Cytomegalovirus (CMV) is associated with congenital infections. We aimed to validate the revised CMV immunoglobulin (Ig) M titer cutoff for IgG avidity measurements as a reflex test in maternal screening to identify women with primary CMV infection and newborn congenital cytomegalovirus (cCMV). We screened maternal CMV antibodies (the Denka assay) in Japan, from 2017 to 2019, using a revised IgM cutoff (≥4.00 index). Participants were tested for IgG and IgM antibodies, and for IgG avidity if IgM levels exceeded the cutoff. We compared these with corresponding results from 2013 to 2017 based on the original cutoff (≥1.21) and recalculated using the revised cutoff. Newborn urine CMV DNA tests were performed for women with low avidity (≤35.0%). Among 12,832 women screened in 2017–2019, 127 (1.0%) had IgM above the revised cutoff. Thirty-five exhibited low avidity, and seven infants developed cCMV. Of 19,435 women screened in 2013–2017, 184 (1.0%) had IgM above the revised cutoff, 67 had low avidity, and 1 had cCMV. The 2017–2019 results were not significantly different from the 2013–2017 results. The revised IgM cutoff improves maternal screening in identifying primary infection and newborn cCMV; however, further study related to other assays than Denka is required. Toxoplasma gondii, rubella virus, cytomegalovirus (CMV), herpes simplex virus, and others . CMV  is the most common pathogen associated with mother-to-child transmission through the placenta and causes damage to the fetal nervous system. On average, 2.7 million new cases of congenital CMV (cCMV) infection occur worldwide each year [Maternal infections during pregnancy that can cause congenital abnormalities in infants include those from the TORCH complex: Reactivation, reinfection, and primary CMV infection during pregnancy can cause infant cCMV, which can lead to neurological sequelae, the most frequent being sensorineural hearing loss (SNHL), intellectual disability, cerebral palsy, visual defects, psychomotor impairments, and seizures. cCMV infection is the most frequent viral cause of intellectual disability and leading non-genetic cause of congenital SNHL in infancy. Congenital SNHL caused by cCMV may become apparent in older children who were not diagnosed in universal newborn hearing screenings and, therefore, did not undergo neonatal anti-viral drug treatment. Infants with cCMV should, thus, be followed up until 6 years of age for earlier intervention and better management and to control long-term neurological sensorineural sequelae .Serological screenings, including assessments of CMV immunoglobulin (Ig) G and IgM antibody levels, are used to identify recent primary infections. Maternal CMV antibody screenings are mainly performed to identify primary infections, which are associated with a higher risk of cCMV transmission than non-primary infections. The risk of occurrence of symptoms related to cCMV infection is highest after maternal primary infection in the first trimester of pregnancy. CMV IgG avidity tests are also used in maternal antibody screenings . SeroconUsually, only the presence or absence of IgM antibodies is considered in screenings. However, even when used in combination with IgG avidity, IgM tests are insufficient for the effective diagnosis of primary infections. Employing the Denka CMV IgM assay , which is widely used in Japan, we previously reported the usefulness of IgM assay titers in predicting low maternal IgG avidity and the occurrence of infant cCMV ; others Despite the possible usefulness of CMV IgM titers in predicting low maternal IgG avidity and the occurrence of infant cCMV, the validity of the revised CMV IgM titer cutoff compared with that of the original cutoff in maternal serological screenings has not been examined. Here, we prospectively examined the validity of the revised cutoff relative to the original cutoff of the CMV IgM antibody titer in a maternal serological screening to identify pregnant women with primary CMV infections and subsequent cCMV.Serum obtained during pregnancy  was used for antibody tests. Negative, equivocal, and positive results were defined as IgG titers  of ≤1.9, 2.0–3.9, and ≥4.0, respectively, and IgM titers (kit-specific CMV IgM antibody index) of ≤0.79, 0.80–1.20, and ≥1.21  in Denka CMV assays, which are enzyme-linked immunosorbent assays ,9. An avNeonatal urine obtained during the first week after birth was used for CMV DNA testing , and real-time polymerase chain reaction (PCR) was performed at Mie University Hospital  ,9. Real-The maternal antibody screening program “Cytomegalovirus in Mother and infant-engaged Virus serology (CMieV)” was launched in Mie, Japan, in 2013. This study was approved by the Clinical Research Ethics Review Committee of Mie University Hospital , and all participants provided written informed consent. This prospective cohort study was conducted in accordance with the Declaration of Helsinki. Early-stage pregnant women were registered at obstetric institutions and tested for serum CMV IgG and IgM antibodies at ≤20 gestational weeks. From September 2013 to March 2017, we used a cutoff of ≥1.21 IgM antibody index  to measure IgG avidity as a reflex test, and from April 2017 to March 2019, we used a cutoff of ≥4.00 index (the revised cutoff). Although prior studies suggested possible revised IgM cutoffs of 6.00 or 7.28 index [Pregnant women were divided into three groups according to their antibody levels. (1) In women with positive/equivocal IgG and IgM above the cutoffs , IgG avidity was measured as a reflex test using the same serum sample. Women exhibiting low IgG avidity were considered as having a primary infection; neonatal urine CMV DNA tests were performed after delivery . (2) In In infants with cCMV infections, neurological tests, such as brain magnetic resonance imaging (MRI), auditory brainstem response (ABR) tests, and funduscopic examinations, were performed approximately 1 month after birth. cCMV infants with abnormalities in these neurological tests were diagnosed with symptomatic cCMV and underwent anti-CMV therapy, whereas those without abnormalities were diagnosed with asymptomatic cCMV and were not treated.We retrospectively re-analyzed laboratory data obtained based on the original CMV IgM cutoff, using the revised cutoff, as below. First, to confirm the validity of the revised cutoff of CMV IgM antibody titer as part of the screening program, we assessed the difference in the proportions of women with positive/equivocal IgG and IgM above cutoffs  among all women. Second, we assessed the differences in the proportions of women with IgM above the revised cutoff, low IgG avidity, congenital infections including symptomatic infection, or symptomatic congenital infections among women with IgM above the original cutoff results. Third, to confirm the effectiveness of the revised cutoff, we studied sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for cCMV. Moreover, we compared the numbers of IgG antibody avidity tests required to detect one congenital infection case including symptomatic infection or one symptomatic congenital infection case.p-values < 0.05 were considered statistically significant. All analyses were conducted using IBM SPSS Statistics 27 .Differences were analyzed using Fisher’s exact test. In total, 12,832 pregnant women were registered at 24 institutions from April 2017 to March 2019 (the revised cutoff period). Median values of age, parity, and gestational week at testing were 30 (range 16–51) years, 1 (0–7), and 11 (4–20) weeks. The result after April 2017 is shown in Among the participants, 127 (1.0%) women had positive/equivocal IgG and IgM above the revised cutoff results. Thirty-five of these exhibited low avidity, and seven infants, who were all live births, had congenital infections. Six of the seven were positive for both CMV DNA and viral isolation in neonatal urine, whereas one was only positive for CMV DNA. Two cases were symptomatic. One showed a cerebral calcification on brain MRI and a unilateral threshold elevation on ABR testing, whereas the other showed a bilateral threshold elevation. Both underwent drug therapy . Among 1Among all 12,832 women, 4910 (38.1%) had negative IgG antibody results. Among these, 2941 underwent IgG and IgM antibody retesting at later pregnancy stages. Their median gestational week at retesting was 35 (range 28–41). Twelve of these exhibited IgG antibody seroconversion; five of them had infants with congenital infections, and all were live births. Four were positive for both CMV DNA and viral isolation in urine, whereas one was only positive for CMV DNA. All were asymptomatic .From September 2013 to March 2017 , 1037 and 184 of all 19,435 women had positive/equivocal IgG and IgM above the original and revised cutoff results, respectively. In total, 67 out of the 184 exhibited low avidity, and 8 infants had a congenital infection; 1 of them was symptomatic.p < 0.01 and 0.03, respectively) after the cutoff of CMV IgM antibody titer revision . These confirms the effectiveness of the revised cutoff of CMV IgM antibody titer.There were no significant differences in the proportions of women with positive/equivocal IgG and IgM above the original or the revised cutoff results among all screened women during the revised and original cutoff periods . MoreoveSpecific CMV IgM antibody titers become detectable between 0 and 3 weeks, with peak titers observed between 1 and 3 months after primary infection. The presence of CMV IgM antibodies in pregnant women is not specific for primary CMV infections because they may persist for months after a primary infection or occur as a result of assay cross-reactivity. Measurements of IgG antibody avidity as a reflex test are, thus, recommended in women with positive IgG and IgM results to identify non-primary or primary infections. Performance parameters, such as sensitivity, specificity, and positive and negative predictive values, for IgM antibodies for primary infections vary . Recent CMV IgM antibody tests used in Japan are generally insufficient for the effective diagnosis of primary infections, with the widely used Denka assay also having a low specificity. We previously reported that in cases with low IgG avidity index, the IgM titer tends to be high . CMV IgMThe maternal screening program detected congenital infection cases in women with low IgG avidity and high IgM titers (above the revised cutoff in the current study) between September 2013 and March 2017, but no cCMV cases in women with low avidity and low IgM titers  . We assuWe have two potential explanations for why women with primary infection are rarely included in those with low avidity and low IgM titers (under the revised cutoff in the current study). One is that some women exhibiting low avidity have been reported to have non-primary infections . MoreoveA limitation of this study is that we were not able to confirm primary infections serologically. Primary infections are typically confirmed by IgG seroconversion. As low IgG avidity does not always indicate a primary infection, other serological or non-serological tests would have been necessary to show that low avidity and IgM above the original cutoff but under the revised cutoff indicate non-primary infections. The number of neonatal urine CMV DNA tests in women with suspected past infection  was low. However, the two cCMV infants of women with suspected past infections that we identified both showed high IgG avidity . Therefore, our hypothesis that only high IgM titer women should be tested for IgG avidity is one of the issues that must be explored further.Neonatal urine CMV DNA screening is more effective than maternal antibody screening in identifying cCMV infants, as maternal antibody screenings cannot detect cCMV infants in mothers with non-primary infection. However, from a different point of view, maternal antibody screenings are able to effectively detect cCMV infants in mothers with primary infection. It is believed that maternal antibody screening can be effective before neonatal urine screening is initiated. We started the maternal antibody screening “CMieV” program in Mie, Japan, in 2013 and have continued it to date. Measurements of IgG avidity were a crucial tool in efficiently identifying cCMV infants in women with primary infection in maternal antibody screening. We would like to emphasize that the present study combines IgG avidity and IgM cutoffs in maternal antibody screening with the main objective of identifying cCMV infants in women with primary infection. This is the first report on the revised cutoff of IgM antibody titer in maternal serological screenings, showing that the revised cutoff was valid and effective in identifying women with primary infections and newborn cCMV infection. We found that it was more effective to identify women with primary infections by administering avidity tests only to women with high CMV IgM titers rather than to all IgM-positive women. Our consistent assertion is that women only with high CMV IgM titers should be tested for IgG avidity in the maternal antibody screening. As the revised CMV IgM titer cutoff improves maternal antibody screening in identifying women with primary CMV infection and newborn cCMV infection, we recommend the continued use or the wider implantation of the revised CMV IgM cutoff for other users of the Denka assay. However, further study related to assays other than the Denka assay is required to apply a revision of CMV IgM titer cutoff to other CMV IgM assays.


Parenting programs have proven effective in improving the behavior of children with attention-deficit/hyperactivity disorder (ADHD). However, barriers such as job and transportation constraints hinder parents from attending face-to-face therapy appointments. The COVID-19 pandemic has further exacerbated these challenges.This study aimed to develop and test the feasibility of a social media–based parenting program for parents of children with ADHD, considering both the pre-existing challenges faced by parents and the additional barriers imposed by the COVID-19 pandemic.This study used a 5-stage design thinking process, encompassing empathizing with parents, defining their needs, ideating innovative solutions, prototyping the program, and testing the program with parents. Qualitative interviews were conducted with 18 parents of children with ADHD to understand their unique needs and values. Brainstorming techniques were used to generate creative ideas, leading to the creation of a prototype that was tested with 32 parents. Participants’ engagement with the program was measured, and posttraining feedback was collected to assess the program’s effectiveness.Parents of children with ADHD encounter specific challenges, including managing impulsive behavior and difficulties in emotion regulation. The social media–based parenting program was delivered through the LINE app (Line Corporation) and consisted of 7 modules addressing topics related to ADHD management and effective parenting strategies. The program exhibited a high completion rate, with 84% (27/32) of participants successfully finishing it. Program provider–participant interaction peaked during the first week and gradually decreased over time. Qualitative feedback indicated that the program was feasible, accessible, and well received by participants. The LINE app was found to be convenient and helpful, and participants preferred content delivery once or twice per week, expressing acceptance for various content formats.This study emphasizes the significance of adopting a human-centered design thinking approach to develop parenting programs that cater to the unique needs and values of parents. By leveraging social media platforms, such as LINE, a parenting program can overcome the challenges posed by the COVID-19 pandemic and other constraints faced by parents. LINE offers a viable and feasible option for supporting parents of children with ADHD, with the potential for customization and widespread dissemination beyond the pandemic context. Attention-deficit/hyperactivity disorder (ADHD) is a prevalent psychological condition among school-aged children, affecting approximately 7.2% of children and adolescents aged ≤18 years .In the management of ADHD, parenting programs and medication are recognized as crucial components. Although medication can help manage symptoms, it is often insufficient to address the complex challenges associated with ADHD, without the support and guidance provided by parenting programs ,5. ParenTraditionally, parenting programs have been delivered through face-to-face group sessions, wherein parents from different families come together at a designated clinic or primary care unit . AlthougThe generalizability and effectiveness of traditional parenting programs may also be limited in low- and middle-income countries (LMICs), where socioeconomic conditions and health care systems differ significantly from those of high-income countries. Factors such as inadequate family income and limited access to mental health services can significantly moderate treatment outcomes . FurtherThe COVID-19 pandemic has disrupted many aspects of daily life, including access to health care services and support programs. Parents of children with ADHD have faced significant challenges in accessing and completing parenting programs during this time . LockdowTo address the challenges faced by parents both during the COVID-19 pandemic and beyond, it is essential to prioritize the accessibility and effectiveness of parenting programs . Social This study, which is part of a social media–based parenting program project, took place at a large university hospital in Songkhla, Thailand, during June 2020 (the first wave of the COVID-19 pandemic in Thailand). A multidisciplinary team of health care professionals, including 1 general pediatrician, 2 developmental-behavioral pediatricians, 1 developmental-behavioral nurse, and 2 child psychologists, developed and coordinated the program.The study protocol was approved by the Human Research Ethics Committee of the Faculty of Medicine, Prince of Songkla University (research ethics committee number: 62-381-1-1).We used a mixed methods approach, which involved participatory action research  and a deSemistructured in-depth interviews with parents and caregivers of children with ADHD were conducted to understand their challenges, problem-solving abilities, and preferences for a social media–based parenting program . DemograThe research team synthesized the information from the interviews into a point-of-view statement , ensurinIdeas for addressing the challenges and meeting the needs of parents were brainstormed, focusing on the creation of innovative solutions for the program content and features. Visual representations and structured brainstorming sessions facilitated the process ,37.One or more prototypes were developed based on the previous phases’ data. Rapid feedback was collected during testing to determine end users' needs, and this feedback was used to further develop the prototype toward its full potential ,37.Feedback from users was collected after the prototype’s launch ,38. DataThis study evaluated the five phases of the design thinking process, assigning distinct study populations to each stage based on the phase-related objectives. Data were collected from parents and caregivers of children with ADHD during the empathizing phase . AfterwaTo assess participant engagement, a manual text mining script was used to extract full transcripts of messages from moderators, researchers, and participants. These messages were categorized as text, images, videos, stickers, and audio messages. In addition to engagement, qualitative research was conducted during the empathy and test phases to gather data on parents’ needs, their perceptions, and lessons learned from the groups. Participants answered an open-ended questionnaire at the empathy phase and participated in in-depth interviews during the test phase.The engagement analysis involved calculating the total number of messages per topic and the frequency of messages sent per week by mothers and moderators. The frequency of messages, according to the day of the week and time of the day, was also evaluated to estimate mothers’ most active moments in social media groups. In terms of the qualitative analysis, a grounded theory approach was adopted. The research team read all in-depth interview transcripts, identified emergent patterns, and used inductive coding to pinpoint key themes and concepts. Text was extracted from transcriptions to generate analysis content, themes, and findings, which were subsequently translated to English.A total of 18 participants (primarily mothers), with a mean age of 42 years, were enrolled in this phase. The demographic data can be found in Participants expressed concerns about their children’s behavior and its impact on their own mental health .Parents expressed a desire to learn techniques to help their children academically and emotionally .Participants identified their children’s primary issues, such as a lack of focus, disobedience, and a lack of self-control .Parents shared information about their preferred electronic devices and social media–based platforms .Participants discussed their daily internet usage habits and preferred times for intervention .Parents indicated their preferred media formats for the parenting program, such as infographics and videos .Participants debated the merits of individual versus group counseling for addressing parenting issues .Parents highlighted the importance of involving all family members in the parenting intervention .In this phase, the research team, consisting of developmental-behavioral pediatricians, general pediatricians, a developmental-behavioral pediatrics nurse, and a psychologist, aimed to incorporate user requirements from the previous phase into the problem statement. They identified the users as “parents and caregivers of children with ADHD” and determined their critical need to be “learning parenting techniques” to help ameliorate their children’s behavioral problems.Through the analysis of the empathize phase, the team gained real insights into the parents’ and caregivers’ perspectives. Parents expressed feelings of being overwhelmed and sometimes felt helpless in the face of their children’s ADHD-related challenges. They also emphasized the importance of practical and easily applicable solutions that could seamlessly be integrated into their daily routines. The point-of-view statement, which was formulated based on these insights, was as follows:Parents and caregivers of children with ADHD need effective parenting techniques and support to improve their children’s behavior and overall well-being, while addressing their own emotional needs and fostering a sense of empowerment.The insight synthesized from the data denoted the desire “to improve the behavioral issues of children with ADHD.” This understanding led to the formulation of a “How Might We” (HMW) statement, which serves as a driving question to inspire innovative solutions. The HMW statement developed was as follows:How might we create a supportive and accessible program that equips parents and caregivers of children with ADHD with the necessary parenting techniques to effectively manage their children’s behavioral challenges and improve their overall well-being, while also addressing their emotional needs and fostering a sense of empowerment?The ideation phase began with the development team discussing potential solutions, using the HMW statement as a guide. The facilitator led a roundtable discussion centered around the HMW question.To ensure a diverse range of ideas during the brainstorming session, the team used the “Work Alone Together” technique. This method allowed individual team members to generate ideas independently before sharing them with the group. This approach fostered creativity and encouraged the team to explore multiple channels, formats, and platforms for the parenting program, such as using social media, videoconferencing, booklets, podcasts, and group meetings to deliver the program content.After the brainstorming session, the team used an affinity map  to categLINE (Line Corporation)LINE groupParent LINE groupLINE group: parents and teacherIndividual LINEFacebook (Meta Platforms Inc)Facebook: changing behaviorFacebook page for children with attention-deficit/hyperactivity disorder (ADHD)Facebook pagesFacebook group of ADHD caregiversYouTube (YouTube LLC) or videosSuggested list of videos in YouTubeDevelop video scenarios for behavioral management (published via a YouTube channel)Videos describing common behavioral problemsVideoconferencesUse Zoom (Zoom Video Communications Inc) program for tracking behavioral problemsBookletsBooklet for behavioral managementBrochureQuestion-and-answer brochure about common behavioral problemsListsList of interesting Facebook pagesLists of websites about parentingSuggest websites about ADHDGroup meetingsGroup meeting for ADHD caregiversParent group meetingTelephone counselinge-CounselingAdvise behavioral managementTarget behavior according to agePodcast: parenting managementBehavioral tutorial via teacherTelevision advertising at schools and hospitalsThe team used a prioritization map  to rank The prototype phase involved the development of a comprehensive social media–based parent training program, based on the insights and ideas gathered in the previous three phases of the design thinking process. The prototype consisted of a LINE-based parenting program, which included various components, such as content creation, user experience (UX) development of infographics, and video clip production, to provide parenting models for parents and caregivers.The content prototype was designed to address the needs and preferences of the target users. The team developed a curriculum of 7 parent training modules, which were to be completed over a 7-week intervention period. Each module covered a specific topic related to parenting children with ADHD and offered practical strategies, advice, and tips. The content was delivered through a combination of text messages, infographics, videos, and assignments, ensuring that the program was engaging, informative, and easy to follow .In order to create a visually appealing, user-friendly experience that also facilitated meaningful interaction among parents, the team focused on the design of infographics and on fostering engagement among users. The infographics were designed to be clear, concise, and informative, presenting complex information in an easily digestible format. They included visuals, charts, and graphs to illustrate key points and concepts, making it easier for parents to understand and apply the strategies discussed in the program. To promote interaction and engagement, the team incorporated features that encouraged parents to share their experiences, ask questions, and provide support to one another. This was achieved through the creation of a dedicated LINE group, wherein users could engage in discussions, share their progress, and seek advice from both experts and fellow parents. The group also served as a platform for sharing additional resources, hosting live question-and-answer sessions, and conducting polls to gather feedback and gauge user satisfaction. By fostering a sense of community and providing opportunities for interaction, the UX development aimed to enhance the overall effectiveness and appeal of the program .To further enhance the program’s effectiveness and user engagement, the team produced a series of video clips that demonstrated various parenting models and techniques. These videos featured expert advice, real-life examples, and step-by-step instructions to help parents and caregivers better understand and apply the strategies discussed in the program. The videos were designed to be short, focused, and easy to access, allowing users to watch them at their convenience.Once the initial prototype was complete, it was evaluated by a group of parents and caregivers who participated in a pilot testing phase. Participants completed a web-based eligibility screening and informed consent process as part of the baseline survey. Those who met the eligibility criteria and provided their consent were directed to complete comprehensive baseline surveys. Participants received a general schedule for the completion of the seven parent training modules and were provided with approximately one or two inputs daily, between 6 PM and 9 PM. They were also given 2 assignments per week, with a 1-week deadline for completing the assigned tasks.The feedback gathered from the pilot testing phase was used to refine and improve the prototype, ensuring that it effectively addressed the needs and preferences of the target users. The final prototype of the LINE-based parenting program was then prepared for implementation and further evaluation.A total of 32 participants from 24 families, who were parents or caregivers of children (aged 4 to 10 years) diagnosed with ADHD, were enrolled in this phase. Participants included mothers  and primary caregivers  with a bachelor’s degree. Most children were boys aged 8 to 10 years who were receiving medication as primary treatment .Engagement was assessed by tracking the content marked as “read” in the LINE app every week over the 7-week intervention period. The responses to interventions were categorized on a 4-point scale . A score of 46 represented that the participant had read all the content, while scores above 46 indicated that they read and interacted with the program providers. Participants’ engagement levels were charted by using a linear graph, which depicted their levels of interaction with the content over the 7-week period . The firThese data highlight the overall participant engagement in the program and how it evolved throughout the intervention.Qualitative data were collected from 32 participants via in-depth interviews after they completed the LINE parenting program. The following four themes emerged from the thematic analysis: (1) social media platform, (2) internet use behavior, (3) content formats, and (4) intervention adherence.Participants found the LINE app to be convenient and accessible, accessing it daily. They appreciated being able to save and review images and videos. One participant said:LINE is convenient, but an OPD visit is still necessary because when the doctor speaks to my son, he listens and follows your advice.Participants often read the content at night or on weekends, and the daily delivery of content was considered appropriate. Primary caregivers preferred daily content delivery, while others favored weekly delivery. A participant stated:I read the content on weekdays, after 21:00. Frequency of content delivery is acceptable at about 2–3 times per day.All content formats were deemed acceptable, and participants found Google Forms (Google LLC) to be user-friendly for assignments and questionnaires. They suggested the addition of more video clips that demonstrate communication techniques. One participant made the following suggestion:Google forms make it simple to complete assignments and questionnaires. Some content should be adjusted to reflect the child’s age and developmental stage.Participants applied the praising and communication skills from the modules in their daily lives. Many believed that a parenting program is suitable for primary caregivers, though some recommended adaptations for specific situations. For example, a participant said:A parenting program is appropriate for primary caregivers. If the recipient is not the primary caregiver, the content should be delivered at a slower rate.The innovative social media–based parenting program, which was developed through a design thinking process, demonstrates the potential of leveraging familiar and accessible platforms to address the needs of parents and caregivers of children with ADHD. By using the LINE app, the program delivered content in varied formats, offering valuable ADHD information, parenting guidance, assignments, and screen-to-screen consultations. This approach made the program accessible, feasible, and acceptable for Thai parents, who found it convenient to save and review information as needed. The success of the program can be attributed to the incorporation of the participants’ needs and values, its feasibility, and its acceptability, as evidenced by the high retention rate and qualitative feedback.The internet use behaviors observed in this study, such as preferred communication times and the use of familiar social media apps, align with previous research -45. ThisThe content, structure, and delivery of the program were crucial factors that contributed to its feasibility and acceptability. Participants appreciated the convenience of receiving the program through the LINE app, which they used daily. The praise-focused content was particularly interesting to the participants, in line with a previous meta-analysis that found a large effect size for praise, reward, and logical sequence techniques . The proParticipants were highly engaged with the program, with 84% (27/32) of participants expressing interest in the intervention. Parents were familiar with the LINE app and discussed their children’s behavioral difficulties. Although participants did not always respond immediately to the inputs, they reported reading the material later, saving photographs and video clips on their devices, and sharing the materials with others who faced similar problems with their children’s behavior. These engagement rates compare favorably with previous studies; Franke et al  found thParticipants believed that the program should also include other caregivers, but the content should be brief and summarized for nonprimary caregivers. Previous research has also shown that interactive programs are more effective in improving child behavior than noninteractive programs . This hiWith regard to future research and implementation, human-centered solutions are necessary to reduce the gap between parents’ needs and the content and structure of parenting programs, particularly for parents of children with ADHD. Future studies should focus on personalization, engagement, and positive parental experiences to improve social media–based parenting programs. Additionally, more research is needed to understand how to optimize the integration of technology into parenting interventions, especially in LMICs, where resources and access to quality information may be limited. Collaboration among health care providers, researchers, and technology developers is essential for the creation of effective and accessible social media–based interventions. By working together, these stakeholders can ensure that evidence-based information and guidance are disseminated to parents and caregivers in an engaging, user-friendly format. Furthermore, public health organizations and educational institutions can play a critical role in promoting and supporting the adoption of such interventions within communities.This study has several limitations that should be acknowledged. First, the sample size was small, which may impact the statistical power of the quantitative findings. However, it is important to note that this study used a mixed methods approach, which allows for data saturation and ensures comprehensive exploration of the research questions beyond mere statistical power. Second, this study was conducted within a single institution; as such, there is a possibility of selection bias, and the findings many not be generalizable to a broader population. To address this limitation, future research should consider multicenter collaborations to include more diverse settings and participants, thereby enhancing the external validity of the findings. Additionally, volunteer bias may have influenced the results, as participants who volunteered for this study may have had characteristics or motivations that were distinct from those of nonparticipants. To mitigate this bias, future studies could explore recruitment strategies that reach a wider range of participants, aiming for a more representative sample.This study provides evidence for the feasibility and acceptability of a social media–based parenting program for Thai parents of children with ADHD. The program was developed by using a design thinking approach and delivered through the LINE app, a social media platform that was familiar and accessible to the participants. The program provided valuable technical skills related to nurturing children with ADHD and was well received by parents and caregivers. Future research on social media–based parenting programs should focus on personalization and on meeting the specific needs of parents and caregivers to improve long-term outcomes for children with ADHD and their families.


The prognostic impact of intrahepatic lymphatic vessel invasion (LVI) in liver cancer has rarely been reported. We sought to clarify the prognostic impact of intrahepatic lymphatic system involvement in liver cancer. Tumor-associated lymphangiogenesis reportedly correlates with prognosis after HCC resection. A meta-analysis showed that overall survival was poorer in patients with positive LVI than with negative LVI after resection of ICC and colorectal liver metastasis. Lymphangiogenesis was also reported to predict unfavorable prognosis in ICC. A few reports showed correlations between LVI/lymphangiogenesis and LNM in liver cancer. LVI and lymphangiogenesis showed worse prognostic impacts for liver cancer than their absence, but further study is needed.Although several prognosticators, such as lymph node metastasis (LNM), were reported for hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC), the prognostic impact of intrahepatic lymphatic vessel invasion (LVI) in liver cancer has rarely been reported. We sought to clarify the prognostic impact of intrahepatic lymphatic system involvement in liver cancer. We systematically reviewed retrospective studies that described LVI and clinical outcomes of liver cancer and also included studies that investigated tumor-associated lymphangiogenesis. We conducted a meta-analysis using RevMan software . The prognostic impact of intrahepatic LVI in HCC was not reported previously. However, tumor-associated lymphangiogenesis reportedly correlates with prognosis after HCC resection. The prognostic impact of intrahepatic LVI was reported severally for ICC and a meta-analysis showed that overall survival was poorer in patients with positive LVI than with negative LVI after resection of ICC. Lymphangiogenesis was also reported to predict unfavorable prognosis in ICC. Regarding colorectal liver metastases, LVI was identified as a poor prognosticator in a meta-analysis. A few reports showed correlations between LVI/lymphangiogenesis and LNM in liver cancer. LVI and lymphangiogenesis showed worse prognostic impacts for liver cancer than their absence, but further study is needed. The liver produces 25–50% of total lymph fluid in the body and includes a dense network of lymphatic vessels linking to the cisterna chyli and thoracic duct ,2,3. TheLiver cancer is the fourth leading cause of cancer-related deaths worldwide . In 2015One of the major concerns regarding intrahepatic LVI in liver cancer is the increasing incidence of LNM. The prognostic impacts of LNM such as hepatic nodes in HCC and ICC were widely reported, and a positive finding is considered a strong poor prognosticator ,49,50,51We systematically reviewed studies that provided information on both LVI and clinical outcomes in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . We alsoWe conducted a meta-analysis using RevMan software . Dichotomous outcomes are shown as risk differences and 95% confidence intervals. Heterogeneity among the included trials was evaluated using a forest plot. I-squared and chi-squared statistics were used to evaluate statistical heterogeneity ,58. A ra2 field) in several areas of highest vascular density identified in low-magnification (×25–40) views were used for assessing LVD .,79.62,79 0.0007) . Several 0.0007) ,82,83,84 0.0007) . Intratu< 0.001) .p < 0.00001 In terms of CRLM, several studies investigated the intrahepatic lymphatic system and clinical outcomes  34,35,3,37. Becap = 0.0001) [p = 0.010) [Schoppmann et al. reported significant correlations between LVI and lymphangiogenesis at both primary colorectal sites and liver metastatic sites . LVD was 0.0001) . They co 0.0001) . They al 0.0001) ,87,88,89= 0.010) . High ex= 0.010) .p = 0.039) [Two main routes of cancer metastasis were reported: hematogenous spread and lymphogenous spread . The rou= 0.039) . They su= 0.039) . They te= 0.039) .p < 0.001 and 59% vs. 38%, p < 0.001, respectively) [High-level lymphangiogenesis was also associated with a significantly higher incidence of LNM than low-level lymphangiogenesis in ICC in studies by Sha et al. and Thelen et al. (ctively) . Tumor cctively) . As mentctively) . Neverthctively) . In poolctively) . With ICctively) .A large-scale study of the intrahepatic lymphatic systems in terms of liver cancer prognosis was rarely reported. However, the invasion of lymphatics may have a clinical prognostic impact as strong as that of blood vessel invasion in liver cancer, since the liver manages almost half the lymph generated in the human body ,2,3,4. Fp = 0.0001) [With regard to HCC, no studies appeared to have evaluated LVI. This may be due to the scarcity of LVI itself in HCC as compared to ICC, because of the reduced invasiveness of HCC compared to ICC . However 0.0001) . Yokomor 0.0001) . Since t 0.0001) . The assSeveral reports found that microscopic serosal invasion in HCC resulted in poor prognosis ,91,92. TAlthough LVI is easy to consider as the main cause of LNM, the correlations between LVI and LNM were not clarified in HCC. This is largely attributable to the low incidence of LNM in HCC, at 0–7.45% in operable cases ,103,104.2 = 66%), LVI (+) showed significantly poorer 5-year OS than that of LVI (−)  showed significantly poor 5-year OS in LVI (+) patients than that of LVI (−) in CRLM patients (p < 0.00001, Regarding CRLM, two routes of metastasis are known: the lymphatic route, such as secondary to initial colonization of regional lymph nodes, and direct hematogenous spread from the primary tumor, which is independent of lymph node metastatic growth ,114. FirThis study showed several limitations. First, the number of patients was insufficient. Second, the accuracy of LVI determinations may have been lacking, as not all the included studies explained the details of the pathological diagnosis for LVI or lymphangiogenesis, such as the use of D2-40. Third, details of LVI, such as the types of lymphatic vessels involved, were also not described in the majority of papers. More precise evaluations of LVI and lymphangiogenesis are warranted in future research to develop more appropriate treatment strategies, including perioperative chemotherapy or lymphadenectomy.LVI and lymphangiogenesis have prognostic impacts for liver cancer, but the correlations with LNM remain unclear. Further large-scale studies are warranted. In other words, to reveal the association between LVI/lymphangiogenesis and LNM/prognosis, thorough pathological evaluation of LVI/lymphangiogenesis using D2-40 antibody should be performed in liver cancer as well as other gastroenterological cancer. However, the definition of LVI/lymphangiogensis needs further discussion. Nevertheless, if the prognostic role of intrahepatic lymphatic system and mechanism of lymphatic spread of carcinoma are fully investigated, the treatment strategy such as surgical procedure or perioperative chemotherapy will be better utilized.


C) into a protease-resistant and/or amyloid form of PrP, called PrP resistant (PrPRes). The RT-QuIC is an automatic assay system based on real-time measuring of thioflavin-T (Th-T) incorporation into amyloid fibrils using shaking for disaggregation. It has already been applied in diagnostics, drug pre-screening, and to distinguish between different prion strains. The seeded conversion efficiency and the diagnostic accuracy of the RT-QuIC assay strongly depend on the kind of recombinant PrP (rec PrP) substrate. The DNA sequences of different substrates may originate from different species, such as human, bank vole, and hamster, or from a combination of two species, e.g., hamster-sheep chimera. In routine use, either full-length (FL) or truncated substrates are applied which can accelerate the conversion reaction, e.g., to a more sensitive version of RT-QuIC assay. In the present review, we provide an overview on the different types of PrP substrates (FL and truncated forms), recapitulate the production and purification process of different rec PrP substrates, and discuss the diagnostic value of CSF RT-QuIC in human prion disease diagnostics.The development of the real-time quaking-induced conversion (RT-QuIC), an in vitro protein misfolding amplification assay, was an innovation in the scientific field of protein misfolding diseases. In prion diseases, these types of assays imitate the pathological conversion of the cellular prion protein (PrP C) into an abnormally folded isoform, termed PrP scrapie (PrPSc). Protein misfolding amplification assays mimic the seeded conversion process of PrP in vitro to amplify minuscule amounts of a PrPSc seed to an aggregated form of proteinase K–resistant PrP, termed (PrPRes) , fatal familial insomnia (FFI), or Gerstmann-Sträussler-Scheinker syndrome (GSS), exhibit a template-induced conversion of the cellular prion protein , were based on sonication and applied non-infected brain material as source of PrPSc amplification and detection which is a prerequisite for routine use.Compared to the PMCA, the RT-QuIC assay facilitates the standardization of PrPSc seed which can be derived from the brain, cerebrospinal fluid (CSF), olfactory mucosa (OM) brushings, or other tissues from CJD patients , and maximal signal intensity can be used as semi-quantitative parameters to compare the seeding conversion efficiencies of different groups  is subjected to dialysis and to filtration (0.2-micron filter)  human sequence, reported a sensitivity of more than 80% and a specificity of 100% in a cohort of 18 CJD patients and 30 controls , FFI and sCJD patients  combined with some modification of the RT-QuIC protocols (incubation at 55 °C and 0.002% sodium dodecyl sulfate (SDS) addition) -analytical protocols. In addition, the composition of patient cohorts, such as the controls  or case group characteristics , may contribute to variable accuracies. To calculate the diagnostic accuracy, many studies applied CJD samples, classified as probable or possible CJD, because confirmation upon autopsy is often missing. Misdiagnosed CJD cases may interfere with the diagnostic accuracy of the assay. A further cause for variability is the kind of (pre)-analytic protocol. Regarding the CSF RT-QuIC (routinely applied in diagnostics), a variety of instruments, rec PrP substrates, and CSF volumes are used across different CJD surveillance centers. Most of them apply hamster rec PrP, either as FL or as truncated form (rec PrP 90–231), exhibiting a very good diagnostic accuracy  and including various sequences from different species have been successfully applied in the RT-QuIC to detect PrP


Randomized controlled trials have demonstrated the effectiveness of workplace smoking cessation programs. However, with low participation rates reported, it is important to understand the barriers and facilitators for the reach and participation of employees in workplace smoking cessation programs. The objective of the present study is to uncover the needs of employees regarding reach and participation when implementing a workplace program to address smoking cessation.We carried out 19 semi-structured qualitative interviews in 2019 based on the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) Framework with current and former smoking employees of organizations with ≥100 employees in the Netherlands. Some of the interviewees had experience with a cessation program. Data were analyzed using the Framework method.The main barriers according to employees were insufficient promotion of the cessation program, completing the program in the employee’s own time and working night shifts and peak hours. Facilitators included being actively approached to participate by a colleague, positive reactions from colleagues about employee’s participation in the program, providing the program on location and integrating the program as part of the organization’s vitality policy.Effective workplace programs for smoking cessation can stimulate cessation but implementers often experience low participation rates. Our study presents recommendations to improve the recruitment and participation of employees in a workplace smoking cessation program, such as using active communication strategies, training managers to stimulate smoking employees to participate and making the program as accessible as possible by reimbursing time spent and offering the program at the workplace or nearby. Integrating the smoking cessation program into wider company vitality policy will also aid continued provision of the program. Furthermore, workplace cessation programs are just as effective as those in other settings at stimulating cessation3 and effective for those with a lower income and educational level6, suggesting utility to address smoking in lower socio-economic groups, under which smoking prevalence is often higher7. Not only does a smoking employee's health gain from quitting, but employers could also recoup and prevent costs incurred due to increased sick leave or disability, productivity losses owing to smoking breaks and increased healthcare costs9. Reduced smoking prevalence also translates into lower healthcare costs and increased quality of life years11.The workplace is a valuable setting for reaching a large adult population for health promotion programs, such as those that encourage smoking cessation12 which may become progressively more challenging as workers become increasingly mobile due to distance-working3, a trend heightened by the COVID-19 pandemic. Part-time or temporary contracts pose additional challenges for recruitment and the scheduling of activities so that they remain accessible to all13. Furthermore, there is a dearth of literature regarding the needs of employees when implementing a workplace health promotion program as most of the attention thus far has been given to the employer’s needs.A problem that remains, however, is the low rate of participation often achieved in such workplace programs14 to include the removal of designated smoking rooms in all workplaces in 2022 and introduction of smoke-free outdoor grounds of institutions such as hospitals, mental health facilities and government buildings in 202516. With these developments, it would be prudent for employers to consider offering a smoking cessation program to their employees and therefore it is important that we learn how this can be done successfully. In 2019, 26.2% and 24.9% of lower and moderately educated adults in the Netherlands smoked respectively, of which 89.3% and 76.3% smoked daily, compared to 15.4% of highly educated adults who smoked, of which 48.7% smoked daily17. To better understand the barriers and facilitators in the reach and participation of employees in workplace cessation programs, we conducted a qualitative needs assessment among employees in the Netherlands, focusing on workplaces with employees with a lower level of education. Our needs assessment focused on the following research questions: 1) ‘How can employees be reached to inform and stimulate them to participate in a smoking cessation program?’, 2) ‘How do colleagues react to the participation of others in the program?’, 3) ‘What are the practical barriers and facilitators to participation in the program?’, and 4) ‘What factors should be considered when maintaining a smoking cessation program in an organization?’.Workplaces in the Netherlands are moving towards becoming totally smoke-free, with legislation expanding on the 2004 workplace smoking banWithin this qualitative study, we performed individual qualitative interviews (n=19) among employees of organizations in the Netherlands. Interviews were performed between January and June 2019.6. The smoking cessation program in this RCT consisted of group-based weekly sessions of 1.5 hours for 7 weeks. Interviewees included were from both the treatment group  and control group . Other interviewees who had not participated in the RCT were recruited via convenience sampling through company representatives. All interviewees received 20€ as compensation for their participation in the interview, which was directly deposited to their bank account. The aims of the research were shared with the interviewees via an information letter and the informed consent form. The Central Committee on Research Involving Human Subjects in the Netherlands requires no ethical approval for non-medical research. The interviewing author and the interviewees did not know each other prior to study commencement.Purposive sampling was used to recruit current and former smoking employees of organizations with ≥100 employees of which relatively many people have a low level of education. Purposive sampling also made sure a variation of organizations from different sectors and employee occupations were included . Our samSemi-structured interviews were conducted face-to-face at the workplace by one of the authors (CB), who is trained and experienced in qualitative interviewing. A qualitative approach was used so that employees could share their opinions and experiences in a detailed way, also allowing the interviewer to probe when new or unexpected findings were reported. See the Supplementary file for interview topic lists for employees who have and have not experienced a workplace smoking cessation program.Interviews lasted between 30 and 80 minutes. Two of the interviews were conducted with a manager or human resources (HR) representative present.18. We focused on aspects of reach, adoption, implementation and maintenance as the effectiveness of workplace group cessation programs has been investigated in previous work19. For adoption, we asked about the acceptability of the program by employees and their colleagues.The interview guide was semi-structured and based on the RE-AIM Framework, which stands for Reach, Effectiveness, Adoption, Implementation and MaintenanceAs mentioned, not all interviewees received a workplace smoking cessation program. The cessation program was described to these respondents before asking them what barriers and facilitators they perceived to exist.20. This method consists of five stages: 1) familiarization, 2) identifying the thematic framework, 3) indexing, 4) charting, and 5) mapping and interpretation. The first stage, familiarization, was undertaken by CB, LdH-B, TM and NP. CB wrote memos and an overall report of the interviews and LdH-B, TM and NP read the report and the transcripts to familiarize themselves with the data. The report was also shared with the respondents so that they had the opportunity to provide comments. LdH-B and TM completed the second stage (indexing), coding the transcripts both deductively and inductively21. The first two transcripts were double coded by LdH-B and TM, before agreeing on a final thematic framework (stage three), whereafter the remaining transcripts were coded individually by LdH-B and TM. Themes were arranged based on the RE-AIM model from which further sub-themes were made, for example, under Reach, sub-themes ‘reasons to participate or quit smoking’ and ‘recruitment general’ were made. These sub-themes were further broken down into individual factors given by the respondents. FvdB and NP created a matrix based on the RE-AIM model and responses were summarized and added to the matrix . In the final stage, mapping and interpretation, the matrix was primarily examined by NP for connections and comparisons across respondents within codes, checking the original transcripts for context. Interpretations were discussed within the research team. For only one theme data saturation was not reached, as the sub-theme ‘not suitable for temporary workers’ emerged in the penultimate interview. The data was also analyzed for patterning in responses based on characteristics such as participation in the program, gender and smoking status; however no substantial differences in responses were found.All interviews were audio recorded, transcribed verbatim and imported into NVivo 12  for coding and analysis. All interviews were coded using the Framework methodEmployees mostly expressed that a more proactive and personal approach is needed to stimulate participation. Respondents felt that more could be done to promote the smoking cessation program as some only received a mass e-mail or saw a message on the intranet . They al‘I came across it on the intranet, but if I had looked a week later … I could have missed it, the message.’ (Participant 11)In addition, more proactive promotion of the program would enable more employees to hear about the program:‘I actually had to enquire about it myself.’ (Participant 10)Another barrier mentioned was being approached to participate with a judgmental tone:‘Don’t go the usual way of “Yeah, you smoke”, “Our sick leave is so high because you smoke” You know, that blaming.’ (Participant 8)Respondents reported discussing the announcement of the cessation program with a colleague, which was an important reason as to why they signed up for the program:‘At first I was like “no” until my colleague who was super enthusiastic said “ah, we’re going to do that”. That won me over.’ (Participant 2)A few respondents, however, did not discuss their decision to participate with colleagues, with one employee noting that shame was a barrier to talking about participating with colleagues:‘But [not discussing participating with colleagues] has a reason and the reason was the shame that I would feel if I didn’t succeed.’ (Participant 7)Employees also emphasized the importance of being personally approached, although opinions on whether one should be approached specifically by a direct manager or someone from the HR department varied:‘[if you personally approach people] I think employees would feel less like a number. If you receive an e-mail, it says “dear [name]”, but that is of program computer work. If they really visit the smokers, people personally, I think you will achieve more.’ (Participant 6)A direct manager was thought of by the majority of respondents to be most appropriate as there is more trust built to discuss these topics and because they know which employees smoke, other respondents suggested a member of HR to convey the importance of the program.Respondents came with their own ideas to promote the program. One respondent who did not participate in the program, from a company with many non-Dutch-speaking employees, recommended that there also needs to be attention for the language in which promotional materials are shared:‘It is important that you give a printed sheet in Polish. Give it to the people.’ (Non-participant 3)Another mentioned that past program participants could be interviewed or share their success stories on the intranet:‘How do you make sure that people are still enthusiastic? You only get that with … a few good stories and keep promoting that.’ (Participant 1)Colleagues were mostly positive about participation, although less so when the program was not held in the employees’ own time. Respondents mostly reported (anticipated) positive responses from their colleagues about their participation in the program and that they received social support from colleagues for their participation:‘My experience is that my colleagues wished me the best.’ (Participant 14)‘[my colleagues] think it’s great that I quit. They motivated me to quit.’ (Participant 10)Seeing colleagues participate in the program also stimulated interest in some smoking colleagues.Whilst colleagues were typically positive about the respondent’s participation in the cessation program, some wondered whether their colleagues were less positive about their time for the program being reimbursed:‘They were positive towards me, but I don’t know what they say behind my back: “how much time does that take?” ’ (Participant 13)A few respondents said that they had received skeptical reactions from colleagues about how successful they would be at quitting:‘Well, there was a bit of “Yeah, (…) you’re not going to make it. You know, you’ve tried so many times, so it won’t work this time either”.’ (Participant 4)Some colleagues only shared their skepticism after the program had finished.Employees named several practical barriers to participation, spanning the setting and timing of the program. Many respondents emphasized the importance of the program being offered during working hours and not having to use their leave allowance:‘I don’t think you should get into that discussion that it’s about hours, because then someone will already drop out. So I think you should fully facilitate it and [the hours] should never be an issue if you ask me.’ (Participant 1)Respondents who were not reimbursed for their time on the program found this to be a significant barrier to participation:‘Our employer let us participate in this, but he has actually said from the start: “We facilitate it in the sense that we make a location available, but you have to invest your own time there”. This has been a thorn in my side, I’m very honest, because I think that if you set up something like this as an employer, which is very good, you should also make people free for that.’ (Participant 2)The workplace setting also lowered the threshold to participate:‘And because it was so accessible, eh, I was already here, it was an hour of your working hours, so the walk was very easy, er, I did it because I thought: well, what have I got to lose? You know, I’m here anyway, I’ll walk over there and I’ll see.’ (Participant 14)Additional barriers were faced by people who work night shifts or experience peak hours during their shift as the timeslots for the program were sometimes not convenient or were at odds with the demands of work:‘I don’t think there are very many people who would like to stay before or after the night shift.’ (Nonparticipant 1)I think it varies from department to department. I have a peak here from 12:00 to 14:00 (...) After or before that, I can arrange something. But don’t touch my peak, you know?’ (Non-participant 4)‘Lastly, it was reported that it may not be possible to offer the program to all employees, such as those with short, temporary contracts:‘The program isn’t for everyone. Some people work for two weeks, sometimes three weeks and then they go again. But this is suitable for permanent workers.’ (Non-participant 3)Respondents suggested ideas for improving the program and some saw it as part of a wider movement towards a healthier lifestyle. Respondents were happy overall with the program, regardless of abstinence status at the time of the interview. Those who had not successfully quit smoking after the program shared their enthusiasm for it to be repeated for themselves or colleagues who had not yet participated:‘I e-mailed [HR] about this: “I actually want to do [the program] again, because I didn’t stop then”. Actually yes, I did stop, but then I started again.’ (Participant 12)The suggestion came from one respondent to integrate the program into existing company vitality policy:‘I would perhaps make this a part of a kind of vitality program. It’s not just a healthy diet and a healthier lifestyle, but smoking is part of it too.’ (Participant 9)Some respondents expressed that, should the program be offered again, they would like the program to be longer than seven weeks, with continued attention paid to quitters for sustained motivation:‘… maybe a little more attention, that you also feel the motivation more. If that fades away, you won’t have that incentive anymore.’ (Participant 10)22. More generally, passive methods of recruitment for smoking cessation programs, such as public announcements, are associated with lower levels of recruitment and retention23. Instead, proactive and personal communication can increase program reach and be particularly beneficial in recruiting those with a low socioeconomic position24. In the current study, employees were far more receptive to a more personal approach, with some having decided to participate due to a conversation with a colleague. Rather than relying on incidental word-of-mouth promotion, employers could actively target team leaders or other key figures among their staff to share and promote the program. The introduction of smoke-free policy presents an opportunity to engage with employees on this topic. Although not mentioned by the participants in this study, an additional social aspect that may play a role in the decision to participate is not wanting to lose time with colleagues, which is currently spent on smoking breaks, by quitting25.Our qualitative needs-assessment identified several barriers and facilitating factors in the reach and participation of a workplace smoking cessation program. Firstly, in reaching employees to inform them about the program, many employees felt that their employers’ efforts were not sufficient, especially when employers relied on digital communication (e-mail or intranet messages). Dutch employers also reported that some employees were not reachable through digital communication channels26 and so testing of promotional materials would be advisable. Additionally, in organizations where this is prevalent, word-of-mouth promotion may be particularly beneficial.Not all groups are equally easy to reach, however. In the present study, we found that language ability could be a barrier to reaching all employees, especially where (a large proportion of) employees do not understand or speak the national language(s). With this, it is important to make sure that any materials are translated accurately22. To temper potential negative reactions from colleagues, employers should clearly explain to their employees that by reimbursing time spent on the program, they are fully supporting employees to embark on a healthier lifestyle. Offering a vitality program, under which smoking cessation is one component alongside other topics such as exercise and healthy eating, also gives other employees the opportunity to engage in a healthier lifestyle.Accessibility for low-threshold participation was important to the employees as they felt that the program should be offered on location or nearby, that their time should be reimbursed and fit into their working hours to the extent that that is possible. Our study found that negotiation over employees’ own time investment may deter participation, especially for those who already work unsociable hours. However, some employees suspected that colleagues would regard the reimbursement of hours as unfair, although to what extent this sentiment may have been voiced is unknown. Employers’ views on the program being reimbursed vary, as some recognized the lowered threshold to participation but others felt it was only fair that the employees invested some of their own time27 and was also mentioned as important by the employees in our study. For some occupations, however, simply offering the program on location and reimbursing the time will not be sufficient, as additional barriers are faced by those who experience peak hours (for instance in customer- or client-facing roles) or for employees who work irregular hours, such as night shifts or who are temporary workers. Time-related barriers to participation such as a high workload, inflexibility to leave their immediate work area and competing work obligations have also been reported for other workplace programs31. Whilst it may not be possible for employees who work from home or who have demanding or incongruous work schedules to participate in a group-based program, these groups should not be forgotten or treated with less priority, as both they and their employer can still benefit from reduced illness and disability as a result of quitting8. Temporary workers hold a particularly unstable position in the workplace and may therefore experience more stress32, furthering their need for cessation support. Other more flexible options such as telephone, online or individual counselling could be more accessible for these groups. Individual smoking cessation counselling of a similar intensity can be just as effective as group-based counselling33 and often requires a smaller time investment from the participant as the sessions are focused on the individual rather than a larger group. This could be offered as an alternative for employees whose work obligations preclude them for joining a group-based program, with the possibility to participate during or after working hours.Providing the program at the workplace has been highlighted as an important factor in deciding to participate previously34 estimate that it can take between 6 and 30 serious quit attempts before quitting successfully (for at least one year) and so smoking employees would benefit from being offered the chance to participate in a smoking cessation program more than once. Moreover, communicating this may remove some of the shame in discussing quitting with colleagues.Respondents were largely positive about the program, regardless of whether they had remained abstinent at the time of the interview. It is clear that for some, however, further support is needed, be that in the form of a longer program for support or the opportunity to complete the program again. The program was offered to employees as a one-off, whereas Chaiton et al.22. Moreover, establishing a company culture of health promotion through the creation of a comprehensive health or vitality program is a component of program success and sustainability35.In order to enable employees to participate more than once, the program would need to be maintained. For the maintenance of the program, a key step would be to entrench smoking cessation support into a greater (existing) health or vitality program offered by the employer. In this way, other barriers can be tackled such as routinising the process of recruitment and delivery of the program31. However, the field overall, could benefit from more employee needs assessments being conducted with regard to other health behaviors.More generally within the workplace health promotion field, the attention thus far has been given to the employer’s needs when implementing a workplace health promotion program as program adopters, whilst to our knowledge, the needs of employees have been hardly studied. As such, we uncovered new factors that may hinder or facilitate reach and participation in a workplace health program, such as feelings of shame preventing discussion of the program with colleagues or the provision of promotional materials in other languages. Whilst our study focused on a smoking cessation workplace program, many of the findings may be applicable to other types of health promotion workplace programs in which group training sessions are given. In particular, similar findings regarding time constraints have been reported in other workplace health promotion programsOur study has highlighted some important barriers and facilitators to the recruitment and participation of employees in a workplace group-based smoking cessation program. These factors should be considered and addressed in order to ensure optimal program outcomes. To address some of the main barriers, we present the following recommendations: 1) use pro-active communication strategies such as word-of-mouth to inform about and promote the program, 2) train managers to discuss with and stimulate smoking employees to participate, 3) explain to all employees why the program is being offered and the benefits it can have for all staff, 4) make the program as accessible as possible by reimbursing time spent and offering the program at the workplace or nearby, and 5) integrate the smoking cessation program into wider company vitality policy.Strengths of the study include the inclusion of employees from different sectors and occupations, increasing the validity of our results for different workplaces. Secondly, by interviewing employees with and without previous experience with a workplace smoking cessation program, we were able to see whether employees who would be hypothetically recruited for the first time would share the same concerns.This study is not without methodological limitations. Firstly, none of the employees was from workplaces where a cessation program had been held for more than once; and so we are not able to know which factors might become relevant if the program was run repeatedly. Issues related to reaching and recruiting employees, in particular, may differ as program recruitment becomes more routinised. Whilst our sample included employees from a range of occupational roles and industries, only two participants reported having a low level of education and so certain factors that may be more relevant to this group could have been missed or underreported. Lastly, we recognize that the results of the present study may not necessarily be applicable to workplaces with younger employees (aged <30 years) or smaller workplaces (<100 employees) due to the characteristics of our sample.Workplace programs for smoking cessation are effective in stimulating cessation but implementers often experienced low participation rates. Our study presents recommendations to improve the recruitment and participation of employees in a workplace smoking cessation program, such as using active communication strategies and making the program as accessible as possible by reimbursing time spent and offering the program at the workplace or nearby. Integrating the smoking cessation program into wider company vitality policy will also aid continued provision of the program.Click here for additional data file.


The Jackpot.fit program was developed by the Austrian health insurance funds and the organized sport with the aim of offering a standardized training for physically inactive adults. The first semester is free of charge. The original idea was that health insurance companies would use different strategies to recruit participants and that organized sports would offer the standardized program in local sports clubs. In this context, we wanted to investigate which recruitment strategies work well.In one region of the province of Styria (Austria), we wanted to offer a dense network of Jackpot.fit classes, as the sports program was to take place close to home. Adults who signed up for Jackpot.fit received an online questionnaire. One question asked: “How did you find out about Jackpot.fit?” Ten answers were available for selection, with multiple responses possible. Responses could be categorized into four areas: Information from the health care system, from the community, from the sports clubs, and from friends/acquaintances. The questionnaire was sent to 394 persons and 133 (34%) completed it .One health insurance company sent letters to its insured, which was the most successful strategy (mentioned by 33 participants = approximately 25%). The second best strategy is word of mouth through friends/acquaintances (28 participants). Other good recruitment strategies are the community newspaper (23 participants), and activities of the sports club trainer (19 participants). 437 general practitioners working within a 10 km radius of a Jackpot.fit course were informed in writing about Jackpot.fit and were asked to inform their inactive patients participating in Jackpot.fit. However, of the 133 participants, only 3 indicated that their primary care physician informed them about the program.Health insurance companies can successfully recruit physically inactive adults with a letter to a standardized sports club program near their home. Community information channels and word of mouth have also been successful. Although the network of general practitioners working in the region is dense, written information about the program was not a successful recruitment strategy. Therefore, different recruitment approaches by different actors seem to work best.