Healthy Living for People with type 2 Diabetes (HeLP-Diabetes): Starting Out (HDSO), as an alternative to face-to-face courses. A Web-based program gives people more options for accessing structured education and may help improve overall uptake.Structured education for people with type 2 diabetes improves outcomes, but uptake is low globally. In the United Kingdom in 2016, only 8.3% of people who were referred to education programs attended the program. We have developed a Web-based structured education program named HeLP-Diabetes: Starting Out) in routine primary health care and its potential impact on self-efficacy and diabetes-related distress.The aim was to explore the feasibility and acceptability of delivering a Web-based structured education program  and diabetes-related distress . Interview data suggested that the course was acceptable, and that uptake and completion may be related to nonprioritization of structured education.It was feasible to deliver the program, but completion rates were low: of 791 people with type 2 diabetes registered, only 74 (9.0%) completed it. Completers improved their self-efficacy (change in median score 2.5, The study provides evidence of the feasibility and acceptability of a Web-based structured education. However, uptake and completion rates were low, limiting potential population impact. Further research is needed to improve completion rates, and to determine the relative effectiveness of Web-based versus face-to-face education. Diabetes self-management education (DSME) aims to help people develop the knowledge and skills to manage their physical and emotional health . There iThe National Diabetes Audit data in the United Kingdom indicates that only 8.3% of people who were referred to structured education attended in 2016 . EstabliHealthy Living for People with type 2 Diabetes (HeLP-Diabetes): Starting Out (HDSO). The content and aims of the HDSO program were based on an earlier intervention named HeLP-Diabetes. The key difference between HeLP-Diabetes and HDSO was that HDSO was aimed at people who were newly diagnosed, and so it followed a structured written curriculum with specific aims and objectives, as recommended by the National Institute for Health and Care Excellence , it’s all there in one day, like packed into a day. And... I mean, yes, they... you go away with nice little booklets and that, but I don't... I swear to God; I haven’t really even looked at it. Whereas this, it’s, sort of, like, telling you that you can make tiny little changes.Participant 1, 61-year-old female completer, duration of illness 1-5 yearsPeople with T2DM described enjoying the variety of formats in which the information was presented, including text, graphics, and videos. In particular, people with a preference for learning using visual information appreciated the videos accompanying the text:The videos explain things... some things really, really well. I think everybody is different, aren’t they? Some people work well with visual stuff, and other people work well with written stuff. I’d always think if you read and look, you know, it gets into the brain. You know, I think those things were really, really good.Participant 8, 60-year-old female completer, duration of illness less than 1 yearSome people with T2DM found the support provided by the program with managing the emotional side of the illness useful, particularly watching the videos of others talking about living with the illness. This emphasizes the need for structured education programs to acknowledge the emotional challenges of diabetes self-management and the need to include emotional support in courses:I thought it concentrated a lot about your emotional side. And listening to some of the other people, and I thought, oh, it’s not just me who was annoyed. I know a lot of people got upset, and, I mean, I didn’t get upset, I was just annoyed. And so I felt that there were similar experiences, you know, other people probably, it’s not just me who was feeling that way. The other people reacted probably similar when they found out that they were diabetic.Participant 1, 61-year-old female completer, duration of illness 1-2 yearsThe HCPs who were interviewed had a number of suggestions for improving the uptake of the HDSO program. These included supporting professionals to improve the discussion at the time of referral by encouraging them to familiarize themselves with the program before discussion with people with T2DM (collective action and reflexive monitoring); and delegating some of the workload by allowing health care assistants or administrative assistants to refer people to the program (collective action). Other suggestions were made by people with T2DM about changes to the program to provide more personalized information, and making the program available to access on smartphones.As discussed above, all the HCPs expressed that there is not enough time in a clinical consultation to discuss and demonstrate the program to people with T2DM at the time of referral. Suggestions were therefore made about supporting HCPs with referral, including allowing health care assistants and administrative staff to refer people to the program before or after their clinical consultation with a doctor or nurse, when there is more time for discussion:Ideally, if there were a health care assistant or an admin person who could catch the patient separately either before or after the appointment to show them the website and sign them up, I think that would work really well.Participant 16, Diabetes Specialist NurseSome people with T2DM expressed the need for more personalized information, particularly specific diet information on what they should and should not be eating. People mentioned that they would like to be able to use the program on their mobile phones, for convenience, and that they were unable to do so with the current format:I, sort of, get on it and go through it, because I'm in that mood. Then go through two of the modules, let’s say, from part four. I’ve done part four and part five today. But when I wanted to [unclear] on my mobile phone, when I was [unclear], I thought: right, no I’ll sit down on the phone, you know. I jumped on my phone to do the modules. I found it, kind of, difficult. I find I had to restart the modules on my mobile phone. It wasn’t... it wasn’t, sort of... it didn’t jump out at me and I found it quite frustrating.Participant 7, 47-year-old male completer, duration of illness <1 yearThis study found that it is feasible to deliver Web-based structured education in the NHS; a wide demographic can use it; and it may improve self-efficacy and diabetes-related distress. The quantitative data showed that there were problems with uptake and completion, with completion positively associated with duration of diabetes <1 year, and self-report of having been offered and/or attended structured education previously. The qualitative data helped us to explore the low uptake more fully. Findings from interviews with people with T2DM and health professionals suggested that professional factors, personal factors for people with T2DM, and program factors affected program acceptability and attrition. More research is needed on improving uptake and determining the relative effectiveness and cost-effectiveness of Web-based and group-based structured education.real-world experience of implementation and delivery of the service within routine primary health care. Other strengths include the use of a mixed method, with quantitative data on uptake, usage, and outcomes, and qualitative data to explore the underlying reasons for these observed data, and the use of theory (NPT) in the data analysis. Using NPT allowed us to make a theoretically informed interpretation of the qualitative data in regard to implementation. The design was appropriate for the study objectives, namely, to determine acceptability, feasibility, and apparent impact of the program. Acceptability and feasibility related not only to patients but also to health professional factors, which NPT allowed to explore more deeply.The strengths of this study include the strong external validity, with our data drawn from real-world data, so that people with T2DM used the program as part of their routine NHS care, and not as part of a research study. Hence, we could not obtain formal informed consent, except from those who participated in interviews, and as such, it would not have been ethical to have access to clinical data. A further limitation was our inability to invite people who were offered the program but did not register to use it to take part in interviews because of the ethical limitations. Interviewing these people would have helped us to understand why some people do not want to use Web-based structured education.It is important to state clearly that this design cannot be used to determine effectiveness of the intervention, nor can any causal links be inferred. Determining effectiveness and ascribing a causal impact of an intervention requires an RCT design, with an appropriate comparator, and a sample size calculation. In light of the multiple tests undertaken, it is possible that the observed associations between likelihood of completion and duration of diabetes, and self-reported offer or attendance at structured education are because of chance. A specific weakness of our study was the lack of clinical outcome data and our reliance on proximal outcomes collected through self-reported outcome measures. This was a direct result of our emphasis on external validity and The percentage of completers was low (9.4%) but compares favorably with attendance at face-to-face education 8.3%)  and adhe.3%  and P=.04). The rationale for including people with any duration of diabetes was that the literature suggests that many people only become ready for structured education after having come to terms with the diagnosis [The study included people with any duration of diabetes, but one of the factors associated with completion was duration of diabetes of less than a year  and having attended face-to-face education (P=.002) also seemed to be associated with completion. The association between likelihood of completion and having been previously offered, or attended, structured education has not been reported previously in the literature. This association could reflect intrinsic characteristics, whereby people with more interest in and commitment to structured education are more likely to remember the offer and attend whatever education they are offered, or could reflect an effect of structured education, in that it makes people aware of how much there is to learn, and hence promotes engagement with subsequent offers. Further research is needed on whether people are more likely to take up structured education if they are offered it more than once, or whether more incentives are needed to increase intrinsic motivation and interest and commitment to complete a course.Having been offered face-to-face education (If Web-based structured education can be found to be effective and cost-effective and have acceptable reach, this could give people with T2DM more options for learning about self-management and help improve structured education uptake.


We investigate the impacts of a widely used sanitation intervention, Community-Led Total Sanitation, which was implemented at scale across rural areas of Indonesia with a randomized controlled trial to evaluate its effectiveness. The program resulted in modest increases in toilet construction, decreased community tolerance of open defecation and reduced roundworm infestations in children. However, there was no impact on anemia, height or weight. We find important heterogeneity along three dimensions: (1) poverty—poorer households are limited in their ability to improve sanitation; (2) implementer identity—scale up involves local governments taking over implementation from World Bank contractors yet no sanitation and health benefits accrue in villages with local government implementation; and (3) initial levels of social capital—villages with high initial social capital built toilets whereas the community-led approach was counterproductive in low social capital villages with fewer toilets being built. •CLTS increased toilet construction and decreased tolerance of open defecation.•The only significant health impact was a reduction in roundworms.•No impacts on child haemoglobin counts, weight or height.•Local government implementation was ineffective, unlike World Bank contractors.•Level of community social capital was important to program success. Diseases caused by open defecation are preventable and disproportionately affect the poor. Millions of people contract fecal-borne diseases, most commonly diarrhea and intestinal worms, with an estimated 1.7 million people dying each year because of unsafe water, hygiene and sanitation practices . In IndoBill and Melinda Gates Foundation funded randomized controlled trials (RCTs) of sanitation and hygiene interventions in seven locations around the world.Community-Led Total Sanitation (CLTS) is a program being widely implemented in more than 60 countries throughout Asia, Africa, Latin America, the Pacific and the Middle East to address the sanitation burden . CLTS aiIn addition to poverty status, we examine two other sources of heterogeneity in program impact. An important component of the intervention is that it sought to create a large-scale sustainable program across the country.3Second, we examine the role of social capital. As its name suggests, CLTS is a participatory development project in which facilitators are sent to villages to initiate a community analysis of existing sanitation practices and a discussion of the negative health consequences of such practices. The community actively participates in the facilitated meeting and is then left to forge its own plan to improve village sanitation with only limited follow-up support and monitoring from the program. Given CLTS' emphasis on community involvement, one might expect that it would function best in communities with high pre-existing levels of social capital. We define social capital as the norms and networks that enable collective action.We find that baseline social capital is an important determinant of program effectiveness. High levels of community participation at baseline are strongly associated with increased toilet construction in treatment communities. However, in communities with low levels of social capital at baseline, significantly fewer toilets are constructed. We present results consistent with villages with higher initial community participation being more able to align community members' objectives with those of the program through the use of social sanctions. Our results thus constitute a caution about using participatory approaches in low social capital settings. At the very least they suggest that more intense involvement of project facilitators and general project support may be warranted in locations with demonstrably low social capital.The paper proceeds as follows. Section 2CLTS was initially developed in Bangladesh in 1999 by sanitation practitioner, Kamal Kar. It is now being widely implemented in more than 60 countries around the world , having The program is a community-led approach that focuses on creating demand for sanitation, in contrast to the traditional approach of supplying sanitation hardware . CLTS fa5In contrast to other approaches that have been used widely in the past in Indonesia and elsewhere, no funding for infrastructure or subsidies of any kind is provided. CLTS founders believe that CLTS is less effective when subsidies are available . They ar2.1In Indonesia CLTS was rolled out across all 29 rural districts in the province of East Java. East Java is Indonesia's second most populous province with approximately 38 million residents. Eight of the 29 rural districts in East Java were involved in the impact evaluation.Two waves of household data were collected. The baseline survey was conducted just prior to program implementation in August–September 2008. Within each village, approximately thirteen households were randomly selected to be surveyed. The endline data collection was conducted approximately 24 months later, between November 2010 and February 2011. The surveys collected a wide variety of information on the households including demographic information, a detailed sanitation module , and a child health module . Fecal samples were collected by leaving a stool specimen container containing a preservative  with the child's carer and requesting that he/she deposit approximately 5 g of the child's feces in the container the next time the child defecates. The specimen was collected the next day. Preserved stool samples were sent to the public health office in Yogyakarta for analysis using the Kato-Katz technique . The fecTo enable an examination of impacts on child health, households with children under the age of two were prioritized, with all surveyed households required to have at least one child under the age of five at baseline. Community level demographic data and information on infrastructure were also collected. In addition, a social capital module was conducted. Budgetary considerations restricted the social capital module to a randomly chosen six of these eight districts.Our total sample consists of approximately 2000 households spread across 160 rural villages in eight districts, with data on social capital available for approximately 1600 households spread across 120 villages in six of these districts.3Yij is the outcome measure for household i in village j; Tj is the treatment dummy, which equals 1 for households in the treatment group, and 0 otherwise; δK is a set of sub-district (kecamatan) dummy variables which are included because the randomization was stratified at this level. The sub-district effects also control for any differences in implementation across the eight districts. In some specifications, we also include a vector of household and village characteristics (Xij) as additional right-hand side control variables. The household variables are household size, the household head's age and educational attainment, household composition, log per capita household income, eligibility for low income support and dwelling characteristics; and the village variables are village population, village land area, the percentage of the village which is Muslim, whether there is a paved road to the nearest city, average years of education of household heads, whether a river flows through the village, and the percentage of households in the village who open defecated at baseline. εij is the error term, and all specifications cluster the standard errors at the village level.Our empirical approach is to present ITT estimates of program impact on the outcomes of interest. This is done by estimating equation β1 if the randomization was effective. The causal average treatment effect is given by Tj with the relevant variables – poverty status of the household; whether the village was assigned to be treated by a resource agency (RA) or by the local government (LG); and baseline social capital. We discuss the issue of balance with respect to the relevant sub-samples in the analyses below.When examining heterogeneity of impact, we include interactions of 4We first examine whether CLTS treatment was successful in stimulating demand for sanitation (column 1). Households report whether they built a toilet between baseline and endline. This report is verified at the end of the interview by an inspection of the household's sanitation facilities. CLTS is hypothesized to stimulate demand for sanitation by inducing shame associated with open defecation. It also imparts information on the negative health consequences of poor sanitation. Column 3 reports the results of whether treatment impacts a measure reflecting the degree to which the respondent agrees (disagrees) with negative (positive) views of open defecation. There is a small decrease in the community's tolerance of open defecation in treatment communities relative to control communities. The program does not affect knowledge of the causes of diarrhea  which may be due to knowledge being quite high already, with the mean score in control communities being 4.9 out of 6 (column 5).9The ultimate aim of CLTS is to improve sanitation so as to improve community health, particularly child health. We examine the health impacts along the causal chain from roundworm infestation, to hemoglobin blood concentrations (with low hemoglobin indicating anemia) to weight and height z-scores (columns 6–11). While columns 1–5 are estimated at the household level, the health regressions are estimated at the child level. The sample of children is those aged 0 to 5 at endline.Column 6 of In column 11 we generate an overall health index. Following 55.1CLTS forms part of the Indonesian government's national strategy to improve environmental and health outcomes in rural areas. Ensuring sustainability of the project by embedding implementation in district governments was the key element of the scale up strategy. WSP followed the World Health Organization's documented steps for developing a successful scale up strategy which were formed on the basis of evidence gathered over years of experience in scaling up public health interventions .1010The scale up model used was the widely-employed “Training of Trainers” . WSP tra1.Demographic context. Different characteristics of target populations when at scale.2.Design effects. Differences in program design that are necessary to bring the program to scale.3.Scale effects. General equilibrium effects associated with the scale of the project, including spillover effects.4.Implementation agent effects. The identity of the implementing agency may alter incentives.There are a number of reasons why program impacts may differ when conducted at scale:implementation agent effect. That is the implementing actors and their associated administrative constraints differed.11In our context, many of these effects are not present. For example, as the program was implemented simultaneously by both RAs and LGs, any general equilibrium effects will be common to both treatment types. General equilibrium effects could include spillovers resulting from widespread increased demand for sanitation (e.g. latrine price changes and spillovers in information about the benefits of sanitation from treatment villages to control villages). In addition, the geographic and demographic context did not differ systematically and the project design is identical. Hence, it is a situation where there is a reasonable likelihood of successful scale up being achieved. The only potential difference between RA and LG implementation is in the Villages were not randomized into LG vs RA status, though discussions with WSP suggest there was nothing systematic about how these decisions were made. If the characteristics of villages differ with implementing agency then we could falsely ascribe differences in program effectiveness to LG versus RA triggering. Tests of whether villages that were assigned to be triggered by local governments are otherwise similar to the villages that were assigned to be triggered by resource agencies are presented in columns 4–6 of We also examine differences at the village level which might influence the population's interest in sanitation panel C, . There a5.1.1As discussed earlier, program impact may also vary with the poverty status of the household, as CLTS does not provide financial assistance in any form to poorer households, the ability of poorer households to participate in the program by constructing a toilet may be limited. Toilet construction requires a significant outlay of capital. In the endline survey, cost is the most frequently reported obstacle to building a toilet, reported by 47% of households. Further, less than 5% of poor households report having sufficient savings to cover the cost of building a latrine (estimated by WSP to be USD 46).We examine the heterogeneity of program impact by poverty status and implementer identity simultaneously. We generate an indicator to identify poor households with a household being deemed poor if they are in the bottom quartile of the distribution of non-land assets.5.1.2i in village j is poor and village j was assigned to be triggered by an RA and zero otherwise; i in village j is not poor and village j was assigned to be triggered by an RA and zero otherwise. j is assigned to local government implementation. The estimating equation is:β1, β2, β3, and β4. Comparisons of these coefficients reveals the differential impact of implementing agency for poor and less poor households. All other variables are as defined previously.Equation 5.1.3Column 2 in These results call into question CLTS's strategy of not providing subsidies for toilet construction since poorer households are no more likely to build toilets in treatment communities than in control communities, and the cost of construction is reported as a main obstacle to improving sanitation. In fact, recent empirical evidence suggests a crucial role for subsidies . Patil eColumn 4 presents results of the same specification but with the score for intolerance of open defecation as the dependent variable. Interestingly, the results for attitudinal change show a corresponding decrease in tolerance of open defecation among the non-poor in communities where a resource agency is the implementing agency, suggesting that the resource agencies are more effective at generating attitudinal change and that the program has difficulty affecting the attitudes of households who are least able to afford sanitation.We also examine whether these differential improvements in sanitation infrastructure by triggerer identity and poverty status are apparent in the roundworm finding. Column 7, 145.1.4There is no significant difference in the way the RAs and LGs disseminated information about the project . The RAs are however more likely to engage with village staff, in particular, with the village office and with village health post volunteers. The intensity of implementation is greater in RA villages . Most villages received only one visit from the team, some villages received two visits and a small number received three. RA facilitators made 0.42 more visits to villages than LG teams (significant at the 5% level). RA implementation also results in significantly greater community participation. Respondents in RA-triggered treatment villages are 13 percentage points more likely to have heard about the program and 12 percentage points more likely to have known about the triggering event.In the field one hears a lot about the importance of the “quality” of the facilitator. In order to test whether the RA facilitators are “better” than the LG facilitators, we collected information from respondents on their perceptions of how charismatic/persuasive the facilitators were. We find no significant difference in the average reported persuasiveness of the facilitators (column 15). An examination of various program reports reveals that there was general satisfaction of WSP staff with the quality of the RA training of facilitators .5.2Given the community-led, participatory nature of CLTS it seems likely that initial levels of social capital in treatment villages would impact on program effectiveness. A higher level of social capital is thought to facilitate collective action by lowering the costs associated with such action ; by reduHigh levels of social capital within a community may also result in households internalizing the social benefit of the provision of private goods, . If a ho165.2.1To examine the impact of social capital on the success or otherwise of the sanitation program we construct a village social capital index from data collected at baseline on participation in community groups and the extent of networks in the village. The index is constructed in the same way as we calculated the index of health outcomes above, following We allow for program impact to differ with the level of baseline social capital (and implementing agency and poverty status) by adding three additional regressors to equation β5, β6, and β7. Everything else is as before.The estimating equation is:The results from estimating equation Columns 4 and 5 in 5.2.2We test three hypotheses to better understand what might be driving the social capital results. First, a more active community may mean a better informed community as members know each other better and exchange information when they meet. To examine this hypothesis we construct an index of information shared within the community at endline from variables reflecting whether the household reported that they knew about the triggering event; whether they learned about sanitation construction from other community members; and whether knowledge about the causes of diarrhea increased between baseline and endline.Second, in more active communities, people may be more willing to be actively involved and share resources as a result of knowing each other better. In the CLTS context this may result in being more likely to attend the triggering event and more shared and public toilets being built. To test this hypothesis we construct an index from these two variables and examine its relationship with the baseline social capital index. Baseline social capital is not a significant determinant of active involvement and sharing of resources  to 5 (strongly disagree) on whether building a toilet reduces the likelihood of being a target of gossip; whether those who defecate in the open will not be accepted by the community; and whether the community imposes social sanctions on those who defecate in the open. 6CLTS modestly increased the rate of toilet construction and reduced community tolerance of open defecation. We find an associated decrease in roundworm infestations but no improvements in children's hemoglobin levels, weight or height. An index of child health also shows no significant overall improvement. Although the rate of toilet construction increased about four percentage points among less poor households, the poorest households did not build toilets. This highlights potentially important roles for the provision of finance to poor households and/or subsidies for the poor in conjunction with CLTS in producing open defecation free communities .The examination of the scale up process shows that CLTS had relatively large positive impacts in villages where the program was implemented by RAs. In contrast, with the identical program design, the same demographic composition of participating households, and common general equilibrium effects, implementation by local governments failed to produce any discernible positive impacts. Understanding what makes for successful scale up is of prime importance to the development sector. Currently there are very few studies that explicitly examine the scale up process through the lens of a rigorous quantitative evaluation and the studies that exist find either a lack of replicability at scale or that successful scale up is not straightforward and involves considerable learning from failure. Integration of quantitative evaluation, qualitative research, and high quality monitoring data is likely to improve researcher and program implementers' ability to understand the causes of success and failure, so as to increase the likelihood of successful scale up in the future.19Finally, our results show that CLTS increased toilet construction in villages with sufficiently high pre-existing social capital in the form of community participation. In villages with low initial levels of social capital, however, the program was counterproductive—resulting in fewer toilets being built. We present evidence consistent with high social capital communities being better able to use social pressure to get community members to conform with program objectives. Our finding are thus cautionary with respect to using participatory development approaches in low social capital environments and at the very least suggest a need for greater investment in community-support for participatory development programs in areas with demonstrably low social capital.


Australian Aboriginal and Torres Strait Islander people experience disproportionately higher rates of sexually transmissible infections (STIs) and blood borne viruses (BBVs) when compared with the non-Indigenous population. Both incidence and prevalence data for bacterial STIs, such as chlamydia, gonorrhea, trichomonas, and syphilis in remote areas of Australia are reported at rates many times higher than that of non-Indigenous Australians. Similarly, rates of hepatitis B are disproportionately higher for non-Indigenous people in remote communities. The Young Deadly STI and BBV Free project was designed to increase the uptake of STI and BBV testing and treatment in young Aboriginal and Torres Strait Islander people living in remote and very remote areas of South Australia, Western Australia, Queensland, and the Northern Territory. Peer education formed one component of this pilot project and involved training up to 100 young Aboriginal and Torres Strait Islander people across 19 communities in a culturally appropriate and respectful manner on the transmission, testing, and treatment of STIs and BBVs. The trained peer educators were then required to deliver three community education sessions to young people in their respective communities in an effort to raise awareness about STIs and BBVs and encourage testing and treatment uptake. Preliminary evaluation findings, limited to the trained peer educators, revealed the peer educator training program contributed to STI and BBV knowledge gains among the trained peer educators and positively influenced their behavioral intentions and attitudes pertaining to STIs and BBVs. Working with remote Aboriginal and Torres Strait Islander populations on a highly sensitive, stigmatized topic presented many methodological challenges, particularly in terms of ensuring the collection of reliable evaluation data across geographically remote communities. The challenges and strengths associated with the implementation of the peer education training program along with implications for developing culturally inclusive evaluation practices will be discussed. Sexually transmissible infections (STIs) and blood borne viruses (BBVs) are significant health issues within the Australian Aboriginal and Torres Strait Islander (hereafter Indigenous) population, with reports of disproportionately higher rates of STIs and BBVs among the Indigenous population when compared with the non-Indigenous population . Young IIn most instances, the more commonly reported STIs of chlamydia, gonorrhea, syphilis, and trichomonas are preventable, easy to diagnose, and successfully treated using inexpensive, readily available antibiotics , 8, 9. TIn addition to the limited distribution of health services in remote areas, service provision to young Indigenous people living in remote communities is further impeded by complex historical, cultural, and personal barriers, including (but not limited to) a mistrust of health services, culturally inappropriate/unwelcoming services, staff turnover, transport issues, financial costs, and in some instances a reluctance to access such services due to shame , 10, 11.Evidently young Indigenous people in remote communities have a sustained personal vulnerability to STIs and BBVs, more so than their non-Indigenous peers . This suPeer education is a well-established and internationally recognized approach to health promotion where information is shared between people of a similar age or from similar social groups . The preIn 2016, the South Australian Health and Medical Research Institute (SAHMRI) was awarded Commonwealth funding to implement a youth peer education sexual health program in remote and very remote Indigenous communities throughout Australia in an effort to combat the disturbingly high rates of STIs and BBVs in these communities. Forming one component of the larger Young Deadly STI and BBV Free project (hereafter Young Deadly Free project), the peer education program involved training up to 100 young Indigenous people in 19 remote and very remote communities, across four jurisdictions, on the transmission, testing, and treatment of STIs and BBVs for the purpose of sharing such knowledge with, and positively impacting behavioral intentions and attitudes of, other young people in their respective communities.The development of the youth peer education training program was a collaborative endeavor. Key community stakeholders in remote health services were consulted on the program content to ensure topics were comprehensive and appropriate.https://www.shinesa.org.au/product/condom-card-game-condom-negotiation-cards/) and the STI story developed by Sexual Health Quarters (WA)  .The Young Deadly Free peer education training program covered: anatomy and conception; STI and BBV transmission, testing, and harm reduction; and sex and the law. Group facilitation skills and practice in delivering content was also incorporated into the training program. Focus groups were run with young people to pilot the training program. The peer education training program was designed to be run over either a two or three day period, for approximately five to seven and half hours each day.n = 46) of the anticipated 100 peer educators had been recruited and trained, comprising 25 females and 21 males aged 16–28 years, and median age 20 years. The peer educators are based in remote communities across three jurisdictions: WA (n = 27), the Northern Territory (NT) (n = 7), and South Australia (SA) (n = 11).The program sought to recruit male and female peer educators who were well-respected community members with a passion for health and community. To be consistent with the demographics of the intended target audience for peer education, the peer educators had to be aged 16–29 years and identify as Aboriginal and/or Torres Strait Islander. Further to this, the eligibility criteria to train as a youth peer educator included: availability to run peer education sessions for other young people in their local community, English language literacy, sound communication skills and people skills, and non-judgmental attitudes toward sexual health, STIs, and BBVs. Recruitment of potential youth peer educators commenced first in Western Australia (WA) in September 2017. Some jurisdictions are still actively recruiting and training peer educators. At the time of writing, 46%  classification of “remote” and “very remote” areas in SA, Qld, NT, or WA; a minimum population of 150 Aboriginal and/or Torres Strait Islander young people aged between 16 and 29 years; and an Aboriginal Community Controlled Health Service with membership of the peak state body, which utilizes electronic medical records that have the capability to extract STI/BBV testing data, or be willing to install data extraction software, and be willing to provide access to non-identifiable laboratory testing data. Following satisfaction of the eligibility criteria, community participation in the program required a formal agreement between the local health service and SAHMRI.Nineteen remote communities, spanning three states and one territory, participated in the youth peer education program . The suHow confident do you feel to run peer education sessions for other young people and why,” and “What was the most significant benefit for you attending the training?”Following the training, oral feedback was collected from the peer educators to determine the suitability and impact of the youth peer educator training program. The Regional Coordinators, who had already established good rapport with the peer educators, conducted the feedback sessions by telephone or in person. The sessions occurred immediately after completion of the training to several days/weeks post training, depending largely on the availability of the Regional Coordinators and peer educators. The feedback sessions were conducted in an informal manner using a semi structured approach to ensure a degree of consistency across the participant sample, however, there was flexibility to ask other pertinent questions as they arose during the course of the session. An example of the types of questions asked included, “Every effort was made to ensure the comfort and participation of the peer educators in the feedback sessions. Peer educators were given the option of providing feedback individually or in a group feedback session. They could also opt to provide feedback to their Regional Coordinator or to a Regional Coordinator from another region for the purposes of respecting cultural protocols related to gender norms or anonymity.The feedback sessions ranged from 8–13 min  and were voice recorded and transcribed verbatim with participant consent. The Regional Coordinators also took written notes during the course of the feedback session to record observations and personal reflections.An evaluation guide, specific to the youth peer education program, was developed by the evaluation team for the Regional Coordinators. The guide was designed to support the Regional Coordinators in the collection of evaluation data and included information on the evaluation tools, ethical considerations associated with data collection and storage, the transfer of data to the evaluation team, important evaluation dates, and the expectations of the Regional Coordinators in the evaluation. Included with the evaluation guide were labeled and prepaid envelopes to organize collected data and confidentially store and transfer such data to the evaluation team. Individual tele-meetings, up to 30 min in duration, were also held with each Regional Coordinator and a member of the evaluation team to discuss the evaluation in greater detail and address any specific questions.The quantitative knowledge survey data were entered into SPSS (version 23) and frequencies were used to calculate summary descriptive statistics for the survey questions. Content analysis was used to analyze the data from the feedback sessions. This involved coding the transcripts to break down larger segments of transcribed data into smaller units to establish an understanding of its meaning. Common categories or themes were then identified.The findings presented focus on the 6 month period from September 2017–March 2018. Forty six peer educators completed the pre knowledge survey and 40 completed the post knowledge survey. Responses were anonymous and could not be matched. The tables presented below highlight responses to the knowledge survey questions. Participant numbers vary marginally for some cells due to missing data. It is acknowledged that the differences reported between the pre and post groups may be accounted for by the six peer educators who did not complete a post knowledge survey.The youth peer educators demonstrated a relatively high level of STI and BBV knowledge prior to commencing the peer education training see . A high Following peer education training there was a substantial increase in the proportion of correct responses for most STI and BBV knowledge questions, suggesting enhanced knowledge in these areas. Despite greater awareness of STIs and BBVs following the training, responses in the post knowledge surveys indicated continued uncertainty among the participants with regards to gonorrhea symptoms with a smaller proportion of participants correctly answering this question. Similarly, the proportion of correct responses to the trichomonas question remained <50% post survey, suggesting participant knowledge on this STI remained limited post training.Generally, the participants indicated a high degree of intention in regards to discussions about STIs and BBVs as well as preventive practices . Similarly most participants agreed (78%) that they were confident they could get tested for STIs when they want, although there was concern among the participants regarding privacy and shame of STI testing with almost one-third agreeing that they were worried about the privacy/shame of STI testing. Many participants acknowledged their vulnerability to STIs, with 65% agreeing with the statement that they could easily get a STI. Responses in the post knowledge survey were relatively consistent for these STI statements, suggesting the peer educator training did not assist in alleviating concerns participants had about the privacy and shame associated with STI testing  agreeing in the pre survey that they do not know when to get a BBV test, decreasing to 30% in the post survey. Despite the uncertainty demonstrated in the pre knowledge survey, there was relatively high agreement among the peer educators about the types of situations that warrant BBV testing, with 67% agreeing that a BBV test is needed if one has been prison (increasing to 82% post survey), 80% agreeing that a BBV test is needed if one has had sex without a condom (remaining consistent at 80% post survey), and 85% agreeing that one should get a BBV test if injecting equipment has been shared (increasing to 92% post survey). Collectively the post knowledge survey responses suggest the peer education training increased knowledge about BBV testing among the participants.Feedback sessions were held with nine peer educators  in SA and WA. One group feedback session was held with five male participants, and four one-on-one feedback sessions were conducted with female participants. Two feedback sessions took place in person, three were conducted via telephone. The feedback sessions were concise in length and as such, data were limited and may not represent the views and experiences of all trained peer educators. Responses to the feedback questions have been analyzed and are presented below.The participants reflected positively on their peer educator training experience, reporting that the informative and interactive nature of the training made for an enjoyable training experience. When asked to rate the training overall on a scale of 1–10, where 1 denoted “very poor” and 10 denoted “excellent,” the participants offered a mean score of 7.7 (mode = 8). Specifically the participants were particularly praising of how the information was presented, the cultural appropriateness and sensitivity of the information, the location of the training, and the effectiveness of the facilitator with each of these receiving mean scores ranging from 9.2 to 9.7.I think the fact that it's gender specific for us has worked extremely well,” while another female participant remarked, “When we do the teachings, we have to like avoid, like you know, females go with the females…we won't like educate the men, like it would be inappropriate if we did that.”Participants commented on the importance of respecting cultural norms by offering gender specific training as indicated by the following remark by a male participant, “they don't like talking about them sort of things.”The relevance and usefulness of the content and the payment received for attending the training were also rated highly, with mean scores of 8.7 and 8.3, respectively. Receiving slightly lower ratings were the length of the training (mean = 7.8) and the behavior and participation of the other participants (mean = 7.4), with one female participant reporting that the topic caused shyness among some of the peer educators because “I feel more confident purely because of the information now, I wouldn't be guessing now, I actually have got some info that I can go to now” and “Because I feel like I've learnt like a lot and like now that I know I'm like more confident in telling people.”Six of the nine participants  reported feeling either “quite confident” or “very confident” in running a community education session with other young people. Peer educators reported various factors contributed to feelings of confidence including: knowledge acquired from training or related work experience; having the support of other peer educators; and knowing the young people who would be participating in the community education sessions. Examples of the feedback provided by the peer educators  included, “Probably cos I not a person to be talking in front of people” and embarrassment discussing the subject matter with others “I can do it, but sometimes I feel a bit shame.” Some of the participants who reported low confidence levels in the delivery of community education sessions indicated that they would feel comfortable speaking with other young people in a one-on-one context or if they had someone co-present with them.For the three male participants who reported a lack of confidence in running a community education session with young people, concern was generally related to a fear of public speaking, “A lot of people don't, aren't educated in this specific area and we just all assume everyone knows what to do…in that area” and “If they're delivered effectively, it could be extremely valuable.”When asked to report on how valuable the community education sessions will be for young people in the community, the participants were of similar opinions that the sessions would be either “quite valuable” or “very valuable”—the highest rating among the four possible options. Responses from the male and female participants included, “Going to a place where people don't go” suggesting a private setting for the training is an important consideration.Participants did not identify many improvements to the peer education training, however some participants acknowledged that shorter training days, possibly spread over several days, would be a helpful improvement. A female participant noted that the training could be improved by “Hearing about all types of diseases that you didn't even think of, wouldn't even think about.” A female participant remarked, “The best thing was the, some stuff you told me about sexually transmitted disease, that I didn't know of, now I know.” This knowledge acquisition was said to be empowering for the participants, with one female participant stating, “It's just like empowered us to just, you know, start educating our family members, trying to avoid early pregnancies, and you know, STIs and stuff.”The participants were unanimous in their opinions that the most significant benefit they gained from the peer educator training was the knowledge they acquired. One male participant reported, “Seeking to remedy the alarmingly high rates of STIs and BBVs among young Indigenous people, the Young Deadly Free project implemented a youth peer educator sexual health training program in 19 remote and very remote communities. Peer education has had limited application in sexual health promotion in the Indigenous Australian population context, despite increasing evidence attesting to its effectiveness , 21–24. Specifically, the pre knowledge survey revealed relatively high levels of STI and BBV knowledge, and high levels of agreement in relation to behavioral intentions and attitudes to STI and BBV testing among the peer educators prior to engaging in the peer educator training. This may be due in part to the project seeking to recruit trainee peer educators with an interest in health and community issues and as such, the peer educators were knowledgeable on the topic. Despite the pre-existing high levels of STI and BBV knowledge among the peer educators, a steady increase in knowledge levels was observed following the training—this was particularly apparent for questions pertaining to HIV curability and BBV testing. Limited knowledge about gonorrhea symptoms and trichomonas remained among the participants post training, however, and some participants continued to report concerns about the privacy and shame of STI testing, suggesting more of a focus on these topics is warranted in the peer educator training.Australian research by Mikhailovich and Arabena  also repThe current peer educator training also enhanced feelings of confidence among the trained peer educators, with more than half of the peer educators who provided oral feedback reporting feeling quite confident or very confident in conducting community education sessions with other young people in their community. Additional support from the Regional Coordinators may assist those peer educators who reported a lack of confidence following the training, particularly in terms of minimizing concerns associated with public speaking and feelings of shame and/or embarrassment when speaking about sexual health with peers. Encouragingly, the trained educators reported that the community education sessions would be valuable for young people in their respective communities due to the lack of knowledge that exists on STIs and BBVs.The favorable outcomes associated with the peer educator training could be attributed to the format and content of the training, which was highly regarded by the participants as being culturally appropriate and respectful, and also of relevance to the target audience. This is consistent with other studies highlighting the importance of adhering to cultural protocols in the delivery of STI and BBV information when seeking to engage young Indigenous people on such a culturally sensitive topic . It is The positive outcomes associated with the peer educator training is noteworthy, particularly when considering the context in which the program and evaluation exist. Most notably, the program was implemented in remote communities, many of which are either experiencing higher priority issues that supersede the importance of sexual health, or are feeling disillusioned by research or suffering research fatigue . Thus, eFurther to the above are the methodological challenges associated with undertaking an evaluation of a multi-jurisdictional program in remote Indigenous communities, commencing with the need to obtain ethics approval from multiple ethics committees for the conduct of the research. This was a time intensive process, due in part to the complexity of the larger project for which ethics approval was sought, different requirements and processes of each committee, including the frequency with which some of the committees met. Future programs of a similar nature will benefit from allocating sufficient time to the ethics approval process.The multi-jurisdictional nature of the program, and the geographical spread of the participating sites, also presented challenges for data collection, which necessitated a heavy reliance on the Regional Coordinators to collect and transfer evaluation data to the evaluation team based in WA. With great variation in the evaluation skill set and experience among the Regional Coordinators, processes had to be implemented to maximize the reliability and validity of the data collected, as well as the secure transfer of data to the evaluation team. The development of the evaluation guide for the Regional Coordinators as well as the supply of labeled and pre-paid envelopes for the organization and return of data are examples of how the evaluation team sought to manage the collection and transfer of data across the 19 remote sites. While one may question the methodological rigor of the data collection responsibility residing with the Regional Coordinators, it was important not only from a logistical perspective but also from an ethical perspective, for it helped to ensure adherence to culturally secure evaluation methods and provided the opportunity for data to be collected from different sites in parallel rather than serially by the evaluation team.The methodological challenges faced in the evaluation of the peer educator training program are evidence of the complexities associated with evaluating a multi-jurisdictional program based in remote Indigenous communities. Notwithstanding these challenges, there are indeed strengths of the evaluation design that have helped to mitigate some of these challenges that are worthy of discussion. Communication has been key to managing many of the methodological challenges that have presented in this evaluation. Undertaking a multi-jurisdictional evaluation where the evaluation team are not active in the data collection process requires the establishment of effective communication between the evaluators and regions. This was established through an initial face-to-face meeting and then via regular email and telephone contact where training and support in the collection and handling of data was provided, and the opportunity to debrief was offered. The development of an evaluation guide for the Regional Coordinators also aided the data collection process and ensured consistency across the program sites, while the data transfer process was efficient to maximize the return of completed and organized data to the evaluation team.The experience of the evaluation team and the flexibility of the team over the extended project timeframe are additional strengths of the evaluation design. Furthermore, the involvement of the evaluation team in the design of the peer education program is a notable strength for this permitted the team to have input into the design of the data collection tools and methods of data collection. It is highly recommended that future projects with an evaluation component seek to engage the evaluation team early in the project design.The strengths of the peer education program governance must also be acknowledged for contributing to the success of the program. To begin, the establishment of a central program coordinator role assisted with minimizing the impact of geographical distance in a program of this scale. This role was responsible for the management of the program at a national level and facilitated the implementation of the program and evaluation. The recruitment of Regional Coordinators who were committed and well-engaged in their respective communities also served to benefit the program and helped to ensure its implementation at a jurisdictional level.The program's strengths-based approach is another recognized quality. At the core of the program is the objective to upskill and build the capacity of young people in the community to make informed decisions about their health and body. The program works collaboratively with local Aboriginal Medical Services, Elders, and other people of influence to encourage participation by young people. This type of approach can energize a community, particularly those that are, or have been, facing challenging issues.The cultural protocols and sensitivities surrounding not only the topic, but the conduct of research in Indigenous communities, combined with the geographical spread of the multiple remote program sites have presented challenges that have required careful consideration. The evaluation was not, however, without limitations, and following are ways of improving evaluations of this nature. Initially a detailed environmental scan of the proposed participating communities is recommended to determine the community's readiness for research and to ensure they have the capacity and interest to commit and support the proposed research. The establishment of realistic timeframes is also of paramount importance when undertaking research in remote Indigenous communities. Such timeframes must be flexible to changes in the research process and also take into consideration the time required to establish trusting relationships in Indigenous communities. The importance of time and flexibility when working with Indigenous communities has been noted elsewhere . Similat-tests to establish the significance of changes observed between the pre and post knowledge surveys were not possible. Future evaluations of this type could consider how one assures participants of the anonymity of their survey responses, while also allowing for a higher level of analysis of survey data.In instances where evaluators do not collect data and outsource this responsibility to other personnel, it would be beneficial to establish a baseline of the evaluation and research skill set among those collecting the data in order to provide more comprehensive, targeted support to those less experienced. Similarly, allocating more resources to the data collection process, such as having an evaluator observe a training session, would be advantageous to improve the reliability and consistency of the data being collected. Also, greater consideration should be afforded to the data collection tools and the rigorous testing of such tools with the target population. In the present evaluation, the anonymous nature of the knowledge surveys placed limitations on data analysis, only permitting comparisons of the pre and post survey data in terms of proportions. Independent Lastly, the evaluation findings cannot determine the ability of the peer educators to go on to deliver effective, factually accurate community education sessions with other young people. The evaluation also did not assess whether some peer educators were more effective than others, in what ways, or the reasons which may have contributed to this . Nor was it possible to determine whether the reported gains in STI and BBV knowledge along with the reported attitudinal changes, will translate into safer sexual practices and ultimately a reduced prevalence of STIs and BBVs among this population cohort. Such factors are important in determining the effectiveness of peer education in sexual health promotion and in influencing changes in behaviors including safer sex practices, testing and treatment of STIs and BBVs. While the full impact of peer education will not be assessed by the methods used for this evaluation, the indirect effects of the peer education program may be observed through increased access to health services and reduced STI and BBV rates in the communities. The final evaluation of this program may provide the opportunity to assess the extent to which the peer education program has positively impacted on the various remote communities.The preliminary findings from the evaluation of the Young Deadly Free youth peer educator training program demonstrate the training program contributed to knowledge gains in STIs and BBVs among the young people training as peer educators and positively influenced behavioral intentions and attitudes in this cohort. These findings are promising for the implementation of the community education sessions in the participating sites, which will provide evidence attesting to the efficacy of the peer education model for sexual health promotion within this population. Determining the long term impacts of the peer education program is a worthy line of enquiry and subsequently will form an important focus of the larger evaluation of the Young Deadly Free project.Undertaking evaluation work in research fatigued populations on a topic abound with cultural sensitivities presents a myriad of challenges, however, this should not dissuade one from engaging in such important work. It requires a departure from traditional evaluation methods where the evaluators must work within the confines of the requests of the ethical committees and the preferences of the participating communities while also balancing the need to collect valid and rigorous data. The identified strengths of the Young Deadly Free youth peer educator training program evaluation, along with the reported limitations, make valuable contributions to the limited evidence base for best practice evaluation in remote Indigenous communities.This study was carried out in accordance with the recommendations of Values and Ethics: Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander Health Research (2003) and the National Statement on Ethical Conduct in Human Research (2007) with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Curtin University Human Research Ethics Committee; Western Australian Aboriginal Health Ethics Committee; Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research; Central Australian Human Research Ethics Committee; and the Aboriginal Health Research Ethics Committee of the Aboriginal Health Council of South Australia.RL and BD contributed conception and format of manuscript. BD performed quantitative and qualitative data analysis, and completed manuscript drafts and revisions. JT wrote a section of the manuscript. RL critically reviewed manuscript. JW is the principal investigator on the Young Deadly Free project and approved the publication of content pertaining to evaluation activities. All authors had the opportunity to comment and approve the version submitted.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


OB  obstetrical patient safety program was phased-in across hospitals in Ontario, Canada. The purpose of our study was to evaluate the effect of the MOREOB program on rates of adverse maternal and neonatal outcomes.In 2002, the MOREOB program was implemented between 2002 and 2012. After accounting for institutional mergers and excluding very small hospitals, 55 hospitals  were included.A retrospective cohort study, using province-wide administrative hospitalization data. We included maternal and neonatal records between fiscal years 2002–2003 and 2013–2014, for deliveries taking place at the 67 Ontario hospitals where the MOREMultivariable logistic and linear mixed effects regression analysis were used, accounting for secular trends, within hospital correlation and over time correlation, and adjusting for a maternal comorbidity index, hospital annual birth volume, and level of care.The main outcome measure was a composite individual-level indicator of incidence of any adverse events, and a hospital-level score, called the Weighted Adverse Outcome Score (WAOS) capturing both maternal and neonatal adverse outcomes.Across the 12 years of follow up, there were 98,789 adverse maternal and neonatal outcomes, a rate of 6.83 per 100 deliveries . The multivariable analysis found no statistically significant decrease in adverse events associated with program implementation ).OB program, and small yet statistically significant increases in some adverse events were observed.We did not find a reduction in the incidence of maternal and neonatal adverse outcomes associated with the MOREThe online version of this article (10.1186/s12884-019-2296-5) contains supplementary material, which is available to authorized users. In high-resource settings such as Canada, maternal and neonatal adverse events during labour and birth are relatively rare , 2. Yet,OB) program was initially pilot-tested in the Canadian province of Ontario in 2002, and subsequently expanded across Canada and elsewhere [OB program [In 2001, the Society of Obstetricians and Gynaecologists of Canada developed a program to improve patient safety. The Managing Obstetrical Risk Efficiently  Discharge Abstract Database (DAD) for Ontario hospitals between April 1, 2002 and March 31, 2014 . The DAD includes hospital separation abstracts submitted by all acute care hospitals in Ontario. Each hospital abstract contains demographic information, medical diagnoses including most responsible diagnosis and 24 secondary diagnoses, interventions received, length of hospital stay, vital disposition at time of discharge and other data elements. Medical diagnoses are coded using the Canadian implementation of the International Classification of Diseases, 10th Revision (ICD-10-CA) from 2002 to 2003 to the present. The DAD captures over 98% of all births, including all live birth and stillbirth events occurring in Ontario hospitals through the maternal record. In addition, there are separate records for live born neonates and stillbirths that capture relevant morbidities, diagnoses and medical procedures. We linked maternal and newborn abstracts together via an encrypted maternal-newborn chart number .OB program is comprehensive and multifaceted, and could affect a number of maternal and newborn outcomes. Therefore, using composite scores would better capture the potential impact of the program. Note that several modifications were required, most importantly the omission of the Apgar score, as it was not available in the hospitalization database.We analyzed two previously-developed measures of obstetric patient quality of care: a composite individual-level indicator of incidence of any adverse maternal or neonatal events, and a hospital-level score, called the Weighted Adverse Outcome Score (WAOS). Both measures capture maternal and neonatal outcomes, and were developed through repeated consultation with leaders in nursing, obstetrics and anesthesia, among others . The decThe composite individual-level indicator of adverse event occurrence was based on the Adverse Outcome Index (AOI), a composite score designed to capture the quality of obstetrical care defined as “the number of deliveries complicated by one or more of the identified outcomes divided by the total number of deliveries” . We modiOB modules, and the post-implementation period. Two different datasets were prepared, one for each outcome. The mAOI was defined as described above and analyzed at the individual level, and the WAOS was defined at the level of the hospital, as the sum of all the weighted composite scores, divided by the number of deliveries that occurred in that hospital. Therefore, the analysis of the WAOS required the creation of a dataset aggregated by month and hospital.The timing of implementation for each hospital was divided into segments based on program implementation: the pre-implementation period, the implementation period which included implementation time for each of the three MOREThe components of the composite indices were coded from the ICD-10-CA and CCI  codes in the DAD, after reviewing published lists of codes used for maternal-newborn research using the DAD , 21–23. We used descriptive summary statistics to examine the distribution of study variables at the hospital level. Monthly time series plots of crude rates of study outcomes  over the 12-year study period were graphed by actual calendar time  for the effect of program implementation. This odds ratio compares the odds of an adverse event for a woman in a hospital after program implementation, to that of a woman in the same hospital before implementation. Three important assumptions of our model are that, after adjusting for covariates, there are no systematic differences in pre-implementation levels and trends across hospitals; that the effect of the intervention is constant over time ; and there is a gradient effect of the implementation across all modules, meaning a constant increase from the first to last modules.The mAOI was specified as the dependent variable and analyzed at the individual woman-level using random effects logistic regression, estimated using restricted pseudo-likelihood estimation. MOREver time ), time wver time  has beenver time . To alloOB program implementation variable yields an estimate of the difference between the mean score post-implementation and the mean score pre-implementation.The WAOS was analyzed at the hospital-level using mixed effects linear regression, estimated using restricted maximum likelihood estimation. Fixed and random effects were as described for the analyses of the mAOI, with the exception that the comorbidity index was aggregated to the level of the hospital in each month. The regression coefficient for the MOREFor both outcomes, the fitted secular trend was obtained from the model and displayed graphically with the covariates  set to their mean values in the study sample.Secondary analyses included separate models for individual components of the composite score, and examining sensitivity due to misspecification of the secular trend by specifying time as a categorical (rather than continuous) variable. Also, between-hospital heterogeneity in the effect of the program was allowed for, by adding a random effect for program implementation defined at the level of the hospital. All analyses were carried out using SAS v. 9.4.OB was implemented, 556,550 (38.5%) taking place during implementation, and 561,659 (38.8%) taking place after.The hospital sample was comprised of 12 level 1, 37 level 2 and 6 level 3 hospital sites, with 16 sites having annual birth volumes less than 1000, 32 sites having annual birth volumes between 1001 and 4000, and 7 sites with annual birth volumes greater than 4000  occurring during implementation, and 38,429 (rate of 6.84%) occurring after. The most frequent adverse outcome was neonatal intensive care unit (NICU) admission for at least 2 days for infants with a birth weight of 2500 g or more, which had a rate of 4.22% . The least frequent event was maternal death, with a rate of 0.005% (n = 69).Table OB implementation and adverse maternal and neonatal events when time was modelled using a restricted cubic spline. This model revealed no evidence of improvements in adverse events after MOREOB implementation. In fact, for the mAOI, there was a small increase in the odds of an adverse event in the post-MOREOB time period compared with the pre-MOREOB time period (aOR = 1.11 95% CI: 1.06 to 1.17).Table OB program was associated with increases in maternal unanticipated operative procedures  and 4th degree tear , and NICU admission . While not statistically significant at the conventional 5% level, the results suggest an association with decreased maternal blood transfusions (aOR = 0.83 (95% CI: 0.69 to 1.00)) and neonatal birth trauma (OR = 0.91 (95% CI: 0.75 to 1.10)). Maternal death and uterine rupture were not analyzed separately due to low frequency of events.In the analyses of individual components of the composite scores Table , the MOROB program. There is evidence that both outcomes are decreasing until the start of fiscal year 2008, at which time the rates level off or slightly increase. These trends support our choice to model time using a restricted cubic spline, which allows for more flexibility in accounting for the effects of secular trends on our outcomes. Results of the secondary analyses with time modeled categorically are presented in Additional file The modelled secular trends for the mAOI and WAOS are presented graphically in Additional file OB program prior to 2012, we found no evidence of improvements in either of the composite indices after MOREOB implementation. In fact, there was a small increase in the occurrence of adverse events as captured by the mAOI. In subanalyses with individual components of the composite indices, we found small but statistically significant increased odds of maternal unanticipated operative procedures, 4th degree tears, and NICU admission; on the other hand, we found evidence of non-statistically significant decreases in neonatal birth trauma and maternal blood transfusion.In our analysis of adverse maternal and neonatal outcomes in 55 Ontario hospitals enrolled in the MOREOB program. In the first study, implementation of the MOREOB program in Alberta hospitals was associated with a reduction in 3rd and 4th degree perineal tears and decreases in maternal length of stay and neonatal morbidity [OB implementation on mandatory reportable events collected by a Canadian healthcare liability insurer [OB implementation (95% CI:-0.5 to 8.1) and a decrease of 8 mandatory reportable events at 6 years post-implementation (95% CI: 1.4 to 15.1). However, this study included a smaller number of Ontario hospitals, 34, whereas the current study included 55 Ontario hospitals.Two previous studies have assessed the effect of the implementation of the MOREorbidity . However insurer . In thatOther obstetric patient safety programs have been evaluated with mixed results. A recently published rapid review included 10 randomized controlled trials (RCT) and reported that “provider education and other quality improvement strategy combinations targeting healthcare providers may improve the safety of women and their newborns during childbirth” . In an eOB implementation  but thereafter, the effect of the MOREOB program was assumed to be stable. An alternative approach may have allowed for either a gradual decay or further gradual improvements after completion of all modules, using, for example, an ITS approach with segmented regression analysis allowing for both a step change and a slope change. However, the staggered implementation of the MOREOB program, combined with the lengthy and variable amount of time required for hospitals to complete the program, precluded the use of an ITS approach. In a classical ITS analysis, the estimated pre-implementation trend (secular trend) is used to predict what the outcome event rate would have been at the end of the study, had the intervention not been implemented  [In our analytical approach, we allowed for a gradient effect of MOREstimate) –14. WithOB program, which occurred over an 8 year period, presented analytic challenges, it also provided an advantage, in that our results are less likely to be confounded by concurrent interventions or local policy changes. Using our multivariable model, we were essentially able to compare outcomes from all hospitals after implementation of the program to their own pre-implementation outcomes as well as to the outcomes from other hospitals who had not yet implemented the program at the same calendar time. As well, the use of previously developed and used [OB program, we considered that indicators capturing multiple components of maternal/newborn care would be more appropriate. Further, aggregation of the components helps to address the rarity of these adverse outcomes in the Canadian healthcare setting. And, given that it had been used for research carried out in Canada [While the staggered implementation of the MOREand used , 18–20 in Canada , this alOB, such as maternal age, parity and comorbidity. We attempted to account for this by including hospital level of care, birth volume and a maternal comorbidity index in our models however, it is possible that unmeasured confounding remains. An additional limitation was the lack of clinical performance measures in this evaluation, such as compliance with guidelines, safety reports, or documentation of near misses. Further, changes to workplace culture were not assessed. It has previously been reported that participation in MOREOB improved workplace culture and increased knowledge [We believe using composite indices as the primary outcomes was the most appropriate choice however it is possible that this masks the effect of the program on specific maternal-newborn outcomes that were not assessed by our study. As well, our analysis was limited to the data elements available in the DAD hospitalization database, and therefore we had to use a modified version of the AOI, which did not include elements such as Apgar score or 3rd degree perineal tears. Data quality is carefully managed and documented by CIHI , and we nowledge , and it OB program on a composite indicator of adverse maternal and neonatal outcomes. In this evaluation, which is one component of a larger mixed-methods evaluation of the MOREOB program, we only measured adverse outcomes. Although these are important outcomes from the perspective of patients, hospitals and policymakers, they cannot fully capture other aspects of MOREOB training related to improved communication, improvements in safety culture and increases in knowledge. Our mixed-methods evaluation of the MOREOB program also assessed individual participant responses, including care providers’ views about the program, changes in their levels of knowledge, and their assessments of the culture change within their organizations. Our findings from that study suggest that the MOREOB program had a positive impact on these factors. It is well-established that clinical behavior and practice change takes time to become entrenched [OB program, they must also find strategies to sustain the activities and practice changes once their dedicated funding for the program runs out. If the activities and practice changes are not firmly established and culture change is temporary, there may be no detectable net benefit of the program on clinical adverse outcomes over time. The MOREOB program does attempt to mitigate this effect, in that it is not just an educational program, rather every attempt is made to embed the program within the culture of each institution. A dedicated core team in each hospital carries out ongoing activities related to the program [It is perhaps not surprising that we were unable to detect an impact of the MOREtrenched , 29. As Improving patient safety and reducing adverse maternal and neonatal outcomes remain issues of critical importance in obstetrics, and our study demonstrates some of the important challenges associated with this area of research. Our study also demonstrates the critical nature of large datasets and long follow-up, which is especially important when studies are carried out in high-resource settings where adverse outcomes are rare. Great care is also needed in the selection of appropriate research and analytical methods. Future studies should look at the effect of obstetrical safety programs on other adverse outcomes such as near misses, as well as including objective measures of behavior change.OB program. Future evaluation studies should consider including other outcomes which might better capture the effect of an obstetric patient safety program.We did not find improvements in a composite indicator of adverse maternal and neonatal outcomes associated with implementation of the MOREAdditional file 1:ICD-10-CA and CCI codes that were used to define the elements of the AOI, and additional definitions. (DOCX 16 kb)Additional file 2:Crude outcome rates over time, Ontario, Canada, 2002 to 2014. This file includes 10 figures showing outcome rates over time for: WAOS, AOI, maternal death rate, neonatal death rate, maternal ICU admission, birth trauma, maternal unanticipated operative procedures, NICU admission, blood transfusion, 4th degree perineal tear. (PDF 514 kb)Additional file 3:OB program. (DOCX 14 kb)Characteristics of the hospitals included in the analysis, and the characteristics for the full sample of hospitals enrolled in the MOREAdditional file 4:Underlying secular trend for WAOS and mAOI, using time modeled as a continuous with a restricted cubic spline function. (PDF 214 kb)Additional file 5:OB implementation and two primary study outcomes. This table shows the Results of sensitivity for association between MOREOB implementation and two primary study outcomes. (DOCX 14 kb)Results of sensitivity analyses for association between MORE


The misuse and abuse of prescription opioids have become an urgent health issue in North Carolina (NC), particularly among Medicaid patients who suffer high rates of morbidity and mortality due to abuse and overdose. The NC Division of Medical Assistance (DMA) implemented a recipient management lock-in program, which limits identified patients for a 12-month period to 1 prescriber and 1 pharmacy for benzodiazepine, opiate, and certain anxiolytic prescriptions in order to prevent misuse and reduce overutilization of Medicaid benefits.To (a) evaluate pharmacists’ perceptions of the implementation of the NC recipient management lock-in program (MLIP) and (b) determine how the beliefs and attitudes of pharmacists could promote or inhibit its success.We conducted 12 structured phone interviews with NC pharmacists serving lock-in patients. Interview responses were analyzed through construct analysis, which identified themes organized into 3 domains: organization and implementation, perceived effectiveness, and acceptability.Most respondents reported a positive experience with the program but expressed doubt concerning its impact on prescription drug abuse. The program successfully utilized the pharmacist role as a gatekeeper of controlled substances, and the procedures of the program required no active effort on pharmacists’ part. However, respondents suggested that the DMA improve communication and outreach to address pharmacists’ lack of knowledge about the program’s purpose and confusion over remediating problems that arise with lock-in patients. The DMA should also address the ways in which the program can interfere with access to health care and treatment, allow patients to see multiple physicians within the same clinic, and clarify procedures for patients whose complex health issues require multiple specialists.Although possible improvements were identified, the NC MLIP has strong potential for success as it utilizes pharmacists’ medication gate-keeping role, while minimizing the effort required for successful implementation.


In this study, 2‐hydroxyethyl methacrylate (HEMA) was used as the monomers for surface grafting on electrospun PU/RC nanofiber membrane via atom transfer radical polymerization (ATRP) method, and the PU/RC‐poly(HEMA) nanofiber membrane was investigated as a carrier for LAC. Free and immobilized LAC was characterized, and efficiency of bisphenol A (BPA) removal was determined. The results indicated that the PU/RC‐poly(HEMA)‐LAC showed relatively higher pH stability, temperature stability, and storage stability than free and PU/RC‐LAC; moreover, more than 60% of the PU/RC‐poly(HEMA)‐LAC activity was retained after 10 cycles of ABTS treatment. Notably, the BPA removal efficiency of PU/RC‐poly(HEMA)‐LAC membrane generally ranged from 87.3 to 75.4% for the five cycles. Therefore, the PU/RC‐poly(HEMA) nanofiber membrane has great potential as a carrier for the LAC immobilization for various industrial applications and bioremediation. ABTS2,20‐azinobis‐(3‐ethylbenzothiazoline‐6‐sulfonic acid)ATRPatom transfer radical polymerizationBPAbisphenol ACAcellulose acetateHEMA2‐hydroxyethyl methacrylateHMTETA1,1,4,7,10,10‐hexamethyltriethyl‐enetetramineLAClaccasePUpolyurethaneTEAtriethylamine1Wastewater discarded from processing industries In recent years, enzymes have attracted special attention, due to its high efficiency and superior substrate selectivity Presently, electrospun nanofiber membrane with high specific surface area and porosity It is worth noting that the surface of electrospun nanofiber membrane exist a certain number of chemical/physical active sites for enzymes immobilization, but not enough In this study, the electrospun PU/RC‐poly(HEMA) blend nanofiber membrane was first prepared and then used as an ideal carrier for LAC immobilization by ion coordination method. This study explored various parameters related to LAC immobilization including the amount, temperature and pH stability, storage stability and reusability, and efficiency of BPA removal. The study demonstrated that PU/RC‐poly(HEMA) has great potential as a carrier for the LAC immobilization for various industrial applications and bioremediation.22.1LAC  was purchased from Sigma‐Aldrich . PU, CA (Mw = 131000 g/mol) was provided by Sinopharm Chemical Reagent . DMF, THF, 2,20‐azinobis‐(3‐ethylbenzothiazoline‐6‐sulfonic acid) (ABTS), FITC, coomassie brilliant blue (G‐250), 2‐methoxyphenol, 2‐bromoisobutyryl bromide (2‐BIB), 1,1,4,7,10,10‐hexamethyltriethyl‐enetetramine (HMTETA), triethylamine (TEA), HEMA, BPA were purchased from Aladdin Chemical Reagent  and used without further purification.PU/RC‐poly(HEMA) nanofiber membrane could be used as a carrier for LAC immobilization and exhibited relatively higher stability and reusability. And it was further applied to waste water treatment with high removal efficiency on phenolic compounds.2.22.2.1Prior to electrospinning, PU and CA mixture with mass ratio of 1/1 were dissolved in a mixture of DMF and THF solution at 45°C under the stirring condition. The electrospinning was carried out at 18 kV and the feed rate was set at 0.5 mL/h, meanwhile, the collector was placed at 17 cm below the tip of needle and the rotating speed of the collector was set at 100 rpm. The collected PU/CA membrane was hydrolyzed through immersion in 0.05 M NaOH aqueous solution at room temperature for 24 h. The resulting PU/RC nanofiber membrane was then rinsed in distilled water for three times and dried in a vacuum oven at 45°C.2.2.2PU/RC nanofiber membrane was first edulcorated by immersed in 20 mL of THF for 10 min, and then the nanofiber membrane was placed into a mixture of 70 µL of 10 mM TEA, 63 µL of 10 mM 2‐BIB and 50 mL of THF for 3 h at 35°C. 2‐BIB would react with hydroxyl groups on the surface of electrospun PU/RC nanofiber membrane, while TEA would neutralize the byproduct of HBr. After completion of the reaction, the nanofibers were taken out and stored in THF.2.2.3First, 24 mL of HEMA and a mixture of 400 µL of HMTETA and 24 mL of DMF were deoxygenated through three freeze‐pump‐thaw cycles by using liquid nitrogen, and then 100 mg of CuCl was added into the HMTETA/DMF mixture inside a vacuum glovebox followed by being magnetically stirred for 2 h. Subsequently, the initiated PU/RC nanofiber membrane and HEMA were placed into the mixture of HMTETA/DMF/CuCl, and the system was kept in the glovebox at 25°C for a predetermined time to complete the ATRP reaction of HEMA. Finally, the poly(HEMA)‐modified PU/RC nanofiber membrane was rinsed by ethanol and dried in air. According to the experimental results, the grafting rate of HEMA monomer in PU/RC‐poly(HEMA) nanofiber membrane was 23.1%.2.2.43 solution whose concentration was 100 mmol/L, the flack was shaken at 25°C for 24 h (120 r/min), then rinsed with deionized water. The obtained nanofiber membrane was dried in air and then dried at 35°C in a vacuum over couch.Prior to immobilization, same weight of PU/RC and PU/RC‐poly(HEMA) nanofiber membrane was added to 40 mL of FeCl2.3For immobilization of LAC, the PU/RC, PU/RC‐poly(HEMA) nanofiber membrane was firstly immersed into 50 mL 3 g/L LAC solution (pH = 4) at 4°C for 12 h. Then, the membrane was removed from the solution and rinsed with HAc‐NaAc buffer solution until no soluble protein was detected, and the immobilized LAC was stored in HAc‐NaAc buffer solution at 4°C. The detailed procedure for making PU/RC‐poly(HEMA)‐LAC nanofiber membrane is schematically depicted in Figures Ge is the amount of LAC bound onto unit mass of nanofibers (mg/g), C0 and C1 are the initial and equilibrium LAC concentrations in the solution (mg/mL), V0 is the volume of the LAC solution, C2 is the LAC concentration in the buffer solution used for washing the immobilized enzyme nanofiber, V1 is the volume of the buffer solution, and Md is the mass (dry weight) of the nanofiber membrane.In this experiment, the amount of immobilized LAC on the nanofiber membrane was determined by the method of Bradford. The fixed amount of LAC was determined by the Equation 2.4−1 with the resolution of 4 cm−1. X‐ray photoelectron spectroscopy measurements were carried out on a Kratos XSAM800 XPS system with Kα source and a charge neutralizer. An Instron 1185 tensile strength tester was employed to test the mechanical properties of nanofiber membranes. The tensile rate and clamp distance were 10 mm/min and 2 cm with a membrane specimen sizexbrk of 5 × 1 cm.Surface morphologies of the PU, PU/CA, PU/RC, PU/RC‐poly(HEMA), and PU/RC‐poly(HEMA)‐LAC membranes were examined by a Hitachi S4800 SEM. Image J software was used to determine the average nanofiber diameter, and 30 individual nanofibers in each SEM image were randomly selected for the diameter measurement. The presence of the fluorophore‐tagged LAC was determined using Confocal Laser Scanning Microscope technique, the LAC was labeled by FITC and the excitation and emission wavelengths were 488 nm. A Nicolet Nexus 470 FTIR spectrometer was employed to study the formation of different functional groups on the nanofibers, each type of membrane pieces was ground with potassium bromide (KBr) before being pressed into thin pellets for FTIR analysis, and the FTIR spectra were acquired by scanning the specimens for 32 times in the wavenumber range from 4000 to 450 cm2.52.5.10A and A are the respective initial and final absorbance of solution at 420 nm; V is the volume of ABTS solution (mL); T is the reaction time (min); K is the molar extinction coefficient of ABTS at 420 nm; and Ew is the amount of LAC (mg).To acquire the respective activities of LAC under free and immobilized conditions, 0.1 mL of LAC solution , as well as nanofiber membrane with equivalent amount of immobilized LAC, were mixed with 2.9 mL ABTS solution (pH = 4). The system was first stored at 30°C for 3 min (five replicates for each membrane). The activities of free and immobilized LAC were determined spectrophotometrically at 420 nm. The catalytic activity of LAC was calculated by using the following Equation In this experiment, relative activities were normalized to the initial activity which was taken as 100% by the following Equation 2.5.2To assess the pH dependence, the free and immobilized LAC were respectively incubated under different pH values (2.0–7.0) at 50°C for 5 min, subsequently, ABTS was added and the catalytic activities were then assayed. The highest catalytic activity of LAC was set as 100%, and then the relative catalytic activities under various conditions were then calculated.In order to assess the temperature dependence, free and immobilized LAC were, separately, mixed with ABTS solution (pH = 4) in the temperature range from 30 to 70°C, immediately thereafter, the catalytic activities were assayed.2.5.3Storage stability was evaluated upon calculating the residual activity of the free and immobilized LAC after being stored at 4°C in HAc‐NaAc for 24 days, and the highest value of each set was assigned as 100%. To examine the reusability of immobilized LAC, the activity of each nanofiber membrane with immobilized LAC was tested 10 times within 24 h. Prior to each test, the membrane with immobilized LAC was rinsed with HAc‐NaAc buffer solution to remove the reaction products and ABTS, and the activity of immobilized LAC was then tested in a fresh reaction medium.2.62CO3 solution  was added to the mixture and shaken for 1 min. Later the solution was brought up to 10 mL by adding deionized water. After 2 h, the absorbance was measured at 750 nm.To evaluate the efficiency of LAC in the degradation of BPA, free and immobilized LAC were incubated with 100 µM BPA in a dark place for up to 2 h at 30°C and under agitation of 120 rpm. Degradation of BPA by free and immobilized LAC was determined according to the method of the Folin‐Ciocalteu spectrophotometric method. The reaction mixture (100 µL) was added to the mixture of Folin‐Ciocalteu reagent (500 µL) and deionized water (6 mL), and the mixture was shaken for 1 min. Then Na33.1Figure 3.2−1 (C=O stretching), 1367 cm−1 (C–CH3 stretching) and 1231 cm−1 (C–O–C stretching); moreover, the two FTIR bands centered at 1630 and 1532 cm−1 in the spectrum of PU nanofiber membrane were attribute to the C=O, N–H stretching. All of the characteristic bands of PU and CA could be identified in the spectrum of PU/CA blend nanofiber membrane, indicating the co‐existence of both PU and CA in the nanofiber. After immersion in NaOH aqueous solution, CA was successfully converted into RC, as evidenced by the significant reduction of acetyl group related FT–IR bands centered at the wavenumbers of 1726 cm−1 (C=O), 1367 cm−1 (C–CH3), and 1231 cm−1 (C–O–C), in addition, the bands at 3500–3400 cm−1 can be respectively attributed to the stretching vibration of hydroxyl groups. The characteristic bands centered at 1746 cm−1 was obviously shown in Figure −1 of Figure Figure 3.33+ in Fe(Ⅲ)‐PU/RC‐poly(HEMA) nanofiber membrane, respectively. With compared to PU/RC‐poly(HEMA) membrane, indicated that iron ions were adsorbed on the surface of nanofiber membrane.Figure 3.4The stress‐strain curves of PU/CA, PU/RC and PU/RC‐poly(HEMA) nanofiber membranes were tested in this study and shown in Figure 3.5A comparison study between the free LAC and the immobilized LAC of PU/RC‐LAC and PU/RC‐poly(HEMA)‐LAC was carried out to determine the optimum reaction temperature and pH value. As shown in Figure Figure 3.6As shown in Figure Unlike free LAC, the residual activities of PU/RC, PU/RC‐poly(HEMA) nanofiber membrane immobilized LAC remained 49 ± 5.1)% and (63 ± 5.2)% of their initial activities upon reuse 10 times (the nanofiber membrane with immobilized LAC were washed with HAc‐NaAc after each time) as shown in Figure .1% and  was quantified during five successive batches of 2 h each. As shown in Figure 4Herein, the electrospun PU/RC blend nanofiber membrane was surface‐grafted with HEMA via ATRP method and studied as innovative carrier for immobilization of LAC. The results acquired from LSCM and Bradford protein assay indicated that the LAC molecules were uniformly immobilized on the PU/RC‐poly(HEMA) nanofiber surface while the corresponding immobilization amounts were 84.21 mg/g, representing the improvements of about 300% as compared to the value of PU/RC nanofiber membrane (21.13 ± 4.3 mg/g). Moreover, the PU/RC‐poly(HEMA)‐LAC exhibited considerably improved resistance against the variations of temperature and pH value than the free and PU/RC‐LAC. Furthermore, the storage stability and reusability of the PU/RC‐poly(HEMA)‐LAC were significantly improved, while the residual activity was retained at (63 ± 5.2)% of its initial activity upon reuse 10 times within 1 day. Notably, the BPA removal efficiency of PU/RC‐poly(HEMA)‐LAC membrane generally ranged from 87.3 to 75.4% for the five cycles.The authors have declared no conflict of interest.Supporting InformationClick here for additional data file.