The Essentials, in mitigating barriers to health professionals treating patients with EDs.Early detection and treatment are essential to ensuring the best possible health outcomes for people with eating disorders (EDs). However, low diagnostic accuracy and a lack of specific ED training are common workforce challenges in Australia and internationally. Online learning provides a potential solution in facilitating the access to evidence-based training programs. The InsideOut Institute has developed the first online clinical training program in EDs to assist with educating health professionals in the identification, assessment, and management of EDs. The aim of the study is to evaluate the effectiveness of the online training program, Pre and post training questionnaires assessed participants’ attitudes, knowledge, and skills in relation to treating people with EDs. Demographic and work-related information  and participants’ ratings of the online learning experience and satisfaction on completion were collected. The Wilcoxon signed rank test was applied to test for changes in learning outcomes before and after completion of the program. A multivariate linear regression model was estimated for each of the learning outcomes with personal and work-related characteristics as covariates.The Essentials program between 1 October 2013 and 31 July 2018, 1160 completed at least 80% of the five learning modules. There were significant improvements in confidence, knowledge, skills to treat EDs and a reduction in stigmatised beliefs among the 480 participants who completed both pre and post assessments. Results from the regression models suggest that psychologists, dieticians, and those working in rural areas were more willing to treat EDs after completing the program. Additionally, those working in hospitals and regional or rural areas experienced the largest improvement in confidence for treating patients with EDs.Among 1813 health professionals who registered for The Essentials program represents a new and effective way of meeting the educational needs of partaking health professionals working with ED patients. Greater investment in the development and testing of evidence-based online training programs for EDs may help to address some of the considerable workforce development challenges in EDs.The online version of this article (10.1186/s40337-019-0243-5) contains supplementary material, which is available to authorized users. The Essentials”. Between October 2013 and July 2018, 1813 health professionals registered for the program. There were significant improvements in confidence, knowledge, skills to treat EDs and a reduction in stigmatised beliefs. In particular, psychologists, dieticians, and those working in rural areas had larger increases in their willingness to treat EDs after completing the program; those working in hospitals and regional or rural areas experienced the largest improvement in confidence for treating patients with EDs; and health professionals in education indicated a significant increase in the level of knowledge. Reaching to a wide audience at a relatively low cost, The Essentials program represents an effective way of meeting the educational needs of partaking health professionals working with ED patients.Early detection and treatment is essential to ensuring the best possible health outcomes for people with eating disorders (EDs). However, low diagnostic accuracy and a lack of specific ED training are common workforce challenges in Australia and internationally. Online learning provides a potential solution in facilitating the access to evidence-based training programs. The InsideOut Institute have developed the first online clinical training program in EDs to assist with educating health professionals in the identification, assessment, and management of EDs, called “Eating disorders (EDs) are serious psychiatric illnesses with severe physical and psychosocial consequences , 2. The Early diagnosis and intervention has prognostic benefits in limiting the ED’s progression and improving physical and psychosocial outcomes , 14. EDsLack of training, experience, and inadequate educational resources have also been associated with negative attitudes of health professionals towards people presenting with an ED . These nTo address the shortage of ED training courses, particularly for rural clinicians, online learning programs present as a viable alternative, enabling skill development in the participant’s own time and location. Compared to conventional face-to-face training, online learning can provide knowledge and skills demanded among non-specialist health professionals for diagnosis, treatment, and recovery, at relatively low cost and without geographical constraints. Moreover, the technology used for teaching allows for the incorporation of essential components of interactivity and feedback into the program, optimising the effectiveness of the learning process and outcomes. Several studies have demonstrated positive impacts in relation to confidence, knowledge, skills, competence, clinical practice, and satisfaction following online training specifically for health professionals –40. HoweThe Essentials, was developed for all health professionals  working in EDs by the InsideOut Institute (formerly the Centre for Eating Disorder and Dieting Disorders [CEDD]) in Australia. A preliminary study of 187 learning participants of the program in 2012–13 demonstrated that the program was an effective tool in increasing health professionals’ level of knowledge, skill and confidence to treat people with EDs [The Essentials.A comprehensively designed online learning program, with EDs . The resThe Essentials program provides comprehensive training in relation to the medical, psychological and dietetic management of patients with EDs. The course incorporates expert videos, role-pays and interactive exercises and quizzes; and teaches extensive skills and techniques for diagnosis, assessment, treatment, management and dealing with service setting issues across all major EDs , Binge Eating Disorders (BED), and Eating Disorder Not Otherwise Specified (EDNO)). The Essential has the advantages of being highly interactive, including a very comprehensive curriculum, and covering a much wider range of topics than previous online training programs which were limited to one particular treatment or to just prevention. Compared to other web-based training programs in EDs [s in EDs , 43, it The Essentials program as measured by improvements in the level of willingness, confidence, knowledge, skill, and attitudes among participants upon completion. To better understand how and for whom the program was most beneficial and best suited, heterogeneity in learning outcomes was assessed by professional discipline, work setting, and geographical location of employment using multivariate linear regression analysis. Data from the in-built post online learning satisfaction measures was used to evaluate useability and learning experience of the program. By assessing the learning outcomes of a large sample of health professionals from diverse disciplines and different geographical locations, this study provides empirical results on the effectiveness of a new comprehensive online program, The Essentials, for professional development of the partaking EDs health workforce.The aim of the study is to examine the effectiveness of The Essentials addresses the nature, identification, assessment and treatment of EDs. The program was advertised via online advertisements on professional body’s websites including social workers, psychologists, nurses, mental health nurses, general practitioners and rural and remote medicine; eating disorders organisation’s websites; general mental health websites; the InsideOut website; and email list services that mainly targeted Australian audiences and by nature of being online reached a small number of international interested registrants. Two state governments in Australia  additionally purchased registrations on the program for their public health staff, as have other major health providers in Australia  progressively from 1 October 2013 to 31 July 2018, and had 3 months to complete The Essentials program.The InsideOut Institute’s online training program This program was funded by, and developed in collaboration with NSW Health. Training modules and topics were designed and written by internationally renowned expert and novice (or newly active) panels of health professionals in the field inclusive of nurses, dietitians, psychologists, psychiatrists and general practitioners, and curriculum development was based on literature reviews and expert consensus building . The proThe Essentials program using Likert scales to measure changes in learning outcomes. The questionnaire was designed to cover best practice in evaluating training programs including what knowledge, skills, and attitudes are necessary to achieve the desired behaviour change in participants attending training [A variety of assessment domain was examined in the study. Participants completed a self-evaluation questionnaire before and after completion of training . The queAdditional items assessing demographic and work-related information including gender, age, Australian state/territory they reside in, primary professional discipline, work setting, length of time in practice and prior experience treating EDs were included at baseline. Participants also rated their experience of the online training program and satisfaction with the program. Participants when enrolling in the online program are asked to give consent to their information to be used for research purposes in a de-identified form. The process of registration and participation is illustrated in Fig. The Essentials questionnaire data, Wilcoxon signed rank test [Given the non-normal distribution of ank test  was usedThe Essentials from 1 October 2013 to 31 July 2018. Of these, 1160 completed at least 80% of the five learning modules and 1287 completed at least 80% of the first two modules (Understanding EDs and Diagnosis) which were considered to be the two most crucial components by the program’s developers and specialist clinicians. As is routinely observed, the completion rate decreased as the modules progressed [A total of 1813 health professionals registered for ogressed , 47. UsiThe Essentials program between 1 October 2013 and 31 July 2018. Participants were from a variety of disciplines, such as psychology (29.7%), nursing (21.7%), dietetics (15.4%) and social work (11.0%). There was also diversity in terms of where participants were primarily employed, ranging from community health centres (30.6%), hospitals (27.0%), private practice (15.6%), ED treatment services (7.5%), and education environment (3.9%). Almost a third of the sample (31.8%) had been in practice for less than 2 years, 41.1% for 3–10 years, and 27.1% for more than 10 years. Additionally, 52.5% of participants worked in metropolitan areas and 44.3% in regional or rural areas. The majority of participants were female (90.3%).Table The Essentials program, the majority of participants (n = 1591 or 87.8%) indicated that they saw patients with EDs in their main place of practice (Table n = 844 or 46.6%) reported that they felt they were sometimes unable to treat patients presenting with an ED, and 306 (16.9%) indicated that they felt this “often” or “always”. Two thirds of participants stated that they had received only 0–5 h of training specifically on ED screening and assessment (62.3%), and 0–5 h of training specifically on ED intervention (65%).Regarding the treatment provided to ED cases prior to completing The Essentials program  (Table There was no significant increase in the willingness of matched participants to treat EDs after completing 0) Table . Failingp < 0.001). Breaking this down by diagnostic category, this equates to an increase of 0.93 points for AN , 1.06 points for BN , 1.07 points BED , and 1.04 points for EDNOS    Table .The Essentials program, with the mean score on the knowledge measure increasing from 2.67 to 3.76  – a shift from the “low” to “moderate” level to nearly “high” level   in participants’ (mean) level of skills for treating and managing patients with EDs between pre and post engagement with The Essentials program   Table .p < 0.001) but not for matched participants . This may reflect that participants with more positive perceptions towards EDs were more likely to complete both pre and post assessment.The increase in personal beliefs about the factors contributing to the development of an ED was statistically significant for unmatched participants , which was larger than the knowledge learning outcomes achieved by health professionals in other work settings.The Essentials program, may provide a potential solution for the urgent need for professional development of mental health service providers in relation to EDs in rural and remote settings. This can be of particular significance in the Australian context where rural and regional areas are generally also under-serviced [Participants working in rural areas achieved a larger (and significant) increase in self-evaluated willingness to treat patients with EDs, compared to those in metropolitan areas. Also notable is that participants in both regional and rural areas achieved a larger (significant) increase in confidence to treat patients with EDs, compared to those in metropolitan areas. These findings suggest that online training programs, such as serviced , 48.The Essentials program for EDs that provides clinical education to health professionals working in this clinical area. Between October 2013 and July 2018, 1813 participants received comprehensive training in the medical, psychological and dietetic management of patients with EDs; 1812 completed the built-in pre evaluation; and 1010 completed the built-in post evaluation. The results of the study suggest that participation in the online program was associated with increases in confidence, knowledge, skills, and attitudes, with higher means and lower variations in evaluation scores upon completion of the program. The feedback from the participants was also very positive regarding the layout and content of the program.This study evaluated the effectiveness of a series of online learning modules in The Essentials program targeted a wide range of health professionals and had a significant impact on health education. Consistent with previous studies, the online training program was shown to be a cost-effective method of knowledge and skill building for mental health providers [roviders , 42; in roviders , 14, addThe Essentials program, dietitians and psychologists had larger increases in their willingness to treat patients with EDs than health professionals working in other disciplines; health professionals working in hospital settings showed a larger increase in their confidence to manage ED patients compared to those from private or community settings; and health professionals in education and teaching indicated an increased level of knowledge that was much larger than that reported by those in other settings. Importantly, the study also suggests that The Essentials program was successful in disseminating EDs diagnosis and treatment training to a broad audience, especially for healthcare professionals in geographically remote areas.In particular, after having completed The Essentials and other training programs. Second, there was no long-term follow-up, which meant that it was not possible to assess how long the online learning outcomes were sustained, and whether the self-reported changes in learning outcomes were effectively translated into changes in clinical practice. A related issue is that the learning outcomes were subjectively evaluated by the participants themselves. Post training tests designed to objectively examine the knowledge of participants may provide additional information on the effectiveness of the program. Third, collecting more information on the sociodemographic characteristics of completers and non-completers would be informative to develop strategies to better engage participants. Moreover, completion and participation can be further improved to best realise the potential of online trainings. As one of the key challenges for e-learning setting, the reach of the online learning program should be further expanded to promote the participation of more health professionals in EDs.The current study has some limitations. First, it lacks a control group or randomisation, and therefore the effectiveness of the current online learning modules relative to other training methods was not evaluated. However, the results from the study will be used to assist with the design and implementation of a randomised controlled trial involving The Essentials online training program was associated with an increase in the inclination, confidence, knowledge, skills, and positive attitudes of health professionals in the management of patients with EDs. Reaching to a wide audience at a relatively low cost, online learning programs for EDs such as The Essentials are a promising training method, enabling the distribution of learning materials to promote mental health literacy among health professionals and, in turn, improve the diagnosis and treatment of patients with EDs in the health system.This study provides empirical evidence that an online learning program can be an effective method to support the professional development of healthcare providers working in the area of EDs, especially the health workforce in remote geographical regions. Participation in Additional file 1:Eating disorder online learning evaluation questionnaire regarding attitudes, knowledge and skills. (DOCX 24 kb)


Attracted by the expected benefits such as reduced absenteeism and increased productivity, more and more firms decide to implement workplace health promotion programs (WHPPs). However, those programs can only be effective if employees actually participate. This study aims to (1) gain insight into the degree of enrolment rates in such programs across companies and (2) identify organizational level factors that are associated with employee participation. Building on existing theory on organizational drivers of participation in corporate wellness programs, the study’s main goal is to investigate which organizational factors determine whether employees enroll in a corporate fitness program or not.A business-to-business fitness platform company provided organizational level data on 61 client firms that have recently implemented a corporate wellness program. The data contained information on the enrolment rate per company and different organizational level variables. The following potential determinants of participation were analyzed: firm size, organizational program support and employee co-payment. A random effects model was used to examine associations between potential determinants and the program enrolment rate.p < 0.001) while employee co-payment – the financial contribution employees have to make to participate – has a negative impact . Furthermore, firm size has a negative relationship with firm enrolment.The average participation is limited (15.37%) but varies highly across companies . Looking at the determinants of program enrolment, we find that organizational program support – the degree to which firm leadership encourages participation – positively influences the enrolment rate (β = 0.051 Enrolment rates in WHPPs are limited, as many companies have difficulties to promote participation in WHPPs among employees. Strong organizational program support and low employee co-payment were identified as drivers of employee participation in corporate health programs. Hence, intensifying both social and financial support of employee participation may help to drive enrolment rates. Firm size was found to negatively affect the enrolment rate in WHPPs, implying that larger firms have to account for their size and corresponding complexity when implementing such a program. Despite the plentiful evidence of the positive effects of physical activity on both physical health , 2 and gHowever, even independent of any external encouragement, firms may be inherently interested in increasing physical activity levels among their workforce, as they occur indirect costs of physical inactivity stemming from productivity losses related to increased absenteeism and a lack of productivity at work . SeveralGiven the evidence on the employer benefits of health promotion among employees, it is no wonder, that more and more companies introduce corporate health programs or have plans to do so , 20. HowTo address the issue of low employee participation rates and design programs that achieve higher ones, it is essential to detect the most influential factors of participation. What are the factors that distinguish programs with high participation rates from those with low ones? Different social ecological models on health promotion –24 propoWhile empirical studies on the relationship between organizational-factors and participation are scarce, there does exist some scientific literature. Several researchers who looked into the association between organizational level factors and participation suggest that manager and co-worker support has a positive effect on employee program participation –34. The As both industry participants and researchers have not yet arrived at an understanding of the determinants of – currently limited – employee participation in corporate health programs, there is a clear need to investigate this topic. This study aims to (1) gain insight into the degree of enrolment rates in such programs across companies and (2) identify organizational level factors that are associated with employee participation. This research is highly relevant for companies that consider implementing a WHPP as it provides insights on how to design such a program in a way that maximizes participation levels. Furthermore, it contributes to the advancement of research, as we are the first to analyze data of a fitness platform company that is interacting as intermediary between members and a variety of fitness outlets – a business model that is currently disrupting the fitness industry.n = 550 observations. The client companies operate in six different industry groups  and have been classified as white collar (43 companies) or blue collar (18 companies) employers, depending on what type of work the majority of their employees engage in. As the data set comprises only company level data and does not include any employee level data, an ethics approval was not required.To test the impact of organizational level variables on employee participation in corporate health programs, we collaborated with a corporate fitness platform (‘Platform A’) that offers corporate clients access to a flexible physical activity and wellness program. By supervising the process of data extraction and an immediate handover, we assured completeness of the data provided. Building on prior research, the authors suggested a study design which was presented to and confirmed by Platform A employees who supported the results interpretation. The data set comprises organizational level information on all Platform A clients in Germany since the national market entrance in early 2017. The time period covered is January 2017 until August 2018 (20 months) as this was the latest recording available when we conducted the study. The total sample comprises 65 companies. Four high-priority customers who received special promotional offers have been excluded due to a lack of comparability. Consequentially, the final sample consists of 61 companies. It is important to mention that the number of data points available per company varies for the data that is reported monthly, as they started working with Platform A at different points in time. Depending on the length of collaboration between the clients and Platform A, there is data available for between 2 and 20 months, with an average of 9 months. Overall, the dataset includes Empirically determining those organizational factors that influence the likeliness of achieving high participation in corporate wellness programs is the main purpose of this paper. Hence, our dependent variables is a measure of participation, the enrolment rate. The enrolment rate is calculated by dividing the total number of employees who are enrolled by those who are eligible for program enrolment. Some clients decided to launch the program gradually at different company locations; hence, the denominator may vary over time. The enrolment rate is reported on a per-month basis.Organizational program support summarizes whether the fitness program receives support within the client organization. A team of Platform A employees responsible for promoting program participation (the engagement team) assigned an ‘organizational support score’ for each company. They assessed to which degree the leadership team of the respective client supports the corporate fitness program and promotes its success. When conducting the assessment, the engagement team looked at several factors that can be categorized into a) willingness to allow Platform A to conduct activation and engagement activities (passive support) and b) effort to promote the program within the company (active support). Passive support comprises elements such as whether the client firm management has allowed Platform A to contact employees directly for motivational purposes or to conduct activation events on company premises. Active support refers to the general attitude of the management towards fitness and health topics. Questions such as whether the firm has made health a priority and acts accordingly  are answered in this context. Both variables are assessed on a scale from zero (=very low) to ten (=very high) and averaged to determine the final variable score. Organizational program support is hence an ordinal variable.Five organizational level variables have been reported: industry, type of work (blue collar vs. white collar), organizational program support, employee co-payment and firm size. After reviewing existing literature, we expect the last three of those variables – organizational program support, co-payment and firm size – to influence program participation. Hence, we included those as predictor variables in our model while the other two serve as control variables. Employee co-payment is the net Euro amount each enrolled employee pays to participate in the fitness program. The costs of the program are shared between employer and employees. Hence, the employee co-payment varies, depending on how much the employer is willing to cover: it decreases as the investment made by the firm increases. There is no employee level data available but only information on the total employee co-payment, which is then divided by the total number of employees; thus, we take a per-employee average for this variable. Co-payment is reported on a per-month basis.Firm size is measured by the total number of employees working at the client organization at the point of contract conclusion. While the companies may have been growing since then, we only focus on the point-in-time number of employees as we argue that the organizational size at the start of the partnership has an impact on how well the new initiative is adopted companywide. For the analysis of the effect of size, we transformed the continuous variable in a categorical one: Firms with 0–50 employees, 51–200 employees, 201–500 employees and > 500 employees. We decided to categorize this predictor as it enables us to uncover a potential relation between firm size and enrolment rate without requiring the values of the predictor to follow a line or fitting a complex non-linear model.Three independent variables of interest on the firm level were considered , which are hypothesized to have a linear relationship (the direction of the relationship depends on the specific variable pair) with the enrolment rate. In addition, we included control variables for firm industry and type of work. As the data contains repeated observations of firms on a monthly basis, we decided to apply a random effects model to account for the individual effects of the different observations and potential correlations among repeated measurements, as well as for inter-company differences that are unexplained by the predictors. The standard errors are clustered at the firm level to consider the fact that the same firm is observed over several months. All statistical analysis have been carried out with the program Stata.Yenrolmentit captures the average enrolment rate of firm i in month t and the three independent variables organizational program support, employee co-pay and firm size are said to predict enrolment. The only independent variable that varies monthly is co-pay. The independent variables under consideration might be correlated which has to be accounted for when interpreting the results. Hence, to assess the existence of any collinearity among the independent variables, variance inflation factors (VIFs) were calculated. As the data set only contains organizational variables, the model is not suitable to predict all variance in the enrolment rate. The enrolment rate also depends on individual level factors such as gender, age, base health factors and many more.The following model equation was formulated to analyze the relationship between the potential determinants and the enrolment rate:n = 550 observations from n = 61 firms with between 3 and 16,000 employees. The average enrolment rate in the corporate health program is 15.37% (SD: 20.59%) and the average co-payment in firms is 18.62€ (SD: 10.18€). The program support is on average at 4.01 (SD: 1.79). Regarding firm size, 18.18% of the firms have between 0 and 50 employees, 42.0% have between 51 and 200 employees, 19.46% between 201 and 500, and 20.36% over 500 employees.Tables p < 0.001) and co-payment  are significant predictors for program enrolment. Also, firm size has a significant effect on enrolment: the enrolment rate is highest for companies in the 0–50-employees category and gradually decreases as the number of employees increases for the other three categories . The overall model fit was R2 = 0.609, hence the model containing organizational program, employee co-payment, and size can explain 60.91% of the variation in enrolment). The collinearity statistics show that we do not face the problem of multicollinearity in this study (variance inflation factors < 10) [When the relationship between the variables and enrolment was investigated, it was found that organizational program support  .2 = 0.609) of the variation in enrolment. We did not only assess the impact of those factors that can be actively adjusted by the shapers of a corporate health program – the firm itself and the fitness platform provider –, but also tested for a potential structural disadvantage of large firms. It was indeed revealed that firm size in terms of employees has a negative relationship with employee enrolment in the WHPP.Primary purpose of this paper was to bring clarity into the matter of designing a corporate health program that achieves high participation rates. Building on prior literature, we identified three potential determinants and empirically analyzed their impact on participation, using data from practice. The results confirm and find significant support for the positive impact of both a supportive organizational environment and low employee co-payments. Given the fact that we only considered a subset of organizational- and program level factors and omitted individual level factors altogether, the model can be considered a good fit for the data set at hand, as it explains more than 60% (RGenerally, when interpreting the results one should keep in mind that the data set contains a relatively small sample of only 61, which certainly limits the explanatory power of this study. Nonetheless, with our findings, we advance the understanding of determinants of participation rates in corporate health programs as we empirically analyze the impact of organizational level factors on enrolment with a sample of companies of from different industries. This study is – to our knowledge – among the first to investigate the specifics of the new platform fitness model, which becomes more and more popular among firms that consider implementing a corporate health program. Our results show that advancing the understanding of the success factors of modern corporate health programs is critical: The average enrolment rate of the analyzed program is only around 15%. In order for an organizational health program to have positive effects, employees have to enroll and actively use the program. 15% enrolment is clearly below the average participation rates of 20–30% prior research has reported , which iPrior research has already hinted at the high importance of social support: Rongen et al.  conducteOur analysis of the impact of employee co-payment provides support for the idea of employing incentives to drive employee participation in health programs. Prior research has already shown that the provision of financial rewards drives employee participation in health programs –42. In tThere is no unequivocal evidence in existing research on the impact of firm size on participation: While some researchers argue for a positive impact of size as larger organization have more resources to push new projects , others In summary, the results pronounce that a leadership team that not only encourages program participation through role model behavior but also establishes a corporate culture in which health is of high value is a key factor for program success. Corporate health programs that are just implemented to ‘Check the box’ of investing in corporate health management are set up for failure. Our findings shall not deter any company from implementing a corporate health program due to the lack of a health culture, but – rather the opposite – seek to encourage firms to realize that physical activity and related health behaviors are of such high importance that they deserve and need a high degree of top leadership attention. A second key learning for firms that are about to implement a health and fitness program is to consider providing thought-through financial incentives for program participation, as our results pronounce that enrolment increases with the amount of employer reimbursement of the program fee. Lastly, firms have to account for their size and potentially associated complexity when planning and conducting the implementation of a firm-wide corporate health program. If they fail to do so, a lagging enrolment rate among employees is to be expected.Although our entire work is grounded on a valuable data set, which comprises real life information of 61 actively operating companies from various industries, there are several limitations to be discussed. First, one has to consider potential biases of this study when interpreting the results. Information bias, selection bias and the risk of confounding are major concerns that one has to keep in mind. Due to the lack of an accurate, objective measurement of program support, the authors had to draw on a subjective assessment method. As the assessment of ‘organizational program support’ has been conducted by Platform A-employees and is no objective measurement, we clearly face the issue of information bias. One cannot be sure that organizational program support was measured accurately; hence, the validity of the study results may be limited. The fact that another employee who assesses the situation differently might allocate different scores also limits the reliability of this work. Furthermore, selection bias has to be discussed as one could argue that the companies who decided to collaborate with Platform A may share certain characteristics that make them different from other firms. Although the companies in this data set differ in many structural variables, the possibility that commonalities exist cannot be ruled out. Furthermore and despite of the inclusion of control variables, we still clearly face the risk of confounding, as there may be additional factors that we are not aware of which confound the association between the three independent variables and the participation rate. Besides the risk of bias and confounding, there are three other limitations that one has to consider: First, given the limited previous evidence on the impact of organizational- and program-level factors on participation in corporate wellness programs, our results are to a large extent explorative. Numerous additional influencing factors as well as further specific situations could be investigated within our research topic and we pave the way for future research to do so. Secondly, we want to point out the limited generalizability of our results, which is due to our purely German sample. Analyses with samples from other countries or optimally an international data set will help to test the applicability of the results to corporate health programs in other nations. Apart from the ‘German only’ shortcoming, our sample has the additional disadvantage that the data set only comprises 61 companies, as the start-up company Platform A has only been operating for less than two years. Lastly, the results prove that financial incentives drive the enrolment rate; however, we cannot make any statements on the ideal incentive type of incentive or money amount. The authors have analyzed the above-mentioned relationship in isolation while incentives also present a cost factor that negatively affects the return on investment in physical activity programs. Hence, researchers are encouraged to assess the impact of incentives within a full cost-benefit analysis to get clarity on this aspect of program design.Using a German data set from Platform A, a corporate fitness platform aggregator for corporate clients, we advance the understanding of organizational and program level factors that influence employee participation in a corporate health program offered by a platform provider. Participation of employees in the program was very limited. Our results pronounce that organizational program support is the key driver behind enrolment, as companies whose leadership encourages participation in health activities see higher participation rates. Furthermore, financial incentives do indeed positively affect enrolment rates in corporate health programs while size has a negative relationship with participation, implying that larger companies have to make a particular effort when implementing a WHPP. This study contributes to research about factors that drive participation in corporate health programs and accentuates the relevance for future work to explore the topic of financial incentives in detail.


Usability feedback did not differ between the groups. Support should be provided in order for programs to be potentially used. More information is needed regarding factors associated with the use of web programs.Little effort has been made to investigate the potential of web programs aimed to support the mental wellbeing of adolescents in school environments in middle-income countries. A quasi-experimental feasibility study was conducted in Thailand with adolescents (N = 180) in three conveniently sampled high schools and with teachers (N = 12) who acted as program tutors. The web program was used in small groups, independently, or it was not used at all. No statistically significant changes were found between the groups regarding depression, stress, or satisfaction. Differences between program users (n = 61) and non-users (n = 48) were not significant. Acceptance was higher among adolescents who used the program independently (n = 40, 73% vs. n = 21, 39%;  Modern technology has become crucial to adolescents for communicating and seeking information, including information about health and wellbeing. Adolescents especially use the web when seeking information about sex, human immunodeficiency virus (HIV), substance abuse , and menA number of studies have tested the effectiveness of the computerized programs or web programs in preventing or reducing depressive symptoms in adolescents and young adults ,7,8,9. IOne of the concerns with using web programs in mental health intervention is delivery of the program, and participants’ low engagement and fidelity . CognitiIndeed, different factors have been found to be associated with the participant adherence to web programs. Females and those who live in rural areas have been found to have greater adherence to programs run in school settings compared to those who access the program spontaneously or directly through an open-access Uniform Resource Locator (URL) . In a stAlthough in western society a wide range of studies about adolescents’ web use to support their wellbeing have already been conducted , coherenA range of concerns has also been raised about how to better understand technology that mediates the provision of youth services . We therThe multicentre parallel quasi-experimental cluster design study with a pre-post design was run to assess the impact of a web program aiming to support adolescents’ mental wellbeing in a school environment. We assumed that if adolescents were to benefit especially from the peer-network possibility in small groups (active control) or either independent web program use over a six-week period, positive results would be seen in the form of decreased depression and stress scores and increased satisfaction levels regarding the services. Beyond the quasi-experimental study, a comparison between program users and non-users was carried out, and an evaluation of the acceptance and usability of the program was assessed from the participants’ point of view using multiple methods.The schools were purposively convenience sampled based on the previous knowledge of the researcher on our team from Thailand, and as the schools and study systems vary greatly depending on the geographic area. The selected schools for the study included both public and private schools with similar curricula and similar numbers of students, and were located in the same city area. Private primary and secondary schools located in the countryside were excluded. Participating adolescents were 15 to 19 years old, could read, write and speak Thai, and were able to voluntarily provide written informed consent for participation. Adolescents who had inadequate Thai skills or were unable to provide informed consent were excluded. Volunteer teachers were invited to participate in the study as tutors for the web program.The trial was undertaken at three high schools in Southern Thailand. The schools were located in the same city, which had around 160,000 inhabitants . In totaSchools were recruited by contacting principals and sending them an information letter about the study and its aims, which was followed by a meeting with the researcher. After a decision that a school would participate, the principals then informed the teachers in the two web program schools about the study, and each teacher could decide if they wanted to collaborate, cooperate and be involved in the web program as a tutor or not.Adolescent recruitment at the three schools occurred during the researcher’s visit in mid-May 2013 . It included an oral presentation of the study. Adolescents and their guardians received written information about the study . Informed consent forms were delivered to the adolescents, and each adolescent who was willing to participate signed a written consent form and filled in the survey questionnaires. Teacher recruitment was organized at the same time at the two program use schools for teachers who were invited to act as program tutors for the adolescents. The study aim and procedures were described to them, and written information leaflets were delivered as well as consent forms and survey questionnaires.DepisNet-Thai is an expansion and implementation of good practices obtained from previous web programs for persons with mental health problems  ,35. ContThe content and theoretical background of the program is based on Garcia’s  construcDepisNet-Thai is a web program with individual user accounts and access codes, which were, in this case, delivered to participants by email. Usernames, rather than real names, were used in the learning management system, Moodle, which was administered by the University of Turku. In addition to a two-week orientation, DepisNet-Thai includes five weekly modules . Each module lasts about 50 min, and the total program takes seven weeks to complete if a two-week orientation is included. Adolescents had weekly exercises accessible on their own and at any time, that aimed to support their self-reflection skills and provide self-management skills.A handbook for DepisNet-Thai was developed for tutors in the Thai language for both schools . Teachers were trained to run the program and how to act as a tutor. They were also instructed to guide adolescents in answering contributory questions, read the students’ exercises, interact in discussions, and provide positive and supportive feedback of the exercises before the next module began. Moreover, tutors were instructed to monitor adolescents, checking that they had completed and returned their exercises according to the instructions. They were also guided in how to provide encouraging support that increases adolescents’ motivation to complete their exercises.Adolescents used the DepisNet-Thai in small groups where participants were able to peer-network online with each other. The intervention group included 4 small groups, 11–14 adolescents per group and one teacher/tutor per group. During the first session, adolescents were asked to identify their problems or concerns related to stressing situations and find information and responses to their concerns via links to reliable Thai web sites, Thai or English literature and PowerPoints. Exercises were delivered in groups and the group members interacted with each other. Detailed description of the program and exercises are presented in Adolescents used DepisNet-Thai independently; they worked with the exercises alone and returned them in Moodle. One teacher/tutor supported and oversaw 14 adolescents in their giving of feedback and completing of exercises.Adolescents did not use or have access to the DepisNet-Thai.The Patient Health Questionnaire (PHQ-9) measures signs of depression among adolescents . It inclThe Perceived Stress Scale (PSS) by Cohen et al.  assessesThe Client Satisfaction Questionnaire (CSQ-8)  used in Acceptance of DepisNet-Thai was assessed based on logged activity of the two web program groups. This activity includes the total number of adolescents and teachers logging onto the program during the study period, the number of activity logs in the program, and the number of activity logs in each module.Usability feedback of DepisNet-Thai was queried after eight weeks of use by the two web program groups. A survey included five questions, according to the Technology Acceptance Model , which hA formal power calculation was not conducted because of the feasibility study . AccordiIndividual randomization for adolescents was not conducted because it was not feasible given the possible information flow between the adolescents . TherefoDescriptive statistics  were calculated for adolescents and teachers’ demographic information such as age, gender, adolescents’ regular school attendance , previous use of mental health services , and teachers’ working experience in years. For the PHQ-9 scale, a total score was formed by summing the values of all items. For the PSS-10 scale, four negative scores were recoded, and the total score was then formed by calculating a value for each of the 10 questions. For the CSQ-8 scale, an overall score was produced by summing all item responses.Skewness was checked to be in the same direction in groups that were compared. As parametric tests have more power to reveal statistically significant differences or associations between groups, and should be used when possible, two measurements were first compared with paired T-tests. To evaluate the effect of background variables over time, a repeated measures Analysis of Variance (ANOVA) with one background variable in each model was used. Fisher’s exact tests were used to find out the dependence between categorical background variables and PHQ-groups. Differences in background variables between schools were tested using Chi Square tests and a one-way ANOVA.A sensitivity analysis  was performed comparing the users and non-users . The users of the web program were therefore collapsed into one group regardless of their initial group allocation for the purpose of examining program impact. F-tests were used to measure differences between the groups.The data regarding acceptance of the program was analyzed with descriptive statistics  for the number of adolescents and teachers using the program in the two web program groups, the frequency of use, and the favorability of the topics. Possible differences between logging on of adolescents between the groups were compared with Chi Squares tests. Usability feedback was analyzed with questions posed to the adolescents and teachers.p-values are reported.Data analyses were performed using the statistical program SPSS 22.0 . Observed significance levels <0.05 were considered to be statistically significant. Exact Local authorities from the Prince of Songkla University in Thailand were consulted about the study proposal and its attachments. The principals of the participating schools guaranteed permission for the study to be conducted. Ethical approval was granted from the Ethics Committee of the University of Turku (17/2016), and the entire procedure has conformed to the standards currently applied in the study’s country of origin. Ethical guidelines and the basic principles of research ethics  were folTeachers/tutors were also instructed to pay special attention to the adolescent’s writings, including any indication of suicidal thoughts or self-harm (serious adverse events). Anonymity and confidentiality issues were emphasized throughout the study, as usernames were used rather than real names. The learning management system, Moodle, is Secure Sockets Layer (SSL)-protected with usernames and passwords. The data were transferred, analyzed and reported in a way that anonymity could be preserved. Data were kept in a locked and safe place; only the researchers and the statistician were able to access the data. A total of 180 adolescents were potentially eligible for the study, and 167 (93%) of them were non-randomly assigned to the groups: intervention (n = 54), active control (n = 55), and passive control (n = 58). Thirteen were ineligible . p = 0.001), % of females  and satisfaction scores . The passive control group contained a larger portion of girls, and the adolescents in that group were older and more satisfied with health and human services compared to the adolescents in the intervention and active control groups. A description of the adolescents and sample characteristics for each group at baseline are provided in Out of 12 teachers, 10 (83%) participated in the study; six were at the school with the intervention and four were at the school with the active control group. The teachers at school offering the intervention were all females, they were older, and they had more teaching experience compared to those at the school with the active control group. Teachers were also queried if there are methods to support adolescent wellbeing and prevent mental health problems at school. The characteristics and answers of the participating teachers (n = 10) are summarized in All adolescents assigned to a condition were included, regardless of their degree of participation. The follow-up was conducted with the remaining adolescents in the intervention , active control  and passive control  groups whether they received the allocated program or not. The number of adolescents included at baseline and in the follow-up analysis of depression, stress and satisfaction were n = 47, n = 50 and n = 26 in the intervention group, n = 46, n = 47 and n = 15 in the active control group, and n = 42, n = 42 and n = 16 in the passive control group. Missing data were not imputed. Moreover, web program users were compared to non-users.p = 0.594)  .p = 0.178). Mean changes in stress scores between baseline and follow-up were as follows in the intervention, active control and passive control groups: −0.7 vs. 0.4 vs. 0.9. The changes between baseline and follow-up did not differ significantly between the groups (p = 0.101).Mean changes in scores of satisfaction with provided services between baseline and follow-up were as follows in the intervention, active control and passive control groups: −0.1 vs. −0.6 vs. 3.8. Changes in satisfaction scores between baseline and follow-up did not differ significantly between the groups (p = 0.194) and stress scores , and they were more satisfied with the services  compared to non-users at the follow-up, even though differences between the two groups did not differ significantly.Web program users  were compared to non-users . The 48 adolescents who did not use the program consisted of 33 adolescents in the intervention group and 15 adolescents in the active control group. The adolescents who used the program had lower depression . Out of the 120 adolescents invited to use the program at the two schools, 109 (91%) participated in the study. Further, 61 out of 109 (56%) logged on to the program, but activity differed between the groups . In addition, each adolescent in the intervention group visited fewer modules ((zero modules n = 33 vs. n = 15), (one module n = 9 vs. n = 8), (two modules n = 6 vs. n = 9), (three modules n = 3 vs. n = 6), (four modules n = 2 vs. n = 3), (five modules n = 0 vs. n = 11), (six modules n = 1 vs. n = 3)) than those in the active control group .The analysis of activity logs revealed that the range of total activity logs was quite similar between the intervention (range 2–68) and active control (2–64) groups. When the total number of activity logs were compared, adolescents in the intervention group were found to log on less often than those in the active control group , and they were all involved with the active control group. None of the six teachers in the intervention group logged on to the program. The analysis of activity logs revealed that the total numbers of activity logs for the active control group teachers were 1, 107 and 141. The analysis of activity logs in each module showed that the number of teacher logins in the active control group was altogether 249 visits, which included six visits to the orientation, 38 visits to Module 1 , 77 visits to Module 2 , 127 visits to Module 3 (Me and my family), one visit to Module 4 (Me and my friends) and zero visits to Module 5 (Me and my society). Adolescents provided feedback about the program . In general, three-fourths of all web program users (77%) were satisfied with DepisNet-Thai regardless of their group. Less than one-third (27%) found the program useful, and 67% thought that the program was easy to use. Four adolescents (4%) expressed that the program was harmful. Over half (57%) stated that they would use the program in the future. No statistically significant differences were found see  when comOf the 10 teachers, all were satisfied with DepisNet-Thai. Four found the program to be useful, half of them evaluated it as easy to use and two considered it to be harmful in some way. All of them would use the program in the future. The aim of this quasi-experimental feasibility study was to study the impact, acceptance and usability of a web program, and make a comparison between program users and non-users. We did not find any statistically significant changes between the groups regarding depression, stress or satisfaction. There have been discrepancies in the results of previous studies regarding changes in adolescents’ stress scores. In a systematic review and meta-analysis of web programs to support adolescent depression , a statiIn our study, we found that acceptance was lower among adolescents who were in small groups compared to those who participated in the program independently. The result is in line with a study by Barak et al. , in whicFurther, adolescents’ log activity decreased more among adolescents who used the program in small groups. During the development process of the program, adolescents suggested the importance of discussion forums for exchanging information and ideas between students and teachers. However, the adolescents in the current study did not use the program in small groups. The result is of interest since Goldbaum et al.  reportedIn total, fewer than one-third (27%) of the adolescents found the program useful although 67% thought that it was easy to use. The results are of interest since the program was developed to respond to the requirements of Thai adolescents by defining the needs and solutions for new programs. Information about adolescent studies and education, tuition, study guidance and schooling were highlighted as important by adolescents during the development process. Adolescents desire accessible and usable information that they find important and advantageous . In our Our study also yielded some limitations. First, a significant limitation is that the participants were non-randomly assigned to the groups which would have prevented the selection bias . Second,Still, mental health promotion using a variety of programs is an investment in the future. It is important that mental health promotion is being done in a place where adolescents spend their time ,69. AccoThis study provides information worthy of future research about the specific tool used at schools in Thailand. It also yields more knowledge for teachers, organizations, society and policymakers of IT adoption, its use in school environments and information about implementation in real practice. It is important to evaluate the procedures of a program in order to assess its impact.Although we could not prove that the DepisNet-Thai program is beneficial in terms of decreased depression and stress scores and increased satisfaction among users in comparison to those who did not log on, we identified that independent use of the program was more popular than use in small groups. Our study indicated that health-related programs and applications need careful training and available local support when introduced into practice in order to be potentially used. We still believe that IT-based programs have potential in school environments. However, they should be incorporated early at the elementary level . More inIndeed, one challenge is how to implement IT services into daily practices . Adminis


Here we present a comprehensive review of the literature concerning the utility of convex probe endobronchial ultrasound (CP-EBUS) in the diagnosis and treatment of nonmalignant conditions and discuss the associated complications. CP-EBUS has been conventionally used for the staging of lung cancer and sampling of mediastinal and hilar nodes. However, its application is not limited to malignant conditions, and it is gaining acceptance as a diagnostic modality of choice for nonmalignant conditions such as tuberculosis, sarcoidosis, pulmonary embolism, thyroid lesions, and cysts. Moreover, its therapeutic value allows for extended applications such as mediastinal and thyroid cyst drainage, fiducial marker placement for radiation therapy, and transbronchial needle injection. The noninvasiveness, low complication rate, high diagnostic yield, and satisfactory sensitivity and specificity values are the main attributes that lend credence to the use of CP-EBUS as a standalone primary diagnostic and therapeutic tool in pulmonary medicine in the foreseeable future. In 1897, a metal tube with an electric light served as the first rigid bronchoscope for the removal of pork bone from the airway . ContinuBecause of its noninvasiveness, CP-EBUS-guided real-time TBNA has largely replaced invasive sampling and diagnostic modalities such as mediastinoscopy. The value of CP-EBUS for the diagnosis and staging of lung cancer is well known. CP-EBUS can also aid in the diagnosis of nonmalignant conditions such as tuberculosis, sarcoidosis, and pulmonary embolism and facilitate treatments such as bronchogenic cyst drainage and transbronchial injection .Here we present a comprehensive review of the literature regarding the utility of CP-EBUS for nonmalignant conditions, with focus on its expanded prospects in terms of diagnosis and treatment. Complications associated with CP-EBUS are also discussed. et al. and Garwood et al. first reported the use of CP-EBUS-guided TBNA for the diagnosis of sarcoidosis, with diagnostic sensitivities of 91.8% and 85%, respectively [Sarcoidosis is a multisystemic inflammatory disorder with an unknown etiology that is characterized by the accumulation of macrophages and the formation of epithelioid cell nonnecrotizing benign granulomas. The lungs and hilar or mediastinal nodes are affected in 90% patients with sarcoidosis; therefore, pulmonary sarcoidosis is the most common form of the disease. Diagnostic modalities include computed tomography (CT), transbronchial lung biopsy (TBLB), endobronchial biopsy (EBB), TBNA, and mediastinoscopy. Pneumothorax and haemoptysis are major side effects of TBLB, which also exhibits moderate diagnostic sensitivity. Although mediastinoscopy is highly effective in the diagnosis of sarcoidosis, the associated costs and invasiveness limit its routine use. CP-EBUS-guided TBNA is an effective, noninvasive approach for sampling on an outpatient basis. Wongectively , 5. In aectively . A meta-ectively . CP-EBUSectively . et al. presented a positive pathological diagnosis rate of 93% for EBUS-TBNA or TBNA alone and 100% for EBUS-TBNA combined with TBNA [Several studies have compared sensitivity and accuracy values among various diagnostic modalities for sarcoidosis. Okiith TBNA . In anotith TBNA . Compariith TBNA , whereasith TBNA . In anotith TBNA . Howeverith TBNA . Finallyith TBNA .Multiple factors influencing the sensitivity of EBUS-TBNA have been studied; these include the gauge size, lymph node size, disease stage, number of sampled lymph node stations, and number of needle passes per lymph node. A prospective, randomized, double-blind trial found no significant difference between 21G and 22G needles in terms of the diagnostic yield of EBUS-TBNA in patients with sarcoidosis . HoweverIn summary, direct comparisons between conventional diagnostic modalities and EBUS-TBNA have favored the use of EBUS-TBNA as a primary diagnostic tool for sarcoidosis . Mycobacterium tuberculosis is a global public health concern for clinicians and researchers. Sputum or smear culture remains the gold standard for the diagnosis of pulmonary tuberculosis (TB). However, these methods are not efficient for the diagnosis of mediastinal tuberculous lymphadenopathy (TBLA). Moreover, 25% and 60% patients have negative sputum smears and no spontaneous sputum production, respectively [ et al. first used EBUS-TBNA for the diagnosis of mediastinal intrathoracic lymphadenopathy in patients infected with the human immunodeficiency virus (HIV) [ et al. demonstrated the use of EBUS-TBNA for the diagnosis of multidrug-resistant TB [Infectious manifestation ofectively . EBUS-TBus (HIV) . Subsequstant TB , anotherstant TB . Similarstant TB . A meta-stant TB . EBUS-TBstant TB . et al. confirmed the utility of EBUS-TBNA for the diagnosis of histoplasmosis in 452 patients, with a diagnostic yield of 78% [Conventionally, diagnosis of fungal infection-related lymphadenopathy requires tissue biopsy for obtaining adequate material for fungal culture. However, Sodhid of 78% . In anotd of 78% . EBUS wad of 78% . The used of 78% . et al. confirmed the accuracy of CP-EBUS in diagnosing reactive hyperplasia in a cohort of patients suspected to have lymphoma or other nonneoplastic lesions [Reactive hyperplasia involving the mediastinal and hilar lymph nodes is a nonspecific diagnosis. The condition is potentially caused by benign etiologies such as fungal infection . CP-EBUS lesions . Nocardia spp. Fujikura et al. successfully used CP-EBUS to sample purulent exudates containing N. asteroids [ Nocardia strains from a lung mass in a patient who had undergone kidney–pancreas transplantation [Nocardiosis is an infectious disease caused bysteroids . CP-EBUSantation . These fPulmonary embolism (PE) occurs when a blood clot gets lodged in blood vessels anywhere in the lungs, consequently blocking blood flow to the relevant parts of the lungs. It is a common disease and can be life-threatening depending on the presence of comorbid conditions, anatomical site, and size of the clot. Thus, prompt diagnosis is essential. Contrast-enhanced CT, ventilation perfusion scanning, and, less commonly, pulmonary arteriography are the preferred diagnostic methods. However, these techniques cannot be used for individuals with contraindications for the use of contrast agents, such as allergy or renal failure, pregnancy, and hemodynamic instability. In such cases, CP- EBUS serves as an effective alternative diagnostic modality. et al. initially reported the use of EBUS-CP for the diagnosis of PE in a 26-year-old patient [ et al. conducted a multicenter pilot study involving the use of CP-EBUS for the diagnosis of PE after angio-CT in 32 patients. Angio-CT detected 101 PEs while CP-EBUS detected only 97. However, CP-EBUS diagnosed at least one thrombus per patient, which was sufficient to establish the diagnosis. Three thrombi in the left upper lobe and one in the middle lobe could not be detected by CP-EBUS. The duration of CP-EBUS was 5 min/patient for the first 16 patients and 3 min/patient thereafter [The pulmonary arteries are located in close proximity to the bronchial and tracheal airways and can be easily visualized by CP-EBUS. CP-EBUS equipped with color Doppler imaging enables the pulmonologist to characterize the size of the thrombus and the extent of the blockage in real time. Casoni patient . Subsequereafter . In 2010ereafter . Subsequereafter –46. The ereafter . Anotherereafter . In yet ereafter .  FigureCP-EBUS can easily visualize and monitor the aortic arch, left and right pulmonary artery trunks, azygos vein, hilum, and lobar arteries; however, the image quality is generally suboptimal because of the low frequency (5–10MHz). Consequently, confirmation by angio-CT is required. Furthermore, the probe diameter of 6.3–6.9 mm facilitates the visualization of clots only in adjacent vascular structures. Nevertheless, CP-EBUS is a safe and sensitive method for real-time evaluation of PE, enabling not only diagnosis but also real-time evaluation of thrombolytic therapies in clinical studies [t al. initially reported the use of EBUS-TBNA for the diagnosis of substernal solitary thyroid nodules [ et al. reported 12 cases of thyroid biopsy performed using EBUS-TBNA [ et al. reported three cases of mediastinal ectopic thyroid diagnosed by EBUS-TBNA [EBUS-TBNA has been infrequently used for thyroid aspiration. Chalhoub e nodules . In anot nodules . Casal eBUS-TBNA . More reBUS-TBNA . et al. systematically reviewed 12 cases where EBUS-TBNA was used for the diagnosis of NELs in the pulmonary artery and lungs. The diagnoses included sarcoma (n = 6), lung cancer (n = 2), thyroid cancer (n = 1), renal cell cancer (n = 1), melanoma (n = 1), and PE (n = 1) [Al-Saffar (n = 1) . The fin et al. successfully used CP-EBUS for the placement of 2–5 fiducial markers around tumor masses in 43 patients scheduled for radiosurgery [CP-EBUS is reportedly used for the placement of fiducial markers for tracking purposes in patients requiring stereotactic radiation therapy and CyberKnife therapy for mediastinal and lung cancers , 54. Harosurgery . et al. used EBUS-TBNI of liposomal amphotericin B for the treatment of symptomatic aspergilloma [EBUS-TBNI in patients with mediastinal diseases is another therapeutic application of CP-EBUS. Two independent case studies have documented EBUS-TBNI of cisplatin for the treatment of lung cancer , 57. In rgilloma . et al. initially reported the therapeutic use of EBUS-TBNA for aspiration during the treatment of central airway stenosis caused by a mediastinal cyst. The Doppler mode in CP-EBUS helps in the differentiation of cysts from vascular structures [Nakajimaructures . Drainagructures , 61. As ructures .n = 50), followed by infectious complications (n = 14), breakage of the ultrasound bronchoscope (n = 98), and needle puncture (n = 15) [CP-EBUS is a noninvasive procedure with an excellent safety profile. Although it has several applications beyond the diagnosis of malignancies, it cannot cover the entire mediastinum and allows visualization of only the anterosuperior portion. Moreover, some anatomical locations such as the upper lobes cannot be accessed by CP-EBUS . A natio(n = 15) .In summary, CP-EBUS is a minimally invasive procedure that plays a pivotal role in the diagnosis and treatment of malignant and nonmalignant mediastinal diseases. CP-EBUS-guided TBNA provides the highest diagnostic yield in cases involving nonmalignant mediastinal diseases such as tuberculosis and sarcoidosis. However, combination with TBLB and EBB increases the yield to 100%, with minimal complications. Furthermore, CP-EBUS can provide adequate information for the diagnosis of most benign diseases without the need for other invasive procedures such as mediastinoscopy. There is overwhelming evidence on the efficacy and safety of CP-EBUS for benign conditions, with the noninvasiveness, low complication rate, high diagnostic yield, and satisfactory sensitivity and specificity values comprising the main attributes that lend credence to its use as a standalone primary diagnostic and therapeutic tool in pulmonary medicine. Therefore, the acquisition of this technology is highly recommended for most institutions to enable pulmonologists to safely and effectively diagnose benign and malignant diseases of the mediastinum.


Pisando Fuerte (PF), a linguistically and culturally appropriate version of “Stepping On”, an evidence-based fall prevention program building on self-efficacy and adult learning principles. The purpose of this study is to describe the implementation of PF at two community organizations in Wisconsin.We previously developed PF consisted of 2 h sessions delivered in Spanish over the course of 8 weeks by two trained leaders, at two community sites in Wisconsin. Participants identified strategies for falls prevention and practiced progressive balance and strength exercises. The RE-AIM framework guided the mixed-methods evaluation. Falls Behavioral Risk Scale (FaB) (Outcomes), and uptake of protective behaviors  were evaluated 6 months after completion. Fidelity of delivery (Implementation) was evaluated by an independent assessor for three sessions at each site using a-priori criteria based on key elements of Stepping On.Outcomes: There was a non-statically significant decrease in the number of falls per person [RR: 0.33 (95%CI: 0.096–1.13)] at 6 months. There was a statistically significant improvement of the mean Falls Behavioral Risk Scale (FaB) . Adoption: Barriers to adoption included leader training in English, time to identify Spanish-speaking guest experts, and time to prepare for each session. Implementation: Satisfactory fidelity of delivery was achieved in 69% of the elements; fidelity lapses were more common in the use of adult learning strategies and programmatic aspects. Eighty eight percent of participants completed the program, and 95% of them adequately demonstrated the exercises. Maintenance: At 6 months, 57.9% of participants continued doing exercises, 94% adopted safer walking strategies, and 67% executed at least one home safety recommendation. These results are similar to those seen in the original Stepping On program.Twenty-four Hispanic/Latino individuals, whose primary language is Spanish, were enrolled in two workshops. The mean age was 70.5 years; 71% were female, and five reported a fall in the year prior. Pisando Fuerte”. Pre-post data demonstrate a significant reduction in falls behavioral risk among Hispanic/Latino participants, similar to results with “Stepping On”.Our study shows good fidelity of delivery with implementation of “NCT03895021. Registered March 29, 2019.ClinicalTrials.gov,  In the United States (US), every hour, three older adults die as a result of a fall, and by 2030 this number is expected to increase to seven older adults . The risRisks factors for falls include certain medications, vision impairment, gait and balance impairments, muscle weakness, inadequate footwear, environmental hazards, and chronic conditions  , 6. SomeStepping On is a multifaceted intervention with similar characteristics to those described as desired by Hispanic communities in Wisconsin. It has been documented to decrease the risk of falls among Australian older adults by 31% [The process to select one fall prevention initiative to implement usually involves a needs assessment process at the community/organization level, which takes into account the cost of the delivery, preferences of participants, capacity of staff, among others. According to Hanlin et al., seniors in Hispanic communities in Milwaukee  would prefer a multi-faceted program that combines exercise with education in Spanish, and with the participation of a healthcare provider . Steppins by 31% –14, and Stepping On to develop Pisando Fuerte for use with Hispanic/Latinos older adults whose primary language is Spanish.Given the growing population of Hispanic older adults, and the need to provide a culturally and linguistically tailored multifaceted fall prevention program for Hispanic seniors, we adapted Pisando Fuerte at two community organizations in Wisconsin using the RE-AIM framework [The primary objective of this paper is to describe the implementation of ramework , which iA single arm clinical trial was performed. Workshop participants were recruited by leaders and staff from the community organizations that participated in the study. After screening was completed by the leader, those that complied with the following characteristics were invited to participate in the program: Self-Identification as Hispanic or Latino, 65 years old or more, living independently, had fallen in the past year or reported a fear of falling, without history of dementia. Individuals that needed help of another person to ambulate or used a standard walker to ambulate indoors were excluded. Each participant completed a written informed consent to participate in the research study, according to the regulations established by the University of Wisconsin – Health Sciences Institutional Review Board, which approved this study.Two community organizations that serve Hispanic/Latino communities in Wisconsin were invited to participate in 2014–2015. Site 1 was a senior center with experience providing fitness programs and health promotion programs for English and Spanish-speaking older adults. The workshop was held at a multi-purpose facility that hosts community activities year round. The leaders for site 1 were identified by the organization and served as co-leaders: a bilingual physical therapist (non-native Spanish-speaker) with experience facilitating health promotion programs; and the outreach and program planner for the Latino Senior Program, who was a native Spanish-speaker with experience working with older adults, and previous experience delivering group-based health education classes to seniors.Site 2 was a community organization that delivers health education programs and other social services at senior housing facilities. The workshop was held within an apartment complex that has primarily Hispanic senior residents. The lead leader was a bilingual coordinator for evidence-base programs at the Wisconsin Institute for Healthy Aging (non-native Spanish-speaker), who had several years of experience delivering self-management programs and facilitating group interventions. The peer-leader was the senior housing coordinator, who was a native Spanish-speaker, without experience facilitating groups.Pisando Fuerte and its pilot study were performed in 2011–2012 [Stepping On curriculum. The Advisory board was formed by providers of community-based programs for Hispanic/Latinos older adults, as well as experts in fall prevention, health promotion in Hispanic/Latinos populations, language translation, and kinesiology. The Advisory Board also included Hispanic older adults whose primary language was Spanish.The process to develop 011–2012 . A commuThe adaptation was done using a systematic, rigorous process, following best practices in cultural adaptation –19: the For the pilot study, only the handouts for participants were translated to Spanish, leaders had to translate information and examples as they delivered the program .Based on results of the pilot, the following changes were implemented to facilitate adoption and implementation by community organizations: 1) Information about the content of the sessions in the leader manual was translated to Spanish, 2) an extra session was added to provide more time for interaction, and 3) pre-qualifications of leaders were expanded to allow health educators and community health workers to train as leaders.Pisando Fuerte) maintains all but two of the key elements of Stepping On [2) Background of the leaders. For Stepping On, potential leader candidates must comply with three characteristics that have been previously identified as key to success [Pisando Fuerte, given the dearth of Spanish-speaking health professionals, to increase adoption we relaxed the requirement that the program leader be an allied health professional or fitness expert, so that the potential candidate could also be a community health worker or other professional working with Hispanic/Latino older adults. Table Stepping On and Pisando Fuerte.The resulting program (pping On : 1) Use  success ; howeverPisando Fuerte is a multifaceted community-based program that is provided in a small-group learning environment to improve falls prevention self-efficacy, encourage adoption of preventive behaviors, and provide progressive strength and balance exercises for older adults whose primary language is Spanish. Pisando Fuerte consists of 8 sessions, each one of 2.5 h, delivered on a weekly basis, by one trained leader and one peer-leader, followed by a booster session at 3 months. Several of the sessions involve the use of guest speakers, who provide a short lecture to participants, followed by time for questions. The guest experts are not compensated for their time, and they represent the following specialties: physical therapists, pharmacist, ophthalmologist or optometrist, community safety expert or law enforcement.Pisando Fuerte leaders took the 3 day English language Stepping On training, offered by the Wisconsin Institute of Healthy Aging [Pisando Fuerte, which covered the differences between the programs, important considerations in Hispanic/Latinos culture, and how these may affect implementation of the workshop and participant uptake of health behaviors.hy Aging , followeThe RE-AIM framework was used to evaluate the implementation of the program . This fr“Levántese de la silla, camine 10 pies a un paso cómodo, gire, y regrese a la silla a sentarse otra vez”, which translates to: “Stand up from the chair, walk 10 feet using a comfortable pace, turn around, and walk back and sit down.” The measure was performed twice at each assessment, but only the second measure was used for analysis.Participants completed a survey at baseline that included demographics, history of falls in the past 6 months, and the Shortened Fall Behavioral Scale (FaB) scale, a 24-item validated tool that assesses the presence of protective behaviors for falls in older adults using a scale between 0  and 4 (very much) . FunctioFidelity of delivery was assessed at sessions 1, 3 and 7, using pre-established checklists that were created based on the key elements of Stepping On . AdditioIn the first week after participants completed the program, they were asked to demonstrate the exercises learned during the program, and they were evaluated on technique and knowledge of the exercise. Semi-structured interviews were performed to gather their impressions of the program, uptake of exercise and protective behaviors, and any consequences of participation  and maintenance. Wilcoxon Rank Tests (Non parametric) were performed as appropriate to compare continuous variables in univariate analyses . A logistic regression with binomial distribution accounting for within-subject correlations assessed intervention effect on falls. All Content analysis was used to analyze the transcripts of the interviews , 33; theFidelity of delivery assessments were analyzed separately for each site to identify implementation differences, and then analyzed together to identify common elements.Cost per participant was calculated by adding the costs associated with the delivery of the program and dividing by the number of participants that completed the study. The information was collected from invoices submitted by the community organizations during the study. We excluded the costs of the training and the time used for research activities .Workshop leaders approached 29 individuals at two community organizations, all of whom fitted the inclusion and exclusion criteria. Out of these, 24 (82.8%) agreed to participate, 15 at Site 1 , and 9 at Site 2 . Mean age was 70.5 years; 71% were female, and five (21%) had reported a fall in the year prior to the program. Table p = 0.07. The FaB scale improved significantly from an average of 2.69 at baseline (SD: 0.41), to 3.16 (SD: 0.31), p < 0.0001 at 6 months post completion, which is consistent with increased uptake and maintenance of fall protective behaviors.Eighteen participants (75%) completed the 6-months evaluation, those that completed the program were more likely to: have at least middle school education, have been born outside of the United States, and have no difficulties reading in Spanish. Using a pre-post design, comparing to the number of falls in the 6 months prior to the program, participants in the study had a non-significant decrease in the number of falls per person, RR: 0.33 (95%CI: 0.096–1.13). Regarding the TUG results, there was a non-significant increase in the length of time required to complete the task (12.5 vs. 13.4 s), mean difference + 1.3 s, Three themes were identified in the interviews of leaders, coordinators and administrators regarding the barriers for facilitators and organizations to adopt the program: 1) Issues with translation 2) Language of leader training 3) Difficulty in finding Spanish-speaking guest experts.issues with the translation of the leader manual, which was characterized by use of words and references that were not native to participants (e.g. Chilean Spanish vs. Mexican Spanish), and the mismatch between the language level of the leader manual (8th grade) and the level of spoken Spanish of participants (3rd grade). A consequence of these issues was that leaders required more time than expected to prepare and deliver each workshop.“Language in the Pisando Fuerte book was a challenge. Different types of Spanish. The translation wasn’t as conversational, more academic. Leader helped by making the language more appealing to participants.”One of the barriers identified in several of the interviews was “Training was difficult—wanted Spanish-speaking–training, but it was done in English. Big mistake”“Materials were not in Spanish. Infrastructure instructions (setting up class) should be in Spanish.”Additionally, the training of leaders and some parts of the leader manual  were in English, which made it more difficult for leaders to learn and implement the program.“... It was difficult getting guest speakers. Finding Spanish-speaking people with expertise for the specific time offering class is a challenge. They are in high demand because there are so few of them. They had to use an English-speaking pharmacist because no Spanish-speaking were available.”All the coordinators stated that it was challenging to identify guest speakers that were fluent in Spanish, even in a large city like Milwaukee, with a higher density of Hispanic/Latinos professionals.facilitators for adoption. The common theme was that the flexibility of the program was very important, because it provided an opportunity to connect with participants and adjust the program to their needs.“It was rigid but there was some flexibility. Seniors were talking during class and learning without an emphasis on the leader getting through every single page.”“Leaders enjoyed having freedom to work with the class as they see fit; not change curriculum.”Interviews also explored the Excluding the time required for training, the time invested by leaders preparing and delivering the classes ranged from 4.6 h to 18.6 h per week. Calculating the salaries for leaders at $31.15 per hour, the total amount spent in salary support per workshop was $4411 or an average of $2206 per leader. Additional costs of the program include snacks, and copies/flyers for participants; the cost associates with this ranged from $17.60 to $31.25 per class. After including the cost of supplies and salaries, the total cost per participant enrolled in the program was $367.63. Additional costs related to training and research activities  were not included in this study.Table Overall, out of the 24 participants, 22 completed the program (87.5%), with completion defined as attending to at least six sessions of the workshop (Out of eight sessions). Fifty-four percent of participants attended all the sessions. Attendance per site was as follow: Site 1 had an average attendance of 90% per session (range 81–94%), while Site 2 had an average 82% attendance per session (range 67–89%). Reasons for non-completion were not collected.Pisando Fuerte sessions. Table When participants were asked to demonstrate the exercises 1 week after the completion of the program, 95% of them adequately demonstrated the exercises; however, only 57% of them were able to adequately explain the purpose of the exercise, even though it was explained during Pisando Fuerte?”, common themes were that participants were taking more time to get up from chairs, concentrating more on walking, walking more slowly, and being more aware of their surroundings when walking.“I pause for balance when standing up”“Don't rush, take my time”“The way I walk up and down stairs, more cautious and take my time.”Although maintenance was not evaluated at the organization level, a quote from a coordinator highlights the overall interest by their organization: “This program is an education piece needed with seniors, especially for Spanish-speaking. It was well received, and participants feel so successful and pleased. Lack of funding would be a reason not to do it. As an agency, we are not set up to charge for programs. End result made all the frustration worthwhile.”Table Pisando Fuerte significantly improves the behaviors that are associated with a decrease in the frequency of falls, as shown by the improvement of the FaB, and continued execution of exercises for balance and strength and safety strategies to prevent falls by older adults whose primary language is Spanish. It is important to note, our participants had low literacy levels, with 45% of participants having less than primary education, and 37.5% having difficulty reading in Spanish. This is substantially different from the experience with Stepping On participants, where participants with less than high school education are less than 20% [This study shows that than 20% , 21. ThiStepping On implementation, which have ranged between 31 and 48% [Pisando Fuerte is on walking more safely, including not walking too fast. In addition, some studies have also suggested that the TUG might not be a good tool to measure the risk of falling, because it might not have the sensitivity required to identify falls risk among older adults whose TUG scores are close to normal values [Pisando Fuerte can’t be compared with the original study published by Clemson et al. [Our study showed a promising reduction in falls 68%), which is similar to the results for  and 48% , 13; how and 48% , 26 and  and 48% , 27. Our and 48% , 34; we l values , 36. Lasl values . Regardi8%, whichn et al. , becausePisando Fuerte. Second, the time required for preparing and delivering the program might be cost prohibitive for many organizations. Third, some of the materials in the leader manual were not translated into Spanish, and those that were translated were at too high of a language level for use with older adults with little formal education. As a result, leaders needed more preparation time to review the information provided, and adjust the language of the program as written in their leader manual to the language used by participants, especially around key words that have multiple variations across Latin America .We identified several barriers for adoption by workshop leaders and organizations. First, Leaders were required to be fluent in English to complete the training, which narrows the number of individuals who could be trained to facilitate Fidelity of delivery was evaluated following protocols established for Stepping On leaders . For SteAlthough most of the leaders had previous experience in teaching health education classes, not all of them had been trained in health promotion and behavior change techniques, which affected the delivery of the program, and potentially influenced the seniors’ adherence to the program, and their uptake of the protective behaviors Another important aspect to consider, is the familiarity that the leaders had with the participants. According to our previous experiences, when the leader is a recognized local champion, it facilitates recruitment to the program and subsequent adherence.Because of the small number of participants per site, it is not possible to assess if the health outcomes, and uptake of health behaviors were affected by the lapses in fidelity, or by the backgrounds of participants Table . CompareThese differences may have affected adherence and uptake and maintenance of behavior change, highlighting the importance of future research studies that assess how participant characteristics may affect outcomes of falls prevention programs, particularly in the setting of cultural adaptation, where adaptations must take into account cultural and socio-demographics differences of the end-users.Stepping On is more effective among those with had multiple falls in the previous year. Future research studies will be powered to assess the effectiveness of Pisando Fuerte in fall rate, and other health outcomes.Our study population is also different from the original Stepping On, in that our participants had a lower rate of falls at baseline. Clemson et al.  describeStepping On to Pisando Fuerte was performed in a previous study, and not described at length in this paper. However, it was characterized by the inclusion of community advisors, older adult stakeholders, leaders, and experts in the field in a process of iterative adaptations. Our study did not assess the cultural adaption per se, but rather the fidelity of delivery for cultural adaption elements, which was low. We hypothesize that this might be a result of the evaluation tool used. As seen in Table The process of linguistic and cultural adaptation of Pisando Fuerte or similar prevention initiatives. Additionally, our results provide evidence of the unique needs that need to be addressed when evaluating programs for Hispanic/Latino communities.The limitations of our study include the small sample size, and the low rate of falls at baseline which limits our capacity to assess the effect of the program on the rate of falls. However, it is important to acknowledge that our study was not designed to identify changes in physical performance measures to assess strength, balance and mobility; neither was it powered to identify a statistically significant reduction in falls. The purpose of this study was to provide information about the acceptability and feasibility of the program in real world-settings, the fidelity of delivery, and participant uptake and maintenance of behavior change elements, and the potential barriers that need to be addressed before the program can be packaged for dissemination. The results of our study provide information that organizations will need in the process of deciding if they will offer Pisando Fuerte is a culturally acceptable program to prevent falls among Hispanic/Latinos communities that increases adoption of behaviors to prevent falls. It provides similar benefits as Stepping On [Pisando Fuerte was well accepted by instructors and participants alike, more work is required to be able to disseminate the program, including: (1) Develop and implement the Spanish language training for leaders; (2) Improve training around elements that had poor fidelity during implementation; (3) Revise materials to assure that cultural adaptation of the program is relevant to a diverse group of Hispanic/Latinos individuals. The rigorous evaluation we conducted was essential to identifying the remaining gaps with program adaptation, and how they relate to the context where the program is implemented. Our findings support the value of conducting a rigorous evaluation of implementation metrics with any cultural adaptation of a behavior change intervention, to ensure that the adapted program has adequate adoption and maintenance, can be implemented with good fidelity and minimal barriers, and can retain effectiveness similar to the original program.In conclusion, pping On , 14, eve