ClinicalTrials.gov, NCT03548558, June 7, 2018. https://clinicaltrials.gov/ct2/show/NCT03548558.Early childhood development (ECD) parenting interventions can improve child developmental outcomes in low-resource settings, but information about their implementation lags far behind evidence of their effectiveness, hindering their generalizability. This study presents results from an implementation evaluation of Msingi Bora (“Good Foundation” in Swahili), a group-based responsive stimulation and nutrition education intervention recently tested in a cluster randomized controlled trial across 60 villages in rural western Kenya. Msingi Bora successfully improved child cognitive, receptive language, and socioemotional outcomes, as well as parenting practices. We conducted a mixed methods implementation evaluation of the Msingi Bora trial between April 2018 and November 2019 following the Consolidated Advice for Reporting ECD implementation research (CARE) guidelines. We collected qualitative and quantitative data on program inputs, outputs, and outcomes, with a view to examining how aspects of the program's implementation, such as program acceptance and delivery fidelity, related to observed program impacts on parents and children. We found that study areas had initially very low levels of familiarity or knowledge of ECD among parents, community delivery agents, and even supervisory staff from our partner non-governmental organization (NGO). We increased training and supervision in response, and provided a structured manual to enable local delivery agents to successfully lead the sessions. There was a high level of parental compliance, with median attendance of 13 out of 16 fortnightly sessions over 8 months. For delivery agents, all measures of delivery performance and fidelity increased with program experience. Older, more knowledable delivery agents were associated with larger impacts on parental stimulation and child outcomes, and delivery agents with higher fidelity scores were also related to improved parenting practices. We conclude that a group-based parenting intervention delivered by local delivery agents can improve multiple child and parent outcomes. An upfront investment in training local trainers and delivery agents, and regular supervision of delivery of a manualized program, appear key to our documented success. Our results represent a promising avenue for scaling similar interventions in low-resource rural settings to serve families in need of ECD programming. This trial is registered at  An estimated 43 percent of children under age 5 in LMICs experience compromised cognitive and socioemotional development due to poverty, poor nutrition, and inadequate psychosocial stimulation . Early cGovernments and organizations in LMICs are now asking for operational guidance on how to implement effective and scalable programs to improve ECD outcomes. Though there is now consistent evidence of effectiveness of ECD interventions to improve child outcomes, there is strikingly very little information about how these programs were implemented to demonstrate how such results were achieved. There are many ways to implement ECD programs, and decisions must be made regarding: program content, duration and intensity, delivery mode –whether group-based meetings, clinic or home visits– and the necessary qualifications of delivery agents. Some designs may be more suitable for low-resource settings where cost is an issue  and wherTo our knowledge, only two published effectiveness studies from Uganda  and PakiUsing the CARE guidelines, this study describes the implementation of a successful parenting intervention that compared the effectiveness of two group-based potentially scalable delivery models for an integrated ECD intervention for families with young children in rural Kenya see . BecauseThe current manuscript reports results from an implementation evaluation of the Msingi Bora trial, with a view to examining determinants and consequences of implementation outputs, such as acceptance of the program and fidelity of delivery, and their association with parent and child outcomes at endline , 16. OutOur research questions were:What program resources were input ahead of implementation? Was the program content and delivery acceptable to parents and delivery agents?fidelity and parental attendance and enactment  change during the intervention, and what determined these Outputs?How did Outputs such as delivery What features of Inputs and Outputs were, in turn, associated with child and parent Outcomes, and how did this differ by delivery mode?We conducted a mixed methods implementation evaluation of the Msingi Bora trial between April 2018 and November 2019 in three sub-counties outside Kisumu. These predominantly rural areas are characterized by high rates of poverty, child mortality, stunting (23%), and spousal violence (60%);  56% of cThe eligibility criteria for parent participants within villages were mothers or other female primary caregivers aged 15 and over with a child between 6 and 24 months without signs of severe mental or physical impairment. Baseline demographic data from 1,152 households across 60 villages are available in Luoto et al. .Program delivery agents were existing village Community Health Volunteers (CHVs), which is a part-time and voluntary position under the Ministry of Health (MOH) tasked with improving community health through home visits .We worked with three Kisumu-based staff and seven sub-county supervisors  from the local NGO to oversee the daily operations of Msingi Bora and to provide training and supervision to delivery agents.ClinicalTrials.gov, NCT03548558, and the study protocol has been published . Sessions took place in local community centers or churches. Households in villages assigned to the comparison group did not receive any interventions besides information about child feeding during the baseline survey.CHVs are members of their own communities and the position is generally part-time. Minimum qualifications include being literate, permanent residents of the village, and accepted in their roles by the community members. Upon selection, CHVs undergo roughly 10 days of training held by county MOHs on topics related to basic health promotion;  ECD topiCHVs were trained on Msingi Bora in two parts. Training of sessions 1–8 took place at the start of the program over 8 days; training of sessions 9–16 took place at midline over 8 days. The first training was conducted in English by international researchers  with all CHVs together, though they had an English and local language version of the manual. The second training was conducted in the local languages by SWAP staff following a train-the-trainers model in which international staff first trained SWAP staff, who then trained the CHVs. Beginning with session 4, monthly 1-day refresher trainings were also performed in each sub-county to help CHVs prepare ahead of each session.Training focused on three critical skills: (a) knowing what children need to develop; (b) demonstrating and coaching caregivers as they engaged in the new practices; and (c) facilitating group discussions about problems and solutions. Trainings followed the sequence of activities in the manual. They emphasized practicing how to demonstrate the activities, coach parents and facilitate group discussions, first among themselves and then with groups of mothers and children from villages not participating in the study.CHVs underwent tests on knowledge and competency to deliver sessions at the end of each training, the former with a paper-and-pencil test and the latter with mock sessions scored using a fidelity rating sheet (described below). Those who were weaker at the end of training were required to attend the session of a peer and undergo extra practice before delivering their own group session.To obtain information from CHVs concerning their perspectives of the program content and delivery format, as well as on their training, supervision, and curriculum acceptance, semi-structured interviews were conducted with eleven randomly selected CHVs at the end of the program. Two local researchers individually interviewed selected CHVs, male and female, from different sites in a private, neutral community setting.www.swapkenya.org) is a local NGO that has operated since 2005 in western Kenya and served as the local implementing partner overseeing the training and supervision of the CHVs. Since topics of stimulation and responsive parenting were new to SWAP staff, the pilot training was delivered by international researchers in English, and attended by six SWAP staff and six CHVs from the selected pilot villages who were trained to deliver the pilot program. For the full trial, four of the six pilot CHVs were promoted to “mentor” supervisory roles to help with local monitoring of the sessions. As mentioned above, SWAP staff and mentor CHVs participated in the two training courses for the main trial, and led the second one under a train-the-trainers model.SWAP . After the session, they asked CHVs to complete their own self-evaluation form and then provided feedback on their performance.The same local qualitative researchers conducted two focus groups at the end of the program with SWAP staff – one with the three lead supervisory staff, and a second with three sub-county staff. They were asked the same questions and probed about four key components of the program: (a) acceptance of the program content and delivery; (b) helpful and unhelpful aspects of training and supervising CHVs; (c) how easy and difficult it was for CHVs to demonstrate practices and to facilitate discussion; and (d) benefits and problems associated with group sessions and home visits.SWAP supervisors utilized a checklist of fidelity items during sessions and provided CHV delivery agents with feedback immediately after each session. In addition, CHVs completed self-evaluation forms following each session and attendance sheets of parent participants. The supervisor and self-evaluation forms were similar in content, and included 5-point scales, from “poor” (1) to “excellent” (5), to rate 13 dimensions of the CHV's fidelity to session content, demonstration of activities, facilitation of group discussions, coaching, use of visual aids and play materials, and other delivery qualities. At the end of the forms, respondents were asked to rate the overall session quality on a 1–10 scale, as well as how much “fun” participants had on a 1–10 scale to capture the level of engagement by participants.Qualitative interviews of eight pairs of participant mothers from the three sub-counties were conducted at the end of the program, in a private neutral setting. Mothers were interviewed in pairs in order to collect more information and to make them feel more comfortable by being in the presence of a familiar person. They were selected by SWAP staff to meet criteria of representing each of the different delivery formats , and we requested that they include mothers with both high and low attendance in the program. The same two independent qualitative researchers used a semi-structured guide of questions. The questions focused on participants' attendance and acceptance of the program, enactment or adoption of the practices promoted during sessions and how easy and difficult practices were to enact; they also evaluated the group sessions and home visits.All qualitative implementation data were collected by a team of two local independent researchers, one male and one female, trained by FA and JL. All interviews obtained informed consent prior to beginning, were conducted in the local language of choice, and were audiorecorded, translated to English and transcribed. Interviewers probed for elaborations. Transcriptions and translations were verified between the two independent researchers.p < 0.0001). For the parent interviews, the same two researchers independently coded four after agreeing on a coding scheme . Because there were only two supervisor FGD, two researchers (FA and DS) together coded their responses.Content analysis was performed to analyse all qualitative data using a pre-arranged list of codes on desired information. For the CHV interviews, two co-authors (FA and RZ) independently coded four interviews after agreeing on a coding scheme and found high inter-rater reliabilities ,  and sociQuantitative analyses used multivariate linear regressions by estimating ordinary least squares (OLS) models for continuous outcomes as a function of program inputs or outputs, as appropriate, and combining different data sources including CHV self-evaluation forms, supervisor monitoring forms, maternal attendance records, and household survey data. More details can be found in What program resources were input ahead of implementation? Was the program content and delivery acceptable to parents and delivery agents?How did Outputs such as delivery fidelity and parental attendance and enactment  change during the intervention, and what determined these Outputs?To answer this research question, we discuss aspects of fidelity, attendance and enactment of practices. Within each topic, we first present quantitative results followed by analyses of their determinants, and under determinants we include relevant quotes from qualitative interviews with parents, CHVs, and Supervisors.n = 686) showed gradual and statistically significant improvement across all sessions in all delivery measures . The median session lasted 90 minutes.Monitoring by supervisors took place as intended during 88% of the 12 (non-review) group sessions across all arms and villages, and 91% of group review sessions were supervised. Fewer home visit review sessions were supervised by necessity (9%). Monitoring forms , had 11 years education (range 7–14), and 9 years experience as a CHV (range 1–24). All CHV characteristics were balanced across intervention arms. CHVs who scored higher on a knowledge test of ECD after the first training delivered better quality and more engaging sessions, and scored higher in all fidelity outcomes on average . CHV agep = 0.17). Their performance scores in delivering a mock session after training served as a way to identify 30% of CHVs who needed extra training.During post-intervention interviews, CHVs and supervisors were asked to comment on training, supervision and monitoring of performance. Their answers reveal important determinants of fidelity. Illustrative quotes are summarized in All 11 interviewed CHVs mentioned ways the supervisor feedback and opportunity to evaluate themselves after sessions was helpful, and reported having prepared themselves ahead of sessions. CHV descriptions of how they demonstrated responsive talk were thorough: 8 out of 11 CHVs described at least 3 key components such as letting the child show what he/she is interested in, and then the parent repeats or expands verbally. However, descriptions of how they demonstrated responsive play were incomplete and none was able to name three key components of responsive play; they often correctly mentioned it was letting the child choose playthings, but then incorrectly required the child to follow the parent's lead. CHVs said they initially found it difficult to facilitate group discussions, but later developed a style to encourage shy mothers and sum up the best solutions at the end. Interviews with supervisors showed they recognized early on that CHVs would benefit from periodic refresher trainings ahead of sessions .p = 0.142). The median mother attended 13 of 16 sessions (IQR 8–15 sessions) with a median group size of 13 mothers at a group meeting (IQR 10–15 mothers). The mixed-delivery model had higher overall attendance, with an average of 74 percent of mothers attending a given session, compared to 64 percent of mothers in group-only villages. The bulk of this difference comes from the review sessions, which were home visits for the mixed-delivery arm . These sessions were the only ones in which attendance was statistically different across arms . Less frequently than requested, they added new materials to the bag. After learning how to engage in responsive two-way talk with their child, they found this relatively easy. When given a picture book in a later session, they were able to apply the responsive talking method to it rather than simply reading. Quotes from mothers and CHVs  confirm Perhaps the most surprising result of our study is the relative advantages shown by the group meetings to improve children's final outcomes. The interviews with mothers clearly highlight group camaraderie and opportunities for peer learning among the children as relative benefits of the group format, and caution against a model that utilizes home visits if they engender a feeling of mothers being under inspection.A key limitation of our study is that, though interviews point to convincing reasons, we cannot say with certainty why children in the group arm outperformed the mixed-delivery arm. Another study limitation is that we have only coarse measures of CHV characteristics and expertise, which constrains our ability to predict who might make the best delivery agents.Our results show that a responsive stimulation and nutrition education intervention featuring large group sessions delivered by para-professional community health workers can benefit multiple child and parent outcomes. An upfront investment in training local trainers and delivery agents, and regular supervision of delivery of a manualized program, appear key to our documented success. Our results represent a promising avenue for scaling similar interventions in low-resource rural settings to serve families in need of ECD programming.jluoto@rand.org.The datasets presented in this article are not readily available because the de-identified datasets generated during the study along with statistical plan and analytic code will be available from the corresponding author on reasonable request at the end of the 5-year project after all planned articles have been accepted for publication. We will make the data without identifiers available to users only under a data-sharing agreement that provides for: (1) a commitment to using the data only for research purposes and not to make the attempt of identifying any individual participant; (2) a commitment to securing the data in case there are still some sensitive variables after the identifiers have been removed, by using appropriate computer technology; and (3) a commitment to destroying or returning the data after analyses are complete; and (4) a commitment to not publish any information that is not treated at the aggregate level so that no specific characteristics can be linked to small communities. Requests to access the datasets should be directed to The studies involving human participants were reviewed and approved by Ethics approval was obtained from Maseno University in Kisumu, Kenya, and RAND. Written informed consent to participate in this study was provided by the participants' mothers and fathers, or legal guardian/next of kin.JL and IL secured the funding, designed the study, and performed the quantitative analyses. JL, IL, and FA wrote the first draft of the manuscript. FA, DS, JL, and IL trained SWAP's trainers into the intervention content. RO and EA became lead trainers for CHVs and managed the study's implementation throughout. FA and JL trained the qualitative researchers. FA, DS, and RZ analyzed the qualitative data. FA and DS reviewed and provided critical input to study design and conceptualization. All authors reviewed and contributed to writing the final draft.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Small, isolated teaching centers have difficulty mentoring interprofessional junior faculty in research methods and grant writing. Peer mentoring programs for grant writing at larger institutions have been successful. In this short report, we describe our program that leveraged mentor experience using four framing seminars followed by project refinement in three-person peer groups and monthly mentored works in progress meetings. In its first year, ten faculty from medicine, psychology, and pharmacy completed the program and successfully obtained six funded grants. Five of the projects transitioned from single profession applications to interprofessional applications as participants connected and profession-specific expertise was identified. Refinements for future cohorts are discussed. Over the past three decades there has been a decline in research funding . Yet, reThe Boise Veterans Affairs Medical Center (VAMC) provides primary, secondary, and specialty care to over 28,000 veterans each year in an outpatient system that includes five community-based outreach clinics around the state, a 46-bed hospital, an 11-bed inpatient substance abuse treatment center, and a collocated 28-bed nursing home. Boise VAMC has affiliations with the University of Washington School of Medicine (600 miles away), Gonzaga University Nurse Practitioner program (400 miles away), Idaho State University School of Pharmacy (250 miles away) and Boise State University School of Nursing. The facility maintains multiple training programs, including a nurse practitioner residency, pharmacy PGY 1 and PGY 2 residencies, psychology internship and postdoctoral residency, and an internal medicine residency.Our local research office, The Boise VA Office of Research and Development, determined that our outcome data collection would constitute Quality Improvement work and would be considered exempt from IRB approval. The data collected was provided voluntarily by the group participants who gave permission to publish the results in a de-identified format.Being a small academic facility, far from our major affiliates, and without a deep and rich network of research mentors, we decided to create a grant writing program with the following objectives:1)Help interprofessional junior clinician educators obtain their first research or program development/evaluation funding.2)Create a small group of peer-mentors with the experience to recapitulate this effort with future cohorts.We developed a year-long program that consisted of four kick-off seminars delivered weekly followed by dividing into small project groups of three that collaborated to refine their questions and methods and share the work of information gathering such as grant opportunities, where to find online human subjects forms, etc. Each group reported back to the larger group approximately monthly during ‘works in progress’ (WIP) meetings.The kick-off seminars were developed by a biostatistician (RT) and a local mentor (CSS) with previous success in obtaining National Institutes of Health, Veterans Affairs (VA), and foundation research funding as well as large program grants. They used a “flipped classroom” format with a research article covering the topic for the session handed out ahead of time to focus and stimulate class discussion and small group interaction. The topics and structure of these seminars are provided inFollowing these seminars, the participants were divided into groups of three based on rough similarity of research questions and/or proposed methods. These groups decided how often to meet and how to support each other with moving forward on their projects.Approximately monthly the large group had a WIP update. There was a report on the current state of each three-person group’s projects and any questions or barriers would be outlined. These sessions tended to distribute early expertise. For example, when one member discovered a new funding opportunity it was shared with the entire group. Or, if someone wondered how to navigate the IRB process, someone else who had navigated it would explain where the electronic forms were and offer to help. In addition, an early career faculty member from our affiliate, who had been a successful career development awardee, spoke to the group about the career development program and offered her contact information and assistance.Twelve (12) participants started the grant writing program. This included five (5) physicians, four (4) psychologists, and three (3) pharmacists. All but two completed the series (both withdrew from the program due to competing demands). Ten (10) were within three years of being hired to the Boise VA, and ten were academically early career, having entry level faculty appointments. Most had completed programs with less emphasis on research .After completing the grant writing program, six of the remaining ten participants submitted at least one research grant or program evaluation proposal for a total of 10 proposals. Six of these proposals were funded see.Additionally, we assessed participant satisfaction with the seminar series and continued productivity. Two years after the seminars were conducted we devised a brief impact questionnaire consisting of 5-point Likert-style questions (strongly disagree-1 to strongly agree-5) and a free text area. Response rate was 60%. The results were as follows .networking as the most important element (67% mentioned it) followed by increased confidence, new grant opportunities, and new skills mentioned by one responder each.Comments identifiedThis cohort has gone on to submit at least 17 new grants, 6 (35%) of which six were funded for nearly $800,000. Funders included HRSA, VA Office of Academic Affairs, Idaho Dept. of Health and Welfare, and Alaska Dept. of Health & Social Services.This grant writing seminar and peer support group met the initial objectives of the program and had some unintended positive consequences. The majority of the completing group members submitted a grant application. For most this was their first attempt. Five of the funding applications transitioned from single profession applications to interprofessional applications as connections were made between attendees in their small groups and profession-specific expertise was identified. Because funding sources look for team-based applications from multiple professions  and a restructuring of the research department.The research department is interested in expanding the scope and number of research projects and our modest success has demonstrated value. Our research department has agreed to partner in the ongoing development and expansion of this group. This partnership will increase access to instructors from the IRB, VA Health Services Research and Development (HSR&D) office and other major funders of VA research, and the Office of Research Oversight, to discuss distinctions between program evaluation/quality improvement research. These opportunities for direct discussion and questions will be invaluable to the next round of beginning grant writers.This project had some weaknesses. Because it was not designed as research, no systematic survey of participants  was obtained. Several topics were identified that might have made the project more effective including types of grants available, navigating the IRB, writing your letter of intent, and budgets. These should be incorporated into future versions.program appears to depend somewhat on faculty and institutional stability. Individuals perceived a broad range of benefits, most notably creating a network of like-minded researchers. The original cohort continued to write and obtain grants at a high level.Small, isolated teaching centers struggle to provide support for designing and submitting research grants for their early career faculty. Any experienced potential mentors are quickly overwhelmed with mentees. Yet, research is an important element for these same early career faculty’s success. This program of four orienting seminars, three-person project groups, and monthly works in progress meetings was successful in obtaining initial grants for individuals and group expertise that could guide future cohorts. Components of the seminar are site-specific, but we still believe that it is feasible for other sites to adopt and adapt it to meet their individual needs. However, continuity of theAll data underlying the results are available as part of the article and no additional source data are required. Thank you for the revisions and comments on sustainability. The satisfaction results as well as the success of the initial cohort are helpful and speak to the benefits of this program. Thank you for taking the time to present those here. I am sorry to hear that the program did not continue as it seems to have been a springboard for interested faculty at your institution.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?Not applicableAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:QI, Patient SafetyI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. This is a well-written brief, descriptive report of a capacity-building program at a relatively isolated small academic center.  The detail is enough to replicate the program and although some of the references are relatively old (Inui), they are sound and useful. I would refer others to this article if they were interested in building a similar program.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?Not applicableAre all the source data underlying the results available to ensure full reproducibility?No source data requiredIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:Medical education, career choice, diabetes, inter professional education.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Thank you for your time, effort, and suggestions. We will be adding a post-script in response to another reviewer's suggestions you may want to see. This is a brief report on a self select group of faculty attending a series of seminars over one year. This narrows the impact of such a program and also speaks to feasibility. Moreover, this poses questions of whether this program could be reproduced at other sites. The authors point out that small isolated teaching centers struggle to provide support for early career faculty and suggest that such a seminar format may be a method to provide support. However,  without evidence that this is sustainable, the report does not help the feasibility argument. If the program is still going on, then comments on how it is being sustained would be helpful.The authors may want to interview the faculty and present some data as to what the faculty thought and how this was helpful. This will provide a "lessons learned" part which again can make the findings helpful to other academic centers in similar situations.It is commendable that the 6/10 programs were funded and is a key outcome for the program. It would be helpful to know if the faculty participants went on to get other funding or seek other funding after completion of the program.This is a brief report describing a grant writing seminar for early career interprofessional faculty in a small teaching center. The article presents the description of the 4 seminars that were included in this larger grant writing program and the authors give clear descriptions of the participants and their demographics. The article only covers one year and is limited to 10 persons (started with 12- but 2 faculty left the program due to completing demands). Below are some areas that need to be addressed: In summary, this is a descriptive report on a grant writing seminar and it is well described and I commend the authors for their work on this. However, in response to their own concern that faculty in isolated centers do not get mentoring in such areas, it would be helpful if they can show evidence of the sustainability of the program, or demonstrate if faculty continue to write grants or bring in funding.  As the faculty are self select, if the authors could comment on what worked so other places could reproduce this at their home institutions- it would further the experience for others.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?Not applicableAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:QI, Patient SafetyI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. sustainability, unfortunately this seminar is not still happening due to loss of key organizers (no longer working at the site) and a restructuring of the research department.Thank you for your time and your comments. We agree that components of the seminar are site-specific, but still believe that it is feasible for other sites to adopt and adapt it to meet their individual needs. RegardingSatisfaction: We devised a brief impact questionnaire consisting of 5-point Likert-style questions (strongly disagree-1 to strongly agree-5) and a free text area. This was administered two years after the program. Response rate was 60%. The results were as follows:             Knowledge and skills for design/grant writing          4.4       +/-  0.55             Developed collaborators                                          4          +/-  0             Learned about new funding opportunities                4          +/- 0.71             Gained confidence                                                   4.2       +/- 0.45             Improved academic career                                      4.2        +/- 0.45networking as the most important element (67% mentioned it) followed by increased confidence, new grant opportunities, and new skills mentioned by one responder each. Comments identifiedOther Funding: This cohort has gone on to submit at least 17 new grants, 6 (35%) of which were funded for nearly $800,000. Funders included HRSA, VA Office of Academic Affairs, Idaho Dept. of Health and Welfare, and Alaska Dept. of Health & Social Services. As you can see, sustainability of the program was poor, while sustainability of the initial cohorts' grant writing was excellent, largely due to networking, skills, and confidence. We will add these data in a post script.


Refugees in Malaysia, who are afflicted by poverty, conflict and poor health, are vulnerable to a range of zoonotic infections in the deprived environmental and social conditions under which they live. Exposure to infections such as leptospirosis, for which rodents are primary hosts, is of particular concern.Leptospira  in 11 refugee community schools and centers in the Klang Valley, Malaysia. A total of 433 samples were assessed for IgG and IgM antibodies against Leptospira, using enzyme-linked immunosorbent assays (ELISA).A wellness program was conducted to determine the presence of antibodies against Leptospira seroprevalence was 24.7%, with 3.0% being seropositive for anti-Leptospira IgG and 21.7% for anti-Leptospira IgM. Factors significantly associated with overall Leptospira seroprevalence included: age, ethnicity, pet ownership, knowledge of disease and awareness of disease fatality. For IgM seroprevalence, significant risk factors included sex, ethnicity, eating habits with hands, pet ownership, the presence of rats, walking in bare feet and water recreation visits.Overall These findings highlight the need for improvements in health and well-being among the refugee community through disease awareness programs and provision of healthy behavior programs, particularly in hygiene and sanitation through community engagement activities. The United Nations High Commissioner for Refugees (UNHCR) has highlighted the limited access to basic services, such as healthcare, formal education and the right to work, among refugees in Malaysia . The excRefugees in Malaysia generally reside in low-cost flats in urban cities such as Kuala Lumpur and Penang and live amongst local communities instead of camps , 5. NeveLeptospirosis is an endemic disease in Malaysia –11 and iHowever, the present study is the first in Malaysia to assess seroprevalence of leptospirosis among urban refugees, and to evaluate their health status and associated risk factors. This in turn will serve as a reference for stakeholders such as NGOs, encouraging and justifying the allocation of resources for improving the health and welfare of these refugee communities.This cross-sectional study was conducted from April 2019 to March 2020 in Klang Valley, one of the most active business areas in Kuala Lumpur, the capital city of Malaysia. The Klang Valley interconnects cities and towns from two States: Selangor and the Federal Territory of Kuala Lumpur where over 52.0% of 178,710 refugees and asylum seekers, who are registered in Peninsular Malaysia, reside with up to 66,030 (36.9%) in Selangor and 27,370 (15.3%) in Federal Territory of Kuala Lumpur  with 3.0% [1.42–6.07%] seropositive for anti-Leptospira IgG and 21.7% [16.82–27.39%] for anti-Leptospira IgM.The study was conducted over a period of 1 year, from April 2019 to March 2020 in order to achieve the required sample size. A total of 433 refugees from 11 refugee learning centers participated in this study including Selayang  with prevalence being high among participants older than 18 years of age. The second risk factor was ethnicity , particularly high among the Kachin and Rakhine, and pet ownership , with higher values amongst owners who did not have pets , with higher prevalence among females compared with males. Ethnicity  also showed significant association with anti-Leptospira IgM, especially amongst Rohingyas and Pakistani. Respondents who ate using hands  and had pets  . Their awareness of mortality and disease  . Two risk factors; walking in bare feet  and visiting water recreation sites  also showed significant association with anti-Leptospira IgM seroprevalence  and fever (P = 0.003) were negatively associated with leptospirosis . This was a robust finding with pet owners demonstrating significantly higher seroprevalences than those who did not own pets  where refugees with a basic knowledge of leptospirosis showed a higher prevalence than those without such knowledge, but the sample sizes were very small .Multifactorial analyses of IgG seroprevalences in a model where host age, ethnicity, pet ownership, basic knowledge leptospirosis, and awareness of disease related mortality were assessed, indicated that pet ownership appeared to be the most significant factor . This arose because among subjects with neither fever nor headaches, IgG seroprevalence was high (10.0% [95% CI 6.31–15.19]) compared with subjects with headache, with/without fever and no headache but with fever.A separate multifactorial model which was used to compare IgG seroprevalences with clinical symptoms Table  and thisχ21 = 5.761, P = 0.016).Multifactorial analysis of IgM seroprevalences on the other hand revealed a more complex picture. We again fitted all significant factors from first stage analyses of refugees including sex, ethnicity, eating by hand, presence of pets, walking barefoot, the presence of wild rodents within communities and visiting water recreation centres. The minimum sufficient model comprised three expressions the first of which is shown in Fig. In all cases, IgM seroprevalences were higher in those who ate by hand but lower in those without pets, while the presence/absence of rats in their communities made little difference. However, IgM seroprevalences were lower in those who neither ate by hand nor kept pets, even in the presence of rats, compared with higher IgM levels in communities where both pets and rats were present.χ21 = 5.314, P = 0.021) showed that IgM seroprevalence was higher in female compared with male subjects in all groups but lower in those who did not eat by hand and wore shoes , is more complex as there are 24 data subsets in six ethnic groups  were also IgM seropositive. In contrast, only a small proportion (3%) of participants were IgG seropositive, indicating previous exposure. IgG antibodies persist for many years following infection and their presence does not necessarily indicate current or active infections [Leptospira was most likely acquired after entry to Malaysia, rather than prior to leaving their country of origin.In the present study a substantial proportion (24.7%) of the study cohort not only showed seropositivity for anti-fections , but ratMalaysia is not a signatory party to the 1951 Refugee Convention that relates to the Status of Refugees and its 1967 Protocol, that safeguards the fundamental rights of refugees, regulates their status, and requires their essential needs to be provided in those countries offering asylum. Therefore, there is no legal framework to register, document and recognize the status of refugees and their rights in this country. These communities are totally excluded from the government system and thus vulnerable to detention and exploitation, especially individuals without the possession of UNHCR identification cards. Many live in squatter homes and overcrowded flats with poor waste management and sanitation, conditions that create an ideal environment for rodents to thrive in. Consequently, there is an elevated risk of transmission of rodent-borne zoonotic infections such as leptospirosis. This disease is endemic in the Asian-Pacific region where poor socioeconomic, and behavioral conditions facilitate its incidence and prevalence  and are Leptospira serovars recovered from urine and kidney samples from 150 local stray dogs [The highest IgM seroprevalence was recorded among subjects who routinely ate food by hand and owned pets, whether rats were or were not present in their living quarters, and both are clearly risk factors in the study cohort. Wild and domesticated mammals including pet cats and dogs have been implicated in the transmission of leptospirosis  by actinray dogs . Pet ownray dogs , 26.There was also a strong sex-linked effect on IgM seroprevalence, which was higher among female, compared with male subjects, whether or not they ate by hand or utilized footwear. The female bias in IgM seroprevalence is consistent with studies on hospital patients –29, wherAge was initially identified as a risk factor for IgG seroprevalence in our preliminary analyses Table , and alsLeptospira IgG and IgM antibodies amongst urban residents of low-cost flats in Kuala Lumpur [Leptospira serovars; L. borgpetersenii serovar Javanica and L. interrogans serovars Bataviae in urban rat populations in Peninsular Malaysia [Indeed, the presence of rats in living quarters was identified as a risk factor for IgM seroprevalence in the initial preliminary statistical models, and subsequently in the multifactorial model, as a component of the interaction with pet ownership and method of eating food. Values for IgM seroprevalence were marginally higher among those who lived in accommodation where rats were present. Overcrowding and poverty have been implicated in rodent-borne transmission of leptospirosis in Bangladesh . Furthera Lumpur  whereas Malaysia . These sMalaysia .Leptospira IgM in the current work, but not when other factors had not been taken into account in the multifactorial analysis. Nevertheless, as reported elsewhere, outbreaks of leptospirosis related to water recreational activities have shown the capacity of pathogenic Leptospira species to live in water for prolonged periods of time, thereby increasing the possibility of infecting a susceptible host [Eating style was another risk factor associated with the raised IgM in the current study. Hand hygiene is known to be important as transmission of leptospirosis can take place through skin penetration . This isble host . This aqLeptospira IgG and IgM. Multifactorial models correlating clinical symptoms with IgG seroprevalences showed that refugees without fevers or headaches had higher levels of IgG. The latter were more likely to be due to past acute infections with IgG dependent immunity still being expressed. On the other hand, leptospirosis can also be asymptomatic especially in areas with high transmission rates [Leptospira can typically manifest itself in a range of nonspecific clinical symptoms such as acute febrile illness with fever, myalgia, arthralgia and headaches [Clinical symptoms often associated with leptospirosis include headaches, fever, jaundice, chills, muscle pain or myalgia, abdominal discomfort, and diarrhea, but in the refugee community from the Klang Valley, none of these symptoms were associated with anti-on rates , resultion rates . Infectieadaches –45. Conseadaches , 47 espeeadaches –51. In meadaches .Overall, the evidence from this study highlighted that many of the participants with past leptospirosis infection most probably acquire the disease due to bad living environmental condition and their lifestyle behaviour that have exposed them to contaminated urine from infected animal reservoirs. This study also suggests that most of the participants may only have limited knowledge on the transmission of the disease.Moving forward there is a need to look at approaches in delivering awareness of disease transmission to the community to prevent the occurrence leptospirosis outbreak. This can be made through the empowerment of the community via community engagement activities such as wellness program and clean-up activities. However, the delivery of the information must be in their respective languages to enhance better understanding.Nevertheless, there may be some biases as there were several limitations to the study. Firstly, this study was conducted with a specific cohort group i.e., students and secondly this screening was conducted as a cross sectional study thus, not able to represent the whole refugee community.Leptospira infection was not assessed in the current study, it is known to be a rodent borne infection with rats being major reservoirs of this and other zoonotic infections. Therefore, a much-improved rodent control program should therefore be undertaken in these low cost residential infrastructures where many of these communities reside.The substantial (24.7%) seroprevalence of leptospirosis infection amongst students in the refugee community warrants an introduction to proper environmental sanitation and good lifestyle behavior programs in tandem with improved knowledge on disease transmission through community engagement activities. Although the prevalence of


There are discrepancies between evidence-based guidelines for screening and management of cardiovascular disease (CVD) and implementation in Australian general practice. Quality-improvement (QI) initiatives aim to reduce these gaps. This study evaluated a QI program (QPulse) that focussed on CVD assessment and management.This mixed-methods study explored the implementation of guidelines and adoption of a QI program with a CVD risk-reduction intervention in 34 general practices. CVD screening and management were measured pre- and post-intervention. Qualitative analyses examined participants’ Plan-Do-Study-Act (PDSA) goals and in-depth interviews with practice stakeholders focussed on barriers and enablers to the program and were analysed thematically using Normalisation Process Theory (NPT).n = 19,562 and n = 20,249, respectively) and in-depth interviews from seven practices. At baseline, 45.0% of patients had their BMI measured and 15.6% had their waist circumference recorded in the past 2 years and blood pressure, lipids and smoking status were measured in 72.5, 61.5 and 65.3% of patients, respectively. Most high-risk patients (57.5%) were not prescribed risk-reducing medications. After the intervention there were no changes in the documentation and prevalence of risk factors, attainment of BP and lipid targets or prescription of CVD risk-reducing medications. However, there was variation in performance across practices with some showing isolated improvements, such as recording waist circumference (0.7-32.2% pre-intervention to 18.5-69.8% post-intervention), BMI and smoking assessment. Challenges to the program included: lack of time, need for technical support, a perceived lack of value for quality improvement work, difficulty disseminating knowledge across the practice team, tensions between the team and clinical staff and a part-time workforce.Pre- and post-intervention data were available from 15 practices , registered 06/02/2015.Australian New Zealand Clinical Trials Reference Number (The online version contains supplementary material available at 10.1186/s12913-021-07310-6. Cardiovascular diseases (CVD) are the leading cause of death worldwide, despite major declines in morbidity and mortality over the last 40 years . In 2015General Practitioners (GPs) play a major role in mitigating CVD morbidity and mortality, and see over 85% of the population (approx. 20 million consultations) in Australia annually . In 2010Quality Improvement (QI) initiatives in primary care have the potential to improve uptake of evidence-based practices . QI is aThe current study applied a QIC approach to improving CVD management in the ‘real world’ of Australian general practice in one Primary Health Network (PHN) in Sydney, Australia. Study aims were to: (1) assess whether a brief QIC program was associated with improvements in the monitoring, prescribing practices and attainment of BP and lipid targets for CVD risk reduction; and (2) understand barriers and factors driving implementation and adoption of the QIC.https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12615000108516). A protocol and set of QI resources were developed for the PHN to implement the program.A mixed-methods sequential study design utilised data from the QPulse study  , 18. TheA QPulse program officer was employed by the PHN. She worked as part of the PHN QI team who oversaw the other QI projects within their footprint. All PHN staff working on QPulse received standardised training from the research group in the CVD risk-reduction intervention, the QI program and the implementation processes. The QI team facilitated the workshops and oversaw the Plan Do Study Act (PDSA) activity. There were regular program updates and meetings with both PHN staff and the research group to support the program roll-out, including discussion around recruitment and implementation. Similarly, there were regular meetings between the lead researcher and program officers to discuss issues and difficulties with the intervention and program implementation.Practices were recruited from the geographical catchment of Central and Eastern Sydney Primary Health Network  between May 2015 and November 2016. Practice recruitment is outlined in Fig. Practices were eligible if they used one of two electronic medical record software programs  for recording risk-factor information, pathology results and prescriptions. There was a total of 127 eligible general practices from a possible 670 in the CESPHN catchment that were approached to participate. Reasons given to the PHN team from 41 of invited non-participating practices included: not enough time, staffing limitations, competing priorities, CVD not being a practice priority area, and not wanting to participate in research.n = 34) participated, with three withdrawing. Practice participation rates were lower than anticipated, and the study did not achieve the target recruitment of 80 practices prior to cessation of recruitment. Recruitment ceased after the PHN felt unable to provide resources to the program, in November 2017. Complete pre- and post-intervention data were available from 15 GP practices. In 16 practices complete data-sets were not successfully extracted using the data extraction software due to a technical problem in the extraction of prescribed medications from some of the practice records, and issues in the automated delivery of the extracted data to the secure study portal  data (Supplementary Table The QPulse program ran over 22 months (May 2015 – February 2017). Participating practices provided the PHN with baseline, de-identified patient data of ‘regularly attending’ patients (defined below). The PHN generated feedback reports at the commencement of the intervention (using baseline data) for each practice targeting the CVD measurable goals.At least one stakeholder from each practice, such as a practice nurse, senior GP or PM attended three 2-h workshops over 3 weeks. Topics covered: CVD risk assessment tools, absolute risk calculators, current guidelines for preventive CVD management including pharmacological management of high-risk patients, QI theory and specifics on how to achieve change using the Plan Do Study Act (PDSA) methodology . By planDuring the workshops, participants were also trained in the use of two quality-improvement software tools supplied to each practice: (1) a desktop ‘point of care’ tool, ‘HealthTracker’; a software application that works in conjunction with the electronic medical record to identify high-risk patients and provides GPs with ‘real time’ personalised guideline recommendations pertaining to cardiovascular risk reduction; and (2) PenCAT Clinical Audit Tool™ a data extraction tool installed onto the computer server at each Practice. PenCAT enabled practices to download specific audit reports containing de-identified patient data on demographics, CVD disease statistics and prescribing information. A data extraction could be performed as frequently as practice staff desired to assist with the PDSA process and was the basis of the monthly data report sent to the PHN.Members of each general practice were also invited to attend monthly webinars after the initial three workshops to collaboratively share their progress and ideas for change with other participating practice teams. Each practice was offered external support from the PHN to assist with provision and interpretation of the personalised practice report, formulating the PDSAs, and submitting monthly data extractions.Eligible patients were those recommended by guidelines for CVD risk assessment , and who2, systolic BP > 180 mmHg, diastolic BP > 110 mmHg or total cholesterol > 7.5 mmol/L) (iii) presence of a CVD diagnosis  [Five-year CVD risk was calculated using the 1991 Anderson Framingham Risk equation using sex, age, systolic blood pressure, smoking status, total cholesterol, high density lipoprotein (HDL) cholesterol and diabetes status . DiabeteOutcome measures were: (1) CVD risk factor assessment including BP assessment in the past year, and lipid, BMI, waist circumference and smoking status assessment in the past 2 years; (2) guideline-recommended treatment for people defined as prescription of a BP-lowering medication and a statin for people at high CVD risk and prescription of a BP-lowering medication, a statin and either an antiplatelet or an anticoagulant agent for people with a diagnosis of existing CVD (see p < 0.05 (two-tailed).Bivariate analyses examined the frequencies and proportions of patients by their sociodemographic, CVD risk, BP/lipid levels and prescription of risk-reducing medications. Logistic regression models examined differences between baseline and post-intervention in the key outcome variables with adjustment for gender, age and Indigenous status. Changes between baseline and post-intervention were assessed by odds ratios (95% CIs), using the baseline sample as the reference category. As the data were hierarchical (i.e. patients clustered within GP practices), all analyses were adjusted for clustering at the practice level and applying finite population correction when estimating variance. Analyses were conducted with SPSS statistics software Version 26.0.0. Statistical significance was considered as The PDSAs submitted by each practice were analysed by thematic analysis. The goals addressed in the PDSAs were coded by two coders who worked independently. Coders then sorted the themes of the PDSAs into larger categories and then discussed their results, examined any discrepancies and reached consensus for a final coding classification. Following this, 19 semi-structured interviews were conducted after completion of the program with a purposive sample of people involved in QPulse implementation, including PMs, nurses and GPs, as well as program officers, IT support personnel and managers at the PHN  . The finNPT is a theory of implementation designed to aid interpretation of how interventions are embedded, enacted and operationalised within routine practice in healthcare settings. This approach assumes four main generative mechanisms  which are needed to achieve change in practice. The aim of the analysis was to examine the ‘real world’ participant perceptions of, and responses to the multicomponent QI program, and at which points it was considered to be sustainable or have failed .This research was performed in accordance with the Declaration of Helsinki and was approved by the University of Notre Dame Australia Human Research Ethics Committee (HREC) (reference 014105S). Signed agreements with participating practices were also obtained. A consent waiver for patient-level consent was granted by the committee.Of the 15 practices with complete pre- and post-data, all attended at least one workshop, 11 attending two and six attended all three workshops. Most practices sent only one attendee to each workshop with three practices sending two attendees and one practice sending three attendees to all three workshops. The PHN recorded contact with all participating practices at least once a month, some requested higher levels of interaction (range 1 to 8 contacts per month) which was provided via phone or face-to-face, to help with IT and QI processes. The program officer recorded a median of four practice visits and 15 phone calls per practice over the duration of the program. Although 12 practices registered to attend the first two webinars, only two attended, and these were consequently discontinued after 2 months. All participating practices submitted a baseline PDSA.n = 10,816) were female. 5.8% (n = 1139) had high absolute cardiovascular disease or high clinical risk, and 12.1% (n = 2372) already had a diagnosis of CVD  rather than focusing on changes in preventive care and guideline-based prescribing (neither lifestyle nor medication). In some cases, PDSA goals aligned with improvements in the practice recording risk factor data, as seen in one practice Fig.  that focThe characteristics of interview participants at the PHN and practice levels are shown in Table There are a whole lot of people at risk, and they could have better outcomes….” (GP6). Access to the education modules and the two QI tools were seen as useful in identifying and providing preventive care guidelines to high-risk patients. Only one participant mentioned that internal leadership (‘Change Champion’) or practice support (‘QI Culture’) was needed to facilitate engagement with the program.Collectively, GPs and PHN staff saw the potential value of the program as very high, for example: “Interviewees from both PHNs and practices noted that the timing of this program (coinciding with major PHN governance and strategy change) prohibited prioritisation of support for the program by PHN Staff.“…when I took it on I didn’t realise there was more to it, so I didn’t really understand...”. (GP1). For PHN participants this was illustrated at the highest executive level where management under-estimated the readiness/ability of practices to be enrolled in this program, along with the need for the PHN to supply adequate resourcing to support both their staff and the participant practices. “With 40 practices enrolled, the workload sometimes got overwhelming despite team members help(ing) me with 6 of the practices”. (PHN3) This lack of strategic planning and resourcing was amplified by the change in focus of PHN staff and a merger of three earlier meso-tier organisations into a single PHN. This affected directly on the PHN’s ability and commitment to supply practice-level support during the program.Most interviewees reported they had not fully appreciated what participation in a QI program would require of them prior to the program, …. formulaic…. uninteresting…” (GP1) and “...to be honest, no, I haven’t done one since we started.” (GP9) with only a few seeing value in this aspect of the program. “It is a problem to stay on track and keep getting things done… I had a million good intentions, and then it gets …too hard”. (P4)GP engagement with the PDSA process was also extremely low. While the PDSAs were understood by most GPs as an essential part of the QI process, they were seen as time-consuming, and “it comes down to the culture within the practice, who is the real leader…the driver in the practice. It could be a nurse or the doctor…. but crucially you really need to have somebody who is going to take the reins, or it doesn’t happen….” (PHN5). It was clear many participants were unable to actively champion or drive the program forward due to not taking on a leadership role within their practice setting. Differing practice systems often meant each GP within the practice worked as an individual rather than part of a cohesive system of care. “It’s quite individual. That’s the way the practice is set up…. your quality control is up to you…. As long as it doesn’t add any extra work…. because no-one obviously is interested if it’s extra work.” (GP2)Participants reported a lack of both ‘QI culture’ and change champions to support engagement with QPulse. Although there was universal agreement that ‘key individuals were needed to drive the program forward’, this did not mean that these individuals were found, nor engaged to help with the program. “…“…didn’t want to do it, so she handed it to me… I actually didn’t know much about it.” (GP12). In addition, GP attendance at the educational sessions was sub-optimal and inconsistent, with many GPs delegating this to the PM or nurse. The scheduled monthly networking/seminar meetings were cancelled due to lack of attendance, despite most participants opting to join at the beginning of the program.Communication systems between GPs, nurses and PMs were cited as a barrier to engagement. Often there was no regular practice ‘team’ meetings or systems in place to report back about QI measures and limited ability to organise tailored educational activities. Jobs were delegated to non-medical staff (e.g. the PM or nurse) who may/not have the skills or motivation to drive the program forward due to a lack of personal engagement with the goals of the program. At one practice, a manager commented that she only became involved because: (the GP) “It’s one thing to get the GPs to change what they do, it’s an entirely different thing to get patients to take in on board.” (GP 6) Several GPs also discussed the problem with many competing projects and lack of time: “I think the difficulty is there’s a plan for one quality of project and then another idea comes up and then the same people are looking at implementing it, or we give the nurses something else to do, and it sort of falls off the radar.” (GP 6)There was commentary that the QI program and data reports did not address key issues around improving engagement with patients: from a practice perspective, it’s not going to be a priority. So really, the PHN needs to take on a lot of that responsibility on behalf of the practice if we’re going to get it up and running”. (PHN1)Participants reported barriers to setting up a sustainable QI processes. This was highlighted by commentary about the difficulty of scheduling data extractions and generation of reports, low attendance at QI educational activities, no engagement with PDSA process, no evidence of sustained use of the IT tools. Several attributed this to both lack of dedicated time to do QI work and lack of any tangible incentives . Many reported that GPs were not keen to engage with an activity that was not aligned with financial incentives and cited such incentives as a mechanism to achieve long-term engagement rather than as the first reason for engagement. However, engagement with individual “contracted” GPs was reported as requiring a financial incentive to engage them with doing any of the extra work involved in QI activities. “…I used it for a couple of weeks and found it was really useful... (when a minor IT issue arose to render the tool inactive) …it just kind of died off, my use of it.” (GP7) Finally, it was noted that the program did not adequately accommodate the roles of individual GPs (and patients) in achieving key outcomes  and medication prescriptions. “It was all a bit clunky…I never saw the Manager’s data reports…and although I tried with Q Pulse, …if a doctor is not interested, they won’t do it ...that’s often the way around here and I just couldn’t engage them with recording the CVD measures.” (GP2)Minor IT issues were also identified as barriers, although it was well understood by participants that IT support was readily available if asked: “Until you start giving monthly reports and with targeted topics and actually educating the GPs about what to do with that data, you’re just extracting data”. (PHN1)PHN staff reported a lack of resourcing to provide individualised GP practice reports, education or face-to-face support despite observing that most practices needed significantly more support than anticipated to complete the basic requirements of the program . “So, we’ve talked about it, but we’ve never implemented it systematically…. most doctors are not taught these things, that’s the whole problem, so we’ve got to re-educate the doctors, our universities haven’t got it in the curriculum.” (GP7)Normalisation of systematised QI practices was not apparent, even among the most experienced and engaged practices. This was despite many participants reporting enthusiasm for ongoing participation in QI work. ““It’s the follow through which can be difficult because you will forget. I don’t know that this is common to everyone, but ...if somebody is not ...pestering you and reminding you... - I’ve actually forgotten how to do it - it falls off the wagon.” (GP 3)Even in solo practices, GPs experienced challenges with translating the QI goals into long-term changes systematic CVD preventive care. The program learnings were discussed as a one-off piece of work rather than something to embed into everyday routine practice. every single patient I see I just flick onto the summary screen of HealthTracker and just see whether the percentage is something I need to worry about, and if it’s not, then I don’t pursue it.” (GP 4) However, few mentioned systematic use of the tools for the whole team. Even the most engaged general practice participants noted a difficulty in systematising QI in the day-to-day running of business. “I think (the workplace of) general practice is a barrier, it’s an unpredictable, busy, chaotic job and so things happen that get in the way. And I think the other barrier is that protected time, to set up systems is an enabler and not being in place is a barrier”. (GP 6)Some GPs reported adopting new ways of approaching CVD preventive care, such as utilising CVD absolute risk assessment tools or using audit data extraction tools to identify gaps in data measures such as smoking status, BMI or waist circumference, “Engagement with the QPulse QI program was limited in most general practices. Pre-intervention data showed a sub-optimal assessment of CVD risk factors, along with low prescribing rates among high-risk patients. After the program there were no significant changes in the assessment of CVD risk factors, the achievement of BP and blood lipid targets or the prescription of risk-reducing medications. Normalisation Process theory provided a framework to analyse participants experiences of implementing the program and focused on the work required to embed and normalise QI processes in the general practice settings . The quaOverall, GPs considered the program as relevant and beneficial to patient care. Stakeholders identified that activity was mainly led by non-medical staff and focussed on improving documentation rather than clinical outcomes. There were substantial challenges for GPs for embedding the program into long-term changes in clinical practice. It is difficult to ascertain whether these were due to limitations in the design of the program or the intervention, or in its delivery, however given the limited success of many interventions in primary care , 23, 24 The challenges associated with achieving collective action for both general practices and the PHN meant participants found it difficult to move beyond ‘new’ and toward ‘normal’. Interviewees reported a ‘project-based’ approach to QI with ‘topical’ engagement and difficulty setting up systematised adoption of change due to the considerable number of competing projects. At the time of this program, there was no systematic funding or incentives for GPs and practices to improve their data collection processes, and such improvements were mainly driven by practice ‘champions’ and needed to be supported by the systems and IT infrastructure to normalise these changes. These supports were not in place and were identified as key factors limiting the program in the stakeholder interviews. In many cases, there was no clear role of a leader within practices, and when leadership developed it was often from non-medical staff. Furthermore, this QI program was unable to capture doctor-patient decision making around individual choices and the adoption of CVD risk recommendations, including medications, diet and exercise.The findings also suggest that implementing change needs to build practice capacity and culture; change needs to be supported by GPs, practice managers and reception staff, and the necessary IT systems, staffing and time allocation to QI activities need to be made available. The results showed that even after the QI program, a substantial proportion of practices (30-40%) were not meeting basic documentation and monitoring targets. These improvements have been identified as key to increasing uptake of evidence-based practice in primary care , 16. ThiLarge-scale QI research in primary care in the US has concluded that practice support is essential to help practices, particularly those with electronic medical record data challenges, build their capacity for conducting data-driven QI . Data isWhile there has been increased interest in supporting QI in Australian primary care, there needs to be a change in thinking from start-up programs to sustained initiatives. A pre-post evaluation of a national QI program, the Australian Primary Care Collaborative program from 2004 to 2014, found improvements in both CVD risk identification and management, but only had partial uptake nationally  and did The current study had a number of limitations that need to be acknowledged in the context of the results. Firstly the practices were located in one PHN region and may not be representative of general practices elsewhere. For example, we have previously found higher performance for CVD risk management in Aboriginal Community Controlled Health Services compared with other general practices . SecondlThere are large gaps between CVD management guidelines and practice in primary care in Australia. This QI program targeting CVD risk identification and management did not bring about overall changes in risk factor documentation, risk factor prevalence, attainment of physiological targets and prescribing for risk reduction. Overall, practitioners see the value in QI programs targeting CVD, however experience substantial challenges in implementing change if this is not supported more widely. GPs and other practice staff need support at all levels of the organisation for QI, in addition to the time, technical support and appropriate remuneration to facilitate long-term improvements in the management of CVD in general practice.Additional file 1: Supplementary Table 1. Baseline characteristics of included and excluded patients. Supplementary Table 2. Pre- and post-intervention characteristics of 4 sample practices.


BCR and ABL1 genes. The ensuing BCR-ABL1 chimeric oncogene is characterized by a breakpoint region that generally involves exons 1, 13 or 14 in BCR and exon 2 in ABL1. Additional breakpoint regions, generating uncommon BCR-ABL1 fusion transcripts, have been detected in various CML patients. However, to date, the impact of these infrequent transcripts on BCR-ABL1-dependent leukemogenesis and sensitivity to tyrosine kinase inhibitors (TKIs) remain unclear. We analyzed the transforming potential and TKIs responsiveness of three atypical BCR-ABL1 fusions identified in CML patients, and of two additional BCR-ABL1 constructs with lab-engineered breakpoints. We observed that modifications in the DC2 domain of BCR and SH3 region of ABL1 affect BCR-ABL1 catalytic efficiency and leukemogenic ability. Moreover, employing immortalized cell lines and primary CD34-positive progenitors, we demonstrate that these modifications lead to reduced BCR-ABL1 sensitivity to imatinib, dasatinib and ponatinib but not nilotinib. We conclude that BCR-ABL1 oncoproteins displaying uncommon breakpoints involving the DC2 and SH3 domains are successfully inhibited by nilotinib treatment.Chronic Myeloid Leukemia (CML) is a hematological disorder characterized by the clonal expansion of a hematopoietic stem cell carrying the Philadelphia chromosome that juxtaposes the  BCR-ABL1 is a fusion gene derived from the t  reciprocal translocation that joins part of the BCR (Breakpoint Cluster Region on chromosome 22) and of the ABL1  messenger RNAs. The regions generally involved in this rearrangement are exons 1, 13 or 14 of BCR (e) and exon 2 of ABL1 (a). Fusions involving one of the aforementioned exons give rise to the more common BCR-ABL1 transcripts e1a2 (expressed in ∼20% of acute lymphoblastic leukemia), and e13a2 or e14a2   or only the DH-GEF region (BCR-ABL1e6a2 and BCR-ABL1e8a2) - trigger different signaling networks despite a kinase activity similar to that of conventional  BCR-ABL1 isoforms  display an inferior outcome compared to those with e14a2 (which comprises a longer DC2 domain) (ABL1 (encoded by exons 2 and 3), interact intramolecularly with the ABL1 kinase domain, thus playing a critical role in BCR-ABL1-mediated cell survival and leukemogenesis as well as TKI responsiveness  and transforms the hematopoietic stem cell by modulating several intracellular mediators involved in survival and proliferation . BCR-ABL in CML) . These c disease . Howeveror e14a3 . The ensisoforms . Further domain) . It shousiveness .BCR-ABL1 transcripts , and two (BCR-ABL1∆DC2 and BCR-ABL1∆SH3) artificially engineered to investigate the role of the DC2 (in BCR) and SH3 (in ABL1) domains. Using in-vitro and ex-vivo models, we demonstrate that modifications in the DC2 and SH3 domains affect BCR-ABL1 signal transduction, leukemogenic potential and TKI response.Although different reports have described the clinical history of CML patients displaying uncommon nscripts , to dateBCR-ABL1INS/Del, BCR-ABL1e13a3 and BCR-ABL1e14a3 fusions were confirmed by Sanger sequencing. For BCR-ABL1INS/Del, cDNA sequencing identified the lack of exons 13 and 14 of BCR and the partial deletion of exon 2 in ABL1 with a 39 bp insert that matched a genomic region from 29534693 to 29534732 (GRCh38) corresponding to chromosome 20. The insertion/deletion produced a breakpoint between exon 12 in BCR and exon 2 in ABL1, generating the BCR-ABL1e12a2 transcript that we refer to as BCR-ABL1INS/Del.Total RNA extracted from primary CML cells was subjected to RT-PCR using the indicated primers as previously described : Fw BCR-Ba/F3 (mouse pro-B cells) cell lines were purchased by DSMZ (German Collection of microorganisms and Cell Cultures GmbH) and cultivated in RPMI (Sigma) plus 10% WEHI3B conditioned medium. Rat1 cells  were cultivated in D-MEM high glucose (Sigma). All growth media were supplemented with 10% fetal bovine serum (FBS) (Euroclone), 2 mM glutamine, 50 µg/ml streptomycin and 100 µg/ml penicillin (All from Sigma). For drug treatments, imatinib (IM) and nilotinib (NIL) were provided by Novartis, dasatinib (DAS) by Bristol Myers Squibb while ponatinib (PON) was purchased by Selleckchem.BCR-ABL1 fusion was performed as previously described (Immunomagnetic separation of bone marrow leukemic CD34-positive progenitors expressing the e14a3 escribed . CD34-poThe pLEX empty vector (EV) (Dharmacon) was used as a backbone to obtain all lentiviral vectors described below.BCR-ABL1WT(e14a2) were obtained as previously reported  using the following primers:INS/Del: 5′-ATATTCAGAGTTTCATGTTCTGAAGCCGCTCGTTGGAA-3′FwINS/Del: 5′-TTGGCCATTATTCTGGCAATTGTTCTCCCTCCACTCTGC-3′Rve13a3: 5′-TTCCTTATTGATGGTCAGCGGA-3′Fwe13a3: 5′-GGTGAAAAGCTCCGGGTCTTAG-3′Rve14a3: 5′-AAGTGAAAAGCTCCGGGT-3′Fwe14a3: 5′-GAACTCTGCTTAAATCCAGTG-3′RvTo generate the pLEX-FLAG-BCR-ABL1 deletion construct was used as a template to obtain the respective 6xHIS-tagged-derivative employing the primers indicated below:6xHIS-BCR: 5′-ACTAGTGCCACCATGCATCACCATCACCATCACATGGTGGACCCGGTGGGC-3'FwABL1: 5′-ACGCGTCTACCTCTGCACTATGTCACT-3′RvEach FLAG-tagged PCR products were ligated using the Spe-I and Mlu-I enzymes.Myc: 5′-ACCGGTGCCACCATGCCCCTCAACGTTAGCTTCA-3'.FwFLAG-Myc: 5′-GCGGCCGCTTACTTATCGTCGTCATCCTTGTAATCCGCACAAGAGTTCCGTAGCTG-3′.RvThe pLEX-Myc-FLAG vector was generated amplifying human c-Myc by RT-PCR using total RNA extracted from HL-60 cells. The following primers were used:The PCR product was then cloned in pLEX-EV using the Age-I and Not-I restriction sites.Recombinant lentiviral production, titration and transduction were performed as previously reported . LentiviBCR-ABL1 constructs reported above. All transduced cells received 3.5 µg/ml puromycin to select resistant clones. Rat1Myc (MOI = 10) and CD34-positive cells (MOI = 70) were lentivirally infected with BCR-ABL1WT and deletion mutants and used for the indicated experiments.All cell lines were transduced by two rounds of spinoculation at 1,200 x g for 90 min at 32°C in the presence of 8 µg/ml of polybrene (Sigma) for Ba/F3 and Rat1 and 4 µg/ml of polybrene for CD34-positive cells. Primary CD34-positive progenitors were maintained in Stem Span SFEM supplemented with 100 ng/ml Flt-3 ligand, 100 ng/ml stem cell factor, 20 ng/ml interleukin-3 (IL-3) and interleukin-6 (IL-6). Rat1 cells were lentivirally transduced (MOI = 5) with pLEX-Myc-FLAG while Ba/F3 (MOI = 10) were exposed to the pLEX-EV and FLAG-tagged 4/ml were cultivated in the absence of IL-3 and counted every 24 h for three days. 1 × 104/100 µL CD34-positive progenitors ectopically expressing native and atypical BCR-ABL1 fusion transcripts, were exposed to IM, NIL, DAS or PON and counted after three days. For both immortalized and primary cell populations, their number was obtained by trypan blue exclusion assays using a 0.4% trypan blue solution.To assess BCR-ABL1-mediated growth factor-independent transformation, lentivirally transduced Ba/F3 cells were deprived of IL-3 for 24 h. At this time, 1 × 103 cells were dispersed in TKI-additioned methylcellulose (Stem Cell Technologies) and 15 days later the resulting colonies were counted under an optical microscope . Only colonies with >20–30 cells were considered  weekly. After 5 weeks of culture, each well was overlaid with methylcellulose  supplemented with 10% of conditioned medium derived from 5,637 cells . ColonieWT, BCR-ABL1∆DC2, BCR-ABL1∆SH3, BCR-ABL1INS/Del, BCR-ABL1e13a3 and BCR-ABL1e14a3, each lentiviral vector was transiently transfected by calcium phosphate in HEK293 cells. Forty-eight hours post-transfection, a purification step was performed employing the Ni-NTA purification system (Thermo Fisher Scientific). In vitro kinase assays were performed as previously reported . The constant catalytic rate (Kcat) was obtained from the equation Kcat = Vmax/[enzyme] and Kcat/Km ratio defining catalytic efficiency.To purify 6xHIS-tagged BCR-ABL1reported  employinWhole cell lysates were prepared by resuspending Ba/F3 or Rat1 cells in Laemmli buffer. Cell pellets were then sonicated, denatured and protein lysates separated by SDS-PAGE. Antibodies used were as follow: anti-phosphotyrosine , anti-actin  and anti-FLAG-M2-F3165 , anti-MYC , anti-AKT rabbit , anti-p44-42 mitogen-activated protein kinase rabbit , anti-STAT5 rabbit , anti-CRKL mouse  and phospho-specific anti-bodies anti-pAKT-Ser473 rabbit , anti-p44-42 mitogen-activated protein kinase rabbit , pSTAT5-Y694 rabbit (9351 9) and pCRKL-Y207 rabbit , all from Cell Signaling. Appropriate horseradish peroxidase-conjugated secondary antibodies were used to detect the indicated proteins using the LiteAblot enhanced chemiluminescence reagent  and signals were acquired using the C-DIGIT system (Licor).3/100 µL cells in 96 well-plates were exposed to logarithmic dilutions of IM, NIL, DAS or PON. Three days later, the CellTiter 96® AQueous One Solution Cell Proliferation Assay (Promega) was used to quantify cell viability according to the manufacturer’s protocol. The absorbance obtained was used to calculate IC50 values employing the Prism software (GraphPad Software).Infected Ba/F3 cells were deprived of IL-3 for 24 h. At this time, 4 × 10BCR-ABL1WT were individually mixed in a 1:1 ratio with those transduced with BCR-ABL1∆DC2, BCR-ABL1∆SH3, BCR-ABL1INS/Del, BCR-ABL1e13a3 and BCR-ABL1e14a3 . For plucked CD34-derived CFUs, RNA was extracted as previously described .BCR-ABL1 oncogene: BCR10: 5′-TATGACTGCAAATGGTACATTCC-3′FwABL4: 5′-TCG TAG TTG GGG GAC ACA CC-3′.RvThe following primers were used to amplify the BCR and ABL1  and stratified on a soft-agar bottom phase (soft-agar medium containing 0.6% agar). Each well was overlaid with growth medium to feed cells every 7 days. Twenty days later, each well was covered with an MTT (Sigma) solution (5 mg/ml in D-MEM high glucose) and placed in a CO2 incubator for 4 h. Images were acquired and colony numbers counted using the Image-J software.Anchorage-independent assays were performed as previously reported  with theThe Prism Software was used to perform analysis of variance (One-way ANOVA).BCR-ABL1 breakpoint region in modulating the oncoproteins catalytic activity. To assess the role of the DC2 and SH3 domains in regulating kinase efficiency, we generated five different BCR-ABL1 fusion transcripts , the maximum reaction rate (Vmax), the catalytic constant rate (Kcat) and the catalytic efficiency (Kcat/Km) of each mutant  for BCR-ABL1∆DC2, BCR-ABL1INS/Del and BCR-ABL1e14a3, indicating higher substrate affinity. Analyzing the maximum rate of the enzymatic reaction (Vmax), we found lower saturation concentrations  for BCR-ABL1∆DC2, BCR-ABL1∆SH3, BCR-ABL1INS/Del and BCR-ABL1e14a3. On the contrary, BCR-ABL1e13a3 presented a 1.57-fold higher Vmax than BCR-ABL1WT. To establish the catalytic rate of each atypical BCR-ABL1 isoform we divided the detected Vmax for the enzyme concentration employed in the assay, thus calculating the Kcat value. We found that BCR-ABL1e13a3 showed a 1.57-fold higher Kcat value, while all the remaining constructs presented values lower than BCR-ABL1WT. Finally, to establish if the BCR-ABL1 breakpoint region modifies the oncoprotein’s catalytic efficiency, we divided the Kcat of each isoform for its Km determining that BCR-ABL1∆DC2, BCR-ABL1∆SH3, BCR-ABL1INS/Del and BCR-ABL1e13a3 were less catalytically efficient than BCR-ABL1WT. Unlike the aforementioned isoforms, BCR-ABL1e14a3 displayed a Kcat/Km ratio 1.23-fold higher than the native construct. These findings strongly suggest that the BCR-ABL1 breakpoint region modulates the oncoproteins substrate binding, substrate affinity and kinase activity.Previous evidence has demonstrated autoinhibition of ABL1 kinase activity by the SH3 domain . Furthernscripts  and emplh mutant . CompareBCR-ABL1 breakpoint region on cell transformation and intracellular signaling, we lentivirally expressed BCR-ABL1WT and five atypical fusion transcripts in Ba/F3 cells. We initially evaluated the ability of native and atypical transcripts to mediate IL3-independent growth. We observed that BCR-ABL1WT was more proficient in inducing cytokine-independent growth than BCR-ABL1INS/Del, BCR-ABL1e13a3 and BCR-ABL1e14a3, while BCR-ABL1∆DC2 and BCR-ABL1∆SH3 showed comparable transforming activity  while the remaining atypical transcripts showed a reduced ability to phosphorylate this protein  while two were purposefully engineered in our laboratory (BCR-ABL1∆DC2 and BCR-ABL1∆SH3). We found that these modifications affected BCR-ABL1 catalytic efficiency, signal transduction, transforming activity and reduced response to IM, DAS and PON but not NIL. Our work follows that of several other groups that have investigated the specific biological contributions of different functional domains within the BCR and ABL1 portions of the BCR-ABL1 chimeric oncoprotein. Nieborowska-Skorska and others have shown that a BCR-ABL1 construct devoid of either the SH2 or the SH3 domains retained the ability to activate STAT5, while STAT5 phosphorylation was lost after the simultaneous deletion of both domains (BCR-ABL1∆SH3) did not affect STAT5 phosphorylation, while partial removal of the domain (as in BCR-ABL1e13a3 and BCR-ABL1e14a3) resulted in increased levels of phosphorylated STAT5. This unexpected finding suggests that alterations in the SH3-SH2 structure affect BCR-ABL1 substrate affinity and catalytic activity. Furthermore, as STAT5 phosphorylation was comparable between native BCR-ABL1 and mutants carrying deletions in BCR domains (BCR-ABL1∆DC2 and BCR-ABL1INS/Del), our results indicate that—within the breakpoint region—only ABL1 functional domains are required for STAT5 activation. On the contrary, BCR domains seem critical inhibitors of AKT activation as AKT phosphorylation increased in cells transduced with BCR-ABL1 constructs displaying a reduced BCR contribution (BCR-ABL1∆DC2 and BCR-ABL1e13a3), supporting an inverse correlation between BCR size and activation of anti-apoptotic signaling. It should also be noted that, for the first time, our findings implicate the BCR-ABL1 breakpoint region in the regulation of cell adhesion as all five mutants included in the study were less proficient than native BCR-ABL1 in promoting anchorage-independent growth of Rat1Myc cells.In the current study we investigated the impact of five different breakpoint regions on BCR-ABL1 leukemogenic potential and TKI responsiveness. Three of the five breakpoints were previously identified in CML patients ( domains . AccordiBCR-ABL1 breakpoint all contribute to the cytokine-independent transformation of Ba/F3 cells. Furthermore, while we confirm that STAT5 phosphorylation is required for BCR-ABL1-mediated growth factor independence (per se is insufficient to transform cytokine-dependent cells, as Ba/F3 expressing BCR-ABL1e13a3 and BCR-ABL1e14a3 showed high STAT5 phosphorylation while displaying reduced IL-3 independence. Interestingly, our results reiterate that BCR-ABL1 transforming potential and clonogenic ability are biologically and functionally distinct as the latter were mostly unaffected in the uncommon transcripts investigated in our experiments with the exception of BCR-ABL1∆SH3.Griswold and others have previously reported that mutations in the BCR-ABL1 kinase domain modify its substrate utilization and kinase activity . These ependence , we findBCR-ABL1 transcripts included in this work. The introduction of ABL1-directed TKIs has dramatically improved the hematological, cytogenetic and molecular responses of leukemia patients displaying a BCR-ABL1 chimeric fusion (BCR-ABL1 variants were successfully treated with NIL (BCR-ABL1INS/Del failed to obtain a good molecular response when exposed to IM or DAS but benefited from NIL treatment (Finally, we wanted to define the TKI responsiveness of the atypical c fusion . Despitec fusion  often rec fusion . Publishc fusion . Moreovec fusion . These rwith NIL  but failwith NIL . Accordireatment . While treatment . It shoureatment . Interesreatment .BCR-ABL1 fusion transcripts.Overall, these observations promote the hypothesis that the breakpoint region influences the structural conformation of the adenine region rendering NIL more effective than IM, DAS and PON against atypical BCR-ABL1 breakpoint region critically regulates the oncoproteins catalytic activity, transforming efficiency and TKI sensitivity and that the variations investigated in this work can reduce IM, DAS and PON sensitivity but not NIL responsiveness. Taken together our results suggest that CML patients expressing uncommon BCR-ABL1 fusions may derive greater clinical benefit from NIL treatment.In summary, our findings demonstrate that the