Due to advances in the field of oncology, survival rates for children with cancer have improved significantly. However, these childhood cancer survivors are at a higher risk for obesity and cardiovascular diseases and for developing these conditions at an earlier age.In this paper, we describe the rationale, conceptual framework, development process, novel components, and delivery plan of a behavioral intervention program for preventing unhealthy weight gain in survivors of childhood acute lymphoblastic leukemia (ALL).A Web-based program, the Healthy Eating and Active Living (HEAL) program, was designed by a multidisciplinary team of researchers who first identified behaviors that are appropriate targets for weight management in childhood ALL survivors and subsequently developed the intervention components, following core behavioral change strategies grounded in social cognitive and self-determination theories.The Web-based HEAL curriculum has 12 weekly self-guided sessions to increase parents’ awareness of the potential impact of cancer treatment on weight and lifestyle habits and the importance of weight management in survivors’ long-term health. It empowers parents with knowledge and skills on parenting, nutrition, and physical activity to help them facilitate healthy eating and active living soon after the child completes intensive cancer treatment. Based on social cognitive theory, the program is designed to increase behavioral skills  and self-efficacy and to provide positive reinforcement to sustain behavioral change.Lifestyle interventions are a priority for preventing the early onset of obesity and cardiovascular risk factors in childhood cancer survivors. Intervention programs need to meet survivors’ targeted behavioral needs, address specific barriers, and capture a sensitive window for behavioral change. In addition, they should be convenient, cost-effective and scalable. Future studies are needed to evaluate the feasibility of introducing weight management early in cancer care and the efficacy of early weight management on survivors’ health outcomes. Dramatic improvements in the diagnosis and treatment of cancer in childhood have led to a rapidly growing cohort of survivors, now estimated to exceed 450,000 in the United States . HoweverFew interventions are designed to promote lifestyle modifications in childhood cancer survivors to reduce obesity and CVD risk . To our Although cancer treatment can directly impact weight patterns, children also develop adaptive behaviors such as poor eating habits and physical inactivity during treatment. We conducted preliminary studies that identified intake patterns and levels of total energy expenditure in young survivors of pediatric ALL and lymphoma ,12. ThesBased on these findings, we developed a Web-based weight management program, the Healthy Eating and Active Living (HEAL) program, tailored for families with patients and survivors of childhood ALL, the most common cancer in children. Here we describe the conceptual framework, development process, novel components, and delivery plan of the HEAL program.A multidisciplinary team of researchers  met weekly and identified behaviors that are appropriate targets for weight management in childhood cancer survivors and formulated the intervention components. Guided by strong evidence in childhood cancer survivors and informed by obesity prevention programs in the general pediatric population, we identified parenting, nutrition, and physical activity as 3 behaviors to change for the development of the HEAL program. Following the identification of behaviors to change, we used a basic framework of core behavioral change strategies as a foundation to formulate program goals and components. These core behavioral change strategies are grounded in theoretical models  ,28, inclParental perception of their child’s weight status is a key factor in determining parents’ readiness for weight management for their child . The curThe parenting focus is to improve parenting practices that facilitate healthy eating and active living in the family. The HEAL program engages parents as the agent of change, because the program targets on young children with ALL who largely fall into the age range of 4 to 10 years old when they start maintenance therapy or within 2 years of treatment completion. It emphasizes parents’ roles in transitioning the family toward healthy eating and active living through modifying the family environment. It also addresses common barriers that parents face in implementing change at the family level.The nutrition focus is to enhance diet quality by (1) limiting consumption of sugar-sweetened beverages (SSBs) and foods high in empty calories; (2) limiting consumption of processed foods and snacks high in sodium; and (3) increasing consumption of vegetables, fruits, and whole grains. Although not a direct target for weight management, the program also includes (4) increasing dietary sources of vitamin D and calcium.The physical activity focus is to increase activity by (1) reducing screening time, (2) gradually increasing activity to 60 or more minutes/day and incorporating physical activity into daily activities, and (3) incorporating bone-strengthening activity 3 or more days/week ,31.The HEAL program is designed to increase behavioral skills through goal-setting, self-monitoring, and problem-solving. Goal-setting uses SMART planning to help parents set Specific, Measurable, Achievable, Relevant, and Time-bound goals and action items . ParentsThe HEAL program is designed to incrementally support and increase behavioral skills. As these are developed, participants acquire mastery experiences to increase self-efficacy.The program uses positive reinforcement strategies to further promote self-efficacy by sending parents motivational messaging throughout the course of the program. The motivational messages were developed by the clinical psychologist and behavioral scientist on the research team. They serve to remind parents to set goals, track child’s food intake and physical activity, and complete self-guided curriculum sessions and to provide recognition and encouragement after parents complete these activities. Some of the messages are also designed to promote 3 basic psychological needs: competence, autonomy, and relatedness, grounded in self-determination theory (SDT). The motivational messages are sent automatically to parents’ email or through short message service (SMS) after parents enroll into the program, following predetermined algorithms based on program usage and completion status. Alternatively, motivational messages can be delivered by a lifestyle coach trained in motivational interviewing who can further provide feedback based on usage and completion. The use of a lifestyle coach as human contact to support the program is optional and is currently only available in research settings. Parents cannot opt out of motivational messages but can choose to receive messages through email or SMS. Some examples of motivational messages are presented in The HEAL program website was created by an in-house facility, the Center for Engineering Education and Outreach, at Tufts University between January and June 2015. The website has incorporated 4 active modules: Curriculum, SMART Plans, Logs, and Rewards . AdditioGrocery Store Scavenger Hunt, Create Your Own MyPlate, Eat the Rainbow, Grow Your Own Veggies, Sugar Detectives, Cook from Scratch, Drinks for Strong Bones and Teeth) and physical activity (such as Body Sketch-Hopscotch and Fun and Fast Circuit Course) for the whole family.The curriculum includes 12 weekly sessions outlining topics on targeted behaviors and specific barriers . Each seParents enrolled in the HEAL program are asked to complete the weekly self-guided curriculum; set up behavioral goals on parenting, nutrition, and physical activity using SMART plans; and complete weekly food and activity logs online (for at least 2 weekdays and 1 weekend per week) for 12 weeks. All curriculum sessions are accessible by the participants after they log in, although instructions are provided in the first session that they are expected to complete one session per week. The HEAL program has built-in functions that monitor how many minutes a HEAL user spends daily on each session to track usage. Based on the usage, the program sends automated motivational messages to parents after completion of goal-setting, logs, and curriculum session. Parents achieve Bronze, Silver, and Gold status after completing each of the 4 sessions as rewards, and children receive a digital certificate after completing family activities. At the end of each curriculum session, parents are encouraged to complete an online evaluation that asks them to rate statements about their knowledge of session-specific topics before and after each session on a 5-point Likert scale and answer open-ended questions on their perceptions of session strengths and weakness. As part of the study end assessment, parents are asked to complete a usability assessment once they have finished the program.Childhood cancer survivors are at substantially increased risk of developing cardiometabolic conditions at a young age. Although treatment exposure, alone or in combination, contributes to elevated CVD risk in childhood cancer survivors, the attributable fraction was less than 50%, ranging from 9.3% for hypertension, 15.5% for dyslipidemia, 41.7% for diabetes, and 42.1% for obesity [Many survivorship programs for childhood cancer lack a focus on nutrition, or when nutrition is introduced, the priority is to satisfy caloric needs and prevent weight loss. Although malnutrition due to cancer-related anorexia and cachexia still represents an important concern in cancer care , overconParenting styles and practices are important behavioral targets for weight management in childhood cancer survivors. For young survivors (aged 10 years or under) with limited autonomy and greater dependence on caregivers, family environment plays a highly influential role in facilitating a child’s eating and activity behaviors. For families with childhood cancer survivors, family environment can be even more important, because a close parent-child relationship is often expected in this context . QualitaAn important characteristic of childhood cancer survivors is that they are geographically dispersed. As a consequence, they have transportation difficulties coming to interventions delivered at a central location. Intensive time commitment to cancer-related care adds an additional barrier for families to participate in interventions scheduled at fixed times . On the In summary, lifestyle interventions are becoming a priority in cancer care to prevent excessive weight gain and early onset of CVD risk factors in childhood cancer survivors. These interventions must meet the targeted behavioral needs of the survivors; address specific barriers; capture a sensitive window for behavioral change; and be convenient, cost-effective, and scalable. Future research is needed to evaluate the feasibility of engaging pediatric ALL survivors and families in early weight management either within or outside cancer clinics and to assess participation, adherence, and retention rates. Such findings will provide an important foundation to inform the design and implementation of a fully-powered randomized controlled trial to evaluate the effect of early weight management on preventing unhealthy weight gain and CVD risk in young survivors of childhood ALL and to identify effective strategies to integrate weight management into cancer care and adapt the program to survivors with other cancer diagnoses.


The Affordable Medicines Facility for malaria (AMFm) Program was a subsidy aimed at artemisinin-based combination therapies (ACTs) in order to increase availability, affordability, and market share of ACTs in 8 malaria endemic countries in Africa. The WHO supervised the manufacture of the subsidized products, named them Quality Assured ACTs (QAACT) and printed a Green Leaf Logo on all QAACT packages. Ghana began to receive the subsidized QAACTs in 2010.A cross-sectional stock survey was conducted at 63 licensed chemical shops (LCS) and private pharmacies in two districts of the Brong-Ahafo region of Ghana to determine the availability and price of all anti-malarial treatments. Drug outlets were visited over a 3-weeks period in October and November of 2014, about 2 years after the end of AMFm program.At least one QAACT was available in 88.9% (95% CI 80.9% – 96.8%) of all drug outlets with no difference between urban and rural locations. Non-Assured ACTs (NAACT) were significantly more available in urban drug outlets [75.0% availability (95% CI 59.1% – 90.9%)] than in rural drug outlets [16.1% availability (95% CI 2.4% – 29.9%)]. The top selling product was Artemether Lumefantrine with the Green Leaf Logo, a QAACT. There was a significant difference in the mean price of a QAACT [$1.04 USD (95% CI $0.98 – $1.11)], and the mean price of a NAACT in both the urban and rural areas [$2.46 USD (95% CI $2.11 – $2.81)]. There was no significant difference in the price of any product that was available in urban and rural settingsAbout 2 years after the AMFm program, subsidized QAACTs in Ghana were widely available and more affordable than NAACTs in the Kintampo North District and Kintampo South Municipality of Ghana. The AMFm program appeared to have mostly succeeded in making QAACTs available and affordable. Plasmodium falciparum  was significantly different and more than half the price of a NAACT [$2.46 (95% CI $2.11 – $2.81)]  about 2 years after the end of AMFm program especially in rural areas. The high availability of QAACTs found in this study is similar to that found by Tougher et al. in their evaluation of AMFm in Ghana at the end of AMFm program . In the A QAACT as a top-selling product mentioned by drug outlet attendants in the entire study area signals the success of one of the AMFm program’s goals to encourage the sale of ACTs to treat malaria. However, SP and Quinine, neither being recommended treatments, were both highly sold in rural drug outlets. Customers prefer products they have used successfully in the past and were less expensive. Quinine is the recommended treatments for patients with complicated or severe malaria as well as the treatment of uncomplicated malaria in the first trimester of pregnancy . SP is uThe mean price of QAACTs were significantly cheaper than their Non-Assured counterparts across all drug outlets where they were available. This observation is similar to that observed by Ansah et al.  and meetThis research could not conclude that in the absence of the subsidy from the AMFm program, the availability of NAACTs would remain as low in rural drug outlets. QAACTs could be acting as a substitute good that would be replaced by NAACTs if the subsidy from the Global Fund to decrease the price of QAACTs never existed.The method to determine the top selling products did not require sales data or confirmation from the sales records of the drug outlets. Only verbal confirmation from the attendant was required, introducing the possibility of a response bias. The attendant may have been inclined to respond that a QAACT is the top selling product because they are aware that it is recommended for malaria treatment.During the study period of this research, QAACTs were more available and were cheaper than NAACTs in the Kintampo North District and Kintampo South Municipality. The mean price of a QAACT was uniform across urban and rural areas and was slightly higher than the price of non-ACT treatments available.


Objectives. To evaluate whether collaboration between existing and new transcatheter aortic valve replacement (TAVR) programs could help reduce the number of cases needed to achieve optimal efficiency. Background. There is a well-documented learning curve for achieving procedural efficiency and safety in TAVR procedures. Methods. A multidisciplinary collaboration was established between the Minneapolis VA Medical Center (new program) and the University of Minnesota  1 year prior to launching the new program. Results. 269 patients treated with TAVR (50 treated in the first year at the new program). Mean age was 76 (±18) years and STS score was 6.8 (±6). Access included transfemoral , transapical , transaortic , and subclavian  types. Procedural efficiency , device success , length of stay , and safety  were similar between programs. We found no difference in outcome measures between the first and last 25 patients treated during the first year of the new program. Conclusions. Establishing a partnership with an established program can help mitigate the learning curve associated with these complex procedures.  The introduction of a novel technology is usually accompanied by a period of learning in which operators develop and refine new skills until they achieve a “steady state” characterized by high efficiency and procedural success with low complications , 2. In tThe number of new TAVR procedures in the US has doubled in fiscal year (FY) 2013 from the previous year, with 10,599 total Medicare claims in FY 2013 as compared to 5,400 claims in FY 2012 .In this context, it is important to develop strategies and partnerships that allow initiation of new TAVR programs that can produce efficacy and safety results that are comparable to existing national benchmarks in a reasonable period of time. In this manuscript, we describe our experience during the launch of a new TAVR program at the Minneapolis VA Medical Center. This program was launched after 1 year of close collaboration, proctorship, and hands-on experience with the University of Minnesota Medical Center.The Minneapolis VA Healthcare System (MVAHCS) is a tertiary, 250-bed hospital within the VA Midwest Heath Care Network (Veterans Integrated Service Network VISN 23). The network serves more than 440,000 enrolled Veterans residing in the states of Iowa, Minnesota, Nebraska, North Dakota, and South Dakota and portions of Illinois, Kansas, Missouri, and Wyoming. The MVAHCS is the only approved TAVR program in an eight-state area and has an academic affiliation with the University of Minnesota. The University of Minnesota Medical Center (UMMC) has an existing TAVR program since 2012 and had performed 140 TAVR procedures prior to mentoring the MVAHCS program.Prior to launching the TAVR program, an institutional collaboration agreement was established between MVAHCS (new program) and UMMC (established program) with the goal of launching the new program with high success and low complications rates that were comparable to national benchmarks.Specific interventions included the following: (1) common weekly TAVR video conference to discuss patients by a multidisciplinary team of interventional cardiologist, cardiac surgeons, anesthesiologists, and cardiac imaging, (2) privileging and hands-on training of lead interventional cardiologist and cardiac surgeon , (3) observation of UMMC cases by MVAHCS heart team members including anesthesiologists, perfusionists, and operating room and cardiac catheterization laboratory personnel, and (4) sharing of order sets and imaging protocols .We included 219 patients treated with TAVR at UMMC since 2012 and 50 patients treated at MVAHCS during the first year of the program (April 2015–April 2016). We excluded patients that underwent transcatheter valve replacement in a nonaortic position . Patients that underwent TAVR procedures for off-label indications  and/or valve in vale (VIV) procedures were included in the analysis.Outcomes measures included procedural efficiency, as assessed by procedural time and contrast volume. Contrast volume included contrast used for peripheral angiography at the end of the procedure, which is routinely used in both programs. Procedural time was the time from arterial puncture or surgical incision until the end of the procedure. Measures of procedural success (device success) and safety  were assessed in both groups using Valve Academic Research Consortium (VARC) definitions .t-test  for continuous variables. Indices were tested for normality of distribution, with nonnormally distributed data compared using 2-sample t-tests after initial logarithmic transformation. Categorical variables were compared using chi-square or, when there are fewer than 5 expected outcomes per cell, Fisher's exact test. Two-sided p < 0.05 was considered indicative of statistical significance. Statistical calculations were performed using STATA Statistics Version 12 .Comparisons between groups were made using Student's n = 50) treated in the new program during the first year was 79 (±8) and the mean Society of Thoracic Surgeons (STS) risk score was 6.8. Transfemoral (TF) access was used in 70% and alternative access in the remaining 30%. Alternative access included transapical (n = 8), transaortic (n = 2), and subclavian (n = 5) types. Of the TF cases at the established program, 90 were percutaneous and 43 used a cut-down approach. Most cutdowns were used during 2012-2013, with first-generation valves. At the new program, all TF cases were percutaneous. At the established program, general anesthesia was used in all cases but 7 which were done with moderate sedation, and 1 was epidural. All of the cases at the new program were done with general anesthesia. A 12% increase, from 64% to 76%, in TF access was seen in the second half of the year (p = 0.36). A balloon-expandable valve  was used in 80% of cases and a self-expandable valve  in the remaining 20%. The average valve size was 27.7 (±2) mm. The mean age of the patients (n = 219) treated in the established program was 81.5 (±9) and the mean STS score was 8. Patients in the established program had a higher prevalence of hypertension, heart failure, and previous myocardial infarction  (p = 0.26) (p = 0.61) (p = 0.5).Overall procedure time was 158 ± 59 minutes for the new program and 148 ± 62 minutes for the established program ( = 0.27) . Average = 0.26) . Contras = 0.61) . Contrasp = 0.08) (p = NS).Device success was high, 96% for the new program and 87% for the established program ( = 0.08) . In the  = 0.08) . Serious = 0.08) . A perma = 0.08) . A trend = 0.08) . A compaThere are several significant findings from this study. First, a new TAVR program launched in close collaboration with an existing TAVR program was associated with low complication rates and high device success from its inception. Second, procedural efficiency and length of stay were similar between the existing and the new TAVR programs. Third, mortality at 30 days was low at 4%, which is similar to the most recent STS/ACC TVT registry report . Fourth,TAVR procedures are highly complex and require a multidisciplinary heart team approach between medical and surgical disciplines to achieve optimal outcomes . A learnIn the United States, the number of TAVR programs enrolled in TVT registry has more than doubled from 156 in 2012 to 348 in 2014 , it is eOur study has several limitations. First, we recognize that most VA Medical Centers have an academic affiliation with Universities and this may not be the case for other programs in the private sector. Competition for market share, limited time for physician training, and obtaining hospital privileges in multiple institutions could be important barriers to collaboration. Second, we are not able to identify which aspect of the training was more important. Third, reductions in the size of the delivery system and enhanced valve performance have significantly simplified the procedure as reflected by increased adoption of conscious sedation . Future We found that establishing a partnership with an existing TAVR program mitigated the learning curve associated with these complex procedures. The new program had similar outcomes to established programs in the US since its inception.This collaborative model could be used by other institutions planning to become TAVR centers.Included in the Supplementary Appendix are the individual operator volumes of the established and new programs. Also included are operator volumes at the new program prior to starting the program.


Objective To evaluate the effectiveness of a comprehensive workers’ health surveillance (WHS) program on aspects of sustainable employability and cost-benefit. Methods A cluster randomized stepped wedge trial was performed in a Dutch meat processing company from february 2012 until march 2015. In total 305 workers participated in the trial. Outcomes were retrieved during a WHS program, by multiple questionnaires, and from company registries. Primary outcomes were sickness absence, work ability, and productivity. Secondary outcomes were health, vitality, and psychosocial workload. Data were analyzed with linear and logistic multilevel models. Cost-benefit analyses from the employer’s perspective were performed as well. Results Primary outcomes sickness absence (OR = 1.40), work ability (B = −0.63) and productivity (OR = 0.71) were better in the control condition. Secondary outcomes did not or minimally differ between conditions. Of the 12 secondary outcomes, the only outcome that scored better in the experimental condition was meaning of work (B = 0.18). Controlling for confounders did not or minimally change the results. However, our stepped wedge design did not enable adjustment for confounding in the last two periods of the trial. The WHS program resulted in higher costs for the employer on the short and middle term. Conclusions Primary outcomes did not improve after program implementation and secondary outcomes remained equal after implementation. The program was not cost-beneficial after 1–3 year follow-up. Main limitation that may have contributed to absence of positive effects may be program failure, because interventions were not deployed as intended. Working in the meat processing industry consists of repetitive, monotonous and physically demanding tasks . WorkersOn top of the health hazards come societal developments such as an aging workforce and rising retirement age . Higher In a recent systematic review limited evidence was found for favorable effects of interventions aimed at sustainable employability in ageing workers . In the The present study evaluated the POSE program (Promotion of Sustained Employability), which is a comprehensive workers’ health surveillance (WHS) program developed by commercial parties in collaboration with an occupational health service . The proWhat is the effect of the POSE program compared to CAU on the primary outcome measures work ability, sickness absence, and productivity?What is the effect of the POSE program compared to CAU on the secondary outcome measures psychosocial workload, subjective health status, and vitality?Which effect does the POSE program have on costs and benefits from the employer’s perspective?A pilot study was conducted before the onset of this stepped wedge trial in which the POSE program led to improved work ability . This result was used for the power calculation of the present trial . Based oThe CONSORT statement was used to describe this study . The MedThe study was designed as a stepped wedge trial with follow-up measurements within a 1–3-year period after start of the intervention. A detailed description is published in the design paper . In brieAll contracted workers (n = 986) were invited to participate in the study. Workers were eligible if they were contracted personnel, performed paid labor for at least 12 h per week at the company (as defined by Statistics Netherlands), agreed to participate in the POSE program, and provided informed consent to participate in the study.The POSE program has previously been described in detail . The proRegular  healthcare, unrelated to the POSE program, was considered CAU. Programs already running within the company were considered CAU as well. These could be company fitness programs, healthy canteens, etc.Primary outcomes: sickness absence, work ability, productivity. Sickness absence data were provided by the company. Sickness absence days  were calculated for 1 year prior to baseline and for the periods in between measurement points. Partial sickness absence was taken into account by multiplying absence percentage and number of corresponding absence days. Absence periods of more than 2 days were recalculated by multiplying by 5/7, to ensure that weekends were excluded. Next, data were recalculated to days per year. Finally, absence days were dichotomized. The cut-off was set at nine work days per year, as this matches the average yearly absence rate at the company (approx. 4.5%). Work ability was measured with the work ability index (WAI)  for whicSecondary outcomes: psychosocial workload, health status, vitality. Aspects of the psychosocial workload were measured by a short form of the second version of the copenhagen psychosocial questionnaire (COPSOQ II) , 24. ThePersonal and work characteristics were assessed as covariate in this study. Most personal and work characteristics were retrieved from the company registry  and POSE program (education).The cost-benefit of the POSE program was evaluated from the employers’ perspective. The cost-benefit analysis evaluated the total costs of the POSE program for the company and compared absenteeism and presenteeism costs before and after the POSE program. Costs (in Euros) included:Direct costs of the POSE program: the costs of the program itself (assessments and counseling).Absenteeism costs. Average salaries per plant department were obtained from the company. The gross annual salary including holiday allowances and premiums was recalculated to salary per workable day  . The numPresenteeism costs. Productivity loss at work was assessed using the QQ questionnaire , consistThe sample size calculation was based on the effectiveness with regard to work ability and resulted in a sample size of 44–46 participants per plant assuming participation of four plants. The sample size calculation for this study has been described in the design paper .POSE program participants  were compared to non-participants with regard to age, gender, job tenure, contract hours, and total sickness absence duration one year before baseline. Group differences were analyzed with Mann–Whitney U tests and Fisher’s exact test and considered significant if p < 0.05.Analyses on the effectiveness of the intervention were performed in SPSS version 22.0 for Windows . The effect of the trial on the primary and secondary outcomes was analyzed using linear (for the continuous outcomes) and logistic (for the binary outcomes) multilevel analyses including a random coefficient for the individual , and a fTo control whether long-term sickness absence affected the results of the primary analysis, multiple sensitivity analyses were performed. First, the analyses on sickness absence were restricted to participants without sickness absence periods of more than 200 standardized days/year (n = 17) or participants without sickness absence periods of more than 100 standardized days/year (n = 47). Second, sickness absence days due to exceptional causes  were set to zero. Sickness absence due to other causes was still included in the analysis. Third, to test whether effects on primary and secondary outcomes were influenced by plant and time effects, sensitivity analyses were conducted including plant and a categorical time variable as fixed effects.The cost-benefit analysis was performed from the employer’s perspective. Only employer costs and benefits were included. Direct costs were defined as intervention costs, in this case the POSE program, being € 200,- per participant. During this study, no in-company interventions were offered. Benefits were expressed as the difference in monetized outcome measures  between the intervention and control condition. Positive benefits indicate reduced spending. Three metrics were calculated : net benTwo analyses were performed on absenteeism costs, one with and another without exceptional causes. Two analyses were performed on absenteeism and presenteeism costs, one with and another without exceptional causes. There were 33 (1.8%) missing values for costs related to absenteeism, caused by the fact that some workers were laid off during the trial. In addition there were 643 (36.0%) missings for costs related to presenteeism, leading to a relatively large number of missings for total costs. Therefore we first performed multiple imputations (n = 20) using chained equations with predictive mean matching. For the analyses on absenteeism costs, the imputation model consisted of the absenteeism costs for every time point, the allocation at every time point, age, day salary and plant. When presenteeism costs were included in the analyses, they were also added to the imputation model. The effect of the trial on the costs was analyzed in these 20 imputed datasets using linear multilevel analyses including a random effect for the individual. Confidence intervals for NB’s, BCR’s and ROI’s were calculated based on 5000 bootstrap samples using the percentile method. Finally, point estimates and lower and upper limits of the confidence intervals were pooled using Rubin’s rules . Cost anPOSE program participants (n = 303) differed from non-participants (n = 683) on gender, age, job tenure, and sickness absence days per year. Among participants there was a higher percentage of men , they were older , worked longer at the company  and had more sickness absence days . Contract hours did not differ (p = 0.52).In total, 305 workers participated in the POSE program. Due to administrative flaws, two participants were excluded from all analyses. Characteristics of the participants are presented in Table 0 and T1). Even though questionnaires were returned, individual questionnaire items could be missing. Only complete (sub)scales were included in the analyses. Sickness absence data were complete, as far as people were employed at the time of the study. For the other primary and secondary outcomes, on average 49.3% of the 2,121 items each was missing (N = 303).A flow chart with returned questionnaires per time point is presented in Fig. Figure Table After exclusion of participants absent for more than 200 days (n = 17) the difference between conditions was still significant, with the experimental condition having higher odds for nine or more absence days . The magnitude of the effect was attenuated and no longer statistically significant when all participants absent for more than 100 days (n = 47) were excluded from the analysis . The analysis on sickness absence excluding exceptional causes (n = 16) showed a reduced, but still significant, effect . Crude and adjusted models are presented in Table Two additional models were constructed to control for plant effects and time effects . SensitiThe cost-benefit analysis on absenteeism showed a significant increase in costs after POSE program implementation. Average total benefits per participant were negative and amounted to €-775 (95% CI: €-1077 to €-440). The NB was on average €-975 (95% CI: €-1340 to €-691), indicating that after implementation costs for the employer were higher. The BCR (amount of money returned per Euro invested) was −3.9 (95% CI: −5.7–−2.5) meaning that after implementation of the POSE program costs for the employer were four times higher. The ROI% (percentage of profit per Euro invested) resulted in a loss of 487% (95% CI: −670–−345%).The additional cost-benefit analysis on absenteeism with exclusion of exceptional causes led to a NB of €-738 (95% CI: €-1057 to €-493), a BCR of −2.7 (95% CI: 4.3–1.5), and a ROI of -369% (95% CI: −528–−247%). The cost-benefit analysis with all absence causes and inclusion of absenteeism and presenteeism costs showed average NB of €-2321 (95% CI: €-2830–€-1836). As shown in the primary analysis, 42% of the NB can be ascribed to absenteeism. BCR amounted to -10.6 (95% CI: −13.1–−8.2), and ROI amounted to −1160% (95% CI: −1415–−918%). The additional cost-benefit analysis on absenteeism and presenteeism with exclusion of exceptional causes led to a NB of €-2040 (95% CI: €-2497–€-1606), a BCR of -9.2 (95% CI: −11.5–−7.0), and a ROI of −1020% (95% CI: −1248–−803%).After POSE program implementation, no positive effects were found on our primary outcomes of sickness absence days, work ability scores and productivity. With regard to the secondary outcomes, only the average scores on the psychosocial outcome meaning of work were significantly higher in the experimental condition. Other differences were small and non-significant. Financially, after implementation of the POSE program costs were significantly higher than benefits. Based on the present findings, implementation of the POSE program did not improve sustainable employability of workers in the meat processing industry within a 1–3-year follow-up period.In literature, only few studies were found that also reported on the effect of interventions on sustainable employability. Two studies were performed among older hospital workers (>45 years), one investigating an intervention on problem-solving behavior , the othIn the cost-benefit analyses, costs related to absenteeism and self-reported productivity loss were included. Both types of costs are assumed to represent the employer’s perspective. However, in a work environment with little autonomy, such as the meat processing industry, it can be debated whether self-reported productivity should be included in analyses. Workers have to keep up with the pace of conveyor belts. The production process continues even when workers report lower self-reported productivity. This can be explained by the fact that their lower self-reported productivity is compensated by colleagues, or that lower self-reported productivity is poorly related to actual productivity, or a combination of both. Lower self-reported productivity may thus not be a relevant measure from a corporate financial perspective on the short term. However, productivity loss (presenteeism) may be a risk for future health and employability , 38. To The results of the cost-benefit analysis of the POSE program deviated from similar studies. A study on sustainable employability in the construction industry showed significantly positive financial benefits, reporting a BCR of 11.0 and ROI of 999% . AlthougWe cannot rule out that ineffectiveness of the POSE program was caused by program failure , becauseA remarkable finding is that the control condition scored better than the experimental condition on all primary outcomes. Several explanations can be postulated. Firstly, time may have had its influence on effects, since almost all effects became non-significant if controlled for time. Nevertheless, effects remained negative, but decreased in magnitude. For sickness absence, this can be explained by the fact that at the end of the study it markedly increased at all plants, due to diverse causes and irrespective of the time workers had been exposed to the intervention. At that time, all workers were included in the experimental condition due to stepped-wedge design. No workers were in the control condition anymore. A rise in long sickness absence could be postulated as a cause of the increase, although sensitivity analyses showed that long sickness absence could not fully explain this observation. Furthermore, no trend in sickness absence in the control condition was observed, or trends were the same in both conditions. High sickness absence in the last study period may as well have been caused by the flu epidemic in winter of 2014–2015, which was the worst in Dutch history . HoweverParticipation in the POSE program was voluntary and partially depended on the invitation strategy, either being automatically enrolled or being invited to subscribe. In plants A and B1 participation was open to all workers, whereas in plants B2 and E only workers aged 50 years and older were invited. When workers were automatically enrolled and had to unsubscribe, participation rates were higher (74–93% vs. 27%). Furthermore, the number of available places in the program was restricted at plants B1, B2, and E. So, not all workers could enter the POSE program during the study. Participants and non-participants differed on age, job tenure, and gender. Differences in age and job tenure can be ascribed to the invitation strategy, which deliberately targeted workers of 50 years and older in plants B2 and E. First inviting these older workers to the POSE program was a strategic choice of the company, because these workers were considered a more vulnerable group . Althoug0–T3, resulting in reduced response rates. This was indicated by respondents as well as by plant managers [4 onwards response rates were improved by using the strategy to let participants fill out the questionnaires at the workplace, and the provision of a possible incentive  to anyone who completed a questionnaire. Reduced response rates might have led to lower power in the analysis. Fewer participants than required according to the sample size calculation responded to each questionnaire. In plant E too few workers participated in the POSE program, and in plant A and B2 response to the questionnaire was not sufficient at every measurement . This caused almost 50% missing items on primary and secondary outcomes. Nevertheless, missings could be accounted for by the analysis design by introducing a random participant effect, so most probably did not influence effect sizes. Moreover, effects on primary outcomes were significant, indicating sufficient power. A possible limitation may be the approach that was followed in developing the POSE program. The company chose to follow the top-down approach mainly because it was assumed that the workforce consists of low-educated workers with limited knowledge and skills to make appropriate health decisions. However, in the decision process towards implementation of the POSE program, the works council was involved. This party is a representation of workers from all company departments. They were consulted to ensure that the contents of the POSE program did reflect the needs of the workforce in the meat processing industry. Another limitation was that the POSE program was only available for contracted employees. This reduces the available population by 30% which consists of temporary workers. Furthermore, 25% of the workforce is foreign, but most of them are temporary workers. These facts, taken together with no availability of materials in foreign languages, may limit generalizability of study results.To our knowledge this study was the first to investigate the effect of a comprehensive WHS program to improve sustainable employability of meat processing workers. The stepped wedge design had the benefit that it was very flexible regarding logistics, i.e. the phased implementation of interventions . In our managers . From T4Primary outcomes did not improve after program implementation and secondary outcomes remained equal after implementation. The program was not cost-beneficial after 1–3 year follow-up. It is important to point out that the POSE program is not a goal in itself, but that it is a strategy to timely intervene and allow restoration of health, improvement of work ability and reduction of sickness absence, i.e. assuring sustainable employability. Regarding detection of workers at risk the program has achieved its purpose, because many workers were identified with one or more risks. A reason for not finding positive effects on primary outcomes may be program failure; in particular, interventions were not deployed as intended. Therefore, future studies should have interventions integrated as part of the workers’ health surveillance program. Interventions should focus both on the individual worker and on the workplace environment. Even though the program may not have a visible positive effect on the short term, it might be beneficial on the long term . From that perspective, it is recommended to continue the POSE program and evaluate its effectiveness for a longer time period. Furthermore, it is recommended to include a more diverse sample in future studies, including temporary workers and immigrant workers to improve generalizability of the results.


Beetles are one of the largest and most diverse groups of animals in the world. Conversion of forewings into hardened shields is perceived as a key adaptation that has greatly supported the evolutionary success of this taxa. Beetle elytra play an essential role: they minimize the influence of unfavorable external factors and protect insects against predators. Therefore, it is particularly interesting why some beetles have reduced their shields. This rare phenomenon is called brachelytry and its evolution and implications remain largely unexplored. In this paper, we focused on rare group of brachelytrous beetles with exposed hind wings. We have investigated whether the elytra loss in different beetle taxa is accompanied with the hind wing shape modification, and whether these changes are similar among unrelated beetle taxa. We found that hind wings shape differ markedly between related brachelytrous and macroelytrous beetles. Moreover, we revealed that modifications of hind wings have followed similar patterns and resulted in homoplasy in this trait among some unrelated groups of wing-exposed brachelytrous beetles. Our results suggest that elytra reduction may affect the evolution of beetle hind wings. The Coleoptera order encompasses almost the quarter of all currently known animal species  or genus Malthinus (Cantharidae). Brachelytrous beetles with exposed hind wings may also be found in the family Ripiphoridae, subfamily Necydaline (Cerambycidae) and subfamily Atractocerinae (Lymexylidae). The elytra reduction varies greatly, irrespective of the brachelytry form, from slightly truncated in Histeridae to the almost completely reduced elytra in Atractocerinae. Apart from the family Staphylinidae, where brachelytry is widespread and even suggested to be the autaphomorphic character  from six beetle families: Cantharidae, Oedemeridae, Lymexylidae, Cerambycidae, Meloidae and Ripiphoridae Table . It was Both the left and right wing from each specimen were dissected, straightened and mounted between two microscopic slides  was used to investigate the significance of differences in hind wing shape between macro- and brachelytrous beetles in Statistica v. 10  and between the comparisons . The interaction between the two factors was also significant .Hind wing shape differed between macro- and brachelytrous beetles (MANOVA: Wilks’ Lambda = 0.0504; Macroelytrous beetles formed a separate clad on the UPGMA similarity tree Fig. , whereasThe pattern of hind wing modification seems to be consistent among some unrelated taxa of brachelytrous beetles Fig. . In bracWe found that hind wings shape differ markedly between brachelytrous and macroelytrous beetles from the same or related subfamily. In most cases, brachelytrous beetles belonging to unrelated taxa were more similar to each other in terms of hind wing shape, than to their macroelytrous relatives. Moreover, our results indicated that in six out of seven comparisons conducted within distinct beetle taxa, the changes in hind wing shape seem to follow the same pattern. The hind wings of brachelytrous and macroelytrous beetles differed mainly in the size and shape of anal and marginal fields Fig. .The only exception to this pattern was the family Lymexylidae where the wing shape change was different than in other families. We suspect that the exception may be related to the specific flight mode of Atractocerus brasiliensis. It was shown that Atractocerus has a unique flight technique which involves movement of the reduced elytra that play a role similar to that of dipteran halteres Miller .The parallel changes in hind wing shape in wing-exposed brachelytrous beetles have an unclear origin. The evolution of beetles’ hind wings is relatively well studied (Fedorenko The data provided here suggest that there is a relationship between elytra shortening and outline of hind wings. However, nature of this relationship remains unknown. It is not clear if the shorter elytra affect the hind wings directly or there is another factor which affects both size of the elytra and wing outline.Comparison of insect wings was widely used in phylogenetic investigations (Browne and Scholtz The parallel modification of wing shape was documented in several different groups of insects and may be acquired by various evolutionary mechanisms (Klingenberg and Gidaszewski


Bolsa Família Program among the families of children who are part of the 2004 Pelotas birth cohort (2004 cohort). To describe the focalization and coverage of Cadastro Único para Programas Sociais do Governo Federal , in the 2004-2010 period. We estimated the program coverage (percentage of eligible people who receive the benefit) and its focus (proportion of eligible people among the beneficiaries). We used two criteria to define eligibility: the per capita household income reported in the cohort follow-ups and belonging to the 20% poorest families according to the National Economic Indicator (IEN), an asset index. The data used derives from the integration of information from the 2004 cohort and the  Between 2004 and 2010, the proportion of families in the cohort that received the benefit increased from 11% to 34%. We observed an increase in all wealth quintiles. In 2010, by income and wealth quintiles (IEN), 62%-72% of the families were beneficiaries among the 20% poorest people, 2%-5% among the 20% richest people, and about 30% of families of the intermediate quintile. According to household income (minus the benefit) 29% of families were eligible in 2004 and 16% in 2010. By the same criteria, the coverage of the program increased from 43% in 2004 to 71% in 2010. In the same period, by the wealth criterion (IEN), coverage increased from 29% to 63%. The focalization of the program decreased from 78% in 2004 to 32% in 2010 according to income, and remained constant (37%) according to the IEN. Among the families of the 2004 cohort, there was a significant increase in the program coverage, from its inception until 2010, when it was near 70%. The focus of the program was below 40% in 2010, indicating that more than half of the beneficiaries did not belong to the target population. At a municipal level, other attempts had already been implemented, but only in the second half of the 1990s this kind of social policy began to expandBrazilian social development policies are not recent, and policies based on food distribution or subsidies for the purchase of necessity goods preceded cash transfer programs. The first of these was the Bolsa Família Program (BFP) was launched, unifying the existing programs  and simplifying this structure. Its main goal was to eradicate extreme poverty and hunger,per capita income below R$154 (BRL), being classified as in extreme poverty if the per capita income is less than R$77 (BRL)In 2003, the BFP offers unconditional cash transfer for extremely poor families and conditional cash transfer for poor families or extremely poor families that have children, young people under 18 years of age, pregnant women, or nursing mothers in their composition. The main BFP conditionalities are the adoption of preventive health habits, such as regular medical consultations, vaccinations, and anthropometric monitoring, and maintenance of a minimum level of school attendance of 85% of the school year, for children in elementary school, and 75% for young people in high schoolCadastro Único para Programas Sociais do Governo Federal , which is managed by the Brazilian Ministry of Social Development (MDS). The application is made in service points of the municipality of residence, but the participation in the program is decided at a federal level, according to specific criteria and system availability. Having the application approved, holders of the benefit receive a debit card with which they can withdraw the benefit on a cash machine. The value of the benefit is the sum of a fixed amount and another which is variable according to the family composition To receive the assistance, which is normally granted on behalf of the mother of the family, it is necessary to be registered on per capita household income. Maintaining the focus of the program, that is, ensuring that most part of the intended resource is received by eligible families, is an important part of the management and ensures that the benefit does not “leak” to groups that, a priori, are not priority for the program. The use of focalization mechanisms in social programs is usually justified as a matter of “efficiency in the allocation of resources”, that is, it concentrates investment of a limited budget on people that are most in needBFP is a focused program, since eligibility is defined according to the per capita income of R$140.00 (BRL), and the extreme poverty line at R$70.00 (BRL)The methodology used by the MDS for defining the poverty line was based on an absolute criterion. Regionalized poverty lines were created based on calory consumptionPesquisa Nacional por Amostra de Domicílios , in different editions. From the 2004 PNAD data, a focus of 52% and 62% was reported for groups in extreme poverty and poverty, respectively, as well as a dramatically low coverage of approximately 14% for both groups,Some studies have evaluated the focus and coverage of BFP, at national or local level, being most of them performed with data from the One of the challenges in evaluating the focus of a national program such as BFP relates to the difficulty in collecting accurate income information, even by the program itself. On the other hand, surveys that collect income and household consumption more accurately do not collect information on the BFP, or have only very limited information. With detailed data on BFP participation for the families with children who are part of the 2004 Pelotas Birth Cohort, and with information on assets and education that allow estimation of the economic level of the families, we carried out a study aiming to describe the focalization and coverage of the BFP among the families of children who are part of this cohort.,This study used data from the 2004 Pelotas Birth Cohort (2004 cohort), including socioeconomic and family composition information. The 2004 cohort included 99% of live births to mothers residing in the urban area of the municipality of Pelotas, Rio Grande do Sul, during 2004, and the residents of Jardim América, current municipality of Capão do Leão (to maintain the same catchment area used for the 1982 Pelotas birth cohort). These children were evaluated at birth, with three, 12, and 24 months and with four and six years of age, when health-related information was recorded and anthropometric measurement were made. In the follow-up conducted between October 2010 and August 2011, when children were aged between six and seven years, we managed to enroll 90% of the original cohort . The data used in this study combines information gathered at the various follow-up waves of the 2004 cohort. Details of the cohort methodology are described elsewherePortal da Transparência Secretaria de Avaliação e Gestão da Informação , comprising information on identification of beneficiaries, amounts monthly paid as well as some features of the house and the family covering the period 2004-2010. In addition, we collected information on participation in the BFP and monthly values received in the 2004-2010 period, taken from the site of Portal da Transparência on December 20, 2013.We also used data from CadÚnico and Data from the three sources were integrated into a single dataset by a deterministic linkage process and, later, by a probabilistic oneUsing this single dataset with complete information on each child, we assessed which children of the 2004 cohort were beneficiaries of BFP in each year, from 2004 to 2010, as well as in which months they received the benefit and the amounts received. We also used the information on BFP participation reported by the mothers at the six-year-old follow-up.According to the proposal by Habitch et al.per capita household income  and the National Economic Indicator (IEN). We used both criteria as a form of sensitivity analysis, in such a way to produce a plausible range of results, since the quality of information on income in surveys has been criticized for being heavily subject to errors of information and temporal variabilityTo define eligible families, we used two indicators of economic classification in the analyses: the per capita income criterion, we used the household income declared in the 2010 follow-up and the number of residents in the house to estimate the monthly average per capita income. In this analysis, we used as cut-off points for eligibility the values defined by the MDS – per capita income of R$100.00 in 2004 and R$140.00 in 20102 of 67%.Therefore, for the ,,,,,For the classification based on the IEN, the eligibility criterion was to belong to the 20% poorest families according to data from 2004 and 2010. This is a definition a little more flexible, since the indicator is not based on income, but produces a ranking of socioeconomic position based on the possession of household assets. The choice of 20% as cut-off point was based on the estimate, at the beginning of the program, that about 18% of the Brazilian population was classified as poor and, therefore, were potential beneficiaries of the programper capita income and IEN). Next, also using the two eligibility criteria, we estimated the coverage and focalization of the program in 2004 and 2010. We present the percentages and their respective 95% confidence intervals to allow an assessment of the accuracy of these estimates, as well as of the difference in proportions between subgroups. All analyses were carried out using the Stata software . All the follow-ups of the 2004 cohort were approved by the Research Ethics Committee of the Federal University of Pelotas Medical School. The use of data identified in CadÚnico has been approved and authorized by an MDS internal process. In all cases, we guarantee confidentiality and anonymity to the individuals involved.We used standard techniques of descriptive analysis, presenting the results in terms of measures of central position and dispersion. Initially, we described the socioeconomic situation of the families presenting averages and standard deviations, overall and stratified by beneficiary status. Then, we identified the proportion of eligible families and the proportion of beneficiaries according to what was reported in the 2010 follow-up cohort and to the linkage dataset, by eligibility criteria . The second was based on being in the first quintile of the IEN (belonging to the 20% poorest). According to per capita income, there were 29% eligible families in 2004 and 16% in 2010. Using the IEN, the proportion is fixed at 20% by definition.The evaluation of BFP coverage and focus was performed in 2004, when both the cohort and the program started, and in 2010, when the children were six years old. The results are presented in per capita, 42.8% of eligible people were covered by the program in 2004, and 70.9% in 2010. Using the IEN, the coverage was lower, 29.2% and 63.0%, respectively. Contrary to what happened to coverage, we observed a considerable fall in the focus of the program between 2004 and 2010 using the household income criterion - the percentage of eligible people between beneficiaries fell from 77.9% to 32.4%. According to the IEN, however, we observed no changes in focus, which has always been low, 36.8% in 2004 and 36.9% in 2010.The results of both criteria are less consistent than in the evaluation of population coverage. According to the The 2004 Pelotas Birth Cohort is an ideal study for BFP assessment. This cohort monitors children born in 2004, coinciding with the launch of BFP, and has detailed information from families and children, including socioeconomic, demographic, and health-related data. The municipality of Pelotas is the target of a large number of population studies due to its several research groups, being also quite similar to other medium-sized municipalities in the country regarding health indicators, despite being situated at the southernmost part of BrazilWe found over 32% of the cohort children families to be BFP beneficiaries, equivalent to 2.5 times the total proportion of beneficiaries in the municipality, which is 13% (about 15 thousand families benefiting in a universe of 114 thousand families). This disproportion is easily explained because all the families of the 2004 cohort necessarily include school-age or preschool children.per capita household income quintiles). Instead of an abrupt fall in the percentage of beneficiaries with increased wealth, standard expected in the case of a focalized program that uses income as an eligibility criterion, we verified a smooth and linear reduction, both in 2004 and 2010 , all well documented in the literature,With this type of distribution, the program was not expected to present high focus. We used two different criteria, due to difficulty to define exactly who is eligible or not for the program. The per capita household income and from 29% to 63% using the IEN. The results differ in the focus assessment. Using household income, 29% and 16% of families were eligible in 2004 and 2010, respectively, and program focus fell from 78% to 32% (percentage of eligible people among the beneficiaries). This reduction in focus suggests that the expansion of the program resulted in the leakage of the benefit to ineligible families. Using the IEN, we have a different picture, in which program focus was already low and remained low, 37%, from 2004 to 2010. This can be partly explained by the number of people considered eligible by the IEN, a smaller group (20%) compared to the 29% using the income criterion. Also, note that there is not an exact correlation between IEN and income, since the each method measures wealth in a different way.Given the discussion above, estimation of coverage and focus based on both criteria (income and IEN) allows for a more comprehensive assessment of the program performance. From the point of view of coverage, both criteria show a significant increase in the proportion of eligible people supported by the program – from 43% to 71% using ,Chile Solidario (Chile) or Oportunidades (Mexico), the focus is almost the sameOther studies using data from the PNAD and the Census estimated BFP focus and coverage that suggest, despite variation in point estimates, that both focus (ranging between 51% and 62%) and coverage (ranging between 14% and 78%) are low at national level,Considering the results based on the IEN, which indicates that in 2004 the program included ineligible families, but that were eligible in terms of income, and considering that we obtained the same focalization in both periods, this study corroborates the literature when showing that, using different approaches (with economic classifications not based on income), focus is low since the beginning of the programThe participation of the municipality is important in this process because the supervision of conditionalities and the update of program register (CadÚnico) is performed at this level. The municipality degree of organization makes application to the program easier or more difficult, and better update and verification of information can result in better applicant data quality. However, the decision on the eligibility of the beneficiaries lies in the federal sphere .Because of the considerable value that has been invested annually in the BFP (more than R$20 billion in 2014, according to MDS


Lymphatic filariasis (LF) and soil-transmitted helminths (STH) have been targeted since 2000 in Haiti, with a strong mass drug administration (MDA) program led by the Ministry of Public Health and Population and its collaborating international partners. By 2012, Haiti’s neglected tropical disease (NTD) program had reached full national scale, and with such consistently good epidemiological coverage that it is now able to stop treatment for LF throughout almost all of the country. Essential to this success have been in the detail of how MDAs were implemented. These key programmatic elements included ensuring strong community awareness through an evidence-based, multi-channel communication and education campaign facilitated by voluntary drug distributors; strengthening community trust of the drug distributors by ensuring that respected community members were recruited and received appropriate training, supervision, identification, and motivation; enforcing a “directly observed treatment” strategy; providing easy access to treatment though numerous distribution posts and a strong drug supply chain; and ensuring quality data collection that was used to guide and inform MDA strategies. The evidence that these strategies were effective lies in both the high treatment coverage obtained– 100% geographical coverage reached in 2012, with almost all districts consistently achieving well above the epidemiological coverage targets of 65% for LF and 75% for STH—and the significant reduction in burden of infection– 45 communes having reached the target threshold for stopping treatment for LF. By taking advantage of sustained international financial and technical support, especially during the past eight years, Haiti’s very successful MDA campaign resulted in steady progress toward LF elimination and development of a strong foundation for ongoing STH control. These efforts, as described, have not only helped establish the global portfolio of “best practices” for NTD control but also are poised to help solve two of the most important future NTD challenges—how to maintain control of STH infections after the community-based LF “treatment platform” ceases and how to ensure appropriate morbidity management for patients currently suffering from lymphatic filarial disease. We present evidence of Haiti’s successful neglected tropical disease (NTD) program targeting lymphatic filariasis and soil-transmitted helminths and the methods used to achieve this success. By 2012, Haiti’s NTD program had reached full national scale, with such consistently good treatment coverage that the program is now able to stop treatment for lymphatic filariasis in much of the country. These findings are in line with the predictions and expectations of the global community for countries where high coverage is achieved for program implementation. In addition to the evidence of successful program outcomes, we present a detailed description of how the program was implemented—from facilitating the effectiveness of the drug distributors to improving drug logistics and supporting a well-informed population. These methods described can be used to inform the design of other mass drug administration programs and enhance the development of global “best practices” guidance. Neglected tropical diseases (NTDs) are a group of 17 parasitic, bacterial, and viral infections affecting more than 1 billion people globally ; in Haiti, IMA World Health leads the ENVISION activities.Addressing such NTD challenges is complex. Although health experts and international organizations have presented general recommended approaches for integrated programs targeting NTD control or elimination , the gloprograms ,13. Thisprograms , focusesHaiti, situated adjacent to the Dominican Republic on the island of Hispaniola, has a population in excess of 10 million people and is a low-income country, with 59% of its citizens living below the poverty line. It has an under-five mortality of 76 per 1,000 live births, and only 48% of its population has access to an improved water source ,15. The Haiti is divided into three administrative tiers—national level, departments , and communes ; the commune is the programmatic implementing unit for all health programming, including NTD efforts. Approximately 60% of the population lives in rural areas, and 40% are spread across four major urban areas, the largest being Port-au-Prince (population of 2.5 million). The geographic areas where mass drug administration (MDA) was supported by USAID’s ENVISION project (the focus of this paper) were mostly in semi-urban and urban communities.In the past decade, Haiti has faced a myriad of development challenges, including political crises, hurricanes, a devastating earthquake, and a deadly cholera outbreak in the aftermath of the earthquake .The national LF and STH programs were developed independently; however, the two programs integrated their MDA activities in 2008.The national program to eliminate LF (NPELF) in Haiti was established in 2001, with the objectives of eliminating transmission of LF and reducing the suffering of persons with the clinical and chronic manifestations of LF disease. Under the leadership of the Ministry of Public Health and Population (MSPP), the NPELF overcame many challenges  to successfully scale up the World Health Organization (WHO)-recommended MDA strategy, reaching at least 65% of the population once yearly with two medicines– 400 mg of albendazole (ALB) and an age-based dose of diethylcarbamazine (DEC) –19.Efforts to control STH focus on maintaining low prevalence and intensity of infection, and are coordinated by the MSPP and the Ministry of Education (MENFP). As per WHO strategy, Haiti’s approach to STH control is based on periodic treatment of at-risk populations  living in endemic areas with an anthelminthic, typically ALB or mebendazole. In areas where STH prevalence is greater than 50% or between 20% and 50% of the surveyed population, twice-yearly and once-yearly treatment is recommended, respectively [In 2008 Haiti formed a single national NTD program—Le Projet des Maladies Tropicales Negligées (MTN)–to consolidate their STH and LF programs. Because STH programs are often integrated with LF MDA in areas where the diseases are co-endemic and ALB is a mainstay of effective treatment for both [The NTD program is led by the government and managed with the support of ENVISION. Human resources comprise a team of health professionals within the MSPP’s units for LF and STH , school inspectors employed under the MENPF, and IMA staff. At the community level, a cadre of community volunteers , selected especially to work on the NTD program, ensure that the medicines are distributed to the target population. This cadre is composed of community drug distributors (CDDs) supported by promoters, who in turn are supported and chosen by community leaders working with the MSPP.CDDs can be health workers, students, teachers, and other individuals chosen from within the community. They are selected based on several criteria: they must live in the community where they will distribute the medicines, be well known and respected by the population, and be able to follow instructions given during MDA training. Because CDDs live in and know the community within their distribution-post areas, they are able to identify easily, and follow-up directly, any individuals who have missed MDA. Each CDD is expected to treat approximately 300 persons during each MDA. Promoters, including health workers, teachers, and political leaders, are chosen based on having had experience working with the health center in previous health campaigns  and having strong standing in the community. As well as recruiting, training, and supervising CDDs and promoters, the community leaders’ role is to sensitize the population at community meetings, schools, churches, and other venues; to meet with and inform other political and church leaders who have influence in the community; and to deliver MDA kits to distribution posts and help manage stock. The leaders report to the MSPP staff member managing the local health post.CDD turnover is low (less than 10% per year), and the NTD program does not encourage changes. Incentives paid (often less than other programs) range from US$25 to US$65 per month worked, for up to three months, and are settled at the end of the MDA. The main source of motivation is believed to be the high level of engagement of national-level program managers who interact directly with CDDs, continually listening to, encouraging, and motivating these CDDs—by letting them know the importance of their work and that it is seen and appreciated. However, further qualitative studies are needed to gain a deeper understanding of what motivates the drug distributors.In Haiti, the MDA medicines, DEC and ALB, are distributed to communities at fixed treatment posts, including schools, set up throughout the community. The entire community is invited to visit the posts; schoolchildren are treated at their schools. The information, education and communication (IEC) efforts are multi-channeled, including posters, flyers, banners, sound trucks, radio, television spots, and community meetings held in schools, churches, and markets. Program managers also hold live press conferences on local radio stations, which include answering listener call-in questions. Another factor contributing to the high level of community awareness of the MDA was the program’s campaign style: for a short period of time, the streets were flooded with volunteers and staff, who were made highly visible by the specially designed NTD program tee-shirts they wore. Messages focused on how to get treatment and on side effects.The IEC approach was informed by results of knowledge, attitudes, and practices (KAP) surveys conducted in 2012 and 2013, which asked how people hear about the MDA program. As a result of survey information, a higher proportion of funding was spent on banners, fliers, and radio and television messages, and a lower proportion on posters. Importance was also placed on messaging through megaphones mounted on trucks.The Haiti NTD program policy is for all treatment to be directly observed. Training emphasizes watching each participant in the MDA take the medicine, and the policy is enforced by supervisors. If people request medicines to take home with them, they are to be refused. If a person arrives at the treatment site and has not yet eaten, the CDD requests that the person eat first and then return for treatment.fear of side-effects was <2%. Such findings were similar to those reported in other studies in Haiti following multiple rounds of MDA, where the most common symptoms were headache (36%) and gastrointestinal complaints (28%) [Because even minor side effects can negatively affect treatment coverage, providing clear information on managing side effects to the community is important. CDDs were trained to encourage people to eat before treatment in order to reduce side effects.Information on potential side effects in included as a key element of all training and social mobilization efforts. Data reported previously from Léogâne showed that although the percentage of respondents who reported any side effects within a day of MDA was approximately 25% (with nausea being the most common symptom reported), the percent of the population reporting ts (28%) . No seriEssential to success has been the large emphasis on training—a cumulative total of 102,375 persons  were trained from 2009 through 2014. Given the low turnover of CDDs, a two-day training is provided in each commune prior to its first MDA round, with shorter refresher trainings (of one day) provided in following years. Key topics include information on diseases and reporting, followed by an MDA simulation. In addition, the ENVISION finance team trains the MSPP’s departmental accounting team annually in a one-day session.ENVISION’s training approach avoids dilution of content—the often-cited potential weakness associated with the cascade training-of-trainers model—by ensuring overlap in the layers within the cascade: community leaders are trained by a joint team of national, departmental, and commune-level MSPP staff; community leaders are then joined by commune-level staff to train the promoters, who in turn are supported by the community leaders and district staff to train drug distributors . This ovSupervisory oversight is provided not only at community level, but also at district and national levels. The CDDs are supervised by a promoter, with each promoter supervising an average of nine CDDs. Supervisor responsibilities include checking that the correct number of CDDs are in place; ensuring that distribution posts are appropriately located and that they have the necessary supplies; and reviewing accuracy of completed data registers. Supervision at the community level is conducted jointly by ENVISION and staff from both the MSPP and the MENPF. Following the MDA, a post-event review is held at the local level, where MSPP staff and the community CDDs review program data before reporting, reflect on lessons learned, and strategize on how to improve coverage in future years.Underlying the program’s drug distribution effort is a strong supply chain. Drugs are received in the country by the national medical stores and then transferred to ENVISION for storage, repackaged by pharmacists, and distributed to communes two to three days in advance of the MDA. During 2009 to 2014, there were no reported instances of drug stock-outs during MDA activities. Furthermore, records consistently have demonstrated a very low percent of drug loss each year—of a total of 136 million DEC tablets and 27 million ALB tablets received from 2009 to 2014, only 0.2% of them were lost.The NTD program in Haiti has been guided by information collected through the ENVISION monitoring and evaluation (M&E) framework, designed according to WHO guidelines ,23. The process indicators that measure fidelity between program implementation and program plans, outcome indicators, and impact indicators that measure infection to identify communes ready to stop MDA. Coverage is the key outcome-level indicator and is defined as follows:Key indicators—assessed at commune and national levels—include Program coverage: number population ingesting medicines/ eligible population targeted for treatment;Epidemiological coverage: number population ingesting medicines / total population areas where program is implemented;National coverage: number population ingesting medicines / total population living in all areas where PC is required; andGeographical coverage: number of communes having received MDA / all communes that required MDAOther data are collected through a number of special evaluations. Post-treatment coverage surveys, involving 30 clusters each, were conducted, with data collection support provided by CDC following WHO LF monitoring guidelines . These sFollowing WHO guidelines, sentinel site and spot-check sites are used periodically to measure impact on infection rates, and transmission assessment surveys (TAS) are used to determine whether MDA can be stopped . The MSPTreatment coverage is a measure of whether programs are on track to achieve program goals and control/elimination targets. Good coverage was reported – 100% gePost-treatment coverage surveys were used to validate the coverage routinely reported by CDDs. Results of the coverage surveys generally confirmed that coverage rates were at least 65%, and often substantially higher .KAP questions were added to the coverage surveys in both 2012 and 2013 . ResultsThe factor most strongly associated with taking the treatment was access, with adjusted odds ratios of 30 and 56.2 for 2012 and 2013 respectively, p <0.001 (t-test). Caution should be exercised when interpreting the odds ratios not to overemphasize the significance of such high odds ratios. If an outcome is rare, odds ratios and relative risk would be roughly equivalent. Here, since the majority of the surveyed took the drug, the odds ratio and relative risk are different. The unadjusted relative risk is 2. Awareness of the program was also significantly associated with taking the drugs . The association between knowledge of disease and taking treatment was inconclusive—knowledge was not associated with taking the treatment in 2012 but was significantly associated in 2013 –odds ratio of 1.8 (p = 0.002) for persons who could reports signs and symptoms and odds ratio of 2.7 (p <0.001) for ability to report prevention strategies.W. bancrofti antigen levels are below 2%, TAS should be implemented to determine whether MDA can be stopped [Program impact is first measured at sentinel and spot-check sites—these are conducted at midterm after two to three MDA rounds and again before proceeding to conduct the more extensive TAS, following a minimum of five MDA rounds. Once a commune has completed a minimum of five rounds of MDA, with epidemiological coverage >65% and where sentinel site  stopped . For theIn 2014–2015, sentinel and spot-check surveys were conducted in 23 communes as part of either midterm or pre-TAS surveys . In all On the other hand, four sites had large reductions but failed to drop below the critical threshold, even after six or seven rounds . The priBy mid-2015, TAS had been implemented in a total of 13 EUs, 10 of which achieved the prevalence threshold required to stop MDA. These 10 EUs are made up of a total of 44 communes in which, according to WHO guidelines, MDA can now be stopped, while post-MDA surveillance will continue for an additional four to six years. In the other three EUs (made up of three communes), MDA will continue for a minimum of two more years.For STH, a national survey was conducted in 2013 to determine the STH infection prevalence in school children (aged from 6 to 16 years old), at least five years after the program of annual MDA with ALB+DEC had begun. This survey showed that STH prevalence had decreased in 9 of 10 departments, with STH prevalence at or below 10% in 3 departments and at or below 20% in another 6 departments. In the tenth department (Grand’Anse), which had an initial prevalence of 72% when surveyed in 2001, the decline was not as pronounced as in the other nine, and the prevalence of infection remained at 55%. AlthougProgram costs. Detailed program cost assessments have been carried out for those communes where MSPP activities have been supported by ENVISION. Although relative costs for some of the program activities did vary slightly from year to year, drug delivery costs always predominated, especially when including social mobilization costs . BecauseBetween 2010 and 2013, the per person treated cost of the program—characterized predominantly by MDA—has remained steady (US$0.35–0.37). However, in 2014 an increase in total budget was observed as the requirement for more comprehensive M&E efforts, including TAS surveys, became necessary.By 2012, Haiti’s NTD program had reached national scale, with consistently good epidemiological coverage reported for MDA. Following TAS results that confirmed LF infection was below the targeted transmission thresholds, MDA could be stopped, resulting in a scaling down of geographical coverage. By 2015, 45 communes– 44 of which were in ENVISION-supported areas—had stopped MDA. Such results add to the growing body of global evidence supporting the feasibility and effectiveness of implementing WHO’s strategy to eliminate LF via once-yearly MDA for at least five years with a minimum of 65% epidemiological coverage .To achieve these results, it is essential that MDA rounds are able to reach and sustain good coverage of the targeted population. In practical terms, the success of MDA programs hinges on two operationally critical elements: a population willing to accept the treatments being offered (community acceptance) and a health system able to deliver the treatments effectively to the community (MDA delivery). These in turn depend on a number of other essential factors, summarized in The likelihood of taking the offered treatment has been positively associated in a number of studies with the community’s knowledge and understanding of the disease, its transmission, MDA strategy, and possible side effects; the community’s perceived risk of getting the disease; and history of side effects experienced –33. In HReluctance to take treatment due to fear of minor side effects was low, reflecting the importance placed on informing the community about expected side effects—achieved through emphasis during CDD training and through dissemination of IEC messages. The program also benefitted from the fact that there were no reported serious adverse events.This program has been able to extensively leverage pre-existing relationships among ENVISION, the field MSPP personnel, and the community leaders—all of whom emphasize the involvement of the community, thereby building on the foundation of existing strong social capital. Other studies also support the idea that drug distributors who are known and respected by the community will have better success in treating the population .The factor most strongly associated with taking the drugs in this program was ready access to treatment . The program’s attention to logistics—in terms of number and location of posts, as well as assurance that the posts are attended by well-trained and supported CDDs—accompanied by a strong supply chain that ensured the availability of treatments, were critical to the successful achievement of persistent high treatment coverage.C. quinquefasciatus is the vector and W. bancrofti the parasite, but where ivermectin was used instead of DEC. This model predicted that the number of rounds necessary to achieve elimination depends to a large extent on both coverage and the pre-program endemicity level [In light of the strong evidence presented on good coverage in MDA rounds obtained by the Haitian program, the excellent results of the assessment of impact on infection at sentinel, spot-check, and evaluation sites should not be surprising. LYMFASIM, a mathematical model predicting elimination of LF using an MDA approach, was developed based on a similar scenario in India, where ty level . This prty level .As noted earlier, seven sentinel sites with initially much lower baseline prevalence had already reached below the <2% antigenemia threshold after only three to four rounds of MDA. These communes continued to implement another one to two rounds of MDA following current WHO guidelines. Researchers in Haiti’s La Tortue Island earlier reported a successful TAS survey and the stopping of MDA after just two rounds of treatment . In the In addition to completing efforts to eliminate LF, Haiti’s NTD program needs to sustain achievements of reduced STH burden. During recent years, the STH program has relied on the fact that ALB is administered to the whole population as part of the LF MDA. As the LF program progressively meets the criteria for stopping MDA, another platform will be needed for delivery of STH treatments. Haiti’s plan is to focus on school-based, STH-only MDA and to add water, sanitation, and hygiene activities.In 2015, the InterAmerican Development Bank provided the MSPP with funds for a national deworming campaign. The InterAmerican Development Bank drew upon IMA’s expertise for support in training of drug distributors and working with department-level STH leads to formulate best-practice MDA strategies—illustrating the continued integration and collaboration between the two disease programs and the potential resources that have been developed in country and can be leveraged to ensure the sustainability of STH control activities.As MDA activities are now reaching the stopping point, Haiti has started to turn its attention to morbidity control efforts for LF, building on hydrocele surgery efforts and lymphedema patient support groups that have been implemented in Léogâne . The MSPFinally, plans are also in place to work Hispaniola-wide on a malaria elimination plan, harnessing the momentum already gained for LF elimination and further increasing the probability of LF elimination though vector control .In summary, in this mostly rural Haitian setting, a very successful MDA campaign was launched in 2001 with sustained high coverage rates, resulting in steady progress toward LF elimination . A strong foundation for ongoing STH control has also been established. The strategies utilized with proven success by the program are summarized in Careful selection of CDDs to distribute drugs—persons known, respected, and trusted within their communitiesStrong motivation of dug distributors resulting in less than 10% annual turnoverTwo days of initial training, followed by annual one-day refresher training—using a strengthened cascade system described aboveLow ratio of drug distributors to first-level supervisors (1:9) who in turn have clear supervision responsibilitiesEasy access to the drugs through numerous distribution posts set up within the communityStrong enforcement in training and during supervision of a directly observed treatment policyAn evidence-based, multi-channel communication approach, combined with high visibility of the MDA itself, resulting in high awareness among the community where the MDA is occurringFocus of key communication messages on where to get treatment and on side effects—strong knowledge on disease was not required.Community acceptance of minor side effects (headaches and nausea) as a result of emphasizing this information during drug distributor training A strong drug supply chain as evidenced by good documentation, the lack of drug stock-outs, and very low drug wastagePost-MDA project review at all levelsA strong M&E system put in place, following WHO guidelinesA strong system to collect data from drug distributors on treatments given so that coverage rates can be followed and lead to action in lower performing areasThe national government’s strong leadership and partnership both with the community and with international stakeholdersS1 Data(XLSX)Click here for additional data file.S2 Data(XLSX)Click here for additional data file.S3 Data(XLSX)Click here for additional data file.S4 Data(XLSX)Click here for additional data file.S5 Data(XLSX)Click here for additional data file.S6 Data(XLSX)Click here for additional data file.S1 Checklist(DOCX)Click here for additional data file.