Falls incidence rates and associated injuries are projected to increase among rural-dwelling older adults, which highlights the need for effective interventions to prevent falls and manage fall-related risks. The purpose of this descriptive study was to identify the geospatial dissemination of eight evidence-based fall prevention programs  across the United States (U.S.) in terms of participants enrolled, workshops delivered, and geospatial reach. These dissemination characteristics were compared across three rurality designations . Data were analyzed from a national repository of 39 Administration for Community Living (ACL) grantees from 2014–2017 (spanning 22 states). Descriptive statistics were used to assess program reach, delivery-site type, and completion rate by rurality. Geographic information systems (GIS) geospatially represented the collective reach of the eight interventions. Of the 45,812 participants who attended a fall prevention program, 12.7% attended workshops in non-metro adjacent areas and 6.6% attended workshops in non-metro non-adjacent areas. Of the 3755 workshops delivered (in over 550 unique counties), most were delivered in senior centers (26%), residential facilities (20%), healthcare organizations (13%), and faith-based organizations (9%). On average, the workshop attendance/retention rates were consistent across rurality (~70%). Findings highlight the need to diversify the delivery infrastructure for fall prevention programs to adequately serve older adults in rural areas. Ongoing efforts are needed to offer sustainable technical assistance and to develop scalable clinical-community referral systems to increase fall prevention program participation among rural-dwelling older adults. Improving access to and utilization of interventions that prevent or delay potentially preventable falls is critical. With approximately one-in-four older adults aged 65 years and older falling each year , non-fatThere is no single solution to combat falls among older adults. The known risk factors are multi-factorial and they can be associated with biological, psychosocial, and environmental causes ,11. One While healthcare access issues among older adults are especially pronounced in rural areas , the vasLittle is known about the simultaneous grand-scale dissemination of multiple evidence-based fall prevention programs and their reach to rural areas. Although some studies have examined the delivery of fall prevention interventions and their effectiveness in rural communities ,24, thesUtilizing a methodology published previously , the priData for this study utilized a national repository created alongside a series of funding initiatives to support the dissemination and sustainability of chronic disease self-management education (CDSME) and fall prevention programs across the U.S. ,31. The Rural-Urban Continuum Codes (RUCC) were used to measure rurality at the county-level for organizations delivering the fall prevention program. RUCCs were developed by the U.S. Department of Agriculture and use a nine-point scale to indicate proximity to nearby metro areas ,34,35. FUsing data in the national repository, the total number of participants enrolled, workshops delivered, and unique counties reached were tabulated. Based on the ZIP Code of the workshop delivery location, the ZIP Code Tabulation Area (ZCTA) was identified, and population statistics were obtained. More specifically, the ZCTA of the workshop delivery location was used to identify the median household income , percent of residents residing in poverty , percent of residents who were white, percent of residents who were Hispanic, percent of participants who were African American, and percent of residents with less than a high school education. The average number of participants enrolled in each workshop was calculated. Because each fall prevention program offers a different number of workshop sessions, the average proportion of workshop sessions attended was reported . Because this national initiative included multiple fall prevention programs, the dissemination of each unique workshop type was of interest. The eight programs included: A Matter of Balance (AMOB) ; SteppinGiven the diverse organizational infrastructure that was used to deliver fall prevention programs, the delivery site type for workshops was of interest. Delivery site types included: senior centers; residential facilities; healthcare organizations; faith-based organizations; recreational organizations; community centers; multi-purpose and social service organizations; libraries; Area Agencies on Aging; municipal governments; county health departments; educational institutions; tribal centers; state units on aging; workplaces; state departments of health; and, other site types ,45.Personal characteristics of the participants that were enrolled in fall prevention programs were collected using self-reported survey instruments and included age, gender, race, ethnicity, education, and the most prevalent chronic conditions .All analyses were performed using SPSS  for this descriptive study. Counts were tabulated for the number of participants enrolled, the number of workshops delivered, and the number of unique counties reached. These counts were stratified by workshop type and rurality see . Counts Overall, 45,812 participants were enrolled in fall prevention programs over the study period (2014–2017). The majority of participants attended workshops in metro areas (80.7%), followed by workshops in non-metro adjacent areas (12.7%), and non-metro non-adjacent areas (6.6%). Overall, 3755 workshops were delivered over the study period. When examining fall prevention program delivery by program type, AMOB was the most widely disseminated , followed by SO , TJQMBB , and TCA . In the U.S., there are 3221 counties : 1236 meOn average, workshops were delivered in areas with median household incomes of $55,861 ; 14.06% (±9.52%) of residents living in poverty; 79.26% (±19.44%) of residents being white; 9.88% (±15.31%) of residents being African American; 12.99% (±18.00%) of residents being Hispanic; and, 12.97% (±9.18%) of participants having less than a high school education. When compared to workshops that were delivered in metro areas, workshops delivered in non-metro non-adjacent areas had lower median household incomes , had more white residents , had fewer African American residents , and had fewer Hispanic residents . On average, fall prevention program workshops enrolled 14.71 (±7.87) participants. On average, participants attended 70.64% (±29.73%) of workshop sessions, and these rates were comparable across rurality.This study provides an overview of a national dissemination of eight evidence-based fall prevention programs. The majority of participants were reached by workshops that were delivered in metro areas (about 80%), which indicates that fall prevention programming requires additional efforts to expand dissemination in rural areas. The majority of U.S. counties lacked access to fall prevention programs, which is consistent with past studies investigating the national delivery of multiple evidence-based programs  ,26. ThatWhile the delivery site types most frequently hosting fall prevention programs were similar in metro and non-metro areas, there were small differences in the leading five site types. These findings highlight the need to diversify the delivery infrastructure for fall prevention programs to adequately serve older adults in rural areas. This will require substantially expanding the delivery infrastructure through leader training and organizational recruitment . Further, ongoing efforts are needed to offer sustainable technical assistance and to develop scalable clinical-community referral systems to increase fall prevention program participation among rural-dwelling older adults . Such efWhile capable of serving rural areas, the reach to non-metro counties was modest, especially relative to other more established evidence-based programs  ,29. As wAs an ongoing initiative, new evidence-based fall prevention programs are being introduced and vetted through a multi-tiered and rigorous process, expanding the highest-tier program list . At the One possible cause of less than optimal dissemination of fall prevention programming in rural areas is the convenience of serving larger communities and meeting grant requirements where older adult populations are abundant. This is also evidenced by our findings that fall prevention program participants were less racially/ethnically diverse relative to the county demographics where programs were delivered. Thus, participation in these programs may have been more associated with participant characteristics than merely the rurality of where the intervention was offered. This emphasizes the need for purposive recruitment strategies to engage racial/ethnic minorities and additional investigations to assess the drivers of race/ethnicity-based participation in fall prevention programs.Grantees must intentionally develop delivery infrastructures in rural communities and engage with local partners to increase program availability without imposing long drive times for workshop facilitators or participants. As such, opportunities exist to translate programs in terms of content and delivery modality, which can facilitate the expansion of services to new audiences  in geospatially remote and rural areas. Examples of three primary methods of translation to reach new populations are described briefly here: (a) from face-to-face to virtual delivery; (b) from professionals to lay facilitators; and, (c) from existing content to other cultural- and needs-based tailoring.Internet-based translations can be effective and they can overcome geospatial barriers if modifications adhere to the critical elements of the original intervention and are made accessible and affordable to underserved areas. While interventions like OEP have been successfully translated for online delivery  , additioThis study is not without limitations. The analyses performed were descriptive in nature using pooled data, and as such provides only a snapshot or cross-section of the overall reach of these fall prevention programs. Workshops were clustered/regional in nature and some areas are more likely to offer a particular program type over another. This clustering is an artifact that data were collected from grantees, and grants were not evenly distributed across all states. Further, grantees were able to select locations for program delivery, which were often in more metro and population-dense areas. It should also be noted that the data used in these analyses were from fall prevention programs that were delivered by ACL-funded grantees and do not represent all fall prevention programs delivered nationwide. While non-grantees are able and encouraged to use the ACL-sponsored data repository, this is only required of official ACL grantees. The proportion of participant characteristics  did not always represent the ZIP Code estimates , which may be indicative of convenience samples and the locations where the programs were offered. This discordance may limit the generalizability of findings. Additionally, while this study reported the number of participants who enrolled in fall prevention interventions, it did not document the success of actual recruitment efforts . The delivery of evidence-based programs is dependent on several factors ; therefore, the decision to deliver a fall prevention program may be made with very different goals, preferences, available funding, target populations, and partnerships. For example, the decision and/or ability for a particular aging services organization or stakeholder to provide services to rural-residing individuals in one location may be extremely different than such decisions/abilities in another area. Further research is needed to identify the factors that are associated with program delivery decisions by grantees and their impact on participant recruitment in rural areas. While data pertaining to self-reported falls and other health indicators were collected from participants as part of this initiative, evaluating the effectiveness of these interventions is outside the scope of this descriptive geospatial study and an area for future research. Despite these limitations, this study is among the first examinations of a national dissemination of multiple, diverse evidence-based fall prevention programs.Ongoing efforts such as this are needed to assess the delivery infrastructure and geospatial reach and adoption of evidence-based fall prevention programs. Findings from such initiatives can inform key stakeholders, including those affecting policy , about successes and challenges to fuel informed decisions about funding priorities, and areas/regions of greatest need. Interventions are needed to prevent falls and mitigate fall-related consequences among individuals, their families, and greater society. Supporting the delivery of a diverse cadre of evidence-based fall prevention interventions ensures the diverse needs and programming preferences of older adults can be met. While there is no one-size-fits-all model for fall prevention programming, the availability of multiple effective interventions are made available to older adults with differing levels of risk across rurality. Given that rural areas have limited healthcare resources relative to metro areas, evidence-based fall prevention programming can complement traditional medical and clinical services by being embedded in an array of community-based settings.


Diagnosis and treatment of alcohol-related problems are time-intensive procedures that often are difficult to implement in busy clinical settings. Computer-based tools are one approach that may enhance the availability and cost-effectiveness of assessment and intervention and also may offer other advantages over face-to-face interventions. Several PC- and Internet-based programs have been developed that can be used for assessing alcohol problems, some of which are based on existing screening instruments. Other programs have demonstrated effectiveness as interventions, serving to increase patient motivation and reduce alcohol-associated harm through skill building. Investigators also have begun to analyze the mechanisms through which computer-based programs can induce these effects. Future efforts should be aimed at developing and evaluating additional computer-based interventions, particularly for specific patient subgroups, and at removing barriers to the incorporation of such programs into clinical practice. Computer-based assessments and interventions are a promising avenue for increasing the accessibility and cost-effectiveness of treatment for alcohol-related problems. This article describes the advantages of computer-based tools and reviews those assessment and intervention programs that have been evaluated in controlled clinical trials, the results of which have been published in peer-reviewed journals. With programs used for assessment and diagnosis of alcohol-related problems, it is particularly important to focus on instruments that have acceptable psychometric properties . Few PC- and Internet-based programs that provide treatment interventions meet this criterion. Moreover, although evidence attests to the effectiveness of some computer-based interventions, their cost-effectiveness has not been formally studied. PC- or Web-based software programs have several advantages over face-to-face interventions:They require little or no therapist involvement, which may increase cost-effectiveness.They can provide personalized feedback to clients in a timely and visually engaging manner.They can minimize bias that could arise in clinical relationships  .They can more consistently provide specific recommendations for change, based on the results of the assessment and other empirical evidence.They offer the ability to store information in a database format so that it can be studied and analyzed by a supervising therapist or health care provider.At least some programs allow for automatic collection of followup data and for the generation of outcome reports.A given assessment or treatment program can be widely disseminated while maintaining treatment fidelity.These advantages are supported by research demonstrating that personal data derived from computer-based interviews in the psychiatry and alcohol and other drug (AOD) abuse fields are accurate and valid. Almost 30 years ago, Assessing Alcohol Problems: A Guide for Clinicians and Researchers, published by the National Institute on Alcohol Abuse and Alcoholism (NIAAA)  . As AlleGuide and are available in computerized versions. The AUDIT also is available in Web-based versions .Two commonly used screening instruments are the Alcohol Use Disorders Identification Test (AUDIT) and the CAGE. These instruments are listed in the NIAAA Guide lists 18 diagnostic tools, many of which allow for computerized scoring .In addition, the NIAAA The Addiction Severity Index–Multimedia Version (ASI–MV) is another good example of a commonly used diagnostic instrument that is available as a self-administered computerized version. The ASI–MV is a PC-based program that leads the user through a series of video interviews corresponding to the domains assessed in the ASI. Both the questions and the answer options are read aloud, and the answers are highlighted as they are read. The user responds by pointing the mouse and clicking on the most appropriate answer. With this design, the user does not need to be literate or computer literate. In a study of the ASI–MV’s psychometric properties, users described the program as easy to use and engaging . In the Far less research has been done on computerized interventions for alcohol problems than on computerized screening and diagnosis. Although both PC- and Web-based brief interventions have been developed, very few have undergone formal testing for efficacy. Module 1 assesses the user’s drinking, risk factors, alcohol-related problems, symptoms of dependence, and motivation.Module 2 provides personalized, objective feedback based on the user’s responses.Module 3 helps the user resolve his or her ambivalence about changing drinking patterns.www.drinkerscheckup.com). The Windows-based version also offers a followup program (the Follow-up Drinker’s Check-Up [FDCU]) that allows providers to collect data at up to three followup points. The FDCU can generate outcome reports for individual users, user subgroups, and the total sample in a database, making it useful as a program evaluation tool.The computer-based version of the DCU is available both as a Windows program and as an Internet application . This program costs $199 and can be used with five clients. Additional uses cost $5–8 each, depending on the quantity ordered.www.drinkerscheckup.com costs $25 per user. A Spanish version is available at http://www.drinkerscheckup.com/index_spanish.htm.The Drinker’s Check-Up/Follow-Up Drinker’s Check-Up. The purchase price of the DCU/FDCU program is $400, and there are no additional user fees. The Internet version available at The Behavioral Self-Control Program for Windows (BSCPWIN)–Therapist’s Version. This program costs $500 and has no per-use fees. It comes with a license to provide copies of the Single User version to the therapist’s clients without further charge. The Single User version’s cost to the general public is $25.It is important to note that the total costs of a given computer-based assessment or intervention tool include not only the program’s purchase price and any per-use fees, but also the time necessary to train counselors in using the program as well as the cost associated with implementing the program and integrating it into the workflow of a clinic. These indirect costs are not discussed in the literature but should be considered in any analysis of cost-effectiveness.The Behavioral Self-Control Program for Windows (BSCPWIN) is a skills-oriented program that helps less severely dependent drinkers learn moderate drinking skills. It consists of eight modules that focus on setting goals, self-monitoring, controlling the drinking rate, setting up rewards and penalties, developing alternatives to drinking, identifying high-risk situations, preventing relapse, and a final progress review and feedback. After users have completed the self-monitoring component, each time users return to the program it asks them to enter their self-monitored alcohol consumption data and gives them feedback on their drinking relative to the goals they set previously. The program then continues with the next module in the sequence.The BSCPWIN program was evaluated as a stand-alone intervention in a randomized clinical trial with a 12-month followup. Forty heavy drinkers were randomly assigned to receive the BSCPWIN program either immediately or after a 10-week waiting period . DrinkinBSCPWIN is available both in a Therapist’s version and a Single User version, which can be given to a therapist’s clients or obtained by the general public. Primary health care settings that screen patients for alcohol problems may find the BSCPWIN helpful in a stepped-care model of treatment for their patients. In addition, the program may be useful for AOD abuse treatment providers whose patient population includes less severely dependent drinkers.The outcome data from the studies described in the previous section support the effectiveness of computer-based interventions in the treatment of people with alcohol problems. But what makes these interventions effective is another question. How do software programs and Web-based applications motivate people to change and help them learn the skills necessary to change their behavior successfully? As yet, no solid data are available to answer this question conclusively. A review by There is both good news and bad news concerning computer-based tools for assessing and intervening with patients with alcohol problems. The good news is that a growing number of PC- and Web-based screening and diagnostic instruments with good psychometric properties are available. The bad news is that there are only a few programs for conducting interventions with clients. However, randomized clinical trials published in peer-reviewed journals have found evidence for the effectiveness of the few available intervention programs.Some factors may interfere with the incorporation of these programs into clinical practice. For example, although the purchase prices for these programs are relatively modest, as noted in the textbox, the costs associated with provider training, implementation, and integration of programs into clinical practice are barriers to their adoption. This issue warrants further analysis.Perhaps the biggest barrier to more widespread dissemination of computer-based interventions is the reluctance of providers and treatment programs to change their mindset about using computer-based tools with their patients, particularly tools that provide direct PC- or Web-based interventions rather than just assessment. Anecdotal data indicate, however, that participants in clinical trials of the DCU and BSCPWIN liked working with these programs. They also clearly benefited clinically from their use. Furthermore, providers’ positive experiences with the growing number of computer-based assessment tools may increase their willingness to explore the use of computer-based approaches for intervention as well.Currently, clinicians, their clients, and the general public who are looking for treatment options for alcohol-related problems on the Internet have relatively few choices. Therefore, additional programs are needed that provide brief motivational interventions particularly for people who primarily use drugs other than alcohol, for people with comorbid psychiatric disorders, and for heavy-drinking college students. Also needed are programs for people actively pursuing abstinence goals who want to use scientifically supported protocols. Finally, PC- or Web-based programs should be developed for people who are not in treatment for alcohol-related problems but are interested in changing their drinking behavior.


The solubility of cellulose in [A2im][CH3OCH2COO]/NMP was determined, and the influence of [A2im][CH3OCH2COO]/NMP molar ratio on cellulose dissolution was systematically investigated. Meanwhile, we also presented the affecting factors of the cellulose material fabrication including preparation approach, [A2im][CH3OCH2COO] and cellulose solution concentration. Attractively, the [A2im][CH3OCH2COO]/NMP solvents display much powerful dissolution capacity for cellulose even at 25 °C (25.4 g 100 g−1). This is mainly ascribed to the combined factors: The hydrogen bond interactions of the H2, H4 and H6 in [A2im]+ and carboxyl O atom in [CH3OCH2COO]− with the hydroxyl H atom and O atom in cellulose; the dissociation of NMP towards [A2im][CH3OCH2COO]; the stabilization of NMP towards the dissolved cellulose chains. In addition, the thermostability and chemical structure of the regenerated cellulose from the solvents was also estimated.The utilization of cellulose in industrial applicat is of great significance to sustainable development of human society and reducing dependence on dwindling fossil resources. Nevertheless, this utilization of cellulose has actually been limited due to its insolubilization. Here, novel solvents consisting of diallylimidazolium methoxy acetate ([A The utilization of this resource in industrial applications is of great significance to sustainable development of human society and reducing dependence on dwindling fossil resources. Nevertheless, the extensive utilization of cellulose is actually warded off in that cellulose is extremely difficult to be dissolved owing to its enormous hydrogen bond network7. As such, many efforts have been made to develop novel and efficient solvents of cellulose. The developed solvents include N-methylmorpholine-N-oxide, lithium chloride + N,N-dimethylacetamide, tetrabutyl ammonium fluoride + dimethyl sulfoxide, NaOH/Thiourea, ionic liquids (ILs), and so on13.Cellulose is a highly abundant biopolymer resource in nature with fascinating properties such as biodegradability, biocompatibility, non-toxicity, and so on17. The dissolution and processing of cellulose in ILs were firstly initiated by Rogers and coworkers in 2002. They found that 10 wt% of cellulose solubility in 1-butyl-3-methylimidazolim chloride could be obtained at 100 °C, and the cellulose solubility (25 wt%) was markedly improved via microwave heating18. Afterward, a number of anion/cation-functionalized ILs have been developed to reduce viscosity of ILs, improve dissolution capacity for cellulose or decrease cellulose dissolution temperature. The reported ILs include 1-allyl-3-methylimidazolium chlorides19 alkylimidazolium carboxylates26, imidazolium dialkylphosphates27, choline amino acids/carboxylates29, quaternary ammonium chlorides30, and tetraalkylammonium carboxylate31. By comparison, some imidazolium carboxylate ILs displayed better dissolution performance for cellulose including 1-butyl-3-methylimidazolim acetate and propionate ILs, 1-allyl-3-methylimidazolium acetate, propionate and butyrate ILs, and 1, 3-diallylmethylimidazolium acetate, butyrate, acrylate, methoxyacetate and ethoxyacetate ILs. However, it was noted that neat ILs are generally viscous, causing the difficult dispersion of cellulose in them. Accordantly, complete cellulose dissolution generally required long residue time or a rise in temperature which can give rise to a degradation of the ILs and/or cellulose. To overcome the issues, some more efficient cellulose solvent systems composed of IL and cosolvent have recently been developed. Among them are 1-butyl-3-methylimidazolium chloride + cosolvent 32, 1-butyl-3-methylimidazolium acetate + cosolvent 36, 1, 3-diallylimidazolium methoxyacetate + cosolvent 37 and 1-allyl-3-methylimidazolium acetate + PEG38. The solvent systems display lower dissolution temperature, higher cellulose solubility and lower viscosity than neat ILs.Among the above solvents, the ILs receive increasing attention based on their unique properties such as negligible vapor pressure, non-flammability, high chemical and thermal stability, and strong dissolution ability for various organic and inorganic materials2im][CH3OCH2COO] with NMP, and the solubilities of cellulose in the solvents were determined at 25 °C. Meanwhile, the influences of NMP/[A2im][CH3OCH2COO] molar ratio on cellulose dissolution and the possible dissolution mechanism for cellulose were investigated. Additionally, the characterization of the regenerated cellulose from [A2im][CH3OCH2COO]/NMP solvent was completed to examine its chemical structure and thermostability.This work aims to develop novel solvents which were expected to more efficiently dissolve cellulose than the solvents reported previously, and fabricate the cellulose material with varying morphologic structures using the solvents. Therefore, we here design novel solvents by combining [CH3OCH2COO] was synthesized according to the method reported previously20.Microcrystalline cellulose (MCC) was purchased from Sigma Aldrich Company, its viscosity-average degree of polymerization is 270. 2im][CH3OCH2COO]/NMP solvents is similar to the procedures described in the literatures35. Typically, 1.8 g of [A2im][CH3OCH2COO]/NMP(RNMP = 0.50) solvent was added to a 20 mL of glass flask, where RNMP represented the molar ratio of NMP to A2im][CH3OCH2COO]. Then, the flask was immersed in a oil bath (25 ± 0.5 °C). Cellulose (0.1 g per 100 g solvent) was added to the solvent. The [A2im][CH3OCH2COO]/NMP(RNMP = 0.50)/cellulose mixture was stirred until cellulose was thoroughly solubilized. Then, additional cellulose was added. The procedure was repeated until cellulose could not be solubilized. The thorough dissolution of cellulose was monitored by a polarization microscope. If cellulose was thoroughly dissolved, the mixture was optically clear under the polarization microscope. Cellulose solubility at 25 °C was calculated based on the amount of solvent and cellulose added. The cellulose solubility data at 25 °C were shown in Table The determination of cellulose solubility in [A2im][CH3OCH2COO]/NMP(RNMP = 1) solvent to gain 1% of solution. The solution was poured in a Petri dish, taken off air bubble under vacuum for 30 min at ambient temperature. Then, the Petri dish containing the solution was immersed in distilled water to obtain cellulose hydrogel. The hydrogel was repeatedly washed with distilled water to remove [A2im][CH3OCH2COO] and NMP. The washed hydrogel was frozen for 8 h at −20 °C, and then freeze-dried in a FD-10 freeze-dryer  to obtain porous cellulose material. The material was named as PCM-1. PCM-3, PCM-5 and PCM-7 porous materials from 3%, 5% and 7% of cellulose solutions were prepared via a similar procedure to PCM-1, respectively.As an example, cellulose was dissolved in [A2im][CH3OCH2COO]/NMP(RNMP = 2) solvent to gain [A2im][CH3OCH2COO]/NMP(RNMP = 2)/cellulose(8%) solution in which cellulose solubility is 8.0%. The 13C NMR spectra of [A2im][CH3OCH2COO] in [A2im][CH3OCH2COO]/NMP(RNMP = 2) solvent and [A2im][CH3OCH2COO]/NMP(RNMP = 2)/cellulose(8%) solution were measured on a Bruker DMX 300 spectrometer at room temperature. DMSO-d6 was used as an external standard. Chemical shifts were given in ppm downfield from TMS.Cellulose was dissolve in [A2im][CH3OCH2COO]/NMP(RNMP = 2.43) solvent to gain [A2im][CH3OCH2COO]/NMP(RNMP = 2)/cellulose(9.0%) solution in which cellulose solubility is 9.0%. Measurements of FTIR spectra for [A2im][CH3OCH2COO] in [A2im][CH3OCH2COO]/NMP(RNMP = 2.43) solvent and [A2im][CH3OCH2COO]/NMP(RNMP = 2.43)/cellulose solution were performed on a spectrometer Nicolet iN10 spectrometer with Ge crystal ATR accessory at room temperature. Spectra were collected in high-resolution mode (4 cm−1 resolution and 64 scans) under an ATR 5% maximum pressure.Cellulose was dissolve in [A2im][CH3OCH2COO] and the solubility data of cellulose in [A2im][CH3OCH2COO]/NMP solvents. Since the thermal stability of a compound is vital in view of its practical application, the thermal decomposition temperature of [A2im][CH3OCH2COO] was determined. Its thermal decomposition temperature is 203 °C. Moreover, NMP is a extensively used solvent which is known to be chemical and thermal stability. Therefore, the [A2im][CH3OCH2COO]/NMP solvents have good thermal stabilities. As can be seen, NMP/[A2im][CH3OCH2COO] molar ratio significantly affects cellulose solubility. The cellulose solubility increases as NMP content increases in the molar ratio range 0–1.22, reaches 25.4 g 100 g−1 of maximum cellulose solubility in [A2im][CH3OCH2COO]/NMP (RNMP = 1.22) solvent, and then decreases in the molar ratio range from 1.22 to 14.61. More interestingly, the [A2im][CH3OCH2COO]/NMP (RNMP = 0.41 – 2.43) solvents display much powerful dissolution capacity for cellulose with as high as 17.5–25.4 g 100 g−1 of cellulose solubilities, much higher than [C4mim][CH3COO]/DMSO, [C4mim][CH3COO]/DMF and [C4mim][CH3COO]/DMA solvents36. For example, the solubility of cellulose in [A2im][CH3OCH2COO]/NMP (RNMP = 1.22) solvent is higher than that in [C4mim][CH3COO]/DMSO solvent by about 69% at 25 °C, which has been reported to be the most efficient cellulose solvent to date. It is also found that the solubility of cellulose in neat [A2im][CH3OCH2COO] is 16.2 g 100 g−1 at 25 °C, but cellulose cannot be dissolved in NMP at this temperature. This suggests that [A2im][CH3OCH2COO] in [A2im][CH3OCH2COO]/NMP solvent mainly contributes to the cellulose dissolution.Table 40. Therefore, after NMP (one of polar aprotic solvents) is added to [A2im][CH3OCH2COO], the concentrations of disassociated [A2im]+ and [CH3OCH2COO]− increase as NMP content increases. Correspondingly, the cellulose solubility also increases as NMP content increases. However, the further increase of NMP content could decrease the concentrations of [A2im]+ and [CH3OCH2COO]− in [A2im][CH3OCH2COO]/NMP solvent. Consequently, the cellulose solubility decreased with increasing NMP content behind the maximum cellulose solubility at RNMP = 1.22.Polar aprotic solvents could disassociate ILs into cation and anion which readily interacted with cellulose to promote cellulose dissolution2im][CH3OCH2COO] considerably enhances cellulose solubility. At a proper NMP/[A2im][CH3OCH2COO] molar ratio range, the addition of NMP to [A2im][CH3OCH2COO] is apparently favorable to cellulose dissolution owing to the increased A2im]+ and [CH3OCH2COO]− concentrations. However, the further NMP addition decreases A2im]+ and [CH3OCH2COO]− concentrations, and thus cellulose solubility. The efficacy of NMP in [A2im][CH3OCH2COO]/NMP solvent is mainly to disassociate [A2im][CH3OCH2COO] into “free” [A2im]+ and [CH3OCH2COO]− which are responsible for cellulose dissolution. At the same time, it was found that, at the same molar ratio range of [A2im][CH3OCH2COO] to polar aprotic solvents, the cellulose solubility decreased in the order [A2im][CH3OCH2COO]/NMP > [A2im][CH3OCH2COO]/DMSO > [A2im][CH3OCH2COO]/DMF > [A2im][CH3OCH2COO]/DMA solvents37, where DMSO, DMF and DMA represent dimethyl sulfoxide, N,N-dimethylformamide and N,N-dimethylacetamide, respectively. This indicates that the cosolvent effects the cellulose dissolution, which is consistent with the results reported previously36. In addition, it was found that absorbent cotton (viscosity-average degree of polymerization of 1586) could be dissolved in [A2im][CH3OCH2COO]/NMP(RNMP = 2.43) solvent at 50 °C while it was very difficult to dissolve in conventional solvents. It was also observed that 5.2% cellulose solution is very viscous and difficult to be stirred  solvent and [A2im][CH3OCH2COO]/NMP(RNMP = 2)/cellulose(8%) solution were determined at room temperature and shown in Figs 13C NMR data of [A2im][CH3OCH2COO] were given in Table 2im][CH3OCH2COO] and NMP were shown in Fig. To investigate the possible dissolution mechanism of cellulose in Aim[CH3OCH2im][CH3OCH2COO]/NMP(RNMP = 2) solvent, the signals of the C2 and C4 atoms in imidazolium ring markedly moves upfield . This indicates that in [A2im][CH3OCH2COO]/NMP(RNMP = 2)/cellulose(8%) solution, as the results of the interaction between the acidic H2, H4 protons and the hydroxyl oxygen atoms in cellulose through hydrogen bonding, the electron cloud density of the C2 and C4 atoms increased, leading to the upfield of their chemical shifts. Moreover, the hydrogen bond interaction between H2 proton and the hydroxyl oxygen in cellulose are stronger than that between H4 proton and the hydroxyl oxygen in cellulose. The carboxyl C10 atom demonstrates the signal considerably moved downfield . This suggests that there’s strong hydrogen bond formed between the carboxyl oxygen atom in [CH3OCH2COO]− and the hydroxyl proton of cellulose. The electron cloud density of C10 atom thus decreases to move its chemical shift downfield. Meanwhile, strong interaction between the hydroxyl oxygen in cellulose and H6 atom leads to the upfield movement of the signal of C6 atom on allyl chain. Moreover, the electron cloud density redistribution may cause the upfield shift of C9 atom and downfield shift of C7 atom. In addition, O8 interacts with hydroxyl hydrogen atom through the hydrogen bond to increase the chemical shift of C8 atom. Nevertheless, the chemical shift of C5 atom remains still. Based on analysis above, the main driving force of the cellulose dissolution in [A2im][CH3OCH2COO]/NMP solvent principally derives from the interactions of the H2, H4 and H6 atoms in [A2im]+ with the hydroxyl oxygen in cellulose along with the carboxyl oxygen atom in [CH3OCH2COO]− with the hydroxyl hydrogen in cellulose.It is clear that, after the addition of cellulose to + and the carboxyl oxygen atom in [CH3OCH2COO]−. To validate this conclusion, the FTIR spectra of [A2im][CH3OCH2COO] in [A2im][CH3OCH2COO]/NMP(RNMP = 2.43) solvent and [A2im][CH3OCH2COO]/NMP(RNMP = 2.43)/cellulose(9%) solution were further elucidated under room temperature. The C-H stretching vibration of the carbon-carbon double bound  is known to be weak. Moreover, the C6, 7-H stretching vibration of the C6 = C7 double bound in allyl groups and C4 = C4′ double bound in [A2im]+ is overlaped. Additionally, the strength of the C-O asymmetric stretching vibration in [CH3OCH2COO]− is greater than its symmetric part. The discussion next will concentrate upon the C2-H stretching vibration of [A2im]+ and C-O stretching vibration in [CH3OCH2COO]−.Taken together, the cellulose dissolution could attribute to the H2, H4 and H6 atoms in [A2im]+ and C-O stretching vibration in [CH3OCH2COO]−. As shown in Fig. 2im][CH3OCH2COO]/NMP(RNMP = 2.43) solvent, the C2-H stretching at around 3091 cm−1 displayed blue-shift, and meanwhile the C-O stretching at around 1602 cm−1, exhibited red-shift. This is mainly due to the hydrogen bond interactions of the H2 atom in [A2im]+ with the hydroxyl oxygen in cellulose and the carboxyl oxygen atom in [CH3OCH2COO]− with the hydroxyl hydrogen in cellulose41.Figure SEM images of the fracture surfaces of the porous cellulose materials PCM-1, PCM-3, PCM-5, and PCM-7 are shown in Fig. et al. in which the porous cellulose material was prepared by dissolving 5% of cellulose in neat [A2im][CH3OCH2COO]20. This reveals that the cellulose solution concentration and [A2im][CH3OCH2COO] dominate the morphologic structures of the cellulose material.It is interesting to find that the morphologic structures of the cellulose materials prepared from 3–5% cellulose solution are quite similar to that reported by Xu 43.As a comparison, we also prepared a cellulose film, and its SEM images are shown in Fig. 44. In the meantime, the typical diffraction patterns of cellulose II are observed at 2θ = 12.5°, 20.3° and 21.2° for the regenerated cellulose exhibits45. This is indicative of a conversion from cellulose I to cellulose II.Figure 2im][CH3OCH2COO]/NMP/cellulose solution are in excellent line with those of the original cellulose, thus implying that cellulose does not react with the [A2im][CH3OCH2COO]/NMP solvent in the dissolution and regeneration processes. The detailed affiliation for the absorption bands of the original and regenerated cellulose are placed in Supplementary Information. The FTIR spectra of the original and regenerated cellulose are similar to those reported in the literatures49.Figure 2im][CH3OCH2COO]/NMP by mixing NMP with [A2im][CH3OCH2COO]. Attractively, the solvents display much efficient dissolution capacity for cellulose and gain as high as 25.4 g 100 g−1 of cellulose solubility even at 25 °C. The efficient cellulose dissolution is primarily ascribed to the hydrogen bond interactions of the carboxyl oxygen atom in [CH3OCH2COO]− with the hydroxyl hydrogen in cellulose as well as the acidic protons in [A2im]+ with the hydroxyl oxygen. The role of NMP mainly dissociates [A2im][CH3OCH2COO] into [A2im]+ and [CH3OCH2COO]− and stabilize the dissolved cellulose chains. The systematic analysis verifies that the morphology of the cellulose material mainly depends on the preparation approach, [A2im][CH3OCH2COO] and cellulose solution concentration. FT-IR analysis reveals that cellulose does not react with the [A2im][CH3OCH2COO]/NMP solvent in the dissolution and regeneration processes. XRD studies confirm the conversion from cellulose I to cellulose II after the original cellulose is dissolved and regenerated in [A2im][CH3OCH2COO]/NMP solvent. Therefore, this work provides a viable strategy for the practical application in cellulose processing/conversion even at as low as 25 °C.This work presents novel cellulose solvents [ACellulose dissolution in diallylimidazolium methoxyacetate + N-methylpyrrolidinone mixture


Chronic myeloid leukemia can be effectively treated with BCR-ABL1 tyrosine kinase inhibitors. However, BCR-ABL1 mutations can develop and cause secondary resistance to these inhibitors. For each of the available BCR-ABL1 inhibitors, certain mutations are known to be associated with resistance, although most mutations that confer resistance to one tyrosine kinase inhibitor remain sensitive to one or more of the other available inhibitors. For patients displaying poor response or loss of response to frontline treatment, the possibility that they have developed a new BCR-ABL1 mutation must be considered, and selection of a second-line treatment must consider the patient’s mutational profile. Here we describe a case in which a patient developed a V299L mutation; although this mutation is known to be associated with resistance to dasatinib while remaining sensitive to nilotinib, limited information is currently available regarding the use of second-line nilotinib following development of a V299L mutation while receiving dasatinib.BCR-ABL1 fusion gene in peripheral blood. The patient initiated frontline treatment with dasatinib. A good treatment response was seen initially, with a complete hematologic response by month 2 of treatment. By month 20 however, BCR-ABL1 transcript levels rose markedly, and a mutational analysis revealed a BCR-ABL1 V299L mutation. Based on the identification of this specific mutation, the patient switched treatment to nilotinib; by month 18 of nilotinib treatment, the patient achieved a deeper reduction in BCR-ABL1 transcript levels than was seen with dasatinib. To date, in month 34 of treatment with nilotinib, the patient has shown good tolerance of the drug and has no clinical evidence of disease progression.A 73-year-old man presenting with fatigue and drenching night sweats lasting for 2 weeks was diagnosed with chronic myeloid leukemia based on an analysis of a bone marrow biopsy and detection of the Our case report illustrates the benefit of having multiple drugs available to treat chronic myeloid leukemia, each with the ability to inhibit a distinct set of BCR-ABL1 mutations. This patient’s case suggests that switching to nilotinib can be an effective treatment option for patients who develop a BCR-ABL1 V299L mutation while receiving dasatinib. BCR-ABL1 fusion gene, which encodes the constitutively active BCR-ABL1 tyrosine kinase [Chronic myeloid leukemia (CML) is characterized by the presence of the Philadelphia chromosome, which is generated by a reciprocal translocation between chromosomes 9 and 22: tq34;q11). This translocation produces the 1. This te kinase . Ponatine kinase . Due to e kinase .BCR-ABL1 transcripts in peripheral blood; RQ-PCR results are then converted to the standardized International Scale (IS) to evaluate the level of response to treatment [BCR-ABL1 level of 0.1% on the IS indicates that a patient’s BCR-ABL1 transcript level is 0.1% of that in the reference sample representing a standardized baseline, pretreatment level [BCR-ABL1 levels at designated time points [BCR-ABL1 transcript levels > 10% on the IS after 6 months of treatment or > 1% after > 15 months; the NCCN also notes that a switch may be appropriate for patients with BCR-ABL1 levels > 10% on the IS after 3 months or > 1% after 12 months [Responses to TKI therapy are typically monitored using real-time quantitative polymerase chain reaction (RQ-PCR) methods to quantify the number of reatment . For exant level , 9. The e points . Current2 months . Further2 months .Development of point mutations in BCR-ABL1 is a frequent cause of secondary drug resistance in CML and is associated with poor prognosis and disease progression , 10–15. We describe a patient newly diagnosed with CML in chronic phase who initiated treatment with frontline dasatinib and switched to nilotinib following the development of secondary resistance and the identification of a V299L mutation. This case report adds to the relatively small body of knowledge regarding outcomes in patients who have switched from dasatinib to nilotinib following the identification of a V299L mutation.A 73-year-old white male patient was referred to the hematology clinic due to a significantly elevated white blood cell (WBC) count that was detected following presentation with fatigue and drenching night sweats lasting 2 weeks. Night sweats and fatigue can be signs of an infection, malignancy, or hormonal abnormality, or they can be side effects of medication. For patients presenting with these symptoms, likely potential diagnoses include tuberculosis, HIV, abscesses, infective endocarditis, lymphoma or leukemia, hyperthyroidism, pheochromocytoma, or carcinoid syndrome.The patient’s medical, surgical, social, and family histories are reported in Table BCR-ABL1 fusion gene were conducted. Examination of cells from the bone marrow biopsy showed hypercellular marrow, with increased megakaryocytes, increased and left-shifted granulopoiesis, markedly decreased erythropoiesis, eosinophilia, decreased iron, severe reticulin fibrosis, and approximately 5% blasts. A CD34 immunohistochemical stain showed scattered CD34-positive blasts comprising approximately 5% of the overall marrow cellularity, with variable distribution of blasts without clusters. A cytogenetic analysis could not be performed owing to a culture failure, likely resulting from a clotted specimen. However, a PCR test was positive for the BCR-ABL1 fusion gene.The patient’s clinical presentation, elevated WBC count, splenomegaly, and peripheral blood smear results were suggestive of a myeloproliferative disorder, with CML suggested based on the peripheral blood smear and cytological analyses. To confirm a diagnosis of CML, a bone marrow biopsy and PCR test on peripheral blood for the P = .0126) [The patient was in chronic phase of CML and according to his Sokal risk score, was classified as low risk. The Kaplan-Meier-estimated 5-year overall survival rate for patients in his age group (65–74 years old) diagnosed with CML in 2000 (before the introduction of TKIs) compared with those diagnosed with CML in 2005 (after the introduction of TKIs) was reported as 38.1% versus 51.2%, respectively  . AvailabBCR-ABL1 transcript levels; isolated RNA was reverse transcribed, after which the complementary DNA was amplified by RQ-PCR for the major and minor BCR-ABL1 fusion genes. The patient had no evidence of disease progression and achieved a molecular response of BCR-ABL1 < 10% on the IS during month 5 of treatment. For patients with this level of response, the NCCN recommends continuing the current treatment, with ongoing monitoring of response levels [BCR-ABL1 levels increased slightly from 2.40 to 3.59% on the IS; however, a subsequent assessment 4 weeks later showed a reduction of BCR-ABL1 levels to 2.99% on the IS.The patient was started on dasatinib 100 mg once daily. Treatment adherence and tolerability were reviewed during each of his follow-up visits to the clinic; the number of pills remaining, if any, was always verified with the patient. He tolerated the treatment well and within 2 months experienced a complete hematologic response. The patient’s response was monitored by evaluating e levels . By apprBCR-ABL1 levels can be an early sign of treatment resistance [BCR-ABL1 levels in single or serial samples was shown to be predictive of BCR-ABL1 mutations [BCR-ABL1 levels and loss of MMR to determine if a change in treatment is needed [BCR-ABL1 levels at month 8 of treatment were below the 2-fold and 1-log thresholds, and they spontaneously improved by the subsequent assessment. At month 12 of treatment, a bone marrow biopsy revealed no increase in blasts (< 1%) and adequate erythropoiesis and granulopoiesis, while RQ-PCR showed a BCR-ABL1 level of 0.22% on the IS, which is close to a major molecular response (BCR-ABL1 ≤ 0.1% on the IS). The favorable results of the bone marrow biopsy and the RQ-PCR results indicated that the patient was responding well to treatment. The patient continued treatment with dasatinib . However, the patient showed no clinical evidence of disease progression, remained on treatment with good adherence, and had normal CBC levels. He was therefore kept on dasatinib treatment, and his BCR-ABL1 levels were assessed again at month 21. This assessment showed that his BCR-ABL1 levels had increased further, to 12.77% on the IS. A bone marrow biopsy revealed no evidence of acute leukemia. Cytogenetic analysis showed that 10 of 20 cells were positive for the Philadelphia chromosome; 10 normal cells were observed. Unlike the earlier increase in BCR-ABL1 levels, this increase was substantial enough to trigger BCR-ABL1 mutational analysis despite the absence of clinical evidence of disease progression. Genetic sequencing of a bone marrow aspirate sample detected a V299L mutation in the BCR-ABL1 kinase domain. Low levels of an insertion event, during which 35 nucleotides from ABL1 intron 8 were inserted at the normal exon 8 to exon 9 splice junction, were also detected; the clinical significance of this is unknown. The NCCN recommends switching patients with V299L mutations to nilotinib [At month 20 of dasatinib therapy, another increase in BCR-ABL1 level of 0.00% on the IS, a greater reduction than was previously achieved with dasatinib. To date, the patient has remained on nilotinib 300 mg twice daily and has demonstrated good tolerability of the drug, no recurrence of abdominal pain or fatigue, and no clinical evidence of disease progression. BCR-ABL1 levels rose to 0.20% on the IS at month 21 of nilotinib but returned to 0.00% on the IS the following month. In the latest assessment, at month 34 of treatment, the patient had BCR-ABL1 levels of 0.30% on the IS, up from 0.00% on the IS at month 28. He showed no evidence of cytogenetic or hematologic relapse and is being periodically followed at the clinic per the NCCN guidelines [After starting nilotinib 400 mg twice daily, the patient developed abdominal pain, slightly elevated amylase and lipase levels, and profound fatigue. Due to these adverse events, the nilotinib dose was temporarily reduced to 200 mg twice daily and then escalated to a 300-mg twice-daily maintenance dose. RQ-PCR testing at month 18 revealed a idelines .BCR-ABL1 levels [Today, most patients with CML have good long-term prognoses, including a life expectancy comparable to that of the general population . However1 levels , 22. Bec1 levels , 22. The1 levels . Thus, tAlthough nilotinib is recommended for patients with V299L mutations, limited data are available on outcomes in patients who switch from dasatinib to nilotinib due to this mutation. Several cases of patients with V299L mutations responding to nilotinib following a switch from dasatinib have been reported , 24. The


BCR-ABL1 transcript levels in patients with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) is a widely adopted method to assess response to therapy. However, a small minority of Ph+ ALL patients express variant BCR-ABL1 transcript types, usually due to splicing of alternative BCR or ABL1 exons. Whether patients expressing these rare, variant BCR-ABL1 transcripts have a distinct phenotype or response to therapy is not known due to the limited number of reported cases. Here, we report the presenting features of Ph+ ALL in a young adult with a variant e13a3 BCR-ABL1 fusion. Molecular monitoring reflected the disease response from diagnosis through allogeneic stem cell transplantation which resulted in undetectable e13a3 BCR-ABL1 transcripts. This case highlights the value of molecular monitoring in Ph+ ALL patients with variant BCR-ABL1 transcripts and the requirement for standardization of such assays.Monitoring  BCR-ABL1 transcripts is a valuable tool in assessing individual patient response to chemotherapy and ASCT . Interphase FISH analysis showed the presence of BCR-ABL1 rearrangement in 64/100 cells analysed. Standardised RT-PCR and Sanger sequencing demonstrated e13a3 BCR-ABL1 transcripts [BCR-ABL1 transcripts lack ABL1 exon a2, thus prohibiting the use of a standardised primer/probe combination for e13a2/e14a2 BCR-ABL1 qPCR [BCR-ABL1 qPCR assay was therefore adopted utilising BCR forward primer ENF501F2 [ABL1 reverse primer ENR1063 and ABL1 probe ENP1043, the latter both complementary to ABL1 exon a3 sequence [BCR-ABL1 standard curve was constructed using serial dilutions of an e14a3 BCR-ABL1 plasmid over a five log range (100% to 0.001% BCR-ABL1 transcripts) with ABL1 as the reference gene as previously described [BCR-ABL1 qPCR and data interpretation were followed [BCR-ABL1 transcripts were of a high level (BCR-ABL1/ABL1 75.7%) consistent with a diagnosis of pre-pre-B cell Ph+ ALL.A 23-year-old male presented with chest pain and dyspnoea, a hemoglobin count of 7.4 g/dL, platelet count of <10 × 10hoblasts . Immunop −10, addp13), +1, +19/L, BCR-ABL1/ABL1 8.11%). After phase-two induction, the bone marrow BCR-ABL1/ABL1 level had fallen to 0.053%. Following high-dose methotrexate, the pre-ASCT BCR-ABL1 level was 0.034%. The patient proceeded to ASCT from an unrelated donor after cyclophosphamide and total body irradiation conditioning and recommenced continued imatinib maintenance. BCR-ABL1 transcripts were not detected in the peripheral blood at one, two, and three and a half months post-ASCT (The patient commenced induction treatment with rituximab, dexamethasone, vincristine, and daunorubicin, with imatinib 400 mg oral daily started on day 15. After phase-one induction, the bone marrow aspirate demonstrated a complete morphological response with residual disease detected by immunophenotyping and RT-qPCR (ost-ASCT . ContinuBCR-ABL1 transcripts lack ABL1 exon a2 that encodes part of SH3 domain thought to contribute to leukemogenesis by inhibition of the kinase domain and by STAT5 activation [BCR-ABL1 CML is rare [de novo Ph+ ALL. Additional chromosomal abnormalities and complex karyotypes are frequently observed in Ph+ ALL, as witnessed in this case. There is some suggestion that in Ph+ ALL, additional cytogenetic abnormalities are associated with a shorter overall survival and might therefore be used for stratification purposes [BCR-ABL1 transcript levels is an essential component of Ph+ ALL patient management [BCR-ABL1 fusion transcripts required [E13a3 tivation . In chrotivation –16; howe is rare . In the purposes . In the nagement  with effrequired .BCR-ABL1 Ph+ ALL and help establishing optimal treatment strategies for patients with this rare genotype.Reporting of further cases would enable identification of any phenotypic characteristics of e13a3


Background: The strategic incorporation of community health workers (CHWs) into health system strengthening efforts is recognized as a critical and high-value approach for meeting the Sustainable Development Goals established by the United Nations in 2015. How to best build CHW programs, however, is prone to a wide variety of opinions and philosophies, many of which are often externally imposed. Partners in Health (PIH) is a non-governmental organization that pioneered an approach to healthcare system strengthening, called accompaniment, in which CHWs play a key role. Learning from PIH is a critical first step in replicating the organization’s achievements beyond PIH. As such, PIH has developed a tool, referred to as the ‘Accompanimeter 1.0,’ that serves to evaluate existing CHW programs and guide adjustments in programming.Objective: To provide a standardized approach for defining, assessing, and implementing accompaniment in CHW programs using a tool called the Accompanimeter 1.0.Methods: Development of this tool included three stages: (1) desk review of literature relevant to the work of CHWs globally, (2) discussions among colleagues and initial field testing, (3) feedback from colleagues who are experts in community health and in the principles of accompaniment.Results: Three core principles of accompaniment in a CHW program were identified: professionalization, CHWs as bridges to institutional strength, and community proximity. These core principles direct five thematic areas that are found in successful CHW programs: Partnering ; Choosing (identifying the right people for the right job); Educating (building CHWs´ capacity); Incentivizing ; Supervising .Conclusions: The Accompanimeter 1.0 can serve as a helpful tool for CHW program implementation and policy decisions that maximize system-side inputs, community engagement, and support for individuals with medical issues. Community health workers (CHWs) are recognized by governmental and non-governmental stakeholders as critical contributors to strong and effective health systems . Yet, hoPartners in Health (PIH) is a Boston-based non-governmental organization that has worked for over three decades across more than ten countries  to produce some of the most notable health outcomes in global health . The PIHAccompaniment in a CHW program is a vulnerability-oriented approach taken to ameliorate harmful social arrangements to improve health . Harmfulaccompaneer  is willing to continuously listen, stand, and walk in solidarity with patients as they seek wellbeing, mediating interactions between patients, communities, and medical care providers, while simultaneously unveiling and addressing the social, economic, and political forces behind the illnesses of his or her patients.Accompaniment, however, is not a static or single intervention at the onset of a CHW program’s design – rather, it is a flexible, responsive and iterative process. As an institutional practice, accompaniment requires health systems to listen and empathize with the populations they aim to serve, identify key vulnerability gaps in care, and fill those gaps with appropriately funded and effective health actions. An In this paper, we describe the development of a tool called the Accompanimeter 1.0. This tool aims to guide the repositioning or re-engineering of CHW programs in low, middle or even high-income countries from an accompaniment standpoint through intentional budgetary, partnership, impact measurement and management process decision-making.To develop the Accompanimeter 1.0, we first agreed on a common definition of ‘accompaniment’: accompaniment is both a philosophical stance and a rubric for programmatic design and implementation. Grounded in notions of social justice and human rights, accompaniment is a unique methodology for approaching, defining, and delivering community-oriented, person-oriented health actions ,13. MoreFor this analysis, a ‘community’ is defined as ‘a group of people with diverse characteristics who are connected by social ties, share common perspectives, and engage in joint action in geographical locations or settings’ . When adAfter agreeing on these definitions, we conducted a literature review to identify similar tools before workshopping the first iteration and received feedback from peers. Finally, we tested the tool using semi-structured interviews with experts on Accompaniment and CHWs.The lead author (HC) conducted a literature search in Medline via PubMed (2006–2016) using combinations of the following MeSH search terms: ‘community health worker,’ ‘village health workers,’ ‘barefoot doctors,’ ‘health care delivery’ AND non-MeSH search terms: ‘framework,’ ‘community-based accompaniment,’ ‘companion’, ‘accompaniment,’ and ‘model.’ Searches were performed in December 2016.Second, the subsequent iteration of the Accompanimeter was envisioned and created by HC through informal conversations and debriefs with peers knowledgeable of CHW programs. This process allowed for the introduction of new ideas and adjustments, many of which were not meant to be traced. On this step, we also performed an initial field test of the tool on two existing community health worker programs in Mexico and Brazil. These programs were chosen by 1) their contrasts – one is a very large, government-run, and well-established CHW program and the other is a small and newly founded program led by an NGO –, 2) our familiarity with these programs, and 3) their documented impact on improving people’s lives ,16. Thenth and July 11th, 2017, semi-structured interviews were administered over the phone and transcribed to ensure the fidelity of the recommendations given. Interview questions were separated into five categories: 1) feedback about the tool, 2) best practices on accompaniment, 3) skills of an effective accompaneer, 4) personal experiences with the concept of accompaniment in programmatic design, and 5) suggestions for additional resources. Experts’ responses were then compiled into a summary document and assessed for key themes and final tool suggestions. If some comments or insights from the experts were found to be vague or unclear, the experts were contacted for a second interview, to reduce the potential of misunderstanding their feedback. Next, the research team reviewed and discussed the notes from all interviews, and synthesized suggestions for a semi-final iteration (not shown). This semi-final iteration was then re-sent to participants for verification and solicitation of any final revisions. The tool  their experience with CHW programs, 2) their unique familiarity with the accompaniment approach, and 3) international work on community health, and requested their review of the tool. We aimed and achieved a balance in gender and 70 percent of the participants were U.S., based (and the rest in Latin America and Haiti). Of the 17 experts, ten agreed to participate in semi-structured interviews. The other seven submitted feedback in writing. In advance of the interviews, all expert advisors were provided with the second iteration of the Accompanimeter and a brief document explaining the goals of the tool. Between June 6In short, the literature review supplied best practices in CHW programs, the informal conversations and initial field testing refined the tool further and semi-structured interviews with experienced individuals in Accompaniment enhanced and polished the tool to its third and final iteration.We identified 82 abstracts and reports that mentioned the elements of a successful CHW program while offering a theoretical framework. From these, five abstracts were excluded because they were duplicative. From the 77 documents remaining, 35 more were excluded because they referred to isolated programs not integrated into comprehensive health systems. The 42 papers and reports remaining were organized into two categories: (1) those that described the structural design elements of effective CHW programs and (2) those that described the practices of effective CHW programs. From these two categories and based on improvement of clinical outcomes and CHW satisfaction, we selected 34 papers and reports to inform the first draft of the Accompanimeter  As opposed to 5-SPICE, the Accompanimeter 1.0 should have more comprehensive domains instead of focusing on narrow human resources’ terminology, 2) the new tool should include levels of performance with concrete examples for each domain, and 3) the Accompanimeter 1.0 should include an implementation guide so that it can become a pedagogical tool and also invite an enlightened dialogue among all the different stakeholders of the CHW program. Iteration 3 of 3 of the tool considered these recommendations along with other minor suggestions such as more positive terminology and changing the accompaniment’s stages from ‘none, moderate, and excellent’ to ‘inadequate, growing and aspirational’. The conceptual idea of the Spidergrams was based on the work of Baatiema and colleagues . We deciThrough the literature search, informal discussions, initial field testing, and semi-structured interviews, three principles emerged as critical to making accompaniment actionable in a successful CHW program.Professionalization: Programs that aim for professionalized CHWs commit to long-term investments in their CHWs to ensure their success and retention as core members of effective care delivery teams. This commitment begins with:Adequate recruitment and hiring based on candidate interest in the CHW responsibilities and candidate potential to excel in the role.High-quality, ongoing training to provide CHWs with the knowledge and skills necessary to perform their roles with confidence.A fair package of incentives commensurate with the scope of work to ensure that CHWs can commit the time needed for the job and achieve the economic freedom required to focus on their duties.Supportive supervision with ongoing mentorship that facilitates personal and professional growth, and fosters active problem solving and sustained performance with excellence and fidelity.Clear career-development pathways that offer opportunities for high-performers to grow professionally.CHWs as Bridges to Institutional Strength: Programs that offer ‘institutional strength’ to community health programs position CHWs not as islands of care but rather as bridges to a functioning health system. In that way, the tasks that CHWs perform contribute to the value chain of care delivery and complement the work of nurses, doctors, pharmacists and other healthcare providers, which is expected to produce better outcomes. While CHWs strengthen health systems, they can only be as strong as the systems that support them. This results in a feedback loop. Practically, this means that the CHW programs cannot be strong if funded alone while the larger health system is comparatively underfunded.Community proximity: Enthusiasm for data demonstrating the CHWs’ capacity to achieve reductions in mortality at a fraction of the cost of other health providers can encourage health systems to convert the CHW into an overly simplified, highly-medicalized mortality-reduction agent. Our alternate and improved model positions the CHW as a colleague who can represent the health system in the community and the community in the health system. There is wisdom in the collective experiences of impoverished communities. CHWs can be the ‘Rosetta stone’ for translating that knowledge into action when designing, adapting and improving health and social services. A health system that values proximity with the community does not assign a CHW to work only inside a health center, but rather empowers a CHW to be out in the community, speaking to people openly  and experiencing what they are truly living. Such a health system also fosters concrete and functional mechanisms for channeling and accounting for community experience .The analytical framework is based on the notion that five thematic areas  serve as the building blocks or platform on which the principles of an accompaniment-based CHW program can mature. Professionalization, CHWs as bridges to institutional strength, and community proximity are the three core principles of the PIH CHW model . When thWe believe that the three principles and five building blocks enable programs to help health systems best reach the three dimensions of Universal Health Coverage: (1) coverage, (2) scope of services, and (3) financial protection. In addition, they add a very important focus on equity, highlighting the imperative for well-designed CHW programs to reach the most vulnerable .Many frameworks offer useful insights on how to design and improve a CHW program. The Community Health Worker Assessment and Improvement Matrix (CHW AIM) (USAID) is comprehensive and well-supported from an academic standpoint, and it offers a detailed pathway to assess a CHW program; however, it does not explain how the different elements interact with each other and lacks examples on how these elements are implemented in real life . The AccThe Program Functionality Assessment Toolkit (Core + World vision) contains a detailed explanation of each programmatic component and is easy to understand, but it lacks evidence on how the components were chosen nor does it offer any practical recommendations to implement it via real world examples .The CHW Principles of Practice is short, concise, visual, and offers a few practical recommendations, but lacks examples of how the different principles look in the field, nor does it highlight any potential interactions among principles .And finally, the 5-SPICE framework (PIH) is comprehensive, concise and shows examples of interactions among elements, but it does not mention how to implement it, nor does it include different benchmarking levels for each programmatic element. Also, it fails to convey system-side and community-side perspectives on each component with practical examples .Nevertheless, the Accompanimeter 1.0 can be considered an extension of 5-SPICE since it uses the 5-SPICE structure to map out what a CHW program built around the values of accompaniment could look like. The practical applications of each tool, however, are quite different: 5-SPICE is most useful for initiating an exploratory conversation about how a program is structured; the 5 × 5 tables described in that paper offer an open-ended methodology to explore what does and does not work in a specific program. The Accompanimeter 1.0, on the other hand, is far more normative about what should be aspired for in a community health program that is guided by the accompaniment approach.The Accompanimeter 1.0 should be used in a collaborative fashion with different stakeholders who are invested in the CHW program at any point in its development or maturation. The process of implementing the tool is iterative; at various points in the program implementation of the CHW program, managers, health personnel, program supporters, CHWs, and community members should carry out an assessment, and appropriate action can be taken.Assess: Each program should use Review ratings: During a CHW program stakeholders meeting, a facilitator should assemble, average, and display the ratings .Plan: The team should order the solutions based on feasibility and then develop action plans for addressing them. This may include re-writing agreements with existing partners, looking for new resources, hiring new managers, allocating resources to new areas, re-defining indicators, and so forth. It is crucial that the stakeholders assigned to lead the implementation of a particular solution are carefully selected; for example, community members might be more effective at reengaging community-level committees whereas the program manager may be better positioned to engage new potential donors.Implement: Once action plans are determined, the teams can take the action plan to the field in a collaborative manner by engaging multiple stakeholders in the implementation process. As many potential changes are expected to emerge, it is important to list them and strategically address them over time, instead of simply stopping once a pressing challenge is solved. In addition, the team should determine a mechanism of follow-up and establish systems for accountability in the Accompanimeter 1.0 implementation process.For existing programs, we recommend the following steps for utilization of the tool:In The Accompanimeter 1.0 can serve policy makers and program implementers in low, middle and high income countries leading small, medium or large CHW programs to:Identify design or implementation gaps that limit a CHW program’s potential to achieve ambitious clinical and/or non-clinical health outcomes.Illuminate the pathway a CHW program can follow to move from a short-term healthcare delivery intervention to a long-term integrated equity-focused solution.Initiate a dialogue on how to build or rebuild community-level health care systems that are well-balanced and responsive to the needs and goals of both the healthcare system and the community.The Accompanimeter 1.0 tool has several distinctive features:reflective of the accompaniment values across PIH;It is simple and allows CHW program stakeholders to analyze their programs with a single and cohesive model;It is visual, which assists greatly in comparing different programs, assessing improvements over time in a single program, and communicating the results of the analysis to lower-literacy stakeholders such as CHWs and community members in a multi-dimensional fashion;It is comprehensive and combines evidence-informed criteria with a wealth of experts’ experience;It is demonstrates how an aspiring accompaniment-based program can be modeled; andIt equity in clinical outcomes, which is defined as concrete and measurable benefits experienced by the poorest or most vulnerable.It is uniquely focused on No single tool can be everything for every environment, organization, and program. The Accompanimeter 1.0 was created primarily to promote the values of accompaniment as central to an impactful CHW program. Though based on decades of experience, many measures of the tool are still subjective. As most key informants were affiliates of the PIH network, non-PIH programs may encounter challenges in using the tool that were not uncovered during the discussions. In addition, most of the experts are based in the U.S. which might have added some biases to the tool. Still, the specific advice in this tool may still be adapted as further research or experience suggest better practice. As such, this tool should not be construed as block advice to be implemented without further analysis, but rather as a collection of normative statements that users can interpret for implementation in their unique contexts.The Accompanimeter 1.0 is a unique tool that enables community health policy makers and program implementers to put into practice the three core principles of accompaniment . Furthermore, this tool also offers CHW program stakeholders a participatory process to assess, discuss, and modify, as needed, the core building blocks of their CHW program to effectively reorient towards a clear path to health, dignity, and equity advancements.


India achieved the title of a polio-free country in March 2014 after a prolonged battle with the poliovirus that threatened millions of children and paralyzed scores of them. Although there has been considerable documentation of the technical strategies applied over the years, not enough has been written on the other warfront that had opened, namely, the battle between the people and the polio eradication program. This article describes the immense people-driven challenges to the polio program and the need for tailor-made and novel responses. This is when the U.S. Agency for International Development–funded CORE Group Polio Project (CGPP)/India stepped in and started work in 1999. The project, a consortium of CORE Group member international non-governmental organizations (NGOs) and local NGOs, formed a bridge between communities and the government program. This article describes how CGPP/India listened to the families and communities who refused to participate in the polio eradication program and then strategically addressed their concerns. These lessons from India can benefit other public health priorities that require civil society involvement, as most public health efforts do. It was commonly believed that India would be the last country to eradicate polio, if ever. However, a mere 2 years later, in January 2011, the last case was identified, and India was certified as polio-free in 2014.At the onset, the Polio Eradication Initiative kicked off with country-wide National Immunization Days in 1995. Women lined up at dawn with their babies at vaccination booths to get them vaccinated against polio. There was a festive air in every locality, hinting at the beginnings of a very successful “people-owned program.”However, once the immunization data were examined, it became obvious that children were being missed in large numbers, jeopardizing the ability to meet immunization targets and ultimately the ability to achieve the herd immunity required to stop transmission. This realization led the government, in 1999, to take the bold step of sending vaccinators to each house to ensure that every child was reached.Then the unexpected happened. Parents started shutting their doors on the vaccinators, refusing to allow their children to be vaccinated, and the enthusiasm of parents turned to reluctance in some states, and strong aggressive resistance in others. The government was faced with a new challenge: understanding why communities would turn against the very people who were trying to protect their children from a deadly disease that had crippled so many children in cities, villages, and slums.3 For families living in places where health systems were weak, this vertical program became viewed as coercive and as threatening as another similarly organized program from years before—family planning. Rumors circulated in communities, leading to suspicions about the vaccine. People started hiding their children, especially boys, fearing the vaccine would leave them impotent. Parents would lock up their houses and take their children elsewhere so that they could avoid being vaccinated. Auxiliary nurse midwives (ANMs) and other government frontline workers also were unwelcome. In one such instance, the author accompanied a CORE Group Polio Project (CGPP) team of mobilizers and an ANM to a house in Bhojpur block of Moradabad district, Uttar Pradesh, in 2004. The grandmother hid the male child in a chicken coop and threatened to kill him and the team with a large knife if the team stepped inside. Rumors and mistruths about harm caused by polio vaccine spread quickly from village to village or from one part of a town to another. Fatwasharam,Widespread resistance highlighted the frail and sensitive interface between the government and communities, particularly those in underserved areas.4 Polio eradication has become one of India’s flagship programs in many states of the country. The CGPP, meanwhile, was using schoolchildren, nursing students, teachers, and community-based groups to mobilize mothers to bring their children for vaccination on booth days. Volunteers listened closely to the communities and when they faced resistance, sought ways to dispel mistruths and convince parents of the value of vaccines. At the height of resistance, the community mobilizers hired by the CGPP knocked at each door to gain entry into people’s houses, minds, and hearts to gain increased acceptance of the oral polio vaccine.Since 1999, the CORE Group  has been working on polio eradication, as described elsewhere in this series.6) would approach households together for fear of being turned away, abused, or assaulted. In 2003, the CGPP and UNICEF jointly approached the Uttar Pradesh government with the proposal of forming a social mobilization network (SMNet). Mobilizers of both agencies would be given the same nomenclature and key responsibilities, and they would be supervised at block, district, and regional levels. Community mobilization coordinators (CMCs) were selected from the high-risk and most resistant communities identified by the government and the National Polio Surveillance Project. These CMCs, mostly women, were trained in interpersonal communication, negotiation skills, and other behavior change strategies and tasked with visiting households to explain to parents the importance of vaccination against polio and other diseases. The CMCs are paid volunteers, meaning that they receive a fixed honorarium, but this is not considered to be a formal salary. The honorarium was originally paid in cash, but more recently it has been paid via bank transfer. The use of the term “honorarium” reflects the temporary nature of this financial support.In the early days, Uttar Pradesh was the state with maximum opposition to the polio eradication program. The United Nations Children's Fund (UNICEF) and CGPP community mobilizers  who would accompany the mobilizers trying to change resistor families into acceptor ones.When it was found that a particular section of society was resisting more than the others, a meeting was arranged with the CMCs noticed persistent resistance in some households. Visits were marked by repeated excuses such as “My child is sick” or “She is too small/weak to be vaccinated.” Community influencers were invited to frequent meetings where CMCs gave information about the benefits of vaccines, dispelled myths, and taught negotiation skills to prepare them for conversations with resistant parents. The contribution of influencers was purely voluntary, but their sustained support and commitment produced a clear, strong impact on the communities they served.Community members asked whether the vaccine contained any material that was forbidden in their religious teachings or whether they were contradicting any religious dogma by repeatedly exposing their small children to the vaccine. The CGPP mobilizers held meetings with smaller groups of both male and female religious teachers, where positive references and supportive religious texts were highlighted. Connections to religious leaders made it easier to approach keepers of mosques and request announcements advising families to take their children to the booths. Friday sermons also began to carry the message that the polio vaccine was safe and protected children from becoming crippled .Bulawwa tolies.Children were used as mobilizers, forming into groups called Meetings with mothers and grandmothers proved easier than those with fathers, who were often working away from home during the hours of the immunization campaign or harbored strong resistance to the campaign. Some women would allow their children to be vaccinated but not let their doors to be marked for fear of their husband’s reaction. The mobilizers were tenacious and repeatedly visited the families to talk about polio and other childhood diseases and vaccinations. Slowly, community mobilizers and influencers formed bonds with resistant families, some of whom were migrant families who had never been reached by vaccination campaigns. It took many meetings and much persistence before families shared their fears, priorities, and problems. Mobilizers also formed links between families and frontline government workers such as Accredited Social Health Activists (ASHAs)Communities often expressed concern over the lack of other health services in their communities. They wanted to know why the government was campaigning for only polio while their children were dying from other diseases. This gave rise to the idea of holding health camps in areas with very high number of resistors, just before the polio campaign rounds. Government medical officers were requested to send staff, drugs, and vaccines for the camp, and the CMCs organized the venue, provided transport to bring medical personnel, and sometimes even arranged for a female doctor to be contracted for a day so that antenatal and gynecological care could be provided. This became a very popular intervention, as it grew out of the stated need of communities and helped establish trust and goodwill among the CMCs, the CGPP, and the communities.India has a very large migrant population, and these families travel throughout the country looking for work. The CGPP created detailed maps to identify migrant sites and high-risk areas so that no family was in danger of being missed . InterstNomadic groups provided a special challenge because one or more families often appeared in high-risk areas overnight, making them increasingly difficult to track. Their children were often never registered in any health post and could have conceivably missed all vaccinations, including even polio rounds. Ration shopWork with the community led to the identification of another gap in vaccination services. The state of Uttar Pradesh is home to a large brick kiln industry, drawing entire villages to migrate there for seasonal work. Children of brick kiln workers were largely bereft of all health care, and parents did not get leave from work for health-care visits or vaccination days. Workshops were held with the brick kiln owners who were sensitized and who provided lists of eligible children to the community mobilizers, who, in turn, ensured that all children were vaccinated during polio rounds.Do boond zindagi ki” (two drops of life). India’s leading superstar, Mr. Amitabh Bachchan, can take sole credit for converting many resistant families just by crooking his finger and asking why they had not given their children the “Two drops of life.”In addition, famous Bollywood stars were recruited by the government and contributed to a very concerted and focused mass media program. Actors, cricketers, and other well-known leaders all joined in a chorus to stress the importance of “These continuous multiple, targeted, multifaceted, and simultaneous approaches paid dividends. Most community members eventually relented and actively participated in the polio campaigns. However, instances of resistance continued to emerge, and some villagers used the program to negotiate with government functionaries, demanding better roads, electricity, and so forth. In some places, systemic failures of public services had to be addressed before the polio round could continue. For example, the district administration had to give in to demands for ration cards that entitle people to avail of the government’s public distribution system of food, for cleanliness drives, and so forth.More than two decades of personal experiences have led to the following deductions that can have bearings on future public health programs. Success did not come easy for the CGPP. However, strong sustained efforts along with both successful and failed strategies led to many valuable lessons, the first and foremost being that civil society must never be taken for granted. Even the least empowered, poorest, and most illiterate people are blessed with wisdom and, therefore, have the right to facts.The next step in the national polio eradication program took people by surprise when vaccinators started appearing on their doorsteps with increasing frequency. In underserved areas where routine immunization and other health services were wholly inadequate, this gave rise to suspicion about the vaccine and about the government’s intentions. To be fair, the resistance came as a big surprise even to the frontline workers who were not trained to handle this kind of behavior. It also strained their capacity to deliver routine services.Program implementers must have their fingers on the pulse of the people and should operate with transparency. All queries and concerns must be addressed honestly and without delay. Failing to address pertinent issues directly can lead to misinformation and distrust that can snowball into a crisis. As bad news travels faster than good news, all adverse reports in the media need to be countered immediately before they spread deeper into the community.One example of queries and concerns that were not addressed early on is the following: Did anyone bother to explain to parents that repeated polio vaccine doses would not harm their children? Or, why babies with 20 doses would still get polio? In India, it is to the credit of community mobilizers and the communities that, in time, parents did start to cooperate and accept the polio vaccine even when vaccinators appeared repeatedly on their doorsteps and/or intercepted parents while they were travelling with their children.In states where the government health services were good, there was not much of a problem, and poliovirus transmission stopped quite early. But in states such as Uttar Pradesh, especially in its western districts with poor indicators, the wild poliovirus managed to take advantage of the weakness of the health system and infect children who were unimmunized or had weak immunity.All members of civil society need to be treated with respect and must be heard. This is easier said than done because listening is an art and needs to be cultivated and must lead to hearing. Interpersonal communication training, particularly for frontline workers, was invaluable and allowed them to hear and react to the needs of their communities. Observing their body language, not engaging in counterproductive arguments, and treating families  with respect—all these skills proved the key to success and took time to cultivate.This attitudinal change among frontline health workers must be maintained and become a part of their curriculum. Monitoring and supportive supervision go hand-in-hand with success. Many public health programs fail because of weak supervision or failing to provide hands-on support where needed. The polio eradication program also began the same way. Workers were punished and suspended for reporting possible polio cases, or for not being able to achieve good immunization coverage at their booths or even during house-to-house visits. But when punishment turned to support and mentoring, the supervisors and those who were supervised became able to devise constructive strategies.In hindsight, communication was one of the keys to success. It is likely that if communication strategies had been better planned well in advance, there would have been less skepticism from the people and acceptance of polio immunization would have been less problematic.For many at-risk families, survival is the foremost priority, and government health services are not very accessible. The polio vaccination program should have been introduced in an environment of mutual understanding to gain community involvement instead of through a vertical, top-down approach. This does not imply that it was totally devoid of planning. The technical components—vaccine availability, cold chain strengthening, microplanning, surveillance for acute flaccid paralysis, and laboratory upgrades—were devised with deliberate precision and careful thought. What the planners underestimated, and therefore missed, was the lack of planning to ensure that the concerns of the population are addressed before and during the campaign. Responding to their needs for information, questions, and concerns, particularly when related to the health and future of their children, should have been the first step.Another issue is that governments sometimes equate civil society with activist NGOs that are not accountable to anybody. Any mutual distrust had to be put aside for the program to be successful, and in the end, a partnership and healthy respect were developed, taking into account each other’s abilities and limitations. A program of this complexity must be inclusive and not coercive. The new and stronger relationship and trust between civil society and the government need to be nurtured and not allowed to fade away.There is hardly any program in the world that has generated so much data as the Global Polio Eradication Initiative. The stakeholders learnt to base their strategies on data and modify them. Something that worked in one community might not work in another, and what worked today may not work tomorrow. This agility to change strategies midstream proved a key strength of frontline workers, including community mobilizers, who were constantly tasked with addressing emerging barriers and issues. Messaging required constant adjustment to respond to rumors, misinformation, and national and world events that impacted the program. Truth and constant sharing of correct information were the keys to combatting anti-vaccine literature and other forms of misinformation. Sharing of appropriate data with community members helped to allay and disprove these claims.madrassamadrassas. They equipped themselves with statements from religious texts regarding the health and well-being of children so that they could dialogue with the very learned faculty members of the various religious schools of thought in these communities.Very early on in the program, we all learned that there was no “one size fits all” solution. Families living next door to each other sometimes had to be spoken to differently, and their participation in the program could never be taken for granted. Each 8Local media too must be treated with great respect and care because they are more important than national media for the program. Using them to spread correct information is invaluable. In this case too, the local press helped to create ownership for community members. The CGPP community mobilizers sensitized representatives of the local media and were able to act as sources of truth. With support from polio partners such as UNICEF, Rotary International, and the WHO, media sensitization workshops were organized from time to time in selected districts and at the state level.The CGPP found that there was a lack of awareness about the importance of routine childhood immunization. If mothers had known about its importance and regularly followed the immunization schedule, there would have been higher levels of immunity among their children and less resistance to polio immunization. An increased emphasis on routine immunization must follow as a natural corollary, and this is the time to strike when doors are open and when people have started to believe in government health services. For parents to take immunization as a natural part of bringing up their children, immunization programs must be of the highest quality and regular. Just as giving polio drops to their children every time there was a polio round, the receipt of other vaccines as the schedule calls for must also become a habit.Last, but not least, the most valuable lesson that all program partners learnt was to work together seamlessly. It did not start out that way, but in the face of so much resistance, there was no option but to band and bond together and to stop blaming each other. Solutions were thought of jointly. Each partner knew its own role and played its part as best it could. Acknowledging the government’s captaincy, its request was taken as a command and no partner ever refused to tackle an issue, no matter how difficult it was.This strategy should pave the way for future programs. Efforts must be complementary, not competitive. Roles need to be defined based on partner competencies: for example, technical agencies are best equipped to provide technical guidance, whereas community-based organizations are skilled in communication and behavior change.Supplemental Figure 1a). The administration also requested the establishment of a polio museum in the district hospital. A polio gallery was made that tracked the history of how polio was eradicated from India. In July 2014, a village headman, using his own unrestricted funds, erected a huge gate called the Polio Eradication Gate in Jansath, Muzaffarnagar, a district in Uttar Pradesh that had had many polio cases in the not-too-distant past .As all sectors of society contributed their best efforts to make the program a success, the program finally turned into a people’s movement. Success came finally when polio transmission ended, and India was certified polio-free in March 2014—a hard-won fight but rich in lessons for the future. In 2012, at the request of the district government administration, a large installation commemorating civil society’s contribution was placed in the middle of a busy thoroughfare in Moradabad, Uttar Pradesh, a town once considered the epicenter of polio transmission in the world (India’s polio eradication program is a shining example of what can be achieved if civil society is brought into the inner circle of planning and policy making and if each partner’s contribution is recognized and respected. The work must not stop here but needs to be continued with the same, if not even stronger, momentum and commitment toward the remaining public health challenges of our time.Supplemental materials