How iCBT is designed and delivered differs across programs. Although iCBT is considered an effective approach for treating child and adolescent anxiety, rates of program use  are highly variable for reasons that are not clear. As the extent to which users complete a program can impact anxiety outcomes, understanding what iCBT design and delivery features improve program use is critical for optimizing treatment effects.Internet-based cognitive behavioral therapy (iCBT) is a The objectives of this study were to use a realist synthesis approach to explore the design and delivery features of iCBT for children and adolescents with anxiety as described in the literature and to examine their relationship to program use outcomes.A search of published and gray literature was conducted up to November 2017. Prespecified inclusion criteria identified research studies, study protocols, and program websites on iCBT for child and adolescent anxiety. Literature was critically appraised for relevance and methodological rigor. The persuasive systems design (PSD) model, a comprehensive framework for designing and evaluating persuasive systems, was used to guide data extraction. iCBT program features were grouped under 4 PSD categories—Primary task support, Dialogue support, System credibility support, and Social support. iCBT design (PSD Mechanisms) and delivery features (Context of use) were linked to program use (Outcomes) using meta-ethnographic methods; these relationships were described as Context-Mechanism-Outcome configurations. For our configurations, we identified key PSD features and delivery contexts that generated moderate-to-high program use based on moderate-to-high quality evidence found across multiple iCBT programs.A total of 44 documents detailing 10 iCBT programs were included. Seven iCBT programs had at least one document that scored high for relevance; most studies were of moderate-to-high methodological rigor. We developed 5 configurations that highlighted 8 PSD features  associated with moderate-to-high program use. Important features of delivery Context were adjunct support  and whether programs targeted the prevention or treatment of anxiety. Incorporating multiple PSD features may have additive or synergistic effects on program use.The Context-Mechanism-Outcome configurations we developed suggest that, when delivered with adjunct support, certain PSD features contribute to moderate-to-high use of iCBT prevention and treatment programs for children and adolescents with anxiety. Standardization of the definition and measurement of program use, formal testing of individual and combined PSD features, and use of real-world design and testing methods are important next steps to improving how we develop and deliver increasingly useful treatments to target users. Cognitive behavioral therapy (CBT) is recommended as a first-line treatment for children and adolescents with anxiety -4. Trainpersuasive system .-34.30-34Journal of Medical Internet Research, Internet Interventions, Journal of Cyber Therapy & Rehabilitation, and Journal of Telemedicine and Telecare, and a review of reference lists of included documents and reviews .We used 3 main strategies to identify literature for iCBT programs. The first search strategy involved an information specialist conducting a systematic and comprehensive search of 8 electronic databases: MEDLINE, EMBASE, ERIC, PsycINFO, CINAHL, Cochrane Library, ProQuest Dissertations & Theses Global, and PubMed for the period 1990 to 2017. The second strategy involved a manual search using Google, an internet search engine, and gray literature repositories  to identify conference proceedings, program evaluations, and government or technical reports. For both search strategies, MeSH terms and text words were based on mental health condition (anxiety and phobias), intervention modality (internet-based and mobile app), intervention type (prevention and treatment), and therapeutic approach CBT; . The thiWe employed the search strategies on an iterative and recurrent basis until November 2017 to ensure the review was up to date and inclusive. Before discontinuing the literature search, a test of saturation was applied to the search strategies, which involved verifying that further searching would not yield any new results .In this study, 2 independent, trained reviewers (authors ADR and LW) screened the identified documents for eligibility using a 2-stage approach. During this process, reviewer discrepancies were resolved by consensus or third party arbitration (author ASN). At stage 1, all documents were screened for eligibility using the title and abstract. During this stage, we randomly selected 100 citations to assess inter-rater agreement for inclusion or exclusion decisions; Cohen kappa was 0.74 between raters, reflecting substantial agreement . All docFor an iCBT program to be included in this synthesis, supporting documents needed to be published in English and provide information on treatment Context, program design (PSD) and delivery features, and program use Outcomes. Each document did not need to provide details on all 3, but all 3 needed to be represented in the total documents for an iCBT program. In addition, at least one published study on the iCBT program needed to be available for inclusion so that we could assess the methodological quality of the study providing program use outcome data.Intervention studies  were eligible for inclusion if they evaluated iCBT anxiety programs with children (aged <14 years) or adolescents (aged 12-19 years). As some iCBT programs were designed for and evaluated with participants from a broader age range , only those studies that provided separate data for participants aged ≤19 years were included. We also required that the type of iCBT program under evaluation be designed for an anxiety disorder(s) or anxiety symptoms associated with a disorder as classified according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition  such as low if little or no information was provided, medium if some information was provided, and high if information was well described. Exemplar documents with a high level of contribution across the 3 domains informed decision rules for the rating of all other documents.Documents were assessed for relevance and rigor based on consensus between 2 reviewers (authors ADR and LW). Relevance was assessed based on the level of contribution a document provided for an iCBT program in 3 domains: (1) underpinning theory and/or the context and sequence for delivery (Context), (2) PSD features (Mechanism), and (3) program use outcomes (Outcomes). The level of contribution for each domain was rated The methodological quality (rigor) of research studies was assessed using the Mixed Methods Appraisal Tool (MMAT) ,39. The Documents for each iCBT program were grouped together during data extraction and coding. Two reviewers (ADR and LW) cross-referenced extraction and coding decisions, with a random subset of 10 documents; the remaining documents were coded by 1 reviewer (ADR). In addition to document characteristics (type and year of publication), iCBT program data were extracted for the following:Participants: eligibility criteria and participant demographics.iCBT program Context: number of modules, module workflow and sequence, delivery setting, adjunct support, and level of prevention according to the Institute of Medicine model .Theory or proposed Mechanisms: program features, content and components, including PSD features, and information on why the iCBT program was designed a certain way or how the program was proposed to work.Program use Outcomes: information related to how many Web-based modules, exercises, or activities were completed by users or how many users completed certain aspects of the program, measured at posttreatment.Adjunct support details were coded when human-derived technological or therapeutic communication was provided to users to complement iCBT program delivery.Therapeutic content in programs was coded according to the 5 main CBT components found in the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameter : psychoeAs most authors did not use PSD terminology or concepts, program descriptions were coded as PSD features using a codebook and glossary  Multime. PSD feaWe found inconsistent and heterogeneous measurement and reporting of program use Outcomes—such as program adherence, compliance, and completion. These limitations have been noted by others .program use. As no applicable cut-off scores have yet been established, when possible, Outcomes were converted into percentages (based on quartiles) to assist with interpreting program use. We used the following parameters to summarize program use: high use (≥75%), moderate use (50%-74%), low use (25%-49%), or very low use (≤24%). Study dropout or attrition data were not included in the analysis because these data may not directly reflect program use , but rather rates of study participants who did not fulfill the research protocol  [For each study, program use Outcomes are reported as published by original authors and are collectively referred to in this study using the umbrella term nnaires) . CorrespWe used a multistep approach to data analysis that was structured according to Pawson’s techniques ,28 and mThe second step in the analysis involved reciprocal translation analysis, a meta-ethnographic technique that involved reviewing the Context-Mechanism-Outcome configurations across iCBT programs ,45. ConfIn the final step, we used lines-of-argument synthesis, a theorizing technique  that invThe literature search and selection progress are presented in All programs described themselves as CBT-based and contained at least 3 of the 5 AACAP-recommended CBT components . The workflow of the programs presented the more foundational and simpler treatment components  before more challenging skills . Many programs also integrated interpersonal therapy skills , such asThe frequency of the PSD features used in the iCBT programs is shown in high for level of contribution for program Context, Mechanisms, and Outcomes. We evaluated 29 research studies (found in 25 documents) for methodological rigor. A total of 19 studies met all 4 MMAT criteria (100%), 7 met 3 criteria (75%), and 3 met 2 criteria (50%). Lower ratings reflected an unclear description of: processes for recruitment, selection, randomization, or allocation; how group differences (if any) were controlled for; the percentage of outcome data obtained; or withdrawal or dropout rates were not within acceptable limits.Details of the quality appraisal are provided in high or moderate program use.When finalizing our proposed configurations, we considered both what program Contexts and Mechanisms were combined using  and 3 anKey Contexts and PSD Mechanisms that may have led to moderate-to-high iCBT program use Outcomes are described in Evidence from 8 iCBT programs suggested that indicated prevention and treatment programs that provided adjunct support along with Tailoring and Personalization resulted in greater program use. Studies supporting this configuration had a mean MMAT score of 90.2%.Tailoring and Personalization were used to provide users with more information to increase the individualized feel of the program and portray that the program knew and could meet the user’s needs. Programs most commonly tailored content  based on the user’s age or mental health condition . User information was often collected by the adjunct support person during study enrollment . Personalization was a feature that could be initiated through program automation  or via program communications . The adjunct support person acted as an extension of the Tailored or Personalized program experience through their contact with users within  oEvidence from 6 iCBT programs suggested that indicated prevention and treatment programs that provided adjunct therapist support along with Reminders also resulted in greater program use. Studies supporting this configuration had a mean MMAT score of 92.1%.The programs contributing to this Context-Mechanism-Outcome configuration involved multiple modules or activities (the number of modules ranged from 6-11 or app use ranged from daily-weekly activities); therefore, users were required to log into the program over numerous instances. Reminders were used to encourage the user to take program action, either by promoting skills practice  or by “pEvidence from 4 iCBT programs suggested that programs and mobile apps that provided adjunct support along with Rewards resulted in greater program use. Studies supporting this configuration had a mean MMAT score of 85.0%.A total of 3 iCBT programs regularly incorporated Rewards into modules to encourage ongoing program use and promote the completion of essential treatment exercises ,47,51. TEvidence from 6 iCBT programs suggested that indicated prevention and treatment programs with adjunct Web- or email-based therapist support that also provided a Social role component, and conveyed Authority, Expertise, Trustworthiness, resulted in greater program use. Studies supporting this configuration had a mean MMAT score of 91.3%.The Social role component of iCBT programs was often fulfilled by a therapist or coach . Therapists engaged in regular, Web- or email-based communication with the user and served 2 roles by (1) facilitating program delivery by providing technical support and answering users’ questions and (2) promoting program completion by providing reminders and encouragement, reinforcing program concepts, and ensuring accurate comprehension and application of CBT skills. Together, the Social role feature and therapist emails complemented (had overlap with) other PSD features such as Reminders, Praise, and Suggestion. Therapists had secure access to users’ written responses or logged data so that they could send specific communications to users, demonstrating therapists’ credibility and competence with both the therapeutic process and individual responsiveness . Moreover, 3 studies measured child-reported therapeutic alliance with their iCBT program therapist and found it to be strong and program use to be high ,81. One Evidence from 5 treatment programs suggested that iCBT programs with adjunct therapist and parent support that also included a Social role component, and conveyed Authority, Expertise, and Trustworthiness, had greater program use. Studies supporting this configuration had a mean MMAT score of 90.8%.Treatment-based iCBT programs were designed to be child-parent combined or parent-supported child-based interventions. Combined interventions required parents to complete parent-specific modules  either before or alongside their child as they completed their own child-directed modules. In parent-supported interventions, parents may have also been responsible for explaining program instructions and assisting their children with their modules ,54,76, cpersuasiveness and its potential to assist the user with their goals of the program [The role of technological, persuasive components in iCBT programs is an understudied aspect of program design and evaluation. The extent of iCBT program use may be a fundamental indication of its  program ,88-91. TThe 5 Context-Mechanism-Outcome configurations provide support for several persuasive strategies to improve iCBT program use: Tailoring and Personalization as Primary task supports; Rewards, Reminders and Social role features in programs serving as Dialogue supports; and Trustworthiness, Expertise, and Authority features serving as System credibility supports for a program. Traditionally, PSD features that stimulate human-computer communication, such as Dialogue supports, have been the most widely used and studied features for improving program use ,89,92,93necessary for program use , whereas others may be complementary to program use (have an impact by enhancing the design framework of iCBT); although both types of features together may influence program use. In this realist synthesis, all 10 iCBT programs described a purposeful design that incorporated Reduction and Tunneling (Primary task supports) and Similarity and Liking  to create a logical, incremental, relevant, and aesthetically pleasing experience for users—these may be the necessary PSD features for iCBT for children and adolescents with anxiety. The PSD features described in our configurations are hypothesized to be complementary—building on the persuasiveness of necessary PSD features to further improve or optimize iCBT program use.Moreover, we suspect that not all PSD features may have equal influence on program use. Depending on the program, some PSD features may be real world and from the user’s perspective [A meta-analysis of PSD features used in internet-based interventions for mental health demonstrated that determining the amount and type of persuasive principles to include may be a delicate balance, as some principles seem to work together, whereas when other principles co-occur, they may have an unapparent or diminishing effect . As was spective ; therefospective .In this synthesis, 3 important potential relationships were identified: (1) adjunct support seemed to improve program use even when input or support was minimal  or when it was provided by a nonexpert  ,25; (2) This realist synthesis not only provides support for incorporating some of the well-studied and highly used PSD features into iCBT activated or present.Although this synthesis and other recent reviews have been helpful for identifying PSD features of interest for improving program use of internet-based interventions ,89,90, tThis is the first study to examine PSD features as they relate to program use in iCBT for children and adolescents with anxiety. A strength of this synthesis is the inclusion of diverse and high-quality evidence  from boprogram use. Adoption of a recent standardized definition and calculation of adherence [effective dose in different delivery settings. Finally, like others [The lack of operationalization of how PSD features and aspects of Context and program use Outcomes were defined, described, and measured by authors affected our data extraction and coding strategies. As adherence to recent recommendations  and repodherence  can clare others -121, we e others ,122), the others ), or pere others )—factorsThe Context-Mechanism-Outcome configurations identified by this realist synthesis provide an initial understanding of how, why, and for whom iCBT programs for children and adolescents with anxiety work from a persuasive systems’ perspective. Appreciating that the effectiveness of iCBT programs may hinge on whether and to what extent programs are used, this study is an important step toward successfully implementing and integrating iCBT into routine clinical care. Recognizing that multiple PSD features are incorporated in iCBT program designs and that individual features may affect each other differently, further knowledge and testing of the purpose and function of these features will help determine the number and combination to use in certain delivery contexts . As PSD features are modifiable, iCBT program designers and developers can look to create more persuasive programs that promote greater use and improved treatment outcomes.


Lesbian, gay, bisexual, and transgender (LGBT) older adults face heightened risks of social isolation, given decades of discrimination. Research on telephone buddy programs with non-LGBT participants have proved predominantly unsuccessful at addressing social isolation and have found the greatest success with same-age matches. However, evidence suggests that LGBT adults may actually benefit from telephone buddy programs and in ways uniquely different from other groups. This article shares lessons learned from 30 participants across a 12-month pilot program that matched LGBT older adults to both LGBT and non-LGBT volunteer callers of various ages. One-third of participants identified as African American or Black. This project employed community-based participatory action research to identify, execute, and evaluate the program. Data includes information from questionnaires and telephone interviews prior to and during the program. In contrast to other research, data here revealed strong support for intergenerational matches. LGBT older adults of color especially benefited from program referrals and matches with/from LGBT adults of color, regardless of age. While the project aimed to capture two groups , the project revealed a third group: LGBT adults at risk of social isolation. This third group usually emerged among the “volunteer” callers but also identified concerns and risk factors for social isolation. The program also revealed unexpected benefits to both LGBT and non-LGBT volunteers, including less loneliness and a stronger sense of community. This article concludes with recommendations for developing similar programs to reduce social isolation in the LGBT community.


Cycling is a green, sustainable, and healthy choice for transportation that has been widely advocated worldwide in recent years. It can also encourage the use of public transit by solving the “last-mile” issue, because transit passengers can cycle to and from transit stations to achieve a combination of speed and flexibility. Cycling as a transfer mode has been shown to be affected by various built environment characteristics, such as the urban density, land-use mix, and destination accessibility, that is, the ease with which cyclists can reach their destinations. However, cycling destination accessibility is loosely defined in the literature and the methods of assessing cycling accessibility is often assumed to be equivalent to walking accessibility using the same decay curves, such as the negative exponential function, which ignores the competitive relationship between cycling and walking within a short distance range around transit stations. In this study, we aim to fill the above gap by measuring the cycling destination accessibility of metro station areas using data from more than three million bicycle-metro transfer trips from a dockless bicycle-sharing program in Shenzhen, China. We found that the frequency of bicycle-metro trips has a positive association with a trip distance of 500 m or less and a negative association with a trip distance beyond 500 m. A new cycling accessibility metric with a lognormal distribution decay curve was developed by considering the distance decay characteristics and cycling’s competition with walking. The new accessibility model outperformed the traditional model with an exponential decay function, or that without a distance decay function, in predicting the frequency of bicycle-metro trips. Hence, to promote bicycle-metro integration, urban planners and government agencies should carefully consider the destination accessibility of metro station areas. As an environmentally friendly transportation mode, cycling can reduce traffic congestion and air pollution in urban areas ,2. It alCycling can also promote the use of public transit, a concept often called bicycle-transit integration. The trip distance between one’s home or office and a transit station is a major barrier to the promotion of transit ridership in large cities ,8; a lonUnderstanding the effects of the built environment characteristics on cycling behaviors can help policymakers to alter the built environment to promote bicycle–transit integration ,15,16. TGravity-based measures are often used to assess both walking accessibility and cycling accessibility due to their relative ease of calculation and interpretation ,20,21. SIn addition, studies have often relied on questionnaires or travel diaries to collect cycling trip data; those methods have some inherent limitations, such as high cost, small sample size and study area, and data inaccuracy due to recall bias. The emerging bicycle-sharing program equipped with global position system (GPS) devices provides a big data source and research opportunity to scrutinize cycling behaviors.To address these research gaps, we assess cycling destination accessibility around metro stations using cycling trip data from a large-scale bicycle-sharing program in Shenzhen, China. The distance impedance is examined, and a corresponding decay function is proposed. The proposed accessibility model is further compared with existing models in terms of the performance of modeling real cycling usage. The relationships between the built environment and cycling trips to and from metro stations are also discussed.Built environment characteristics have been recognized as significant determinants of cycling trips to and from metro stations; these characteristics include the presence of cycling infrastructure, urban density, land-use mix, street connectivity, destination accessibility, and aesthetics ,23,24,25Urban density and land-use mix are both important indicators of cycling behaviors. It has been shown that population density and destination density  have positive relationships with public bicycle use ,27,28,29The presence of cycling infrastructure directly affects cycling behavior. Generally, the presence of bicycle lanes contributes to a higher likelihood of cycling . In partAesthetic factors are essential in encouraging cycling behavior, in addition to factors related to urban density, the land-use mix, and the cycling infrastructure. Among the aesthetic factors, the presence of urban greenness plays an important role in promoting cycling, because the presence of urban greenness often gives cyclists a more pleasant experience ,37,38,39Cycling destination accessibility reflects a person’s ability to reach destinations via cycling. It is indirectly or directly covered in some built environment measures. For example, density and land-use mix can be regarded as proxies for overall accessibly, because denser areas with mixed land use may provide more cycling destinations within cycling distance. The distance to the closest facilities is an explicit measure of accessibility. For transit riders who use cycling as a transfer mode, the distance from their home to the transit station is an important factor ,41. The iA represents the accessibility to place i; ja denotes the activity in place j; i,jt represents the travel impedance between place i and j, which can be considered as time, distance, or other cost; and f is an impedance function that measures the spatial separation between i and j.In addition to cycling accessibility based on a fixed distance threshold, studies often measure dynamic accessibility on the basis of certain distance-decay functions . CyclingIt should be noted that the key component of this formula is the definition of the impedance between two locations. An array of distance-decay functions have been used in empirical studies. Prins, et al.  applied Walking accessibility and cycling accessibility are usually not distinguished from each other, and the combination of the two is sometimes referred to as “active accessibility” or “non-motorized accessibility”. Although walking and cycling share some common features, they also have marked dissimilarities ,46. For Public bicycle-sharing systems have often been advocated to encourage both cycling and transit use because transit passengers can cycle to and from the transit stations ,48. The Free-floating public bicycles allow users to access bicycles at nearly any location and avoid the necessity of docking stations and kiosk machines used for docked bicycles . More imPrevious studies have used cycling data from free-floating bicycle-sharing systems for the following topics: Demand forecasting and bicycle redistribution issue, users’ travel patterns, and determinants of the use of free-floating public bicycles. For example, Pal, Zhang and Kwon  analyzedAlthough the main function of free-floating public bicycles is to integrate with public transit stations, especially metro stations, to solve the “last-mile” issue, few studies have examined cycling transfer trips in metro station areas. Liu and Lin  addresseIn sum, two research gaps exist in cycling accessibility assessment. First, few studies have distinguished cycling accessibility and walking accessibility. The methods of assessing cycling accessibility were mainly adopted from methods of assessing walking accessibility. Walking and cycling are both important modes of active transportation. However, cycling has a higher financial cost and a different time cost  relative to walking, especially for short trips. People prefer walking to cycling when the trip is short. Hence, competition between cycling and walking exists within a certain distance threshold. The willingness to use cycling does not always decrease as the distance increases. It is thus crucial to assess cycling accessibility.Second, most studies have relied on survey data to assess cycling behavior, which is inefficient and includes a limited number of participants and study areas . Public In this study, we aim to fill these gaps by measuring the cycling destination accessibility of metro station areas in Shenzhen, China. First, the specific distance-decay function was estimated with cycling data from a dockless bicycle-sharing system. The performance of the proposed distance-decay function was then compared with the existing distance-decay function in terms of fitting with the number of cycling trips to and from metro stations. We also discuss the potential implications of our results for the transportation planning process.Shenzhen is an emerging megacity in Guangdong Province in South China. It is also a “young” city that underwent rapid urban development from a tiny fishing village in 1979 to a massive modern city with China’s Open-Door Policy. Due to its limited land resources and growing population, the metro system and other types of public transportation have been intensively developed. By 2017, eight metro lines had been built and opened, including 167 metro stations . All metShenzhen’s first free-floating bicycle-sharing system began in October 2016. More than 890,000 bicycles have been put into service, and the number of registered users surpassed 20 million in December 2017. The purpose of about 50% of trips is to commute to or from work or school . More thWe obtained cycling data for approximately 20 million trips from a large bicycle-sharing company. The data consist of all cycling trips in Shenzhen over a 14-day period from 1 to 14 December 2017, including the location  and the time stamps for the origin and destination of every trip. The weather during that period was mild , which allowed us to exclude the effects of weather on cycling.Because we focused on cycling destination accessibility around metro stations, all bicycle-metro transferring trips were selected from the original data. The data processing consisted of three steps: Data cleaning, selection of bicycle-metro transferring trips, and assignment of these trips to each metro station.bX, aY) and the ending point is B , the cycling distance A,BD for this trip is shown as Equation (2).Cycling trips with missing trip information or an abnormal duration (<1 min or >30 min), speed (>3 m/s), or distance (>5 km) were excluded. Because cycling trajectory and its distance were not included in the original dataset, the cycling distance was inferred by Euclidean distance between cycling starting point and ending point. If the starting point of trip n is A . The data consisted of six categories of facilities: Residential, commercial, working, leisure, park, and public transportation POIs. The residential POIs consist of all residence communities and urban villages. The working POIs contain all companies and industry zones. The commercial POIs include shopping centers and malls. The park POIs consist of all kinds of parks and famous scenic spots. The leisure POIs refer to sports facilities, cinemas, and theaters. The public transportation POIs include bus stations. Those POIs represent the destinations or origins of cycling trips that are closely related to our daily life around metro stations.P(d) is the cumulative percentage of trips with a distance of at least d or the value of the trip distribution, and β is the distance-decay parameter to be estimated. The decay parameter indicates the steepness of the decline in the percentage of trips of at least a given distance. The cumulative distribution was used because people prefer shorter walking trips to longer trips. For example, if a person can walk 500 m, he or she can also walk 300 m.Distance decay is a transportation planning method used to model travel behaviors in cities. Distance-decay functions are usually estimated from the distribution of sample data to represent changes in people’s willingness to cycle as the trip distance increases. Exponential functions are usually recommended for short trips as in Equation (3) .(3)P(d)However, we argue that bicycle-metro transferring trips may differ from walking behavior. The willingness to engage in metro-related cycling may increase within a certain distance threshold. In this situation, the distance-decay function cannot accurately represent the change in people’s willingness to cycle as the cycling distance increases.x is the cycling distance, and α, σ, and μ are the values of the parameters to be estimated, which together determine the shape of the curve.To explore the new distance-decay function with the bicycle-metro trip data and test the accuracy of our findings, we randomly selected 10% of the samples from the original bicycle-metro trip data for fitting curves and used the remaining 90% of the data to check the fitting results. The distribution of the frequency of bicycle-metro trips was plotted in 100 m distance bands up to 5000 m; the distribution of standardized trips is shown in An Excel spreadsheet with visual basic code was used to fit the curve. The dependent variable was the number of trips in each distance interval. The distance values are taken by selecting the maximum point of each distance interval.iA represents the cycling accessibility of metro station i; i,jd represents the distance of j facilities around metro station i; i,jO is the facility j in metro station i; and f is the cycling distance-decay function calculated in Equation (4), which represents the attenuated values that correspond to various distances. The logic behind Equation (5) is the cumulative likelihood of cyclists reaching a variety of facilities when considering the effect of distance impedance.Gravity-based measures are used in accessibility measures. We define each station’s cycling accessibility as Equation (5).The distance between a variety of facilities and metro stations was calculated using the nearest-facilities method in ArcGIS 10 . In addition, we excluded any facilities beyond 2.5 km from the nearest metro station because the number of bicycle-metro trips changes little beyond 2.5 km and 95% of bicycle-metro trips fall within this threshold.According to existing evidence, cycling accessibility, cycling facilities, and aesthetic factors all affect bicycle-metro integration  9,23,2424,25. CyIn addition, cycling facilities are directly related to cycling. A low terrain slope and high road density may have a positive effect on the cycling rate ,57. The Num is the number of bicycle-metro trips; β0, β1, β2, β3, β4, β5, β6, β7, β8, β9 is the parameter to be determined; and ε is the random variable.A regression model was used to model the bicycle-metro trips with all the independent variables above, including variables of the proposed cycling accessibility, cycling infrastructure and aesthetic. The remaining 90% of bicycle-metro trips which has been removed the 10% of samples of original bicycle-metro trips used for the fitting curve were as the dependent variable. The regression formula is shown by Equation (7).To examine the performance of the proposed cycling accessibility with a lognormal distribution function, three regression models with different measurements of cycling accessibility were built. Model 1 used accessibility without a distance-decay function, which means that the willingness of cycling to facilities at different distances from metro stations had the same weight. Model 2 used accessibility with an exponential distance-decay function . The wilIn the three models, the only difference is the way of calculating cycling accessibility , all othα = 10.369, σ = 0.685, and μ = 2.087), and the goodness of fitness for the estimation is 0.99. The distance-decay function can be given as follows:i,jd represents the distance between metro station i and destination j. The curve f represents the change in people’s willingness to cycle as the transferring distance increased. Observation of the curve reveals that 500 m was an important turning point, that is, the most popular cycling distance for transferring was 500 m. Within the range of 100 to 500 m, people’s willingness to ride gradually increased as the distance increased. Their willingness then slowly decreased as the distance increased, and it approached 0 at 5 km. The fitting curve was shown in With the aid of our visual basic code, the parameters of logarithmic normal distribution decay function were estimated , were developed earlier, and Baoan, Longhua, and Longgang districts, located outside the SEZ, were developed later. Hence, the metro stations and POIs in the SEZ are densely distributed, and the transferring distances are relatively short. In this situation, people prefer to walk to connecting metro stations. In contrast, metro stations and POIs outside the SEZ are sparse, and the transferring distances are relatively long. In this situation, people prefer cycling as a transfer mode. In addition, some interchange metro stations, such as Chegongmiao, Huaqiangbei, and Houhai stations, had greater accessibility. However, interchange stations that link to high-speed rail stations, such as Shenzhenbei and Luohu, had lower accessibility. The interchange stations have more passengers and more kinds of facilities than normal stations. Hence, people can reach more facilities by cycling, and the bicycle-metro trips are longer, because the passengers at high-speed rail stations mainly transfer within the stations or integrate with taxis and buses. Thus, a variety of transfer options may affect the choice of cycling.2 = 0.445) than the model without distance decay (R2 = 0.365) or the model with exponent decay (R2 = 0.411). The results indicate that Model 3 can explain 44.5% of the variance in the number of bicycle-metro trips. The regression results are shown in In addition, the working accessibility and leisure accessibility were both significant at <0.01 level in the three models, which means that working accessibility and leisure accessibility were both crucial factors influencing bicycle-metro integration. Road network density was also significant in all the models. Cycling is a viable transfer mode to promote the use of public transit, and a policy of bicycle-transit integration has been actively advocated by many governments in both developed and developing countries. Destination accessibility is believed to be a critical factor that can facilitate or hinder transit-transferring cycling behaviors. However, destination accessibility was not rigorously defined in previous studies because walking and cycling behaviors were not distinguished. In this study, we found a lognormal distribution decay curve for bicycle-metro trips of a large public bicycle-sharing program in Shenzhen, China. The destination accessibility with a lognormal distribution distance-decay function was proposed by considering the competition between cycling and walking within 500 m around each metro station. Our new accessibility measure had greater associations with the number of bicycle-metro trips than existing models. More specifically, this study has three major findings.First, the superior performance of our new accessibility measure indicates that the distance decay of bicycle-metro trips conforms to a lognormal distribution. The findings of this study differ from those of previous studies that the distance decay of both cycling and walking trips fits an exponential curve ,44,58,59In addition, walking and cycling may compete as transfer modes to transit service within 500 m. From the cycling distance-decay curve , we founSecond, the working POI accessibility, leisure POI accessibility, and road density are important built environment indicators that affect bicycle-metro trips. Similar results were found in that the availability of cycling infrastructure ,60 and aThird, the threshold of bicycle-metro trips was higher than that in previous studies. Most studies used the 85th-percentile access distance to confirm the catchment area. In this paper, the 85th-percentile distance of all bicycle-metro trips was about 1.5 km, which is not consistent with previous conclusions generated by survey data. For example, the access distances to metro stations for cyclers in Beijing fall mainly between 0.4 and 1.4 km, which is less than our finding .However, the access distance above is commonly obtained from a self-reported distance or a distance calculated from an algorithm-identified route with a reported origin/destination and stop location, which may lead to an inaccurate result. This problem was improved in this study using the bicycle-sharing big data. We defined the threshold of bicycle-metro trips in Shenzhen as about 2.5 km, which covers 95% of cycling trips, because the number of bicycle-metro trips changed little beyond 2.5 km and 95% of bicycle-metro trips are within this threshold. The findings from this study have important policy and planning implications; by providing a safe and comfortable cycling environment and well-established public bicycle-sharing systems, we can promote bicycle–transit integration and thus improve both cycling and transit usage in the 2.5-km transit-catchment area. Further validation about the 2.5 km threshold is needed to confirm the generalizability of this finding.This study has both strengths and limitations. We distinguished cycling and walking as transfer modes to and from metro stations. The competition between cycling and walking within 500 m of metro stations help us to develop a new cycling destination accessibility model with a lognormal distribution decay curve. Furthermore, we used the big data from more than three million trips of a public dockless bicycle-sharing program, which addressed many limitations of previous cycling data collected from surveys or travel diaries, such as limited sample size and study area. The limitations of this study arise mainly from the nature of the bicycle-sharing data and the lack of metro ridership data. First, we cannot collect individual factors , which prevent us from controlling for the potential influence of those factors on cycling behavior. Second, the decision to cycle is affected by the availability of public bicycles around metro stations. The tidal phenomenon of sharing bicycles  may affect the number of bicycle-metro trips. Third, the dataset does not include summer season data, hence we cannot understand the effect of weather on cycling behavior. Forth, the metro ridership data is also an important factor affecting the cycling transferring trips, which may lead a relatively weak explanation in the regression model. In addition, we assume that the six types of facilities have the same distance-decay function and weight in the accessibility model process. Although the geographic locations of the trip destination were collected, the destinations of our data were uncertain . Future studies may combine various data sources, such as travel diary and geocode public cycling-sharing data to address these issues.In this study, we measured cycling destination accessibility with the big data from more than three million trips on a public bicycle-sharing system. We found that the distance-decay function associated with cycle-metro trips conforms to a lognormal distribution. Most specifically, the frequency of cycle-metro trips increases with distance within 500 m of a metro station and then decreases beyond 500 m. The pattern differs significantly from that of walking behavior. Our results also show that our proposed destination accessibility model outperforms existing models in fitting the frequency of cycle-metro trips. Furthermore, the optimal distance of bicycle-metro trips in Shenzhen is about 2.5 km, or around 15 min by bicycle. Hence, promotion of a policy of cycle-metro integration can effectively extend metro service coverage areas 800 to 1500 m from metro stations. By proposing robust and validated metrics for cycling destination accessibility, the findings of this study may help policymakers and planners create a cycling-friendly built environment and thus lead to better cycle–metro integration.


We conducted a mixed-methods process and outcome evaluation for a statewide fruit and vegetable prescription program. The process evaluation assessed program implementation, identified opportunities for quality improvement, and provided recommendations for future programmatic activities. The outcome evaluation measured how the program affected purchases of fruits and vegetables among low-income patients and patient satisfaction with the program.The Washington State Department of Health (WA DOH) partnered with public and private health care systems, public health agencies, a community-based organization, and a supermarket chain to launch a fruit and vegetable prescription program in 2016. The prescription was a $10 voucher redeemable for fruits and vegetables at any one of 169 participating supermarkets. Prescriptions were distributed to eligible low-income patients in clinics and community settings.WA DOH reviewed quarterly reports, meeting minutes and notes, telephone call logs, and email logs to solicit feedback on program implementation processes. We calculated overall prescription redemption rates on the basis of the number of prescriptions distributed by implementing partners and the number of prescriptions redeemed at participating supermarkets. We assessed patient satisfaction through a web-based survey. The study period was July 1, 2016, through June 30, 2018.Best practices for implementation included using the prescription to improve patient engagement and retention and connect patients to additional services, and working in the community to enhance program support and uptake. Overall, $154,810 in fruit and vegetable prescriptions were redeemed during the study period (54.4% redemption rate). Most survey respondents (88.2%) reported eating more fruits and vegetables than previously as a result of the prescription.Fruit and vegetable prescriptions are an effective way to increase affordability of healthy foods for low-income patients. These programs are scalable and translatable across various types of patient–provider encounters. Programs that increase affordability of fruits and vegetables through financial incentives have improved fruit and vegetable consumption and food security among participants. However, program scalability is limited when programs rely on partnerships with farmers markets and small-scale grocers.Through a process and outcome evaluation, this report highlights program implementation successes and barriers of providing fruit and vegetable prescriptions in partnership with a supermarket chain to low-income residents in Washington State.A statewide fruit and vegetable prescription program is scalable and translatable across various types of patient–provider encounters and helps improve affordability of fruits and vegetables for low-income residents.Despite public health efforts, people in Washington State and the United States overall do not eat enough fruits and vegetables to meet national recommendations for a healthy diet –3. This Although in 2017 the overall food insecurity rate in Washington State (11.5%) was lower than the national average (12.5%), intrastate geographic and demographic disparities exist; the rate in some Washington counties is nearly 1.5 times the national average . Howeverwww.doh.wa.gov/FINI). As part of the FINI grant, WA DOH began implementing a statewide fruit and vegetable prescription program in July 2016.The US Department of Agriculture’s Food Insecurity Nutrition Incentive (FINI) Grant Program supports projects that incentivize the purchase of fruits and vegetables among SNAP participants . In 2015The objective of this study was to describe mixed-method process and outcome evaluation results after 2 years of implementation of the fruit and vegetable prescription program, using data collected from July 1, 2016, through June 30, 2018 . The purpose of the process evaluation was to 1) examine strengths and weaknesses of the fruit and vegetable prescription program implementation and 2) gain insight into successful programming activities for fruit and vegetable prescriptions. The purpose of the outcome evaluation was to 1) assess overall effectiveness of the program in improving affordability of healthy foods among low-income patients and 2) assess patient satisfaction with the fruit and vegetable prescription program. Although the program is planned to run through December 2019, the reporting of mid-program evaluation findings, given the current national climate for fruit and vegetable incentives , can helIn July 2016, WA DOH partnered with public and private health care systems, public health agencies, and a community-based organization , and a supermarket chain to launch a fruit and vegetable prescription program in counties where the prevalence of low fruit and vegetable intake, food insecurity, and chronic disease are disproportionately high . The fruProgrammatic planning exercises during the first 15 months of the grant period (April 2015–June 2016) included an in-person meeting, email correspondence, and webinars with implementing partners. Through these exercises, WA DOH and implementing partners identified that they needed flexibility in implementing the fruit and vegetable prescription program.Implementing partners used various types of patient encounters, prescribers, and dosing amounts , which wPatients redeemed the prescription at any one of 169 participating supermarkets in Washington State. Patients presented the prescription at point-of-sale to purchase qualifying items, which included fresh, canned, or frozen fruits and vegetables without added fats, oils, sugars, or salt. No additional purchase was necessary to redeem the prescription, but patients were encouraged to purchase at least $10 of qualifying items per transaction. WA DOH and the supermarket chain provided training to store staff members to prepare for prescription redemption. At the point-of-sale, the prescription was scanned and purchase information was stored in the supermarket’s sales database. The supermarket chain provided data on the number of prescriptions redeemed by PLU, by quantity and characteristics of items purchased, and by dollar amount.Overall, 14 implementing partners participated during the study period. The program began with 9 implementing partners; 3 implementing partners discontinued distributing prescriptions in 2017 and 2018 because of staffing limitations. In 2018, 5 new implementing partners began distributing prescriptions, resulting in 11 implementing partners with 185 prescribers in 86 prescribing sites in the program in June 2018 .To assess the fruit and vegetable prescription program, we conducted a mixed-methods process and outcome evaluation. The process evaluation assessed program implementation, examining strengths and weaknesses of the program and identifying successful programming activities, to identify opportunities for program quality improvement and provide recommendations for future programmatic activities. The outcome evaluation measured program use: how the fruit and vegetable prescription program affected patients’ purchasing of fruits and vegetables and patient satisfaction with the program. We developed the evaluation plan and questions on the basis of extensive stakeholder input through annual in-person meetings and presentations, quarterly telephone calls and webinars, and frequent email communication with implementing partners. The Washington State Institutional Review Board deemed evaluation activities exempt from review.As part of process evaluation activities, we reviewed quarterly reports, meeting minutes and notes, and telephone call and email logs to solicit feedback on program implementation processes. Each quarter, as part of regular reporting required for participation in the program, implementing partners identified key successes in their fruit and vegetable prescription program implementation activities and overall experiences with prescription distribution, including facilitators and barriers to effective implementation. We collected this information electronically through a secure online survey platform. All implementing partners responded to the same open-ended questions on facilitators, barriers, and key program activities. WA DOH staff members reviewed these electronic reports each quarter and tracked responses through a Microsoft Excel 2013 spreadsheet, providing technical assistance as needed for continuous program quality improvement. In all, this review included 89 reports generated during the study period.WA DOH staff members also kept records of telephone calls and emails from implementing partners requesting technical assistance for program implementation and telephone calls and emails that described the steps taken as a result of this assistance. We matched details from telephone call and email logs to implementing partner reporting to identify and confirm quality improvement measures taken. In all, we reviewed records from 20 telephone calls and emails during the study period.In addition to required implementing partner reporting and requests for technical assistance, WA DOH staff members held quarterly meetings, including 6 virtual meetings and 2 in-person meetings, during the study period. These meetings were an opportunity for the study team to ground-truth key themes emerging from reporting and provided a venue for more in-depth knowledge sharing among all implementing partners. WA DOH kept detailed agenda and meeting notes from each of these meetings.Evaluation staff members reviewed all compiled responses from reporting, technical assistance efforts, and meeting notes and closed-coded responses to answer the following questions:What are major facilitators and barriers to 1) program implementation in the clinic setting and 2) patients’ use of a fruit and vegetable prescription?What are key activities and/or resources considered critical to the successful implementation of an incentive program in the clinic setting?Evaluation staff analyzed coded responses and identified patterns across responses by using thematic analysis.Although one-on-one in-depth interviews were originally planned during the study period as part of the process evaluation, staffing limitations led to a change in methodology and approach. Additionally, preliminary review of documents received from implementing partners and sharing of results with key stakeholders showed that information from regular reporting and technical assistance activities was more than sufficient for identifying facilitators and barriers to program implementation and provided more timely information for continuous program quality improvement than would have been possible from interviews.We calculated overall prescription redemption rates for each implementing partner as a measure of program use. Each quarter, implementing partners reported the number of prescriptions distributed each month via a secure online portal. Each month, WA DOH also received point-of-sale transaction details for each prescription redeemed, including the PLU, dollar amount spent, and characteristics of items purchased, from the supermarket’s sales database via secure file transfer. Fruits and vegetables purchased at the point of redemption were categorized according to type  and whether they were eligible to be purchased with the prescription . We calculated redemption rates by dividing the number of prescriptions redeemed by the number of prescriptions distributed over the specified time period. We reported rates to implementing partners each quarter. We assessed redemption rates by quarter and time of month  to determine how timing of SNAP benefit issuance affected prescription redemption. We compared redemption rates from earlier in the month  with the third 10 days to assess whether the fruit and vegetable prescription was helping to stretch participants’ SNAP benefits. We used data on purchases and redemption data to assess program use to answer the following evaluation question: To what extent did patients use the fruit and vegetable prescription?We surveyed patients to assess their satisfaction with the fruit and vegetable prescription program. Because response rates for telephone and mail-based surveys are declining  and becaPatients could complete the voluntary survey on any electronic device and were eligible to take the survey each time they received a prescription. When the prescription was distributed to an adult on behalf of a child’s participation, the parent or guardian was invited to take the survey on behalf of the child. The survey consisted of 30 questions, including validated questions on demographic and socioeconomic characteristics , food inTo what extent did patients find the fruit and vegetable prescription acceptable to use?How does receipt of a fruit and vegetable prescription change patients’ knowledge, attitudes, and practices toward fruit and vegetable consumption, health behaviors, and perceived access to healthy foods?The survey first became available to patients in September 2017. Each participant received a $3 electronic gift card at each survey completion (maximum 1 per week). We managed and calculated summary statistics  by using Microsoft Excel 2013.Implementing partners identified several key milestones and lessons learned as a result of the prescription program, illuminating potential areas for future program success.Offering the fruit and vegetable prescriptions improved patient visits. Implementing partners consistently reported increased attendance and retention in health care appointments and community-based classes when prescriptions were offered. For example, one implementing partner reported higher-than-average completion rates among patients in the Chronic Disease Self-Management Program as a result of offering the prescription, with 95% of patients completing the 6-week program. Anecdotal evidence also showed that as a result of the fruit and vegetable prescription program, patients scheduled and kept more follow-up appointments with primary care dietitians, and no-show rates for home visiting decreased slightly.Providing a method to identify high-need patients helped connect these patients to additional services. Several implementing partners incorporated food insecurity screening and nutrition wraparound services into their institutional workflows as a result of offering fruit and vegetable prescriptions. One pediatric primary care clinic referred food-insecure families to an outreach organization that helped families determine eligibility for and enroll in SNAP and other food assistance resources. Another implementing partner worked with community health workers who lived and worked in low-income housing sites to distribute prescriptions during nutrition education events. The community health workers were uniquely situated in these low-income housing sites and connected their peers to other health-related screenings and programs that improve food security and other social determinants of health.Working in the community enhanced program support and uptake. Implementing partners reported using several methods to best reach eligible patients in their communities. One such method was having bilingual dietitians, nutrition educators, and other health care providers distribute fruit and vegetable prescriptions. One implementing partner hosted culturally relevant nutrition education classes in Russian and distributed the prescriptions in the Russian-speaking community. Other implementing partners reported efforts to engage with the Spanish-speaking community; however, some patients expressed hesitancy in enrolling in SNAP for fear of negative consequences to their documentation status.Eliminating administrative burden helped ease program implementation. Implementing partners reported difficulty tracking distribution of the paper-based prescriptions for various reasons. First, the prescriptions required a hand-written expiration date, which increased workload on prescribers, as well as time required for distribution, which could affect patients’ perception of the program. Prescribers in many encounters also had to count out each prescription during distribution, which required time and introduced potential human error in the number of prescriptions distributed. Many prescribers distributed prescriptions outside of traditional clinic visits , and they used paper tracking sheets to document distribution because they did not have access to an EMR. Although prescribers could have used technology — for example, tablets or smart phones — for tracking purposes, the use of technology could have been perceived as intrusive to patients or as a barrier to prescribers. Finally, in the few locations where the EMR was available, implementing partners found that introduction of an EMR tracking method was cost-prohibitive because of the involvement of outside vendors or information technology staff.Redemption rates and other characteristics of fruit and vegetable prescription transactions. During the study period, 28,481 prescriptions were distributed, with $284,810 provided to patients to use when purchasing fruits and vegetables. Of these, 15,481 prescriptions were redeemed, for an overall redemption rate of 54.4% . Because each prescription was valid for 1 month from the date of distribution, and the exact date of prescription distribution was not linked with date of redemption, this redemption rate is a conservative estimate; true redemption rates cannot be calculated until one month after the program’s end, in December 2019. Redemption rates varied by quarter , patients spent more than $10.00 on qualifying items . On averPerception of the fruit and vegetable prescription program among patients receiving prescriptions. From September 1, 2017, through June 30, 2018, 144 patients completed the electronic survey. Most respondents  reported the prescription was easy to use. Of the 144 respondents, 74.3% (n = 107) reported food in their home was less likely to run out as a result of the prescription, and 86.8% (n = 125) reported increased ability to afford balanced meals.Patients also reported a perceived increase in fruit and vegetable intake as a result of receiving the fruit and vegetable prescription: 88.2% (n = 127) reported eating more fruits and vegetables than previously and 70.1% (n = 101) reported that they tried a new fruit or vegetable. In addition, 76.4% (n = 110) reported increased fruit and vegetable consumption among family members.Participation in the program also resulted in patients’ perceived health benefits: 71.5% (n = 103) reported managing their health conditions better, and 81.2% (n = 117) reported improvement in meeting nutrition, diet-related, or meal plan goals.Results from the mid-program evaluation affirmed that the fruit and vegetable prescription program improved affordability of fruits and vegetables for low-income patients and helped them achieve their health behavior goals. Our analysis shows patients maximized the full value of the prescription, and stretched limited food budgets to buy healthy foods. Patient-level survey responses showed a perceived improvement in consumption of healthy foods and perceived health benefits as a result of receiving the prescription.Findings from our evaluation highlight several important points. First, our results show that fruit and vegetable prescription programs are scalable and translatable across various patient–provider encounter types in various geographic settings, but they require flexibility for implementing partners to fit into their typical institutional or programmatic workflows. Despite this requirement of flexibility, offering the prescriptions is an effective way to engage patients in educational and counseling sessions. A key reason for its effectiveness is that the prescription simultaneously addresses food insecurity and chronic disease prevention/management by providing financial support for patients to modify purchases and achieve healthy eating goals.Second, our evaluation results show how social determinants of health can be incorporated into patient-provider encounters. Implementing partners can capitalize on fruit and vegetable prescription programs by establishing consistent, holistic enrollment criteria and processes for patients. Although funding for this program requires patients to be enrolled in SNAP, a useful screening tool for other fruit and vegetable prescription programs would be the Hunger Vital Sign , a validThird, minimizing the amount of time required by prescribers to distribute the prescriptions is helpful for effective program implementation. Although streamlining the process of distribution for all implementing partners may not be feasible, one strategy is to move from a paper prescription to a reusable card. Prescribers would issue the card and load it with a certain amount of dollars for fruits and vegetables, and patients would use it just like any other payment card at participating food retailers at point-of-sale. Prescribers could reload cards during follow-up appointments or classes. Although a card-based system may be more expensive than a paper-based system, ultimately it could increase efficiency and improve tracking for distribution and redemption.Implementing partners worked with various populations, including racial/ethnic minority groups, senior citizens, and residents in urban and rural areas. For all implementing partners, redemption rates were 34% or higher. We realize that a statewide fruit and vegetable prescription program may not be feasible for other states to implement because of lack of funding and resources. However, similar programs at any scope or scale can benefit from the lessons learned in our evaluation. Additionally, such programs can play a role in connecting health care with social determinants, which ultimately can improve population health; therefore, funding organizations and legislators should consider investing in programs that support healthy food purchases for low-income patients.This evaluation has several limitations. The diverse implementation of the fruit and vegetable prescription program limited the evaluation design, data collection methods, and subsequently the generalizability of findings. WA DOH supported flexibility in program implementation, which increased the number of patients receiving a prescription; however, this flexibility prevented the clear, concise interpretation and translation of results that is possible under the conditions of a controlled trial. Although a redemption rate of 54% is respectable, 46% of prescriptions were not redeemed. Because of the varied approaches in program implementation, we could not collect information from patients who did not redeem the prescription and better understand reasons for not using it. Data collection was logistically and ethically challenging because of the number of implementing partners and prescribers; for this reason, we collected a minimal amount of patient-level data. Additionally, program implementation hindered the collection of preprogram and postprogram measures, so we could not ascertain causal relationships. Finally, information on perceived benefit was limited to self-report, which is subject to bias. More objective measures, such as biometric measures collected from an EMR, could eliminate potential bias, and will be added to data collection activities in future years, where possible. Although the use of the electronic survey to collect data from patients enhanced data collection and minimized administrative burden, the response rate could be improved, and evaluation staff members will continue to work with implementing partners to improve this rate.Despite these limitations, we believe that these evaluation activities were effective in providing a snapshot of the fruit and vegetable prescription program in Washington State. By using an electronic survey to collect data from patients and having electronic access to implementing partner reports and point-of-sale data, we streamlined the process of data collection, entry, and analysis. Consistent reporting from implementing partners allowed for continuous program quality improvement and provided an easy outlet for partners to report programmatic facilitators and barriers. We also believe that our findings and our approach, compared with those of a controlled trial, more accurately describe best practices for translating a fruit and vegetable prescription program to US settings that would not be appropriate for a controlled trial.


Heated, humidified, high-flow nasal cannula (HHFNC) oxygen therapy allows optimal humidification of inspired gas at high flows and creates a distending pressure similar to nasal continuous positive airway pressure . It has A 53-year-old female with hemophagocytic lymphohistiocytosis (HLH) was admitted to the intensive care unit because of respiratory failure. After weaning from mechanical ventilation which lasted for 2 weeks, HHFNC therapy at 40 L/min with an FiO2 of 0.5 was started for hypoxemia. Four days later, dyspnea and hypoxemia occurred and chest X-ray and CT scan revealed localized pneumothorax, subcutaneous emphysema, and massive pneumomediastinum. After cessation of HHFNC, respiratory condition improved.Subcutaneous emphysema, pneumothorax, and pneumomediastinum should be notified as a serious complication during HHFNC therapy. Meanwhile, as an adverse effect, Kang and colleagues found that using HHFNC for longer than 48 h before intubation was associated with higher ICU mortality and less success at extubation and ventilator weaning, and fewer ventilator-free days. They examined all subjects who failed HHFNC delayed and required intubation [Humidified high-flow nasal cannula (HHFNC) is useful before and after mechanical ventilation in tracheal intubation. Above all, it has been considered to be of advantage that it can be done safely and that the patient’s QOL is maintained. There are other benefits as well. For example, the positive end-expiratory pressure (PEEP) effect of HHFNC is considered to have a positive effect on acute heart failure, and it is also said that it has a COIO2 of 0.5  was applied through nasal cannula , and a mini tracheostomy cannula  was placed to treat her sputum. Her oxygenation was improved, and FIO2 was decreased to 0.35. Four days later, she complained of respiratory discomfort. Her oxygenation worsened and hemodynamic status also deteriorated. Specifically, FIO2 was 0.35 and PaO2 was about 60 mmHg, and PaCO2 was less than 30 mmHg because of respiratory acceleration (35 per minute). In hemodynamics, blood pressure itself was maintained, but it became sinus tachycardia of about 100 to 130 times per minute. Her chest X-ray revealed a localized pneumothorax and subcutaneous emphysema . She could not improve subjective discomfort easily, but her oxygenation and hemodynamic status gradually improved. On the next day, it was confirmed by a chest X-ray that the localized pneumothorax and emphysema disappeared  was admitted to the intensive care unit (ICU) because of respiratory failure. Immediately after admission, her airway was established using a cuffed 7.0-mm tracheal tube. Her chest X-ray showed severe bilateral infiltrates, and blood gas showed moderate level of acute respiratory distress syndrome (ARDS). Immediately after beginning of mechanical ventilation, high positive end-expiratory pressure (PEEP) combined with low tidal volume was applied. Her respiratory status gradually improved. Two weeks after commencement of mechanical ventilation, finally, her trachea was extubated. However, she developed mild hypoxemia with standard oxygen therapy and was suffering from tenacious secretion. HHFNC therapy at 40 L/min with an FMoreover, she had a lung with bulla, and it is undeniable that the bulla ruptured due to cough caused by suction after extubation, and the pressure by HHFNC was applied to it and pneumothorax occurred.The air leak is a well-known complication of positive pressure ventilation, and HHFNC provides increased pressure within airways , which mIn the present case, air leak would have been ascribed to positive airway pressure generated by HHFNC through micro-tear of the trachea caused by mini-tracheostomy cannula placement or damage to the tracheal wall due to suctioning through the mini-tracheostomy. Otherwise, air leak might have occurred due to rupture of bulla and alveoli due to cough associated with suctioning. However, these could not go beyond speculation. Serious air leaks related to HHFNC therapy have been reported in pediatric patients . Our casThe reason why the pneumothorax was localized is probably because her pleural space was adhesive after inflammatory reaction. After cessation of HHFNC therapy, airflow under spontaneous breathing without any artificial support was regulated in her airway because of the absence of excessive airway pressure, which did not worsen air leaks and improved her respiratory condition.Positive pressure ventilation should be used with caution if there is a possible airway injury. HHFNC also may contribute to the development of air leak syndrome although HHFNC therapy tends to be sought gentler than other conventional therapy.