Learn format, adaptation to the local context was frequently required. Specifically, larger hospital systems often had more complex procedures for implementing new programs that required vetting and legal approval at a variety of levels; whereas, smaller systems were more nimble and responsive. Moreover, the pandemic exacerbated institutional challenges arising from understaffing and stretched resources.At the patient level, we identified program-factors, such as lost logins/passwords and lack of reminders, that can be addressed to support engagement. However, factors such as negative attitudes toward behavioral health treatments or overall fatigue and burnout have proved harder to address. Additionally, complex comorbidities have raised issues among both parents and referral sources regarding how to sequence treatments and where TOPS fits in that sequence.Our experiences to date should be considered in the context of a number of important limitations. As with any multisite implementation, there was inconsistent fidelity to critical elements and cross-site variability in some procedures. This included variable patient screening procedures, which made it difficult to accurately evaluate patient uptake and reasons for nonparticipation. Tracking of implementation metrics across sites has been variable based on site resources . Additionally, as with any multisite quality improvement project, sites varied in the exact timing of introduction of different improvement strategies across sites . This made it challenging to evaluate the impact of each specific intervention on reach.In summary, the initial two years of TOPS implementation have illustrated the complexity and challenges of moving an EBP of complex eHealth program into clinical care. They have also underscored the importance of a team-based approach and ongoing trouble-shooting/problem-solving. Future directions include creation of a sustainable online platform for training and extending the program to additional sites. Additionally, development of subsequent pediatric rehabilitation interventions could benefit from thinking about clinical implementation during the intervention development phase, thereby promoting longer-term institutional buy-in.


Mw 9.0 earthquake, we show a quantitative integrated ME in the rupture zone, including principal stress, pore-fluid pressure and friction strength. We discover from this environment a large asperity composed of two asperities induced by relatively high friction coefficients and relatively lower pore-fluid pressures. The integrate ME quantitatively explained the reasons of the overshoot and relatively lower shear strength of the trench, which caused huge displacement and tsunami at the trench. We suggest that the asperities favor the horst and graben structure system which provides a geology environment for interseismic stress accumulation and thus for breeding the megathrust tsunami earthquake.It is a key to know mechanical environment (ME) of pre- and post-rupture fault of giant earthquakes at subduction zones for predicting earthquake and tsunami disaster. However, we know little about its details till now. In this paper, using the inverted stress change three hours before and three hours after the mainshock in the rupture zone of the 2011 Tohoku-Oki  Mw 9.0 occurred on megathrust faults at subduction zones4. We know little about the mechanical environment (ME) of faults to breed them in quantitative details, such as the magnitude and distribution of stress, pore-fluid pressure and friction strength. The Mw 9.0 Tohoku-Oki earthquake of March 11, 2011 provided an opportunity to probe this issue. We have known better about the rupture process and slip distribution of the earthquake by using the dense global positioning system (GPS) networks5 and the seafloor displacement data close to the Japan trench8. The surprisingly large slip up to 60 m on the shallow portion of the fault has been qualitatively explained with dynamic overshoot9 or low frictional resistance of the fault12. However, the integrated ME to breed the earthquake is rarely reported to quantitative details.Up to now all recorded earthquakes with magnitude of greater than or equal to 10, which is consistent with the plate convergence direction13 and its magnitude is about 87 MPa estimated by assuming Anderson's stress state and a vertical stress calculated from a sediment density profile as maximum principal stress10. The rock friction experiments were conducted on samples retrieved from the borehole at the depth close to the plate-boundary11, the shear stress obtained from the experiments is 1.32 and 0.22 MPa, respectively, for the in-situ condition under permeable and impermeable cases, which correspond to values for the in-situ apparent coefficient of friction of 0.19 and 0.03. The contribution to pore-fluid pressure on the fault is little known, it is considered as nearly hydrostatic pore pressure at a shallow part and nearly lithostatic pressure at a deep part of the plate interface based on a numerical simulation14.After the mainshock, for further understanding the giant earthquake mechanism, the Japan Trench Fast Drilling Project  drilled to the ruptured fault at shallow depth and made borehole measurements. The borehole breakouts revealed that the azimuth of local horizontal maximum stress  is in the direction of N139° ± 23°These results above give us some insight into the ME of the Tohoku-Oki earthquake though only at some locations on the fault. However, the details of the ME in pre- and post-rupture fault of the earthquake are still unclear, which is very important for understanding earthquake preparation, occurrence and earthquake prediction.15, which may allow us to recover ME of earthquake fault  with standard deviation (SD) is 42.7 ± 5.8 MPa in the Region A at the depth of 14.5 km below sea level. The direction of S1 is N124.1° ± 8.4°  and the minimum principal effective stresses (S3) are nearly along the trench and vertical del Fig. , we solvIn this paper, we aim to search such a possible integrate ME in the fault rupture zone of the Tohoku-Oki earthquake, that can produce the stress change caused by the earthquake. Here, the integrated ME only includes principal stress state (magnitude and direction), fault friction strength and pore-fluid pressure.16, S1, S2, and S3. In consideration of the effect of pore-fluid pressure on stress state14, the stress change caused by the earthquake is taken as the sum of the total effective stresses change (compressive stress as positive) and the pore-fluid pressure change before and after the earthquake,18, superscripts ‘b’ and ‘a’ denote ‘before’ and ‘after’ the earthquake, S1, S2, and S3 and their directions n, that isi, j = 1, 2, 3, and 16 and that the fault is in an undrained state during earthquake rupture17, that may allow us to recover the ME of the earthquake to get a definite solution.As the Tohoku-Oki earthquake is a pure thrusting event, we use the azimuth and dip angle of maximum principal stress, mentclass2pt{minim18, each size is 25 × 25 km2. The maximum curvature of the curved sub-fault is less than 0.005 (nearly a straight line), thus each sub-fault can be approximated as a plane.The fault geometry is irregular Fig. , which l28, the occurrence of these earthquakes is supposed to be controlled by the Coulomb failure criterion with a known fault plane16,Since the foreshocks close to the fault rupture area are almost thrusting events, and their focal mechanism is nearly the same as that of the main earthquake28 with different strike and dip angle, we suppose that the fracture planes of these earthquakes were controlled by the Coulomb failure criterion with an unknown slip plane,Considering the aftershocks close to the rupture zone are basically normal fault earthquakes17 andB is the Skempton coefficient, a parameter reflecting the capacity of pore-fluid pressure change under one unit change of mean normal stresses.In coseismic stage, the pore-fluid pressure change 13, thus if the coefficients of frictions B and normal stress changes). Considering the accepted ranges of 13, 32 and 33, we need to search all solution sets in their possible ranges30:15, As the value ranges of the direction of pre-seismic maximum principal stress, mentclass2pt{minimen, Eqs.  allow usd by Eq.  using thEquation  is a sete is the error threshold tensor, which is set as 0.01 MPa.The solution precision is controlled by B at one sampling point in each sub-fault in the earthquake stress model18, we present an average solution to these solutions to represent the ME there. Considering that the solutions related to the principal effective stresses at the sampling point cannot be made a sum directly as they are tensor with different direction, we need to solve an eigenvalue problem of the sum of the stress tensor Since there exist many possible solutions to meet the constraints above for the given ranges of the entclass1pt{minima8 and taking the lithostatic pressure after the mainshock as the total vertical stress, we can obtain the magnitude of pre- and post-seismic pore pressures (Table In consideration of that the accumulated stresses almost all releasedes Table  in the rSupplementary Information.