Media advocacy plays an important role in public health initiatives, as it can provide vital information to target populations, policy makers, or other relevant stakeholders. Unfortunately, little is currently known about the use of media advocacy to promote occupational safety and health programs. This study explores media coverage related to the Rollover Protection Structure (ROPS) Rebate Programs, which were designed to encourage the use of rollover protection on agricultural tractors, thus reducing the risk of tractor overturn fatalities. The Program’s portrayal in the media, as well as the role that the media has played in implementing and sustaining these Programs.Media articles pertaining to any of the state-based or National ROPS Rebate Programs and published between November 1, 2006 and October 31, 2018 were included for review. Discourse analysis was used to understand the messages portrayed by the media and how those messages shaped the outcomes of the ROPS Rebate Programs.During the study period, 212 unique articles were published about the ROPS Rebate Programs. While these articles all portrayed the ROPS Rebate Programs in a largely positive light, they were used at different stages, from pre-implementation through sustainment of the ROPS Rebate Programs, and to different extents.Media articles have played an important role in implementing and sustaining the ROPS Rebate Programs. Based on the results of this study, more robust and continuous media coverage are important for the longevity and success of public health programs. As it relates to public health, media can both help and hinder efforts. Similarly, media can both influence and be influenced by readers at all levels from policy and decision makers to the general public. As such, media advocacy efforts, which can be defined as, “the strategic use of mass media to support community organizing and advance healthy public policy ,” have bTo help fill this gap, this study seeks to explore and understand a series of media advocacy campaigns surrounding an agricultural safety intervention first developed in New York State and then expanded to additional states and eventually nationally.Given that the average working adult spends more than a quarter of their lives at work , 7, occuIn 2006, the first ROPS Rebate Program was implemented in New York State to reduce farmers’ barriers to installing ROPS on their older tractors. The Program consists of three primary components: 1) a social marketing campaign aimed at raising awareness of tractor overturn fatalities and the Program, 2) a hotline to assist farmers with identifying the correct ROPS kit for their tractor, and 3) a 70% rebate toward the cost of purchasing and installing a ROPS kit . These cDue to the success of the New York Program, the ROPS Rebate Program model was replicated to varying extents in Vermont, New Hampshire, Pennsylvania, Massachusetts, Wisconsin, and Minnesota between 2010 and 2016.In addition to individual state Programs, the National ROPS Rebate Program was launched in 2017 . The NatThough all ROPS Rebate Programs currently operate under the umbrella of the National ROPS Rebate Program, they are referred to as individual ROPS Rebate Programs in this manuscript. This is in order to highlight the role that media has played in each Program, and how differences in these media strategies could have contributed to differing outcomes.The short-term outcomes presented in this study are the amount of funding dedicated to ROPS Rebate Programs, as well as the number of retrofits through the Programs.New York, which was the first state to launch a ROPS Rebate Program, has dedicated the largest amount of funding for rebates, and has thus retrofitted the greatest number of tractors (1765 in 12.5 years). Rebate funding in New York is provided by the New York State Department of Agriculture and Markets.Both Vermont and Pennsylvania fully implemented the three core components of the ROPS Rebate Program in 2010 and 2011; however, both states relied on private donations to fund rebates. Unfortunately, this resulted in the quick depletion of rebate funding and the development of waitlists by 2012. These waitlists continue today. The New Hampshire Program, which is funded through private donations, and the Massachusetts Program, which is funded through the State Department of Agricultural Resources, also implemented all aspects of the ROPS Rebate Program; however, with less emphasis on the social marketing campaign. As such, demand for the Programs is limited, and rebate funding has been sufficient to meet those demands.Both Wisconsin and Minnesota have ample funding, and are able to utilize all aspects of the ROPS Rebate Program. However, while Minnesota’s rebate funding is provided by the state legislature, rebate funding in Wisconsin is obtained through an annual fundraiser. In recent years, organizers of this fundraiser have discussed redirecting the funds to another agricultural safety and health program, thus challenging the sustainability of funding. In response, Wisconsin Program staff have begun efforts to obtain other sources of funding.Finally, the National ROPS Rebate Program has had some success in obtaining rebate funding  and retrofitting tractors (13 since 2017). However, a more important short-term outcome in this case is the preservation of funding for administrative tasks. This includes the cost of facilitating the ROPS Rebate Programs  and working to procure funding in under-served areas. At the time of this study, this funding has been provided continuously since the Program launched.Long-term outcomes of the ROPS Rebate Programs include the number of lives saved, as well as resulting cost savings. Because these outcomes require a great deal of data over a longer period of time, they have so far only been assessed relative to the New York ROPS Rebate Program. Recently published research demonstrates that this Program not only save lives, but are fiscally advantageous, as the cost to administer them is markedly less than the cost of addressing overturn fatalities and injuries once they have occurred . DespiteAs part of the implementation and sustainability strategies, media has been used to varying extents across all ROPS Rebate Programs to share information, promote the Programs, and gain political and public support. Though used frequently to promote the Programs, no pre-planned media advocacy strategies existed for any of ROPS Rebate Programs. Instead, media was used as opportunities arose in the various settings . Despite these efforts, in interviews with stakeholders involved in the implementation of the National ROPS Rebate Program conducted in 2017 and 2018 , the individuals interviewed were generally unaware of media or related political commentary surrounding the National ROPS Rebate Program, thus leaving a major gap in fully understanding the implementation efforts. This study aims to fills this gap by assessing 1) how the ROPS Rebate Programs are portrayed in the media, and 2) how media are used to advance the ROPS Rebate Programs.This study used a discourse analysis for print media approach, which begins with collecting media publications relevant to the topic. In doing so, specific key words are used to monitor media sources for real-time updates and retrospectively search online databases to identify published media reports.Discourse analysis assumes that language both shapes, and is shaped by the real world –17. In aIn conducting discourse analysis of print media, three areas of consideration are of particular interest: the text or news story, the process used to develop the news story, and the news story’s relationship to the audience .Textual analysis, which is most common in discourse analysis  can be lThis links to the process used to develop the media report in that those of differing social status or power (relevant to the media report) may be used in varying ways during the development process. In the case of the ROPS Rebate Programs, an array of individuals from varying backgrounds  are used as sources of information and quoted in media reports.Finally, the language used in the text as well as the power and societal structures defined help to dictate (or are dictated by) the audience for the particular media report. Together, these can be important tools in shaping or reinforcing the readers’ opinion of the topic, the individuals involved, and the societal hierarchy relevant to the issue , 19.Media reports that related to the ROPS Rebate Program were gathered from collections that Program staff had maintained since its inception in November 2006. These collections were developed based on web-based media alerts set up through Burrelles Luce News Clippings and Google Alerts, as well as visual inspection of printed media publications upon receipt. In order to ensure that all media reports were included, ProQuest Newspapers was searched using the key term “ROPS Rebate Program.” All media reports referencing one of the ROPS Rebate Programs and published before October 31, 2018 were included in this analysis. Media reports were excluded if they only mentioned the Program as part of a list of an organization’s services and did not provide additional detail.Media reports were first organized based on the date in which they were published, as well as the specific ROPS Rebate Program that was referenced . Media reports that referenced multiple state Programs, but were published prior to use of the term “National ROPS Rebate Program” were still considered to be related to the National Program. By organizing the media reports in this way, the authors were then able to identify reports that had been replicated either in full or partially. Additionally, this allowed for media discourse to be compared between each of the current ROPS Rebate Programs, as well as states that do not yet have Programs. Analysis of media reports by state was key to the aims of this study, as it allows for assessment of how differences in media strategies can contribute to different outcomes in each case.The lead author, who is heavily involved in the administration of the ROPS Rebate Programs, first inductively coded each media report line-by-line using NVIVO 12 qualitative analysis software . ThroughAn external reviewer who was unfamiliar with the ROPS Rebate Programs provided written summaries of the media reports relevant to each Program. These summaries included overviews of the target audience, key messages, important players, and media strategies used, but did not include in-depth analysis or latent meanings. While conducting the analysis, the authors used these summaries to ensure that their own viewpoints and those of individuals less connected with the ROPS Rebate Programs were maintained and considered in the analysis. Though there were differences in the analyses conducted by the coder and the reviewer, these differences were not related to content. Instead, these differences related to the emphasis given to certain aspects of the data, which was based on each individuals’ knowledge of the Programs. Thus, the minor discrepancies between the coder and the external reviewer served to balance the two perspectives.n = 259) of these media reports were published through non-agricultural media sources  while the remainder appeared in agricultural-specific sources .The earliest identified media report was published in New York on November 20, 2006. During the 12-year period included in this study, a total of 212 unique media reports (i.e. new media reports) were published 357 times  referred primarily to the New York ROPS Rebate Program, 67 (18.8%) to the National ROPS Rebate Program, 40 11.2%) to the Minnesota Program, 32 (9%) to the Wisconsin Program, 13 (3.6%) to the Pennsylvania Program, seven (1.9%) to the New Hampshire Program, six (1.6%) to the Vermont Program, six (1.7%) to states without Programs as of October 31, 2018, and 1 (0.2%) to the Massachusetts Program. The numbers of media reports published about each Program are highlighted in comparison to Program outcomes (rebate funding and retrofits) in Table % to the Based on the numbers of unique media reports published compared to the Program launch dates, New York and, to some extent, Wisconsin, have used media extensively since the launch of the initiatives. New Hampshire, Vermont, Pennsylvania, and Massachusetts similarly used media to launch their Programs; however, these efforts were discontinued after a short time. Both the Minnesota and National Programs have used media to introduce the possibility of a Program, and then have continued to varying degrees after their respective launches. These trends are highlighted in Fig. Based on the media reports review, the origination of these reports (part of the process of developing text) was different across the states. Those published in Vermont, New Hampshire, Pennsylvania, Massachusetts, and Wisconsin primarily stemmed from press releases and announcements provided by Program staff. The New York and National ROPS Rebate Programs’ media involved a mixture of staff-prepared press releases and announcements, political press releases, and organically prepared materials initiated by external journalists and reporters. Finally, on the far end of the spectrum, media reports published in Minnesota were primarily initiated and prepared by journalists and reporters external to the Program.Most often, the media reports included in this paper used quotes and input generated from ROPS Rebate Program staff. Examples of these types of media reports could be found for all Programs. Similarly, examples of media reports that featured farmers could also be identified across all Programs. Though farmers were quoted in media reports across all Programs, such examples were most common media reports about the New York ROPS Rebate Program, while the Pennsylvania ROPS Rebate Program media reports incorporated farmer opinions sparingly. In addition to these two groups, legislative officials were portrayed to a great extent in both media reports about the New York and National ROPS Rebate Programs. Legislative officials were also quoted in Minnesota and Wisconsin, but to a much lesser extent. Lastly, other groups, including insurers and equipment dealers were occasionally quoted. Often, the presence of input by these types of organizations were generally tied to prior support for the Programs by the organizations.Two key audiences were identified in these media reports: 1) the farmers who can participate in the ROPS Rebate Programs, and 2) the potential supporters or funders of the Programs, both legislative and non-legislative.The remainder of the results section is divided into two overarching areas: commonalities across all media reports in this study, and differences between the media reports across ROPS Rebate Programs.Across the board, media reports related to the various ROPS Rebate Programs tended to highlight the important role that farmers play in their communities and in the United States as a whole. These quotations came from a number of different parties, further highlighting the importance of having farmers in the community. Often, individuals who were quoted speaking of farmers’ importance used this as a way to convey the idea that the Program provides a way to thank farmers for their hard work by providing reduced-cost safety technologies (ROPS).“Minnesota’s farmers work hard to feed people around the world, and take care of their families and communities. Minnesota’s new Rollover Protective Structures Rebate Program helps to take care of them by defraying the cost of important improvements to aging farm equipment that would otherwise lack modern safety features,” .In addition to the ROPS Rebate Programs’ staff using media reports as a method for recognizing farmers and thanking them for their work, the vast societal benefits of the ROPS Rebate Programs were also highlighted in much of the media. The immediate and intended benefit of the Program  was highly praised in many media reports.“With increasing use of ROPS on tractors we are seeing fewer accidents and fatalities. This is a very effective program for a lot of reasons. Our research data shows the ROPS tractor safety program has made farm work less dangerous,” .In addition, many media reports highlight other benefits of the Program: the long-term impacts on the individual farms, the economic impact of preventing tractor overturn fatalities, and job preservation at agricultural equipment dealerships and ROPS manufacturing organizations.“What’s more, farmers aren’t just risking their lives when operating tractors without these roll bars, but their entire businesses too,” .Finally, across the majority of media reports, one misconception related to the ROPS Rebate Programs was addressed. This relates to stakeholders belief that farmers’ are not interested in safer work practices or participating in programs such as the NRRP.“An old friend, a very careful man, was killed in a rollover some years ago. Other neighbors and friends have been thusly injured. On occasion, I get into a situation where I myself am afraid. So there is a clear danger that a rollbar would reduce. Yet, I choose not to install one,” .While occasional media reports have quoted individuals, such as the one above, many more have made an effort to highlight farmers’ need and appreciation for the financial assistance that the ROPS Rebate Programs provide, thus negating opposing arguments.“You know, most farmers, dairy farmers, they milk in the morning, do field work, have to milk at night, so safety is always a concern and anything we can do to improve safety is what we look for,” .In addition to these portrayals, another overarching trend in media reports was that often, incorrect information was provided through the articles. In some cases, this misinformation related to the rebate amount, availability or Programs, or the idea that ROPS are only effective when used with a seatbelt . In regBased on the reviewed media reports, media seem to have been used differently across the various ROPS Rebate Programs. In New York and Minnesota, as well as at the National level, media reports seem to be more closely aligned with principles of media advocacy to support implementation and sustainability of Programs. However, in the remainder of the states, media reports seemed to focus less on advocacy and more on awareness-building. Though both strategies can be seen in almost all efforts, this analysis focuses on the primary use of media within each Program.Media in Minnesota was strongest prior to implementation. There, a local reporter prepared a multi-part series on the growing number of fatalities on Minnesota farms, which then sparked the interest of legislators and government officials in the state. In one of the media reports, the journalist stated;“Lawmakers said they were prompted to act by a 2015 series in the Star Tribune that revealed a disturbing spike in the number of Minnesota farmers killed in work-related accidents,” .Though ROPS Rebate Program staff were interviewed for this series, the reporter had developed and executed the series based on his own personal interests and without any prior efforts to promote the Program in Minnesota. After the initial media report introducing the ROPS Rebate Program, attention shifted to the growing interest in funding a Program. In several instances, media reports focused on the past success of the ROPS Rebate Programs in other states and legislative interest in mimicking these efforts.“I thought if other states can do it and feel it’s a worthwhile program, maybe we should try something like that in Minnesota,” .The media reports closely followed the legislative discussions surrounding the ROPS Rebate Program with some reports more positive than others. In publishing this information, a few media reports also presented arguments from those who were opposed to the ROPS Rebate Program. In fact, Minnesota was the only state in which explicit opposition to the Program, or parts of it, was depicted in media reports.“On the other hand, if we want to reduce unnecessary deaths and injuries and as taxpayers are willing to spend an extra $250,000 to do so, would giving it to farmers to buy rollbars for old tractors save the most lives for the money? I think not, but opinions will vary,” .Once a bill supporting the ROPS Rebate Program passed in 2016, the media attention shifted. Rather than focusing on the political debate surrounding the Program, most media reports refocused on letting farmers know how the Program works and sharing early successes before media ended just 3 months after the Program launched.“Since its inception, 150 farmers have been approved for a rollover protective structures…Another 127 farmers have an application pending, some of which are approved and in the process of finding an appropriate rollover protective structure kit,” .Media reports in New York were used initially to support the launch of the ROPS Rebate Program; however, over time, media has been used as an aide to Program sustainment. Initial media reports related to the New York ROPS Program were largely targeted at farmers and focused on explaining and promoting the Program; however, the strategy used transformed over time. Media reports focused more on farmer stories and evidence of lives saved through the Program as well as arguments in favor of the ROPS Rebate Program as an investment opportunity for farmers.“I was very fortunate. It prevented (the tractor) from going all the way over and got the tractor upright. If it hadn’t been on it would have probably rolled over and broke my neck,” .Though most of the media reports published about the New York ROPS Rebate Program focused on sharing information with farmers, these media reports doubled as a way to engage politicians and other supporters in the public discussion of the Program. About three quarters of these media reports included quotes or were written by state legislators who have supported the Program and assisted in securing state-based rebate funding.“In the past few years, I have been proud to have secured $1.2 million in funding, including $250,000 in the new state budget, for a program that helps to protect farmers from tractor rollover incidents,” .In addition, the necessity and importance of legislative support for the Program was often referenced even when legislators were not directly quoted. These quotations served to reinforce the important contribution of political stakeholders.“I am writing to recognize the leadership role that Senator Catharine Young and the New York Senate Agricultural Committee have assumed to protect the lives and well-being of farmers in our area and throughout New York State,” .Media on the National ROPS Rebate Program varied more in its content and intended target audience than coverage related to individual state Programs. These media reports tended to focus almost entirely on generating support from non-farming stakeholders for the National ROPS Rebate Program, with many including direct asks for support .Almost all of the initial media reports about the National Tractor Safety Coalition referred to the group’s push for a National ROPS Rebate Program modeled off those previously mentioned. In general, these media reports shared basic information and provided additional stakeholders with methods of getting involved.“Through a series of facilitated exercises over 2 full days, the group created a vision for tractor safety and made organizational commitments to reduce tractor-related deaths in the United States and to promote retrofits of older tractors with roll-over protective structures (ROPS),” .After the initial media reports about the Coalition, little was published until June 2017 when the National ROPS Rebate Program was officially launched. However, this launch came at the same time in which cuts to the presidential budget severely threatened continuation of the Program.“It has been terminated in the past but the cuts are deeper and we are not sure if we are going to survive so I guess the shortest answer to your question is there would be no program. Why should somebody have to put their life at risk to make enough money to make ends meet? It just seems like- it seems unjust,” .Having made national headlines, the budget cuts threatening the National ROPS Rebate Program were then addressed through many media reports featuring United States Senator Chuck Schumer, then the Senate Minority Leader. These media reports followed Senator Schumer through a series of press-events in which he addressed the need to maintain funding for the Program and vowed to “[do] everything possible to make sure this program, which puts farmers first, is protected,” . In this push, the Senator, and the reporters covering the effort, focused primarily on both the lives saved by the Program, as well as the extensive cost savings seen.“The work done by organizations like the NEC is exactly the type of work the federal government should be investing in: it’s cost-effective, informed by real industry experts, and helps save farmers’ lives every day,” .Similar sentiments are echoed throughout the effort to preserve funding, as well as after a press announcement highlighting the Center for Disease Control and Prevention’s commitment to maintain funding for the Program in July 2018.Aside from New York, northeastern states  focused little attention on sharing Program information through the media. In these states, media reports were primarily limited to the time directly surrounding the launch of each states’ Program. Most of the initial media reports tended to be fact-based and simply described the various aspects of the Program and its importance. In both Pennsylvania and Vermont, media reports were also used to highlight that rebates provided through the Program are from private donations. While well intentioned, these highlights hinted at the potential insufficiency of Program funding and therefore the Program.“[Vermont], meanwhile, is working to secure more private sponsors for the program: The number of sign-ups is about to eclipse the rebate fund,” .Media reports in Wisconsin began briefly before the ROPS Rebate Program was launched; however, the vast majority of the reports were published after the start of the Program. In general, these media reports used a three-piece strategy directed at farmers and dictated by Program staff rather than journalists. This strategy involved advertising for the Program by 1) briefly describing the issue of tractor overturns and the purpose of ROPS, 2) announcing the availability of the Program, and 3) sharing information on how to sign up for the Program.“A ROPS helps prevent injury or death in the event of an overturn. All Wisconsin farmers are eligible to apply for the rebate program, which reimburses up to 70 percent toward the total cost of purchasing, shipping, and installing individual ROPS,” .In using this format, farmer quotes and stories were used; however, this was often done sparingly with little space provided for elaborate descriptions. In 2016; however, several media reports were published promoting the Program as a potential candidate for legislative funding. These media reports tended to be longer and included more detail about farmers’ experiences with tractor overturns as well as general safety issues. Only a handful of these media reports promoting the Program as a possible legislative effort were published in 2016, with one follow-up sharing an unfavorable legislative outcome in early 2018.“This program makes Wisconsin farms safer. It’s very positive that the bill made it through both committees this year, but we’ll need at least one more big push to get it signed into law. This is something Wisconsin farmers need,” .Five media reports were published advocating for ROPS Rebate Programs in states not previously mentioned . These media reports tended to share general information about the nationwide burden of tractor overturns and the need for a ROPS Rebate Program; however, little information was provided about next steps in establishing such a Program. Only one of these media reports was a follow-up to another.The work carried out in this study provides evidence that media advocacy can be effective as a part of public health program implementation. In particular, honing in on correct and positive public health messages, the timing of media compared to that of the intervention, and the individuals involved in creating the media coverage (i.e. reporters and experts) were shown to influence the impact of media on implementation and sustainability of the ROPS Rebate Programs.Across the different Programs, there were commonalities in how the Programs were portrayed that are likely to have had a positive impact, overall, on implementation and sustainability. Overall, the public health messages were positive, highlighting the Program as an expression of gratitude for farmers, the benefit of the Program to farmers and communities, and farmers’ interest in the Program. It was incredibly rare to find media reports with negative portrayals of the ROPS Rebate Program. Though true, it is also important to examine why so few negative media reports existed. First, the ROPS Rebate Programs are intended to save lives, a goal that was met and proven from early on . As humaThough the media reports were mainly positive, some information about the Programs was presented inaccurately. This raises the issue of ensuring that public health messages are clear and that, to whatever extent possible, all individuals speaking with the press are presenting consistent and accurate messages. Such confusion could be problematic for public health programs .While the components of the public health messaging are important, in this study they were not sufficient for creating a meaningful impact on implementation and sustainment of the NRRP. Instead, it is important to examine the differences in media strategies (timing and spokespersons) used across the Programs. For the most part, media reports were published in response to ROPS Rebate Program launches; however, in Minnesota, media reports provided motivation for officials to launch a ROPS Rebate Program. Both of these strategies were beneficial; however, in Minnesota, the burden placed on Program staff and state champions to launch a ROPS Rebate Program was significantly reduced compared to that of other states. This can be important considering that limited project budgets and a wide array of competing priorities can limit the staff and champions’ ability to work on implementation efforts. In addition, in many cases funding is provided through government grants, meaning that that staff (including those working on the ROPS Rebate Programs) are not able to act as political advocates. Thus, media provides an alternative outlet for legislators and others to be educated about the benefits of public health programs.In addition to being helpful prior to implementation, media advocacy after implementation can help sustain public health programs by keeping the program at the forefront. In New York, where media has been used regularly to highlight the impact of the ROPS Rebate Program, funding has been sustained for 12 years. Those states where media ended shortly after implementation tended to be the ones with less successful ROPS Rebate Programs (i.e. fewer rebate dollars and retrofits). Similarly, few stories have been published in Minnesota since the implementation of the Program. While funding was secured for a second year in a row, the amount was reduced and spread across 2 years rather than one. It is possible that the decreased media related to this issue created the illusion that tractor overturn fatalities are no longer an issue, and thus the Program is no longer needed. Further monitoring of media and legislative decisions over the next legislative session will provide additional insight into these trends and their relationship.Given the importance of timing media related to public health programs, the question of generating enough interest to warrant media becomes problematic . In MinnThis was the experience with the National ROPS Rebate Program launch, which was marginally covered by the press. However, a well-placed media report in POLITICO highlighted the financial struggles that the Program faced. A prominent US Senator with an interest in the Program then spurred tremendous media report in response to these issues as he worked to sustain Program funding. Similarly, in New York, legislators have played a key role in generating media about the ROPS Rebate Programs through both press conferences and personally authored media reports. During legislative sessions, the support of these politicians has been crucial for securing or restoring funding for the Program. Such media emphasizes the importance of gaining and maintaining political allies. In addition, the Programs make these alliances visible to the public, including farmers, who can then hold stakeholders accountable .Though political support is extremely important for these Programs, the diversity of expertise  presented in media reports examined in this study is also important for bringing the issue to the attention of diverse readers with a variety of interests. By presenting these diverse viewpoints, the media likely helped to further increase knowledge of, and demand and support for the Program, thus further encouraging legislative action.In gaining traction, either at the policy level or within other groups, the source that media reports are published in can be of importance. Agricultural publications, which are directed primarily at the farm community, are useful in sharing information about the Program with the target population; however, these are less visible to policy makers and other supporters. Similarly, publications targeted at specific groups of stakeholders  can be useful in reaching individuals or organizations who wish to contribute to implementation. While these sources are important, the results of this study show the benefit of engaging policy makers in the discussion. The use of local, non-agricultural media sources , as well as more targeted media (e.g. POLITICO) can be useful in two ways. First, these sources have a greater potential to help capture the attention of policy makers . Second,Based on the results of this study, it is likely that the robustness of the media efforts surrounding the ROPS Rebate Programs can determine the trajectory of the Programs. In particular, media reports that feature a variety of expertise are present in states with strong financial support for the ROPS Rebate Programs. These varied expert views of the ROPS Rebate Program provide ample opportunity for the benefits of the Program to be highlighted in several ways, making it easier to appeal to supporters with varying agendas and views.Moving forward, robust media providing diverse perspectives on the many benefits of the ROPS Rebate Programs could be used as viable implementation strategies as additional states look to launch ROPS Rebate Programs. Ideally, local champions and reporters would work together to provide adequate coverage to begin a “domino effect” similar to what was seen in Minnesota. Once launched, these same collaborations can be used to further highlight the local impact of the Program and engage policy-makers and supporters in public discussions of the Program. By making both the implementation and sustainment of the Program public through use of media, the commitments made by various parties become part of an accountability plan which encourages these partners to continue their support, thus promoting the success of the Programs.This study has two main limitations. First, some relevant media reports may not have been captured at the time of publication or available online at the time of this study. Thus, it is possible that important sources of information were missed. Second, it was outside of the scope of this study to interview the journalists and Program supporters referenced in the media reports for their perspectives on publicly supporting the ROPS Rebate Program. The knowledge that could be generated from such discussions, particularly related to motivation for their involvement in media reports, would be helpful in understanding the relationship between media and the trajectory of the ROPS Rebate Programs. Such interviews could be the basis of a follow-up study.A strength of this study is the trustworthiness of the analysis. Both the first and second authors have been heavily involved in these Programs, and thus, are biased to certain aspects of the media. To reduce this bias and improve trustworthiness of the study, several individuals with different levels of involvement in the Programs were involved in the analysis. This included two authors who are heavily involved in Program administration, two who have primarily been involved in evaluation of the Program, and one external reviewer who had not been exposed to the ROPS Rebate Programs ahead of this study. Though there were no disagreements related to content between the authors’ analysis and that of the external reviewer, the two summaries placed different emphases on different aspects of the media reports. In the results, these viewpoints were combined to reduce any relevant biases.The use of media to implement and sustain the ROPS Rebate Programs has been documented across the different Programs. Those Programs which used more comprehensive media strategies also are those with more promising funding structures and thus greater overall success. Though it can be difficult to distinguish which came first – ample media or overall Program success - this suggests that media advocacy can be an important component of implementation strategies, not just in occupational safety settings, but in public health overall.Such strategies have the potential to not only influence relevant policy-makers, but also require accountability by program supporters who make their commitments public. By identifying appropriate media champions and utilizing media before, during, and after implementation, public health programs can expect to see benefits.


Open streets programs are free and multisectoral programs in which streets are temporally closed allowing access to walkers, runners, rollerbladers, and cyclists. The Move on Bikes program (by its name in Spanish Muévete en Bici) (MEB) consists of 55 km of interconnected streets in middle-high income areas of Mexico City. There is scarce evidence on the evaluation of this program in Mexico. The purposes of this study were to estimate the participation, physical activity levels among the MEB participants, and the association of the frequency of participation with sociodemographic, physical, and program characteristics. Methods: From October 2017 to July 2018, six hundred seventy-nine MEB participants were surveyed using a questionnaire that contains sociodemographic, physical, and program characteristics. A wide-angle video camera was used to estimate the average speed of each activity per event per participant. Based on the information collected by the program authorities and survey interviews, we estimated the number of participants per event. Results: On a typical MEB program day, 21,812 people participated. MEB program users accumulated an average of 221 min of moderate-to-vigorous physical activity (MVPA) per typical Sunday and 88.4% accumulated at least 150 min of MVPA. In total, 29.6% of users attended the program every Sunday. Those who were more likely to attend the program frequently included: men, those aged 41 to 64 years old, users classified as very and sufficiently active, those that used active transportation to travel to the program, and participants that came alone. Conclusions: This study provides evidence that the MEB program adds an extra 71 min/week of MVPA to more than 20,000 users. Chronic diseases are the leading cause of death worldwide . They arOpen street programs, such as the Ciclovia program , are a cSince 2007, the Ministry of Environment in partnership with 20 private and public organizations have implemented the Move on Bikes program (by its name in Spanish Muévete en Bici) (MEB) in Mexico City. The goal of the MEB is to reduce reliance on motorized vehicles while increasing physical activity levels. The MEB route consists of 55 km of interconnected streets in middle-high income areas, which are closed from 8:00 am to 2:00 pm on the first three Sundays of each month. Several free services are provided along the MEB route including first aid, hydration stations, washrooms, bicycle rentals, bicycle mechanics, and cycling classes . The rouThe Ministry of Environment has made crude estimates of the number of MEB participants and the influence that the program has had on the use of motorized vehicles and bicycles . HoweverData were collected from the start (8:00 am) to end (2:00 pm) of the MEB program each time it was offered  from October 2017 to July 2018.The program authorities arranged for the collection of information on the number of program participants at 16 observation points along the MEB route from the beginning (8:00 am) to the end (2:00 pm) of the program. The 16 observation points were spaced ~2.5 km apart. This spacing was selected to avoid over counting . The 16 observation points were as follows: Reforma Avenue at intersections with Julio Verne, Mariano Escobedo, Insurgentes, and Juárez (points 1 to 4); the Simón Bolivar traffic circle (point 5); Calzada de Guadalupe at intersections with Acero and Excelsior (points 6 to 7); Tlaxcoaque square (point 8); intersection of Durango and Veracruz (points 9); intersection of Mazatlan and Alfonso Reyes (point 10); intersections of Division del Norte with Viaducto, Cuauhtemoc, and Churubusco (points 11 to 13); intersection of Eje 7 Sur Zapata and Av. Universidad point 14); intersections of Patriotismo with Empresa and Puente de la Morena (points 15 to 16). Volunteers were located at each observation point. They manually counted cyclists/rollerbladers/skateboarders, runners, and walkers for 15 min each hour, from the beginning to the end of the program. The official number of participants was estimated by summing the total number of cyclists/rollerbladers/skateboarders, runners, and walkers from all observation points for each of the 15 min measurement periods multiplied by four [; interseN = ((100 / (% people that reach Reforma Avenue) × total number of participants counted in Reforma Avenue)N = total number of participants% People that reach Reforma Avenue = 76.3%, andTotal number of participants counted in Reforma Avenue per day (average from January to July 2018) = 16,643 participantsWhere:Between October 2017 and March 2018 trained research assistants approached 871 MEB participants, at random, and asked them to complete a questionnaire; 150 (17.2%) declined and 42 (4.8%) had incomplete data, leaving a final sample of 679. Interviewers were primarily placed on Reforma Avenue, the most used street along the route, at a point where MEB participants frequently slow down or stop. The questionnaire took approximately 10 min to complete and was done using pen-and-paper or Survey Monkey on a cellphone. The questionnaire was originally developed by the Ministry of Environment to gather sociodemographic information on program participants . For thi2 and converted into underweight (<18.5 kg/m2), normal weight (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2), and obese (≥30.0 kg/m2) categories [On the questionnaire participants reported their birthdate, last grade of school completed, zip code, marital status , weight, and height. Zip code was used to estimate the income of participants based on the National Institute of Statistics, Geography and Informatics database (by its acronym in Spanish: INEGI) ,16. Bodytegories .The participants’ habitual physical activity was determined using the Global Physical Activity Questionnaire (GPAQ). This questionnaire assessed the time and frequency of physical activity performed during leisure time, work, and active transportation  in a typical week. The GPAQ has been validated internationally  and adapAdditional questionnaire items  were used to measure the type of physical activity  and the typical duration spent in the program on the day the questionnaire was completed. The intensity was obtained by estimating the average speed of participants from data collected using a wide-angle camera. The camera was placed on a pole approximately 1.50 m off the ground in the middle of the street. The street contained a mark on the route with the number of meters to the camera. Fifty participants per activity were randomly selected. We estimated the time it took each participant to cycle, walk, rollerblade, and run from the mark on the route to the camera. Average speed was calculated by the following formula: speed = distance/time. The average speed was 13.8 km/h for cycling, 4.7 km/h for walking, 9 km/h for rollerblading, and 9.8 km/h for running. The activities were classified as moderate  or vigorous (running) based on the intensity for these travel speeds noted in the compendium of activities . Using tWe also asked questions to assess the frequency at which they participate in the program  and the Ciclotón program (similar program than the MEB but carried out the last Sunday of each month), twice per month, once per month, do not attend regularly, first time), their mode of travel to get to the program on the day the questionnaire was completed ), if they attended the program alone or were accompanied by another person on the day they completed the questionnaire , and the type of activities they normally do on the Sundays where they do not attend the program . To estimate the distance they travelled while participating in the program on the day the questionnaire was completed, participants were asked: “Where did you start your journey?”, “Where did you finish your journey?”, and “Which is the farthest point you reached during your journey?”. A route was drawn on Google MyMaps based on the connection of the three journey points (beginning–farthest–end point) and the total kilometers of each one of the journey points were added to obtain the total distance traveled.All participants provided their written informed consent prior to participating. The National Public Health Institute Ethics Review Board of Mexico approved the study (No. 1703).p < 0.05. Simple descriptive statistics  were used to make inferences. Kolmogorov–Smirnov test was used to examine normality. Variables that were not normally distributed were logarithmically transformed prior to subsequent analyses. Percentages and confidence intervals were used to describe the sample based on sociodemographic, physical, and program characteristics. Logarithmic transformed mean differences between MEB minutes per week according to sociodemographic, physical, and MEB characteristics were examined using independent Student’s t-test and ANOVA. The p value used to denote statistical significance was adjusted for multiple comparisons using Bonferrioni’s method. Univariate ordinal regression analysis was used to examine the association between frequency of participation and the characteristics of the users. Multivariate ordinal regression analysis was adjusted by sex, age, educational level, habitual physical activity, and body mass index. The model was tested for assumptions before further analysis.Statistical analyses were performed using SPSS software version 25 . The level of significance was set at We estimated that 21,812  people attended the program on the average MEB program day. Reforma Avenue, the most important and emblematic street in Mexico City, was used by more than 70% of participants at some point while participating in the program. The second most frequently used route section was Division del Norte, a route that connects the south and the north parts of Mexico City .Sociodemographic, physical, and physical activity characteristics of the 679 MEB participants who completed the questionnaire are in On average, participants accumulated 221 min of MVPA at the program on the days they participated. Information on what participants did when they attended the program is in p < 0.05), 41–64 year olds spent more time in the program than those aged 18–40 years (p < 0.05), and those with a Master’s degree or higher spent less time in the program than those with a high school or Bachelor’s degree (p < 0.001). Those who rode a bicycle reported spending significantly more time at the MEB program compared to those who performed other activities (p < 0.01). People that used active transportation to travel to the program spent more time at the MEB program compared to those who travelled to the program by car or public transportation . Finally, those that came alone and every Sunday reported a higher number of minutes in the MEB compared to those that came with someone and less frequent users (p < 0.05).As shown in The aims of this study were to estimate the number of people who participate in the MEB program, the physical activity levels of MEB program participants, and the associations between the frequency of MEB program participation with sociodemographic, physical and program characteristics. On a typical Sunday, 21,812 people participated in the program. MEB participants accumulated an average of 221 min of MVPA at the program. In total, 29.6% of the participants attend the MEB program every Sunday. Approximately 88.5% of the participants used a bicycle, 62.8% were single, and 34.2% came to the program alone. Men, those aged 41 to 64 years old, those classified as sufficiently active or very active, those that used active transportation to travel to the program, and those who came alone were more likely to attend the program frequently.On average, 21,812 participants attended the program on a typical Sunday. Estimated participation numbers in other Ciclovia programs held around the world range from 1000 to 1,000,000 people ,24,25,26Based on our results, MEB users spend on average 221 min on the 34-mile route (55 km) during the 6-hour duration of the program. Participants from other Ciclovia programs spent between 56 to 180 min in a 3 to 7 h event ,30,31,32In total, ~55% of the MEB users reported that they would have been engaged in sedentary or light activities if they were not at the MEB program. This means that 47% of people who meet the weekly physical activity recommendations at the event would be classified as physically inactive if they did not attend the program. A high proportion of users in other Ciclovia programs, such as those in Atlanta (38%) , Saint LWe found that men, middle to older aged adults, those that cycle, those that used active transportation to travel to the program, those that came alone, and those that attended every Sunday reported spending significantly higher minutes at the program compared to their counterparts. In addition, participants classified as very and sufficiently active regularly and during the program, were more likely to participate more frequently. These results are similar to those reported by other studies ,24,28,33Despite the fact that the MEB program offers strategies to encourage participation amongst people from diverse income areas, such as free public transportation and bicycle rentals, the majority of participants came from middle-to-high income areas. Moreover, people from these areas spent more time at the program upon arrival. Thus, strategies to encourage greater participation amongst people from more disadvantaged areas are needed.Strengths of this study included the collection of sociodemographic and physical characteristics of MEB participants. In addition, our study included a wide age range . Finally, the sample size was large enough to observe differences between groups. One of the main limitations is that our sample was recruited by convenience and the results may not be representative of all attendees. In addition, MEB participants that agreed to answer the questionnaire could be more aware of their health and physical activity levels than those who chose not to participate. The percentage of women who completed the survey was 51.3%, which is considerably lower than the 70% proportion who participate in the program. Moreover, instantaneous speed, collected by the video cameras, may not represent the average speed of participants per event. The formula we used to correct the official number of participants may not estimate the exact number of users because we assumed that all participants who reported reaching Reforma Avenue were counted at that observation point.More than 20,000 people participate in the MEB program on a typical Sunday. The time spent in physical activity while participating in the MEB program contributes toward 40% of the minimum weekly physical activity target recommended by the WHO. The most frequent program users were more likely to be physically active and use a bicycle to participate in the program.


The present study aimed to investigate the effects of a stepwise, bottom-up participatory program with a tailor-made intervention process addressing the level of mental retirement in a sample of Dutch employees. Mental retirement refers to feelings of being disconnected from your work and your organization. Prevention of mental retirement is important since sustainable employability is becoming more important in today’s society due to the ageing of the working population and the changes in skills demands.This prospective cohort study with a one-year follow-up employs a sample of 683 employees of three organizations in The Netherlands, who filled out two questionnaires: at baseline and 1 year later. The dependent measure was mental retirement, which consists of three sub-concepts: developmental pro-activity, work engagement and perceived appreciation.N = 466) showed that employees who more actively participated in the intervention(s) had a small but statistically significant larger decrease in mental retirement at follow-up.Multilevel analysis . Sustainable employability – referring to employees’ capacities to function in work throughout their working life – has become an important issue in the last decades , 2. Two mental retirement can play an important role in the maintenance of these abilities [These two developments lead to an increasing pressure for maintenance of physical, mental and cognitive abilities of the labor force to ensure that employees remain employable, stay healthy, motivated, competent and productive at least until the age or retirement , 2. The bilities . EmployePrevious studies show that mental retirement consists of three factors: developmental pro-activity, work engagement and perceived appreciation , 9. An iIn the literature the concept of mental retirement has been mentioned before e.g. , 17. HowIn contrast to the concept of older worker identity and the definitions mentioned earlier on mental retirement, mental retirement is not necessarily connected to age since a previous study showed no differences in the level of mental retirement in different age groups . AlthougAlthough mental retirement is a fairly new concept and more research is needed to study the predictors and effects of mental retirement, there are indications that it might have negative consequences for employees , and therefore also for the organization  and society in general  , 28, 29.Research has shown there are several features that are important in order for organizational programs or interventions to be effective. First, a tailor-made approach is necessary. Tailoring improves the utilization of the results, helps to choose the interventions that meet the specific needs of the team or organization and make effective action plans –32. HoweNext to the features of an organizational program the research design is also very important, especially in applied research. Although a randomized controlled trial (RCT) is often considered as the golden standard, this is not always feasible. Particularly in applied occupational health research, the interventions and the context are often complex and therefore hard to control –41. Thermindmapping sessions. Two sessions are held with 10–20 participants each. These sessions are each led by two facilitators. At least one of the facilitators is a researcher, the other can also be a researcher or an employee of the organization that is trained in the mental retirement program. The sessions have two goals. First, these sessions create awareness of mental retirement within the team and gain acceptance for the program and the possible changes it may bring. Secondly, the information gained during the sessions is used to tailor the model of mental retirement with organization-specific concepts and to adjust the basic questionnaire accordingly. In the mindmapping sessions the employees and supervisors discuss what they believe mental retirement is and what the predictors and effects are of mental retirement. To not only create awareness but to also set people in motion, the participants contemplate on possible actions for themselves, their supervisor and the organization to decrease mental retirement. The employees who participate in the mindmapping sessions are contacted by management or the HR-professional of the department who invite them to participate. Participation is voluntary. The employees that are approached are selected so that they represent the entire department with regard to age, sex, function, time employed and level of mental retirement . Furthermore, in this stage a project group of approximately six people is created, which consists of several employees of the team, a HR-professional and sometimes the supervisor or manager. The team itself decides who will join this project group and participation is voluntary. The project group is the first point of contact for the researchers as well as for all the employees in the department.To address the issue of mental retirement, a bottom-up program was designed based on the principles of a participatory, stepwise, tailor-made approach. The program consists of five steps see Fig. . The prodiagnostic phase, the basic model of mental retirement is tailored to the team with the input of the mindmapping sessions. Where necessary questions are added to the basic questionnaire. This questionnaire is available in an online portal for all the team members to fill out.In the chooses the interventions that they want to implement in order to decrease mental retirement in their team. Each team chooses their own intervention(s), so these may differ between teams. The interventions are selected based on the results of the baseline questionnaire as well as their fit with the team in terms of process and culture. First a pre-selection is made by the project group in one session. Next, the team results of the baseline questionnaire and the pre-selection of interventions are presented in two interactive sessions. In these sessions the team members formulate an action plan for the implementation of the interventions they agree with. When necessary, they select or design new interventions. The participants in these sessions are the same as those who participated in the mindmapping sessions. The results of the questionnaire and the action plan are distributed across the rest of the team in a way the project group sees fit.In a tailor-made intervention process, step 3, the team implement the interventions. The selected interventions do not necessarily start all at once, but are spread out through time. There needs to be enough time for carrying out the action plan and for the interventions to take place and have effect. Therefore, the duration of this implementation step takes approximately six to nine months.In the next step, the organization is in charge and the role of the researchers is marginalized. The team starts to evaluated. In consultation with the project group and based on the implementation process of the interventions, the timing of the follow-up questionnaire is determined. Approximately one year after the start of the intervention (step 1), an online follow-up questionnaire is made available in the portal to evaluate the effects of the program. The questionnaire is largely the same as the baseline questionnaire, but also includes questions regarding the interventions that were implemented.In the fifth and final step, the program is Hypothesis 1: the level of mental retirement will decrease between baseline and follow-up, due to the mental retirement program as a whole and independent of the specific interventions that are implemented in step 4.Hypothesis 2: the improvement in mental retirement will be stronger for employees who actively participated in the interventions than for those who participated to a lesser degree.The current study aims to explore the effects of this mental retirement program in a broad population of employees within several organizations. The effect of the program as a whole is examined, rather than the effects of the specific interventions that are implemented in step 4 of the program. As each team or department chooses their own interventions, the range of interventions is very wide which makes it difficult to examine the effects of each intervention separately. In addition, we believe that the effect of our program is due to the program as a whole  and not so much to the specific interventions of step 4.N = 175; N = 185; N = 175, respectively). The other two organizations were an archive department of the Dutch government (N = 291) and one location of a non-profit organization that implements national insurance schemes in the Netherlands (N = 209). The reasons for participating in this study differed across organizations and teams, but included issues such as minimizing the effects of a reorganization, creating more awareness among employees regarding their own development, getting employees out of ‘sleep mode’ to prevent them from getting stuck in their career.The research population of this study consisted of a sample of employees of five departments of three different organizations in the Netherlands. Three departments of the Dutch National Police participated: two departments of police officers and one facility department (N = 1035) in step 2 (baseline measurement) and step 5 . The baseline questionnaires were sent between March 2014 and October 2015 (depending on when the organization started with the program). The follow-up questionnaire was sent out approximately one year after the baseline questionnaire.Online questionnaires were sent to every employee of all departments  from the Utrecht Work Engagement Scale (UWES) [perceived appreciation, is measured with one question: “Do you feel appreciated in your current job?”. The response categories ranged from 1  to 4 (“very much”). The scale scores of the three mental retirement sub-concepts were standardized (into scores between 0 and 1) because their response categories differed. A mean score was calculated over these three sub-concepts, which created a variable that measured mental retirement in one variable .Mental retirement was measured with three concepts . Firstlyur items . An exame (UWES) , includiintervention exposure were included. Respondents were asked if they were familiar with each intervention  and if so, to what extent they had participated in the specific intervention(s) which were chosen and implemented at their workplace . For each respondent the intervention exposure was calculated: a sum score was made of the number of interventions in which they had participated (very) much, divided by the maximum number of interventions they could participate in.In the follow-up questionnaire measures of Missing values were imputed using multiple imputation procedures in the SPSS “Missing Values” module, based on an iterative Markov chain Monte Carlo (MCMC) method. Overall data missingness was 31.5%, mainly due to dropout at follow-up and not filling out the questionnaires completely. It has been shown that multiple imputation-based procedures are superior to case-wise deletion of missing data . In our Multilevel modelling (MLM)  was usedBesides the quantitative results, also qualitative results are reported. The researchers monitored the context and setting of each department and kept track in a digital logbook. In the logbook, the sequence of planned and unplanned events was listed alongside impressions of the researchers. These impressions were based on their own observations during the sessions. At the end of each session the researchers shortly evaluated the sessions by asking the opinion of the participants. In addition, the impressions of the researchers are based on their periodical contacts with the project group. In these contacts, the project group informed the researchers on their observations as well as the progress made. Furthermore, the researchers logged all changes that occurred in the context or setting of the organizations. The logbook was kept up to date throughout the duration of the study. The logbook data were grouped per department to form a chronological list of events, including the impressions of the researchers. The qualitative results will be discussed in accordance with the five steps of the program.In total 683 (66.0%) employees filled out (part of) the baseline questionnaire and just over 400 (39.5%) participants filled out (part of) both questionnaires . Another obstacle in this phase was the timing of the questionnaire. Sometimes the questionnaire had to be sent out during the same time as the employee engagement survey or a survey for a different study. This had possible negative effects on the response-rate. However, the timing of the questionnaire was always in coordination with the project group.The way participants received the results of questionnaires during the choose the interventions that would be implemented and made an action plan for this implementation, the participants again valued the possibility to give their opinion and the influence they had on the implementation-plan. The participants were perfectly able to make up their mind about the suggested interventions, to tailor those interventions for their own team or organization and to make an action plan. However, it was difficult for them to come up with new interventions themselves based on the results of the questionnaire and their own needs. Examples of interventions that were implemented in the teams are making employees themselves responsible for the distribution of work; allowing every employee to spend two hours per week on keeping their knowledge up-to-date; “secret service” ; and various training programs, including a training in ‘appreciative dialog’ (which is based on the appreciative inquiry aiming at enforcing the positive instead of battling the negative); a training in providing feedback; a training on the job ; and a training in job crafting.In the interactive sessions where the participants intervention implementation phase, the teams struggled to effectively implement the interventions that were chosen and to keep the team members involved in the program. Nevertheless, the program still continued and in all teams interventions were implemented. However, in some cases these were different interventions than initially planned, due to evolving circumstances and insights gained. One of the teams installed a project manager whose fulltime job it was to implement the action plan and the interventions. This helped to keep the focus on the program and to carry out the action plan.In the evaluation and sending out the second questionnaire was difficult. The response rate was lower  was prevented.The present study investigated the effect of a stepwise, bottom-up participatory program to decrease the level of mental retirement of employees in three different organizations. This study showed no difference in mental retirement between baseline and follow-up one year later. However, multilevel analysis also showed that employees who actively participated in the intervention(s) that were implemented during step 4 of the program did show a decrease in mental retirement and its sub-concepts. By incorporating the measurement of intervention exposure, a type-III error . The positive effects of the use of participatory designs have been well established in other studies , 33–35. Even though the present study shows small but good effects of the mental retirement program, there are some improvements imaginable. First of all, in the current study the setting and context of the organizations changed throughout the study. Although the researchers kept a log book to document these changes, it is difficult to pinpoint if and how these changes affected the results. In addition, the response-rate on baseline and follow-up was reasonable, but the number of employees that filled out (part of) both questionnaires was low in some departments. Furthermore, in the intervention implementation phase, the organization is in the lead and has complete autonomy and the role of the researchers is marginalized. During this study it appeared that this might be too big a change compared with the first three steps of the program. The teams struggled to keep the program ‘alive’, to preserve the commitment of the team members and to implement changes when there were no researchers to keep them on track. Earlier research has also shown this struggle , 49. OneTo our knowledge, the present study is the first that examines the effects of a program for diminishing mental retirement. Such a program may become more important because of the increasing interest in sustainable employability due to the rapid changes in skills demands and the labor market and the fast aging of the workforce. Therefore, there is a necessity for more attention and awareness for concepts like mental retirement. Another strength of this study is that this study shows that more generic principles like a participatory, stepwise and tailor-made approach, appear to be more important than the specific interventions that are implemented within an organization. Future research should focus more on these generic principles and study how and in what circumstances this leads to success.However, when interpreting the findings of this study some limitations should be kept in mind. First, although an intervention exposure measure was used in this study a control group is missing. Even employees who reported that they had not actively participated in the intervention(s), are exposed to the program. All the members of a department were informed about the mindmapping sessions, the results of the baseline questionnaire and the interactive sessions where plans of actions were made for the intervention(s). In addition, only employees that reported to participate (very) much in an intervention were classified as exposed to an intervention. Employees that reported to participate only a little in an intervention were classified as non-exposure. So, in the present study it wasn’t possible to select a control group that wasn’t exposed to the mental retirement program. Second, in this applied research study the contextual setting changed continuously, for example by the restructuring in one organization. It is possible that confounding biased and influenced the data . To get The present study aimed to gain insight in the effect of a bottom-up participatory program to decrease the level of mental retirement of Dutch employees. This study showed that the participatory program had positive effects: it tends to decrease the level of mental retirement for employees who actively participated in the intervention(s) that were implemented during step 4 of the program. Important aspects of the mental retirement program are a bottom-up participatory approach and a stepwise, tailor-made intervention process. However, the phase of implementing the interventions could be further improved since this process proved to be very challenging and commitment to the program was diminished during this phase. Although the present study showed small effects and had some limitations in design, future research could study the effectiveness of this program further to strengthen the concept of mental retirement. Future research should not only study the concept itself but also its predictors and make use of an improved design with for instance a control group, multiple follow-ups and several data sources.


Integrated agricultural-nutrition programs are often implemented under the premise that program effects are durable and spillover. This paper estimates one year post-program effects, three-year aggregate program effects and spillover effects using treated and untreated household cohorts. Two treatment interventions implemented agricultural interventions with behavior change communication strategies varying implementers using either village health committees or older female leaders. In the post-program period, program effects deteriorated relative to program period impacts documented in  ProgramTo estimate spillovers of agricultural production techniques, health knowledge, and children’s nutritional status, we build on a cluster-randomized control trial conducted in partnership with Helen Keller International (HKI) in Burkina Faso. From 2010–2012, HKI implemented an Enhanced Homestead Food Production (EHFP) program in Burkina Faso with the specific objectives of improving women’s agricultural production of nutrient-rich foods and children’s nutritional status.The EHFP program was successful in improving women’s agricultural production during the program implementation period, specifically women’s production of vitamin A-rich foods. No additional agricultural treatment effects on treated households or non-treated households were found after the program implementation period. Women’s use of manure and fertilizer decreased in the post-program period, though manure use and number of plots cultivated by women were still statistically significantly higher over the three-year period of the study in treatment as compared to control villages. Increases in women’s production of vitamin A-rich crops found during the program implementation, however, were not sustained in the post-program period. These results suggest that program extension advice, monitoring and input provision were critical to the small production gains found during the program implementation period. No spillover effects on new cohort households were found in terms of utilization of inputs or production outcomes.We also found positive program effects on mothers’ knowledge of optimal IYCF and hygiene and healthcare practices as compared to non-treated mothers. The analysis of the post-program period impacts suggests that mothers’ health and nutrition knowledge deteriorated after the end of the program, though knowledge gains were statistically significantly higher among treated as compared to non-treated mothers for the over the three-year period of the study. Spillovers on health care practice knowledge and exclusive breastfeeding practices for children less than six months of age were estimated between treatment village cohorts. We estimate a 23 percentage point increase in later OWL treatment village cohorts on exclusive breastfeeding of children less than 6 months old. In the HC and OWL later treatment cohorts, there was a 10–11 percentage point decrease in treating diarrhea with traditional medicine and in the HC treatment cohorts, a corresponding 10 percentage point increase in giving rehydration salts for diarrhea treatment.With respect to children’s nutritional outcomes, the primary findings during the program implementation period were that the EHFP program improved hemoglobin concentration and decreased the prevalence of anemia, wasting and diarrhea among children living in HC villages relative to those living in control villages . In the Because there are multiple hypotheses for agricultural, knowledge, practices, or nutritional set of measures, we correct all estimates using multiple hypothesis testing following In the next section of the paper, we present the experimental design, while the third section details the post-program and spillover effects identification strategy. The fourth section presents the results, while the last section concludes.22.1HKI’s EHFP program implemented in the province of Gourma in Burkina Faso consisted of an agricultural production component and a nutrition and health BCC strategy. The agricultural production activities included input distribution  and agricultural training provided by female village farm leaders at village model farms. Program beneficiaries started their own homestead food production activities after the receipt of inputs and training. Production activities primarily included the promotion of micronutrient-rich fruits and vegetables, eggs and poultry production. The BCC strategy was designed using the essential nutrition actions framework that focuses on seven practices: women’s nutrition, anemia prevention and control , iodine intake, prevention of vitamin A deficiency, breastfeeding practices, complementary feeding practices, and nutritional care for sick and severely malnourished children . Benefic2.2The EHFP program was evaluated using a cluster-randomized controlled trialWithin the selected villages (n = 55) all women with children 3–12 months of age were invited to participate in the study.In 2012, during the endline study, an additional cohort of younger children 3 to 12 months of age was sampled in treatment and control villages from both treated households, who participated in the EHFP program or impact evaluation, and from a new cohort of non-treated households in both treatment and control villages. A post-treatment follow-up survey was administered between March and June 2013 to track this younger cohort of non-treated children, and their households, in addition to the original treated households, mothers and children interviewed in treatment and control villages at baseline and endline.Thus, we have a cohort of treated households, mothers and children 3–12 months of age at baseline interviewed at baseline in 2010, endline in 2012 and follow-up in 2013. In addition, we have a cohort of younger non-treated children 3–12 months of age at endline born into the treated and non-treated households in treatment and control villages. This younger cohort and their households were surveyed in 2012 and again in 2013. Half of these younger cohort children are siblings with the same mother, and the remaining are siblings with a different mother (co-wife) and cousins due to the frequency of polygamous household structures. All age eligible children were interviewed in both the original and follow-up cohorts.3Three treatment effects are specified to measure different types of program effects after the program implementation period (2010–2012): a post-program effect (2012–2013), a three-year effect of the program (2010–2013) and spillover effects to non-beneficiary households. The specifications are estimated with the following regressions for the 2010 cohort restricting the sample to treated households in OWL and HC villages and control households from the 2010 cohort:Program implementation effect:Post-program effect:Three-year effect:The identification of spillover effects in our study builds on the recent literature ) which uTo estimate potential program spillovers the following specifications are estimated for the 2012 cohort which includes non-beneficiary households with children 3–12 months of age at the time of the endline survey in 2012 in treatment and control villages. This is a post-program spillover effect on the subsequent cohort of households with children who would have been targeted by the intervention had they been born earlier.As an alternative spillover measure we also estimate the within village cohort spillover effect:Hcohort= A strength of the above econometric strategy is the direct testing of production, knowledge, practice and nutrition outcomes which the program was designed to impact. One statistical concern is that because there are multiple primary and secondary effects of an integrated agriculture-nutrition intervention, our results could over report false positive effects without corrections for multiple hypothesis testing. To address this concern, we first present all treatment effect results. We follow t-test of the difference in mean attrition at the 1% level of statistical significance. Female headed households, households with male household members and fewer children were more likely to attrit from the household panel, but predictors such as education, durable asset values, land size or baseline production were not significant determinants of the attrition rate. We address differences in attrition between the treatment and control groups by first analyzing whether these differences leads to observable characteristic differences in balancing tests of the sample at baseline in Table A1 in Supplementary material. We also estimate attrition weightsAttrition between the panel cohorts are also a potential source of bias to treatment effect estimation. We analyzed this potential source of bias in 44.1To test whether the sample has statistical balance in observable characteristics between the treatment and control groups, balancing tests on household- and child-level characteristics are estimated for the 2010 and 2012 cohorts in Tables A1 and A2 in Supplementary material, respectively. We report household characteristics by treatment group, HC or OWL, and control, as well as the p-value of the test of mean equality between the three groups for the non-attrited sample. Household characteristics such as household size, value of men’s and women’s assets, and household head’s and mother’s educational status were all balanced across the three groups at initial randomization in 2010. One housing characteristic, having a dirt floor, was not balanced between the treatment and the control groups, with higher prevalence of dirt flooring in HC and OWL villages, indicating a lower level of housing quality. Children’s characteristics, including the gender and age, were balanced at baseline, though children’s nutritional indicators were not. Household attrition does not seem to be a significant source of observable characteristic imbalance, though there are differences in attrition rates between the treatment and control groups.In Table A2 in Supplementary material, we test the mean equality of the same household and child characteristics at selection for the 2012 cohortWe test for balance between the old and new cohorts and report those results in the Table A3 in Supplementary material. Due to variation in agricultural production and disease environment between years, it is not necessarily expected that cohort characteristics will be balanced between years. The balancing tests demonstrate that household and child nutritional indicators are not balanced between the cohorts while characteristics such as child age, child gender, household size and women’s assets are balanced between cohorts. Differences between cohorts motivate the inclusion of time fixed effects in the between cohort spillover specification described above.4.2HKI’s EHFP program in Burkina Faso was designed to improve household agricultural production of nutrient-rich foods and the nutritional status of the targeted children who were 3–12 months of age at the time of the baseline study through an integrated set of production and nutrition interventions. We estimate treatment effects of the program on the primary outcomes – household agricultural production of nutrient-rich foods, women’s health and nutrition-related knowledge, IYCF practices, and children’s nutritional status including anemia and anthropometric measures.As expected, HKI’s EHFP program was successful in increasing women’s agricultural production during the program implementation period, particularly women’s production of vitamin A-rich foods . Although there was no overall impact on household or on men’s production, impacts on women’s agricultural production were fairly consistent, albeit small, across the different types of crops. These results are consistent with other studies that have shown small impacts of small-scale agriculture interventions on household food production .In the post-program period, women’s use of manure and fertilizer decreased in the post-implementation period, though manure use and the number of plots cultivated by women were still statistically higher over the three-year period of the study. Increases in women’s production of vitamin A-rich foods found during the program implementation period were not sustained in the post-implementation period -Panel A.In terms of health and nutrition-related outcomes, we found a significant impact of the EHFP program on improving mothers’ health and nutrition-related knowledge in both treatment groups compared to the control group during the program implementation period . Treatment effects for the post-implementation period suggests that mothers’ knowledge deteriorated after the program implementation, though overall knowledge gains were significant and substantial for the three-year period -Panel B.Following on the improvements in mothers’ knowledge, our analysis of birth cohorts at endline indicated that mothers living in OWL villages were more likely to have exclusively breastfed children less than 6 months old as compared to mothers living in control villages - Panel AIn any integrated agriculture and nutrition intervention targeted to children, the primary outcomes of interest are children’s nutritional status indicators. The primary findings during the program implementation period indicated improved hemoglobin concentration, and reductions in the prevalence of anemia and, wasting among children living in HC villages relative to those living in control villages . In the post-implementation period, no further increases in hemoglobin concentrations were measured or reductions in the prevalence of anemia or severe anemia -Panel A.In To measure spillovers within households, the effect of the intervention on younger siblings within treated households is estimated in No other spillover effects were measured for the new cohort of children with respect to their nutritional status estimating the spillover using a between village specification -Panel D.4.3As we estimate different treatment effects over varying time periods and multiple spillover effects, The overall program effects are robust to multiple hypothesis testing . The sustained impacts on anemia and hand washing were not robust to multiple hypothesis testing, while the results on women’s agricultural land holdings, inputs, breastfeeding knowledge, and nutrient rich food knowledge were robust to multiple hypothesis testing.Three out of the seven post-program effects are statistically significant after multiple hypothesis corrections. The results which were not robust to multiple hypothesis testing were the results on mother’s knowledge of vitamin A rich foods (dark leafy vegetables and eggs) and treating diarrhea using traditional medicine. Results on agricultural inputs and breastfeeding knowledge were robust to multiple hypothesis testing among the post-program effects.Five out of the eight statistically significant spillover effects estimated are also robust to multiple hypothesis correction. The results that were not robust to multiple hypothesis testing included the within and between cohort results on breastfeeding and the anomalous result on increased anemia prevalence among younger siblings. The spillover effects on the treatment of diarrhea, anemia and wasting remained robust to multiple hypothesis testing.5This paper demonstrates the importance of post-program effects in evaluating the impact of an integrated agriculture and nutrition program where disadoption dynamics, knowledge deterioration or spillovers may affect overall program impact assessment. Despite deterioration of some of the program implementation period effects and limited production and knowledge spillover effects, we found a significant impact of an agriculture and nutrition program on improving children’s hemoglobin concentration during the program period and sustained impacts one-year after the program ended. We also demonstrate a potential protective effect of the program on younger children born into beneficiary households during the program period on preventing wasting during the first two years of life. While no impacts across treatment cohorts were estimated on children’s anthropometric outcomes, within HC villages, younger children were statistically less likely to be severely anemic.Production or nutrition BCC mechanisms provided some explanation for these sustained and spillover effects. We found small effects from increased agricultural production over the program implementation period and limited spillovers to non-treated women from production interventions in the post-program implementation period. Knowledge related to some optimal health and nutrition practices deteriorated during the post-implementation period, though it remained significantly higher than knowledge among mothers in control villages over the three-year study period. Overall, program spillovers are limited with respect to health and nutrition-related knowledge, except for an important decline in the belief that traditional medicine should be used to treat children’s diarrhea. Finally, we found a statistically significant child feeding spillover effect on exclusively breastfeeding children under 6 months of age, though this result is not robust to multiple hypothesis testing corrections.Despite significant positive effects during the program implementation period on hemoglobin concentrations, several factors may explain the lack of impact on other nutritional outcomes with respect to the between village spillovers. First, agricultural production impacts one year after program implementation were not detected in our sample. Given these disadoption dynamics, availability of nutrient-rich foods did not significantly change for beneficiary households or non-beneficiary households in treatment villages. Without program support, the agricultural component implemented over the two-year project was not able to sufficiently resolve the production constraints including access to water during the dry season, faced by rural Burkinabe producers. Second, agricultural production requires labor that women with young children may not have been able to sustain after the initial program period. Without program monitoring, the incentives to provide labor may have decreased, resulting in lower production.With respect to the role of nutrition education in sustaining program impacts or promoting spillovers, the impact estimates clearly show that the modality of providing nutrition education either through health committees or drawing on the experience of older women leaders was critical to sustaining impacts and spillovers within beneficiary households and across cohorts. In