The past two decades have seen unprecedented student demand for global health education through experiential and engaged learning within institutions of higher education in the United States. This demand created a need for innovative institutional partnerships. Since 2007, faculty from Cornell University’s Global Health Program and Kilimanjaro Christian Medical University College (KCMUCo) have worked together to design, implement, and evaluate an innovative experiential learning program in global health and development policy. Since its inception, 176 Cornell undergraduates and 188 KCMUCo medical students have successfully engaged in the policy case study collaborative program and course, leading to the development of 75 policy case studies.This long-term partnership between Cornell and KCMUCo has led to an innovative cross-cultural teaching model, funding support, professional presentations for students and faculty, a visiting scholars program at Cornell, and new avenues for research and collaboration. Fifteen years of sustained partnership has required the navigation of several unique and complex challenges, providing the opportunity to reimagine and strengthen this program and partnership. The objective of this article is to share a powerful program model for global health training and education, and discuss the challenges, successes, and lessons learned through this continued collaboration. The past two decades have seen unprecedented student demand for global health education and engaged learning in institutions of higher education in the United States 2. In resWith this increased demand for global health education came the need for innovative institutional partnerships . In 2007This program was founded on principles of educating and inspiring future global health leaders and practitioners from diverse backgrounds, going beyond didactic teaching and learning. The program was tailored to engage and expand students’ critical thinking capacities, interpersonal and cross-cultural skills, and frames of reference through a mutually rewarding partnership between low-income and high-income country institutions . BetweenRecent literature and dialogue has called for an examination of global health, global health training programs and the inequities and power imbalances that are pervasive in global health work and partnership 567. We w564While there is considerable literature discussing global health research and training partnerships in clinical education settings, there is a need for further documentation of undergraduate and non-clinical collaborative global health program models 10. The oIn this collaborative program, students come together at KCMUCo in teams of five to six Cornell and KCMUCo students to develop, write, and present a new global health policy case study on a topic relevant to Tanzania. Through this process, groups work together to analyze a policy problem, identify policy issues and evaluate relevant policy options. This offers participants the opportunity to develop broad knowledge about global health and development issues in Tanzania. In addition to academic deliverables, students must demonstrate effective engagement in a cross-cultural learning environment through participation in reflective practices related to cultural diversity, professional growth, collaboration, and service learning. The following sections expand on who we bring together, the policy case study approach, and collaborative models for learning and support.From the initial stages, this collaborative program has been developed and sustained through equitable long-term institutional commitments. Many partners at both KCMUCo and Cornell come together each year to prepare, develop, and offer this program. While students and faculty are crucial to the success of this collaboration, this partnership also depends on support from staff members in administrative, legal, and budget offices at both institutions. This requires cultivation of relationships across Cornell and KCMUCo in order to successfully execute contracts, legal agreements, budgets, and logistics. The program also relies on the support of affiliated faculty and staff to offer additional instruction that prepares students to engage in this program. For example, Kiswahili instructors and expert stakeholders teach students about health systems and critical public health issues in Tanzania.Introduction to Global Health, Preparation for Cross-Cultural Engagement and Collaborative Research, and Elementary Kiswahili for Global Health prior to engaging in the program. KCMUCo students are required to complete a week-long preparation seminar where they are introduced to the policy case study analysis approach, literature search process, citation management strategies, writing skills, and elements of cross-cultural interaction. The preparatory courses are a critical opportunity for students to develop the skills necessary to engage successfully in this program and to demonstrate their preparedness and commitment to fulfilling their academic and professional responsibilities.This program brings together equal numbers of students from Cornell and KCMUCo in Moshi, Tanzania. Cornell undergraduates in the program are rising juniors or seniors, representing a diverse collection of academic majors and minors. KCMUCo students are fourth year undergraduate medical students in a five-year postsecondary program with interests in global and public health. Since the inception, KCMUCo and Cornell faculty have recognized the importance of a competitive application and rigorous preparation process for students at both institutions, acknowledging the unique academic knowledge, values, culture, and lived experience that each student brings to the program. The application process requires demonstration of academic excellence and commitment to engagement in the program. As demonstrated in For both groups of students, the collaborative program is integrated into their coursework. For KCMUCo students, the program fulfills their research elective requirement. For Cornell students, the program serves as an Experiential Learning Opportunity, a requirement for students pursuing the Global Health minor or Global and Public Health Sciences major.A unique aspect of this program structure is the use of a policy case study approach as opposed to other documented frameworks 11. KCMUCIn addition to the academic components of the policy case study structure, this model is guided by further pedagogical cornerstones including open communication, active learning, community building, teamwork, critical reflection, and faculty and program support . These vFaculty and program support involves mentorship, direct feedback, faculty presence during group work time, and facilitation of community building activities. The teaching team actively cultivates an environment where students feel valued and cared for which allows them to lean into the challenges of teamwork, ask for support, and learn from their mistakes.Critical reflection serves as an example of a challenge, an element of support, and a pedagogical cornerstone in this program. Critical reflection is not only a foundational value, but also an invaluable tool of learning, which allows us to respond to diverse forms of dissonance. The program approaches critical reflection in two ways. First, through course-specific reflection related to content, mode of delivery, collaborative learning, newly acquired skills, and expectations for the next phase of training. This is essential to creating a harmonious learning environment. Second, interpersonal and cultural reflections bring in students’ own perspectives and lived experiences. This allows students to reflect on the personal identities that shape their participation in the program, allowing for mutual exchange of shared values and promoting a personalized sense of collaborative learning. Critical reflection is incorporated through weekly individual written assignments and group discussion activities tailored to encourage open mindedness, critical analysis of the learning process, and introspection. An integrated critical reflection practice creates opportunities for students to engage beyond the academic learning process.Over the nearly 15 years of collaboration, faculty and students have had to navigate several unique and complex challenges to sustain this program and partnership. Through these challenges, we have learned many lessons about the principles and practices that are critical to continued partnership growth and advancement.Bringing together our two universities requires that all involved acknowledge and challenge the inherent inequities and power dynamics. This involves everything from aligning academic calendars to balancing institutional priorities and navigating different approaches to teaching and learning. A shared commitment to reciprocity through challenge is critical to sustaining and growing this partnership 13.Since the inception of the program, faculty have always collaborated on program design, development and delivery of course content, assessment of student engagement, evaluation of program components, and investment in future partnership priorities and initiatives. The development of a visiting scholars program at Cornell is just one of the many outcomes of this commitment to reciprocity. Through the visiting scholars program, Cornell University hosts scholars from KCMUCo for a month each year to attend classes, explore academic interests, and interact with Global Health Program students in and out of the classroom. Reciprocity requires not only active collaboration, but also trusting relationships, open communication, and a genuine excitement and curiosity for the ways in which we can learn from each other. Faculty and partners strive to model for students that we can learn best by learning from one another in all aspects of program implementation.We invite and expect all students to join the teaching team in reciprocal learning by engaging in deeply collaborative teamwork, which is time intensive, demanding, and often a challenge for students. It requires that all participants be open to navigating new forms of dissonance. Over the years, supporting students engaging in this type of personal and academic learning has required centering the value that we are co-creating a rich and unique opportunity to learn from one another across many forms of difference. This requires us all to lean into discomfort. Faculty and students must bring a sense of humility and cultivate relationships of mutual respect to not only fulfill academic responsibilities, but also learn from one another. While bringing together students and faculty across cultures, identities, and academic experiences can be a challenge, it is crucial to sustainably engaging in global health practice and training future global and public health professionals.With the disruption of in-person learning and international travel, the COVID-19 pandemic challenged the ways in which we were able to collaborate. The teaching team relied on shared values and past lessons learned as we took advantage of a unique opportunity to reimagine and strengthen this program and partnership utilizing virtual learning platforms .Given the need to adapt the existing program format, faculty from Cornell and KCMUCo worked to generate a new instructional model for the 2021 program. Faculty members met weekly for nearly a year, reviewing and preparing not only curricular materials but also opportunities for community building and critical reflection. Faculty remained committed to creating a collaborative community across cultures and computer screens, and a meaningful engaged learning program for students. In doing this, we overcame the immense challenges inherent in this mode of instruction, including technological glitches, time zone differences, Zoom fatigue, and the complexities of building community in the virtual environment. Despite these barriers, the successful adaptation of this program demonstrated a shared commitment to this long-term partnership and its educational mission to train future global health leaders and collaborators. In 2022, the program was able to return to an in-person format with students and faculty coming together at KCMUCo in Moshi, Tanzania.Over the years, 75 case studies have been successfully written and presented, with 12 student groups having their work accepted for presentation at international conferences.Case studies have encompassed a wide range of topics and global health issues as depicted in Building Strong Nutrition Systems in support of Scaling Up Nutrition in Tanzania. Additional collaborations include a Geographical Information Systems (GIS) workshop and short course at KCMUCo, a partnership between KCMUCo Institute of Public Health and Better Health for African Mother and Child (BHAMC), and the establishment of the Uzima Garden: Spaces of Nourishment and Healing Project.In addition to the successes of the collaborative course, this partnership has created many additional opportunities for further research and collaboration at Cornell and KCMUCo. Faculty members from KCMUCo have been selected for participation in the WHO Cochrane Institute at Cornell. In addition, nineteen KCMUCo faculty members and eighteen KCMUCo medical students have traveled to Cornell as part of the visiting faculty and visiting scholars programs respectively. Many further collaborations have stemmed from this partnership, including a two-stage implementation research project titled, The achievements of this program model demonstrate that reciprocal and sustainable global health partnerships are built on 1) cultivating relationships grounded in mutual trust, respect, and open communication 2) addressing the inherent inequities between low-income and high-income institutions, and 3) creating transformative learning experiences for all students, faculty, and affiliated partners. Other institutions can learn from this model by evaluating how the presented programmatic components and partnership principles may be adapted and utilized towards navigating complex challenges and strengthening their own global health programs and collaborations.


The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides supplemental foods and nutritional education to low-income women and children up to the age of five. Despite evidence that WIC improves diet and nutrition and the nationwide availability of this program, many participants exit WIC before they are no longer eligible for benefits. To date no study has systematically reviewed factors that influence participants’ exits from WIC. The study systematically reviewed the relevant literature to identify factors related to discontinuing participation in WIC before children reach the age of five and 1503 citations were reviewed, 19 articles were read for full text review and eight studies met inclusion criteria. Participants’ higher socioeconomic status, attitudes and behaviors around breastfeeding, having shorter prenatal participation in WIC, administrative barriers, confusion regarding program eligibility, feelings of stigma and embarrassment at the store checkout lines, personal and family challenges, dissatisfaction with insufficient fruit and vegetables benefits and living in suburban areas or in the Southern US were salient factors that influenced WIC exits. These findings will be of interest to policymakers and stakeholders as they consider ways to increase participation and retention through program modernization and innovations. The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a federal nutrition assistance program that provides supplemental foods and nutrition education, including breastfeeding promotion and support, at no cost to pregnant, postpartum and breastfeeding women, infants and young children up to the age of five from lower-income households . To be ePrevious research has shown that WIC improves diet and nutrition. Longer WIC participation has been associated with higher diet quality among children, measured by total Healthy Eating Index (HEI) scores at age 2  and at aWIC is a cornerstone of USDA’s efforts to promote nutritional security and by extension, health and, wellbeing. Declining participation is a concern among policymakers and program officials. Between 2009 and 2020 the number of program participants declined each year  and in 2This paper provides information directly relevant to WIC program modernization efforts by systematically reviewing the existing literature on factors related to discontinuing participation in WIC before children reach the age of five, which we refer to hereafter as WIC exits. From a policy standpoint, a better understanding of the complex process involved in decisions to leave the program can inform programmatic efforts to increase WIC retention. Moreover, studies included in the present review had diverse study designs  which allowed the current work to provide different perspectives on the topic studied. Across study design and type, we found similar individual and interpersonal factors that influenced participants’ exits. Finally, self-selection into WIC is a barrier to understanding the impact of WIC on mothers and their children, since those who exit the program differ systematically from those who remain enrolled in ways that may be linked to diet and health outcomes. To date, many studies have attempted to account for selection bias in analyses of WIC program effects by including socio-demographic characteristics, which differ between the participant and non-participant groups and may contribute to differences in outcomes of interest, as controls or covariates in multivariate regressions ,11,12. Fhttp://www.nlm.nih.gov/mesh/) by conducting mock searches to ensure that the final list of terms will be captured in articles that met inclusion criteria. Terms used in the search included a combination of the following words: mother, mothers, caregivers, women, grandparents, WIC, The Special Supplemental Nutrition Program for Women, Infants and Children, food assistance, satisfaction, participation, experience, barrier concern, leave, exit, and retain. Vocabulary and syntax were adjusted across databases. Articles included in this review were extracted from The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and PubMed through a systematic review of the literature from December 2021-February 2022. We used the systematic review software Covidence for screening and data extraction and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) format for data reporting. The present review was completed in a systematic, highly rigorous and transparent way to minimize bias. A priori and with the guidance of an experienced medical librarian, we tested key words related to WIC exits found in the Medical Subject Headings Library  independently conducted the title and abstract screening to check for inclusion criteria, compared data and resolved discrepancies. Next, two reviewers (K.L. and L.H) independently conducted full text review of the articles that were considered relevant. The reference lists of these articles were reviewed to include relevant articles not initially part of the title and abstract screening, resulting in the addition of one study for full text screening. This step minimized risk of bias due to potentially missing results in the initial synthesis. The Review Board determined that the study did not require review for human subject research.In total 1503 articles’ titles and abstracts were initially screened, 19 articles were read for full text review  and 11 were excluded because they did not meet inclusion criteria, resulting in eight articles used for data extraction ,18,19,20Studies used diverse criteria to assess child exits from the WIC program. This included participant reports of voluntary exits from the program obtained from survey responses , and participants who initially reported receiving WIC but indicated later not being part of the program in longitudinal studies . Studies also used administrative records to assess child exits from the WIC program. This included records indicating that the participant was terminated from WIC due to failure to attend appointments with food benefit issuance for 60 days (non-participation), and child identification number absent from monthly participation record or a new certification date was not present in two consecutive months.Eight studies reviewed reported race and/or ethnicity of their study samples or provided a measure that could serve as a proxy for race and/or ethnicity. In five studies a majority of the study sample identified as non-Hispanic White ,16,20 orStudies that reported participants’ exits via information obtained from quantitative and qualitative studies indicated that administrative barriers such as difficulty scheduling, rescheduling and recertifying appointments, an extensive wait time during check pick up (data collected when WIC benefits were provided via paper vouchers or “checks” rather than current use of Electronic Benefit Transfer cards), and needing to comply with redundant clinical requirements were factors that influenced exits ,17,20 T. ParticiStudies that used administrative records to assess child exits from the WIC program reported that in general participants with higher socioeconomic status (SES) were more likely to exit WIC ,16,19. FWIC participation is at its highest in infancy; when infants transition to the child package, participation drops despite considerable evidence that WIC participation is associated with better childhood diets. The evidence presented in this systematic review shows that several individual and interpersonal factors influenced participants’ exits from WIC at this critical juncture. Participants’ higher socioeconomic status; attitudes and behaviors around breastfeeding, such as low intentions to breastfeed during the prenatal period, never breastfeeding or breastfeeding for less than 6 months; and having shorter prenatal participation in WIC were factors related to WIC exits ,16,19. FThe factor most commonly associated with exits from the WIC program among studies in this review was a participant’s higher socioeconomic status within the economic range eligible for WIC. Parents/caretakers of children with higher incomes, higher rates of employment, higher education (completed at least high school) and higher household savings were less likely to continue receiving WIC benefits. While this may suggest that children who continue receiving WIC services are from families with higher economic needs and thus less likely to be income ineligible for WIC, it is also possible that infant/children that exit WIC remain eligible and could continue to benefit from the program if they reenrolled. Gundersen (2005) indicated that infants who left WIC were from families that had incomes below the poverty line, received federal food assistance and almost all remained eligible for WIC . SimilarLow adherence to breastfeeding recommendations was also associated with exits from WIC in childhood. Participants who reported never breastfeeding or breastfeeding for less than 6 months were more likely to exit WIC . FurtherWIC, like other food and social assistance programs, requires beneficiaries to periodically reverify eligibility. Before the COVID-19 pandemic, only about half of all eligible families received WIC, with many eligible families leaving the program due to the complexity of the recertification process . While tThe ARPA modernization and innovation funds and Child Nutrition Reauthorization provide important opportunities for making permanent changes to the WIC program to increase participation and retention. For example, one approach currently being considered to increase caseload and reduce exits from WIC is opening clinics late during the day or offering Saturday clinics . This apFeelings of embarrassment at checkout due to in-store item mislabeling of foods and stigma were factors related to exits from the program. WIC participants’ feelings of feeling stigmatized from community members and/or at store checkout lines have been previously reported ,34. A quIn addition to limited selection of WIC foods available at certain stores being cited as barriers to continued participation in WIC , dissatiFinally, living in suburban areas or in the Southern US also emerged as a factor associated with early exits from the program. In southeastern states such as Mississippi, Arkansas, Kentucky, Louisiana, South Carolina and Alabama over 60% of all infants participate in WIC . Two stuThe study had multiple strengths. This is the first systematic review to report factors that influence participants exits from the WIC program. Studies included in the present review had diverse study designs  which allowed the current work to provide different perspectives on the topic studied. We did not restrict publication year of the studies included in the review. This allowed us to capture factors related to WIC exits in the context of changes the WIC program has undergone through the years. In addition, the methodology followed in the present systematic review minimized risk of bias. Study limitations include a lack of consistency in the factors investigated related to exits from the WIC program in all studies included in the present review. Socioeconomic status was identified in more studies than other factors; however, other factors such as household location in the Southern region of the U.S, embarrassment at checkout due to item mislabeling, or stigma were only assessed in three different studies. Further, some studies had larger, more nationally representative samples than others making generalizability of each finding challenging. Studies addressing these limitations may add to our understanding of factors influencing WIC exits. Further, there is a need for future research to examine how and to what extent the factors related to exits from WIC found in the present review change over time and in response to different policy and economic contexts, and to continue to monitor to what extent these factors remain relevant in the current policy and economic context.In conclusion, understanding the complex factors that influence exits from the WIC program opens opportunities for engaging participants and addressing barriers to continued participation. The studies we reviewed suggest that streamlining certification and recertification processes, continuing the promoting and advocating for breastfeeding adherence (particularly during the first 6 months of a child’s life) and providing positive client-staff interactions in which WIC participants feel supported all have the potential to reduce participants’ exits. The effectiveness of strategies addressing these factors has not been tested. In terms of messaging about WIC, our review findings suggest that communication and outreach with current and prospective participants about eligibility, particularly those closer to the income eligibility threshold, is another potential method to increase participation among those eligible. Our findings also reinforce the importance of modernization such as the use of electronic benefits and mobile apps. In particular, mobile apps offer opportunities to improve WIC participants’ shopping experience and increase redemption rates of food packages  and may


Open decompression with fusion is the gold-standard surgical technique for spondylolisthesis. However, it may be too extensive for patients with foraminal stenosis with stable spondylolisthesis. The endoscopic lumbar foraminotomy (ELF) technique was developed as a minimally invasive surgical option for foraminal stenosis. Some authors have reported the outcomes of ELF for various spondylolistheses. However, few studies have demonstrated foraminal stenosis in advanced stable spondylolisthesis. This study aimed to describe the surgical technique and results of ELF for radiculopathy due to foraminal stenosis in patients with stable spondylolisthesis.Consecutive 22 patients who suffered from radiculopathy with spondylolisthesis underwent ELF. The inclusion criterion was unilateral radicular leg pain due to foraminal stenosis in stable spondylolisthesis. After the percutaneous transforaminal approach, foraminal decompression was performed using various surgical devices under endoscopic visualization. Surgical outcomes were measured using the visual analog pain score, Oswestry disability index, and modified MacNab criteria.Pain scores and functional outcomes improved significantly during the 12-month follow-up periods. The rate of clinical improvement was 95.5% (21 of 22 patients). One patient experienced a dural tear and subsequent open surgery.ELF can be effective in foraminal stenosis in stable spondylolisthesis. Technical points specializing in foraminal decompression in spondylolisthesis are required for clinical success. The gold standard surgical technique for lumbar spondylolisthesis with foraminal stenosis is decompression and fusion surgery, which may be performed using different methods. However, this surgery may result in considerable morbidity or sequelae, particularly in older patients.In cases of foraminal stenosis with fixed or stable spondylolisthesis, adequate foraminal decompression may be a good solution while avoiding the surgical risk of extensive fusion surgery. Therefore, a minimally invasive decompression technique is required for cases with stable stenosis.The endoscopic lumbar foraminotomy (ELF) or foraminoplasty technique was developed for effective foraminal decompression under a working channel endoscopic view –4. The fSome studies have been published on transforaminal endoscopic decompression for spondylolisthesis with lumbar stenosis –12. HoweThis study aimed to demonstrate the clinical outcomes of ELF for foraminal stenosis in stable spondylolisthesis and describe a practical and technical approach to achieving good clinical outcomes with ELF.Twenty-two consecutive patients with foraminal stenosis in spondylolisthesis were treated with ELF between January 2019 and January 2021. Cases were prospectively registered in the database, and records were retrospectively analyzed. The institutional review board approved the study, and written informed consent was obtained from all participants.The inclusion criteria for ELF were as follows: 1) chronic unilateral radicular leg pain despite more than 3 months of nonoperative treatment, 2) foraminal stenosis in spondylolisthesis demonstrated on magnetic resonance imaging (MRI) and computed tomography (CT) scans, 3) spondylolisthesis without definitive hypermobility on dynamic x-rays, and 4) foraminal stenosis documented as the source of radiculopathy by imaging studies, neurologic examination, and selective nerve root block.The exclusion criteria were low back pain alone, acute lumbar disc herniation, severe central stenosis, segmental instability or hypermobility, and other pathological conditions such as inflammation, infection, trauma, or tumor.Changes in clinical status were assessed using the visual analog pain score (VAS) and Oswestry disability index (ODI). The global outcome was evaluated using the modified MacNab criteria. Follow-up data were obtained through regular outpatient clinic visits or telephone interviews.The surgical procedure was performed according to a previously described method of ELF , 13. It Intramuscular midazolam (0.05 mg/kg) and intravenous fentanyl (0.8 μg/kg) were administered on call. The patient was placed in a prone position on a radiolucent spine table.This step was performed to ensure the safe docking of the working sheath at the foraminal zone. The skin entry point and approach angle were determined according to the target point and body size on preoperative MRI, CT scan, and x-rays.An 18-gauged needle was introduced into the foraminal zone in the posterolateral direction under fluoroscopic guidance . The typical approach angle is approximately 45° for foraminal decompression and can be adjusted to become steeper when the pathologic point is located in the extraforaminal zone. The needle tip was deeply inserted into the foraminal disc or on the vertebral body, along the surface of the superior articular process (SAP). The needle was replaced with a guidewire, and an obturator was introduced along the guidewire until the head of the obturator was fitted into the foramen without any access pain. The beveled final working sheath was advanced along the obturator by gently tapping with a mallet and placed firmly in the foraminal zone with its sharp end away from the exiting nerve root (ENR). The surgical field was created outside the foramen, and decompression proceeded into the foramen (outside-in approach). Thus, the ENR was protected during the entire procedure , 2A.Endoscopic foraminal decompression was initiated after a working channel endoscope was inserted. The initial view included the ENR with perineural fat and disc surface. These structures helped the surgeon maintain the correct orientation during the entire procedure. Next, the surface of the SAP was exposed by rotating the working sheath and the endoscope. The tip of the SAP was then drilled using various endoscopic burrs along the ENR until the ligamentum flavum (LF) and foraminal ligaments at the axillary zone were sufficiently exposed. Finally, any bone or venous bleeding was coagulated using radiofrequency tips and hemostatic agents. In cases of advanced spondylolisthesis, the ENR is usually pinched by a narrow space between the upper pedicle and lower vertebral endplates rather than by the SAP. Therefore, the ENR should be decompressed by resecting these bony structures. Bone resection is an essential and critical process of foraminal decompression specific to spondylolisthesis cases , 2B.After sufficient bone work, delicate soft tissue removal was performed, and the ENR was released. The decompression process was directed toward the proximal side, and the nerve root course was traced to the axillary epidural zone. The hypertrophied LF and protruding disc material were removed gradually using micropunches, forceps, and radiofrequency tips . AlthougP < 0.05.Statistical analysis was performed between the pre- and postoperative clinical results using repeated-measures analysis of variance and a paired t-test. Statistical significance was set at 2. The degrees of spondylolisthesis were grade 1 in 20 patients (90.9%) and grade 2 in 2 (9.1%). The operating levels were L5-S1 in 12 (54.5%) patients, L4–5 in 8 (36.4%), and L3–4 in 2 (9.1%). The mean operative time was 63.6 min . The mean postoperative hospital stay duration was 1.9 days .The mean age of the patients  was 69.2 years . The mean BMI was 22.94 ± 2.59 kg/mP < 0.001) (P < 0.001)  . The mea< 0.001) . The glo< 0.001) .During the procedure, one patient experienced a dural tear in the axillary zone at the L3–4 level. The patient complained of severe pain and underwent subsequent open surgery . Otherwise, no other significant perioperative complications were observed. No newly developed back pain or radiological signs of further instability were noted during the follow-up period.The ELF technique is usually suitable for geriatric patients because of its minimal invasiveness. However, the average age of the surgical candidates in this study was higher than that of other case series of ELF. The disease entity appears to be chronic radiculopathy due to long-standing or advanced spondylolisthesis. Therefore, most patients may be older individuals or long-suffering. Additionally, older patients do not prefer extensive fusion surgery for perioperative morbidities.The operative data showed the typical benefits of minimally invasive spine surgery. The mean operative time was 63.6 min, which was shorter than that of open fusion surgery –17. BlooP < 0.001). Conversely, the mean ODI improved by 56.64 at the final assessment (P < 0.001). A reduction of more than 50% in the VAS score  based on the modified MacNab criteria was 90.9%, with a clinical improvement rate of 95.5%. These findings are comparable to those of published open foraminotomy procedures –27.Our series had no significant complications except for one dural tear and conversion to open surgery. None of the patients experienced any further clinical or radiological segmental instability during the follow-up period. Although some bony structures were removed to decompress the nerve root, the ELF technique did not cause the development of further instability in any of the patients in our study.Given the innate characteristics of ELF, the clinical success and complication rates may depend on the surgeon's skill. However, once technical proficiency is achieved, surgeons can produce relevant and reliable results. Therefore, an extensive and systematic learning process is required to implement this procedure.Owing to the development of decompression devices, ELF has become a practical foraminal decompression technique. The first-generation procedure uses a laser for foraminal decompression. Knight et al. , 28 intrSince Knight et al. published endoscopic lumbar laser foraminoplasty for isthmic spondylolisthesis , some auWithout open fusion surgery, ELF can resolve chronic and intractable radiculopathy caused by spondylolisthesis. In addition, this minimally invasive technique may be efficient for patients who refuse fusion surgery or medically compromised older patients because the procedure can be performed percutaneously under local anesthesia. Consequently, the surgical complications of extensive fusion surgery can be reduced, and the patient can return to normal life earlier.However, this minimally invasive procedure has a steep learning curve and limited indications. Therefore, the clinical application of ELF in spondylolisthesis should be carefully considered.Hypertrophic SAP and thickened LF compressing the ENR are the primary pathologies of foraminal stenosis. Therefore, the basic ELF technique consists of bone resection of the SAP and removal of the LF by endoscopic burrs and other surgical devices. The final landmark of the decompression process is the axillary epidural space, which is the starting point of the ENR.However, the foraminal anatomy of advanced spondylolisthesis is different. Unlike the usual foraminal stenosis cases, the main offending structure may be the lower vertebral endplate rather than the SAP. In the foraminal zone of spondylolisthesis, the SAP is away from the ENR because of slippage of the upper vertebral body. Therefore, the ENR may impinge between the upper pedicle and lower vertebral body.To achieve sufficient foraminal decompression, the surgeon should target the lower vertebral endplate rather than the SAP during the initial approach. Once the working sheath and endoscope are ensured to be in the foraminal working zone, the surgeon should confirm the route of the ENR and disc between the upper pedicle and lower vertebral endplate. Next, the upper pedicle and lower vertebral endplate should be sculptured using an endoscopic burr and punch. Finally, the ENR is released between the two resected bony walls after bone work.This study had some limitations. First, the study was conducted retrospectively without a control group. Therefore, selection bias in the inclusion criteria may have been present. Therefore, a prospective randomized trial or comparative cohort study comparing ELF and open fusion surgery for foraminal stenosis with spondylolisthesis is warranted. Second, the one-year follow-up period may be relatively short for drawing a conclusive result because the spondylolisthesis status or segmental stability may change with time, even after successful decompression. Therefore, a long-term follow-up study with a larger number of cases is required to verify the effectiveness of ELF for foraminal stenosis in spondylolisthesis.The advanced ELF technique is effective in adequately selected cases of lumbar spondylolisthesis. In addition, ELF may be suitable for intractable radiculopathy due to foraminal stenosis with fixed spondylolisthesis without segmental hypermobility—a specialized technique is required for the clinical success of foraminal decompression in spondylolisthesis. Moreover, it may provide an excellent minimally invasive alternative to extensive fusion surgery in older or medically compromised patients.


This quality improvement study evaluates the outcomes associated with a program to improve clinician adherence to management guidelines for acute ischemic stroke in hospitals in China. Can a multilevel, centrally supported quality program promote clinician adherence to stroke guidelines?This quality improvement study included 45 091 patients from 58 hospitals. The multilevel system program was associated with a significant increase in the absolute percentage of key performance indicators achieved per patient per week , the absolute rate of all-or-none success , and a decrease in the rate of severe disability or death at discharge .These findings suggest that this multicenter program may serve as a model for ischemic stroke–related quality improvement activities. Promotion of clinician adherence to stroke guidelines can improve stroke outcomes.To investigate the outcomes of a multilevel system program on clinician adherence to guidelines for treatment of patients with acute ischemic stroke (AIS).This quality improvement study used a prospective interrupted time series (ITS) and difference-in-difference (DID) design, from August 1, 2018, to January 31, 2020, divided into preprogram term and short and long postprogram terms; each term had 6 months. Data were collected during hospitalization and at discharge with an automated medical record data capture system in 58 public hospitals in Zhejiang province, China. Data were analyzed from August 2018 to January 2020.The multilevel system program included a modularized standard template for medical records, centrally supported continuing education, continuous monitoring and feedback, and collaborative workshops.The primary outcome was adherence to 12 key performance indicators (KPIs), expressed as (1) percentage of patient-applicable KPIs achieved in each participant and (2) percentage of participants among whom all applicable KPIs were achieved . The secondary outcome was severe disability or death  at discharge.Among 45 091 patients , 28 721 from 30 hospitals received the program and 16 370 from 28 hospitals continued routine care. In adjusted DID analysis, the program was associated with an increase in the absolute percentage of KPIs achieved per patient , absolute rate of all-or-none success , and decreased rate of severe disability or death at discharge . The ITS result showed the program was associated with an increase in KPIs achieved per patient per week  and in all-or-none success .The centrally supported program was associated with increases in clinician adherence to guidelines and reduced the proportion of severely disabled or deceased patients with AIS at discharge, providing support for its wider implementation. To enhance clinician adherence to stroke guidelines, the American Heart Association has set a model by initiating the Get With The Guidelines (GWTG)–Stroke program in 2003, which has reshaped stroke care delivery and remarkably improved national stroke care quality in the US2 with the monitoring of performance measures, alternatively called key performance indicators (KPIs). Later in 2018, a small improvement in performance measures for acute ischemic stroke (AIS) was also confirmed in China by a cluster randomized clinical trial with a population of 4800 patients.3 However, a similar quality improvement program did not result in a significant increase in composite adherence score in another Brazilian clinical trial.4 It remains unknown whether quality improvement can be generalized to general population settings in developing countries with large populations, but less well-financed national health systems.Stroke has imposed an enormous disease burden on the health care system, especially in developing countries, such as China.5 aiming to evaluate whether the implementation of a multilevel, centrally supported quality of care program for hospitalized patients with stroke promotes stroke care quality in China. To clear the major barrier of collecting clinical data, an automated medical record data capture system was developed to routinely obtain the KPIs from the original medical documents of patients with AIS without manual data entry that may lead to the loss of original authenticity. This quality improvement study aimed to set a practical model for developing countries with less well-financed national health systems to improve stroke care quality.An interrupted time series (ITS) design was conducted through the CASE-Stroke program , which was characterized by a central quality care initiative teamNCT03684629). The current quality improvement study was approved by the local ethics committee and followed the Standards for Quality Improvement Reporting Excellence (SQUIRE) reporting guideline for quality improvement studies. Written informed consent was obtained at the hospital levels. Because patient information was deidentified and anonymized before being released to the researchers, the informed consent requirement was waived by the institutional review board. The study period included 2 stages: the preprogram term, from August 1, 2018, to January 31, 2019, and the postprogram term, from February 1, 2019, to January 31, 2020. Considering that the outcomes of the program may take time to manifest,6 we divided the postprogram term into a short-term period from February 1, 2019, to July 31, 2019, and a long-term period from August 1, 2019, to January 31, 2020.The detailed information for the methods is available in the eAppendix in All hospitals in the CASE-II registry volunteered to participate in this study, then we conducted a prerandomization survey and randomly selected 30 hospitals to join the program group. Among the remaining hospitals, 28 were selected for the nonequivalent control (nonprogram) group after matching hospital characteristics by propensity score matching. Two hospitals refused to participate in this study because they were unable to participate in monthly video conferencing. Finally, we enrolled 30 hospitals in the program group and 28 hospitals in the nonprogram group. Patients were eligible if they were aged 18 years or older with AIS confirmed by brain computed tomography or magnetic resonance imaging within 7 days after symptom onset and admitted to wards directly or through the emergency department. Patients with other cerebrovascular diseases, such as cerebral hemorrhage and cerebral venous sinus thrombosis, were excluded.An innovative automated medical record data capture system was used to collect the data of stroke care quality in each hospital. The original medical documents were saved as portable document formats or images, then recognized, preprocessed, and sent to multiple optical character recognition engines to build documents with recognized text  was calculated as the total number of patients receiving rt-PA treatment divided by the total number of patients within 7 days of symptom onset, as the number of patients eligible for rt-PA treatment within the 4.5-hour therapeutic time window was not available from participants. The secondary outcomes were the distribution of modified Rankin Scale (mRS) score at discharge and severe disability or death, which was defined as mRS score 5 to 6.KPIs are the objective quantitative management indicators that facilitate adherence by the hospital. The primary outcomes were clinician adherence to the 12 predefined evidence-based KPIs, as detailed in eTable 1 in 9 Data from the preprogram period were also included to control for biases at the baseline level and linear trend (linear slope). The rapid change of rates in KPIs was observed in the short-term period of the program and the gradual change in KPIs was observed over the long-term period, which were defined as slope change and level change, respectively. Segmented linear regression models were used to estimate the changes in levels and linear trends after the implementation of the program.Baseline characteristics of hospitals and patients were compared between the program and nonprogram groups. An interrupted time series (ITS) model was used to evaluate the outcome of the program on the KPIs. A control (nonprogram) group was included to further control time-varying confounders.Multiple imputation (5 times) was performed for missing values. Only National Institute of Health Stroke scale (NIHSS) and low-density lipoprotein cholesterol had missing data at 3.8% (1734 participants) and 10.2% (4621 participants), respectively. A difference-in-differences (DID) analysis was further used to compare changes in outcomes that occurred over time in the program group to the changes in outcomes from the nonprogram group. The model includes the outcomes in 2 periods, preprogram and postprogram. To account for selection bias, the DID model allowed the use of propensity score weighting to match characteristics of both hospitals and patients between the program and nonprogram groups. Characteristics  that were not well matched for propensity score weighting were further adjusted in the DID regression analysis.P < .05. Analyses were conducted using SPSS statistical software version 24.0 (IBM) and R statistical software version 4.0.1 . Data were analyzed from August 2018 to January 2020.Sensitivity analyses were performed by repeating the segmented regression models only in the tertiary hospitals and secondary hospitals, respectively. The significance level was set at 5% as 2-sided and This study included 30 hospitals in the program group and 28 hospitals in the nonprogram group. Baseline hospital characteristics between the program and nonprogram group were comparable. The analytical population comprised 45 091 patients, with 28 721 (41.5% women) in the program group and 16 370 (41.5% women) in the nonprogram group. Of the included patients, mean (SD) age was 69 (12) years, 18 347 (40.7%) were female, and median baseline NIHSS was 3 . Baseline patient characteristics are generally similar between the 2 groups, except that the variables of hypertension, low-density lipoprotein cholesterol value, and baseline NIHSS score were slightly higher in the program group .The composite measures were increased from 73.2% before program to 80.3% and 85.4% in short-term and long-term periods after program, respectively , an increase in the absolute rate of all-or-none success , and a decrease in the rate of severe disability or death at discharge   .P < .001; level change in long-term period, 9.64%; 95% CI, 4.58% - 14.69%; P < .001), and in all-or-none success  (The ITS model further determined the program’s outcomes on changes in the linear regression slope and level . The ITSP = .04) . The resP = .04) . The proP = .04) A and 2B.P = .04) C and 2D.P = .04), and level change in the long-term period was −5.18%   . The disThe outcomes of the program on individual KPIs were also analyzed. The results suggest that the program was statistically associated with an increased linear trend (slope) of NIHSS assessment, deep vein thrombosis (DVT) prophylaxis, dysphagia screening, and intravenous rt-PA in the short-term period, but not the remaining 8 individual KPIs. The program was also significantly associated with increased levels of NIHSS assessment, DVT prophylaxis, dysphagia screening, and antihypertensive medication at discharge in long-term period, but not the remaining 8 individual KPIs . The DIDDaily and monthly mean scores for all individual KPIs identified 3 KPIs still needing further improvement even after the program: rt-PA, DVT prophylaxis, and anticoagulation for atrial fibrillation  at discharge. Similar findings were reported that participation in GWTG-Stroke was associated with increases in discharge to home and reduced mortality at 30 days and 1 year, both of which are of great clinical importance.20 In addition, DVT prophylaxis in China varied substantially among patients by age and stroke severity and among hospitals by location, bed number, and annual stroke discharges,21 which may explain its great fluctuation on the scatterplots. The underuse of rt-PA among patients with AIS, similar to the GOLDEN trial, prompts a stronger program on a national scale. The National Health Commission in China has listed “improving the rate of reperfusion treatment in AIS”22 as 1 of the national medical quality and safety improvement goals in 2021. The impact on patient care and outcomes will be of great interest.Intuitive evidence from the scatterplots of individual KPI scores extend the findings from the ITS and DID models, clearly identifying 3 important KPIs that still require further improvement: intravenous thrombolysis, DVT prophylaxis, and anticoagulation for atrial fibrillation at discharge (eFigure 7 and eFigure 8 in Our study has several limitations. First, the absence of a randomized comparison group had the possibility of residual confounding and inherent selection bias. However, the baseline characteristics of the hospitals in the nonprogram group were matched with those in the program group. Second, the number of patients within the therapeutic time window of 4.5 hours for rt-PA administration was not available; thus, we could only calculate a relative proportion of rt-PA treatment among all patients with stroke admitted within 1 week of symptom onset. Third, the definition of performance measures in this study was described on the basis of the formula released by China Stroke Center Alliance, which is applicable only in China. Fourth, although we conducted propensity score weighting to match characteristics of both hospitals and patients between the program and nonprogram groups, clustering was not included in adjustment of DID analysis. Additionally, the current study did not include postdischarge outcomes. The long-term outcomes are still under collection for analysis.In this quality improvement study, a multilevel, centrally supported quality of care program was associated with substantial increases in clinician adherence to stroke guidelines and reduced the proportion of severely disabled or deceased patients with AIS at discharge in China. This quality program model with automated medical record data capture system and continuous feedback from a central quality care initiative team via video conference may serve as a model in a much broader range in the world for stroke care quality improvement, especially during the current COVID-19 pandemic.


Following projections of an emergency medicine (EM) physician oversupply, the growth of EM residency programs affiliated with for‐profit hospitals has been subject to increased attention and speculation. However, essentially no literature exists regarding these programs. Resident pay is one area where these programs could differ from nonprofit‐affiliated programs, as investor obligations could make for‐profit corporations more likely to reduce resident salaries to increase profit margins. Here, we aim to quantify the growth of EM for‐profit affiliated residency programs from 2001–2021 and determine if PGY1 salaries differ between these program types.Medicare and ACGME accreditation data were used to determine the profit status of hospitals affiliated with EM residency programs. ACGME new accreditation data from 2001–2021 were used to quantify the growth of both for‐profit and nonprofit affiliated programs over this period. We searched program websites and called programs to determine 2021–2022 PGY1 salary. Multiple regression was used to model the relationship between profit status and salary using program characteristic covariates to control for confounding variables.n  = 24) was $3840 lower than mean nonprofit affiliated program salary . For‐profit affiliation was a significant predictor of lower 2021–2022 PGY1 salary after controlling for other program characteristics using multiple regression .The number of EM programs increased from 117 to 276 from 2001–2021 while the number of for‐profit affiliated EM residency programs increased from 1 to 29 during this period. Most  for‐profit affiliated programs were accredited from 2016–2021. Mean for‐profit affiliated program salary ($55,658, We found a substantial growth of newly ACGME accredited for‐profit affiliated EM residency programs from 2016–2021. We also found for‐profit affiliated programs pay lower PGY1 salaries than nonprofit–affiliated programs after controlling for potential confounding variables, which suggests more oversight over the salary determination process could be necessary to prevent resident underpayment. For‐profit corporation involvement in emergency medicine (EM) graduate medical education (GME) has been the subject of increased attention and speculation following a workforce study that projected a surplus of nearly 8000 EM physicians by 2030.One area that may differ between these program types is resident salary—a topic attracting increased attention following resident calls for unionization at several institutions.There are several factors that reinforce the current level of resident pay, including a match process that insulates programs from market forces that traditionally influence salary levels and an opaque salary determination process with limited oversight. The main funding source for resident salaries is Medicare Direct Graduate Medical Education (DGME) payments, which are calculated by multiplying a base period per‐resident amount by the number of full‐time equivalent residents and the Medicare share of total inpatient days.The method for classifying programs as nonprofit or for‐profit affiliated was adopted from our prior study comparing board certifying exam pass rates between these program types.A list of all accredited EM residency programs as of August 2021 was acquired from the public ACGME accreditation database, along with the name and date of accreditation of every program accredited from 2001–2021.We searched residency program websites to determine 2021–2022 PGY1 salary. If no EM specific salary was found on the website, current salary information from other specialties at the institution was used. If no current salary was listed for any specialty, we called programs using phone numbers available on public program websites to obtain this information. Graduate medical education phone numbers were prioritized if available, followed by EM program numbers and finally other specialty programs if the former two could not be reached. If another specialty program was used to determine salary, it was always confirmed that salaries are identical across PGY levels at the institution. See Figure osteopathic.org were used to determine the programs that had previously held American Osteopathic Association (AOA) accreditation and recalculate new program growth after removing these programs. We also determined the geographic distribution of for‐profit affiliated residency programs. Programs no longer accredited as of August 2021 were not included in these analyses.The ACGME accreditation data and profit status determinations were used to quantity the growth of new for‐profit affiliated programs from 2001–2021. We determined the number of programs that became accredited each year and determined if each program was for‐profit affiliated or nonprofit affiliated to calculate growth in the number of each program type throughout the 2001–2021 period. Public data acquired from We used multiple linear regression to analyze the relationship between profit status and salary and included the following covariates to control for confounding variables: program size, cost of living, year founded, census region, program type, Medicare share of inpatient days, and estimated DGME funding per resident. These variables were chosen because they were publicly available, and we hypothesized these variables could reasonably influence the relationship between profit status and resident salary. Program size and year accredited (if prior to 2001) were acquired from Doximity residency navigator. To estimate cost of living we used 2019 Census Bureau Regional Price Parities,During the 2001–2021 period, the number of EM residency programs increased from 117 to 276, which corresponds to a 135.9% increase. During this time the proportion of for‐profit affiliated EM residency programs increased from 1/117 to 29/276, corresponding to a 1129.4% increase. Most  of the for‐profit affiliated programs were accredited between 2016–2021. The number of for‐profit affiliated and nonprofit affiliated programs accredited during the 2001–2021 period is shown in Figure We were able to obtain salary data for 70.3% (189/269) of eligible programs simply by searching program websites. Of the remaining programs we were able to obtain 47.5% (38/80) of salaries by calling programs. In total, we were able to obtain 2021–2022 salaries for 84.4% (227/269) of eligible programs. The rate of salary data acquisition was similar between for‐profit affiliated programs  and nonprofit‐affiliated programs .n = 24) was $3840 lower than mean nonprofit affiliated salary . Figure ß = −1919.88, P = 0.010). The adjusted R2 for the model was 0.597. Complete regression results are shown in Table Mean for‐profit affiliated program salary  in clinical sites involved in EM GME. Many emergency rooms in the United States are staffed by large corporate‐owned CMGs.Our study is limited by our sole focus on salaries without consideration for benefits. Programs can vary widely regarding specific benefits they offer, which can include technology, food, travel allowances, paid time off, childcare, etc. These benefits can significantly alter the total compensation package at a given program and could compensate for a lower salary; thus, exclusion of these factors is a major limitation of our data.There are also limitations to the sources we used to collect the data. We relied heavily on public sources like Doximity residency navigator and internet searches, and it is possible that these sources provided incorrect information. While we attempted to determine profit status in an unbiased and systematic way, it is possible that status could have been misattributed in some instances due to human error or hospital affiliation changes. Further, we were unable to acquire salary information for all programs. It is also possible that program representatives contacted via phone calls provided incorrect or outdated salary information.Additionally, there are potential market changes that we did not account for that could impact the accuracy of our data. The newly accredited program analyses used to create Figure Finally, it is important to note that in this study we only examined corporate involvement in GME through the profit status of hospitals affiliated with residency programs. We did not consider the involvement of private‐equity‐backed CMGs in GME, which is another avenue through which for‐profit corporations could be involved in GME.The number of ACGME accredited EM residency programs affiliated with for‐profit hospitals has increased considerably over the past 5 years. These programs tend to pay their residents lower salaries, even after controlling for other program factors that could influence salary. We suggest that more oversight over the salary determination process could be necessary to ensure salary equity across all program types to not only protect residents from underpayment, but also to potentially disincentivize the excess production of new programs. Future work is needed to explore reasons for the proliferation of for‐profit affiliated EM residency programs and other differences that could exist between these program types.JL was responsible for the study concept and design. JL and AS were responsible for acquisition of the data. JL, JA, AS, and PK contributed to the analysis and interpretation of the data. JL was responsible for drafting of the manuscript. JL, JA, AS, and PK were responsible for critical revision of the manuscript for important intellectual content. JL takes responsibility for the paper as a whole.This work was presented at SAEM 2022.This study was not funded. We have no conflicts of interest to report.Figure S1Click here for additional data file.Figure S2Click here for additional data file.Table S1Click here for additional data file.


Recreovía and My Body) to assess and visually map the perceived barriers, facilitators, and outcomes to promote programs’ improvement, scaling and sustainability.Community-based physical activity (PA) programs are appealing to women in Latin America and show potential for improving women’s health. This study aimed to engage healthy middle-aged women, breast cancer survivors and local stakeholders participating in two publicly funded community-based PA programs in Bogotá, Colombia  Ripple Effects Mapping to visually map the intended and unintended outcomes of PA programs. We used thematic analysis to classify the results at the individual, social, and community levels.We used two participatory action research methods, the 1) N = 6) and program users  from the two programs . Program users were women with a mean age of 55.7 years (SD = 8.03), 65% lived in low-income neighborhoods. They identified infrastructure as the main feature affecting PA, having both positive  and negative  effects. Regarding program improvements, stakeholders advocated for parks’ cleaning, safety, and appropriate use. The most highlighted outcomes were the expansion and strengthening of social bonds and the engagement in collective wellbeing, which leveraged some participants’ leadership skills for PA promotion strategies in their community. The facilitated dialogue among program users and stakeholders fostered the sustainability and expansion of the community-based PA programs, even during the COVID-19 pandemic.The stakeholders engaged in the participatory evaluation included cross-sector actors from the programs (The implementation of both participatory methodologies provided a multidimensional understanding of the programs’ impacts and multisectoral dialogues that fostered efforts to sustain the community-based PA programs.The online version contains supplementary material available at 10.1186/s12889-022-13180-2. The global trends of physical activity (PA) consistently show that women are less physically active than men (68.3% vs. 76.6%) . This isFrom a socioecological standpoint, PA is a behavior influenced by factors at multiple levels, including the individual , social , and community  levels . AccordiOV model  where we do our exercises. It is a good area, very spacious, the floor is very safe, there’s good air flow and good lighting.” (My Body participant)“For inappropriate infrastructure, concerning poorly built areas, lack of facilities’ improvements in parks, and the inadequate/hard surfaces for PA sessions (which generated knee pain). The second most mentioned aspect hindering participants’ PA and enjoyment of urban settings in both studies, was limited civic culture, a concept typically used to refer to the behavior of citizens in public spaces. Specifically, the participants of both studies mentioned the citizens’ poor management of dog waste. Additionally, this category contains one comment about sexual harassment in the Recreovía study, and comments about psychoactive substance use in parks in the My Body study. The third most mentioned barrier by Recreovía users was poor sanitation maintenance concerning unsanitary toilets and poor waste management. Whereas in third place, breast cancer survivors indicated space logistics issues, referring to underused spaces for potential PA practice [relevant for all evaluated urban settings].Regarding barriers, the one most mentioned in both studies was As you can see in the picture when you’re distracted you can fall down or hurt yourself because there’s a lack of maintenance of the park. A lot of people move around here and people on bikes as well which could also cause an accident.” (My Body participant).One citizen scientist described: “Recreovía program was attended by the director of the program, two physical activity instructors, and five citizen scientists, while for My Body, the participants included one consultant in public health, two clinical practitioners, and six breast cancer survivors. In both meetings, citizen scientists shared their data with others who did not specifically collect these data. Upon discussing the most relevant issues to address, all attendants proposed solutions.The community meeting for the Recreovía study, citizen scientists proposed expanding park cleaning and security staff to address the issues. Likewise, My Body citizen scientists proposed improving the parks’ safety with cameras, security staff, and public lighting. All participants noted that this would require more regular infrastructure maintenance to mitigate damage to the cameras and public lighting. In addition, women suggested implementing signage to mitigate the use of psychoactive substances/drugs  and to promote “civic culture” or shared values for the appropriate use of park settings. Faced with this issue, the Recreovía director agreed to discuss those concerns directly with the relevant decision-makers within the IDRD.Safety and civic culture concerns were prioritized in both community meetings. In the Recreovía sessions take place, based on the consensus built during the meeting, the Recreovía director agreed to ask the PA instructors to provide participants with lower-impact forms of PA, and posture guidance to help to reduce knee and joint pain.Additionally, to address the issue of the hard surfaces where the My Body study used the community meeting with stakeholders to highlight the Recreovía program as the main alternative to continue PA practice beyond the intervention. They celebrated the relevance of the cancer-specific focus integrated into My Body’s intervention, and Recreovía’s coordination decision to maintain the tailored sessions in the same site where the intervention took place. Some breast cancer survivors indicated that despite the distance/travel barrier, the main determining factors for continuing PA practice were PA-supportive infrastructure and safety.On the other hand, citizen scientists of Recreovía and My Body programs, respectively. The Recreovía REM session was attended by 18 program users, two family members, two physical activity instructors, and the program director. For My Body REM session attendants included 17 breast cancer survivors, two family members and friends, two clinical practitioners, and a consultant in public health. The review of the ripple effects map led to organizing the reported intended and unintended outcomes into the following: 1) Recreovía program: eight themes with 33 subthemes  expansion and strengthening of social bonds .One citizen scientist noted: ““You can talk about chemo [therapy] freely, about breasts, about a lot of things that we have in common. This was very pleasant for me, to be able to be a part of a group” (My Body participant).Another participant noted: Recreovía users, the second most relevant outcome was awareness and engagement in collective wellbeing. Participants highlighted that the PA experience led to a desire to share wellness with others. According to participants’ narratives, experiencing a caring network within the program fostered community ownership and responsibility for the program, and developed and raised new leaders in the community. Similarly, breast cancer survivor from My Body intervention reported experiencing civic empowerment and leadership (third most frequent outcome) to advocate for PA and cancer care opportunities. For instance, when the intervention was over, participants submitted a right to petition  to the IDRD asking to maintain the PA sessions with a cancer focus as part of the Recreovía program. The institution positively responded to this request.For “What caught my eye was that they [Recreovía users] would take the program to heart so that they became a fundamental part of its development. People explained that in the park, the neighbors would strive to get to their sessions; they’d bring the people together and involve them in the process. The program gave people meaning and has also greatly influenced not just their health but also the community around them.” (Recreovía stakeholder).One stakeholder noted: “I always loved to dance and starting the classes was such a joy. Thanks to you, I can come back to the Clinic not just as a patient but as someone who can help other patients. I dance for them for two hours to Colombian music in the Chemo room, and I provide lectures on my experience with cancer to the patients and their caretakers. I was chosen as one of the leaders of the User League at the Clinic and I am taking classes to help not just the oncologists but also the people that come from out of town. Look at all that, where I am now, and to think I started out in the rumba sessions.” (My Body participant).A participant described: increased motivation for PA practice (third most frequent theme in Recreovía study), also named in My Body study as deepened PA engagement (second most frequent theme). Some Recreovía users acknowledged that practicing PA with other participants enhanced their recognition of PA benefits , helped them to value their motives to have an active lifestyle , and increased their enjoyment and satisfaction in doing PA. Similarly, breast cancer survivors stated having recognized PA as a pleasant habit for personal enjoyment. Indeed, a participant mentioned PA understanding and participation as a therapeutic practice. According to the women’s experiences, ongoing PA engagement was linked to increasing their overall motivation for regular PA practice and their interest in new forms of PA in addition to dancing. As citizen scientists mentioned: “Exercise is life, health and it’s like a magic pill that you must take every day” (Recreovía participant).Another outcome mentioned in both studies was Honestly, I think that as of now I’ve seen changes. I think that for me this program was imperative and wonderful because it has seeded that habit within me. It’s true that now you feel the need to do it [physical activity] and doing it with others’ company is much better that going around the park by yourself” (My Body participant).“My Body underscored as relevant outcome the use of coping strategies for dealing with difficulties. Breast cancer survivors expressed that by attending the program, they gained the self-confidence to overcome barriers that women often experience in practicing regular PA. For instance, family setbacks, household chores, and prioritization of caregiving activities. To handle some of these difficulties, they mentioned shifts in family dynamics regarding caregiving duties, and focusing on continuing to build their self-efficacy for PA. The participants mentioned that as the increased their self-knowledge of their bodies, they gained confidence and changed their risk perceptions concerning PA.Moreover, participants from “ I was able to get my siblings to become more involved in taking care of my parents and I was also able to get away from the monotony and the stress. It was a way for me to let go, delegate and spend some time on myself.” (My Body participant).As noted by a participant: “The first two classes I never laughed. The instructor would ask “Where’s that smile?” and I’d just think “How do I laugh?” I didn’t even remember how to laugh. I’d get home, look in the mirror and say ‘How do you smile?’ That changed me a lot and opened up a whole new space as a human being within me.” (My Body participant).Another participant noted that: According to participants’ narratives in both studies, engaging in a community-based PA program enhanced wellness at all levels. They underscored that self-care was positively impacted through having a practice of personal enjoyment, leading to improved mental health, self-esteem, perceptions of well-being, better quality of life, and physical improvements. At the social level, they improved their social support and gained affectionate relationships. Particularly, breast cancer survivors mentioned experiencing social support from the intervention staff. Regarding the community level, all participants reported that engagement in the corresponding PA program created bonds with local public institutions.“I learned to love myself and make room for that space for me. Because normally, men are misogynists and for example I would go [to the Recreovía] every now and then when he wasn’t around. Other times I’d watch from my neighborhood and I couldn’t go because I had to make lunch. But no! I learned to make time for myself in that space. I learned to stop being submissive and defend something that’s mine. I owe that to the Recreovía.” (Recreovía participant).As noted by a citizen scientist: Recreovía has implemented at least two new strategies to continue promoting PA during the COVID-19 pandemic. They have offered “La Ruta del Movimiento” which provides free PA sessions led by trained instructors in outdoor locations such as the communal areas of apartment buildings, enabling residents to see them from their windows, balconies, and terraces and participate at a safe social distance [Recreovía n = 14; My Body n = 16) completed the follow-up assessment. Of them, 63% knew about the Recreovía’s adaptations during the pandemic, and 47% of participants had engaged in the Facebook Live sessions.After concluding these phases, our research team followed up concerning participants’ and stakeholders’ actions to continue promoting PA in their communities. With respect to stakeholder ongoing actions, distance . In addiRecreovía participants reported continuing their PA practice after concluding the study and prior to the COVID-19 pandemic, and 71% of them continued their PA practice during the COVID-19 pandemic. The reasons why the others stopped during the COVID-19 pandemic included health, quarantine, fear of infection, and work. From the My Body study, 75% of participants reported continuing PA after the study was over, as well as during at least the first 9 months of the COVID-19 pandemic. For the four participants that stopped doing PA, the reasons were health, cancer-related complications, and limited space in their homes.All My Body WhatsApp group, some participants took initiative to keep promoting PA by sharing dancing sessions and events. Additionally, participants from both studies have attended virtual academic events organized by our research team, aimed at leveraging continued dialogues between citizens and stakeholders.Through the OV method indicated that for both groups, infrastructure was the most mentioned aspect for the maintenance of PA practice in urban settings, performing both as a facilitator  and a barrier . Also, civic culture and safety were underscored as key social environmental factors for the enjoyment of PA. Among the potential program improvements, stakeholders prioritized measures to improve parks’ cleaning, safety, and appropriate use. The REM showed that the expansion and strengthening of social bonds was the most mentioned ripple effect among both programs. The engagement in collective wellbeing even leveraged some participants’ leadership skills to engage further in PA promotion strategies in their community. Ultimately, the facilitated encounters among program users and stakeholders enabled the celebration of such broad impacts of the PA programs and engagement for further PA maintenance, even during the COVID-19 pandemic.Through a participatory action approach, this study successfully documented the perceived facilitators, barriers, and outcomes from two community-based PA programs mainly benefiting healthy middle-aged women and breast cancer survivors in a middle-income country. The implementation of both methodologies using the socioecological framework provided a multidimensional understanding of the programs  and multOV findings highlighting physical facilities as the main enablers, and limited infrastructure, as the most common obstacle to be physically active [Recreovía study findings showed that the park was perceived as an appropriate environment for PA, with potential improvements regarding sanitation, maintenance, safety, signage, and park logistics. In contrast, the breast cancer survivors participating in the My Body study expressed that, given their perceived need for cancer-specific PA programs, finding urban settings that could provide safe environments for them to regularly engage in PA was challenging. Nonetheless, they underscored as facilitators the PA sessions offered in shopping centers, parks, and community centers, which are facilities that can provide proper infrastructure, safety, and accessibility. Our results are consistent with Our Voice’s overarching purpose to set in motion a self-sustaining process of citizen science where residents become aware of their ability to leverage urban settings and create a “culture” of active living, health, and well-being [Our study corroborates previous y active , 40, 41 ll-being , 27, 41.ll-being , 41, 42.REM allowed stakeholders to further uncover and celebrate outcomes from the PA programs which benefitted themselves, their communities, and their environment. The findings add to the literature on the relationship between social capital and positive health outcomes indicating that community-based PA programs, as social interventions, use the social structures as drivers to support PA behaviors, enabling women to access and mobilize social capital for improving their health [Recreovía strategies or self-managed groups, which is promising.The implementation of the r health , 43. In Recreovía and My Body have been reported in other studies involving PA and women, such as time management, caregiving roles, and safety; generally, caregiving roles have been reported often concerning child care [Some of the contextual barriers reported by participants from ild care , 44, 45.ild care , 46 Ultiild care , 48. Thiild care .Finally, our findings reveal the interconnectedness nature of the multi-level outcomes stemming from community-based PA programs and how these can rebound in program sustainability: as women engage in PA of personal enjoyment -feeling safe and supported-, their raised awareness towards self-care and increased motivation to be active expand to experiencing civic empowerment and advocating for collective wellbeing. Altogether this leads to PA maintenance at individual and program level, possibly indicating the relevance of including a “leadership skills strengthening” component in the PA interventions, as we never know who might be compelled to become a PA promotion agent. As reported by the participating stakeholders, the acknowledging of these rippled outcomes within multisectoral dialogues fosters efforts to implement and sustain community-based PA programs. Sustainability and scaling up of the programs is a never ending top-down, bottom-up synergy , 30.The study findings must be seen in the light of some methodological limitations. The first is a possible selection bias given that participants were recruited during their participation in the targeted community-based programs. Therefore, this may show a generally high acceptance of the programs. Future studies should consider efforts to include those who refuse to engage or who have dropped out these programs to provide further information on program barriers to participation in particular. Second, a relatively small number of participants supplied contextual data through the use of the Discovery Tool app and the community meetings had limited participation from relevant decision-makers, which may limit program advocacy occurring for positive changes. Nonetheless, some tangible outcomes were produced through this participatory action process, including the ongoing dialogues between the IDRD and researchers to advise on the strategies within the COVID-19 pandemic. It would be worthwhile to continue to explore how community meetings could engage higher levels of participation from multi-sectoral stakeholders.By promoting women’s voices as the central target for engaging women in systematic community participatory action activities, this first-generation study revealed how community-based PA programs can contribute to addressing some of the barriers that women with different social and health conditions face to engage in PA , 51 and Additional file 1: Supplementary material 1. Our Voice results: themes used to code Discovery Tool data per study and respective examples.Additional file 2: Supplementary material 2. Ripple Effects Maps created by participants to report outcomes of the Recreovìa and My Body physical activity programs, respectively.


Economic analysis of health interventions is essential to the development and implementation of sustainable health policies, especially in noncommunicable diseases area. Type 2 diabetes (T2D) is one of the most relevant noncommunicable diseases globally. Regular physical activity is an established cornerstone of T2D control, with benefits in glycemic control, cardiovascular risk factors and quality of life. Thus, the current study aimed to assess the cost of a community-based physical activity intervention for patients with T2D.We assessed the SWETT-Football program - a community-based walking football exercise program for middle-aged and older male patients with T2D. The program was tested in Portugal through a scientific project (NCT03810846) funded by FIFA (FIFA Research Scholarship 2018). One season of this program consists of three sessions per week (60 minutes per session) during nine months (October to June). For the calculations, we considered a total of 40 patients (two groups of 20). We calculated the direct costs of one season for the host institution: 216 hours of renting a sports hall and hiring human resources ; cardiac stress tests and sports insurance for the participants; sports equipment ; vital signs monitoring equipment ; logistical equipment (disposable and non-disposable); and technical training. In addition, we considered an economic depreciation of five years for sports and electronic materials. Cost analysis dated January 2022.One season of this program for 40 patients with T2D was estimated to have a total implementation cost of 11,026.51€: 1,225.17€/month; 275.66€/patient; 51.05€/session; 30.63€/patient/month; and 2.55€/patient/session.A community-based walking football program for patients with T2D has an affordable cost and is feasible for large-scale implementation by local communities with the involvement of football clubs, municipalities and primary health care units, promoting physical activity and contributing to T2D control.