Introduction: The national rate of obesity in US Hispanic/Latinos exceeds all other major ethnic subgroups and represents an important health disparity. Plant-based diet interventions that emphasize whole plant foods with minimal processing and less refined grains and sugar have shown great promise in control of obesity, but there is a paucity of data translating this treatment effect to disparate populations. The objective of our study was to evaluate the efficacy of the Healthy Eating Lifestyle Program (HELP) for accomplishing weight management in a hospital-based, family centered, culturally tailored, plant-based diet intervention for Hispanic/Latino children who were overweight or obese. Methods: Our mixed methods evaluation included: (1) A one arm study to measure changes in body mass index (BMI) from pre- to post-intervention, and (2) A stakeholder analysis of the program staff. Results: For children ages 5–12 years who were overweight/obese, we found no evidence of excess weight gain evidenced by BMI Z scores . Among the parent/guardians who were overweight or obese, we found a decrease in BMI that was stronger in men  than in women . A program strength was the cultural tailoring of the plant-based diet choices. Conclusions: The evaluation raises the possibility that incorporating intervention components of HELP  into pediatric weight management can improve the standard of care. The 2016 National Health and Nutrition Examination Survey of the US reported a very high national prevalence of obesity in Hispanic/Latino adults ages 20 years and older (Hispanic/Latino (47%), Black (47%), Asian 13%), White (38%)) [%, White 1c levels, and (2) 6 out of 9 reported reduction or discontinuation of diabetes medication. Taken together, we find convincing data from randomized controlled trials in the experimental setting that plant-based diet interventions can improve management of both obesity and T2DM. The next step in this research is the translation of plant-based diet treatment effects to high risk , disparate populations in the US such as Hispanic/Latinos.Plant-based diet interventions that emphasize whole plant foods with minimal processing and less refined grains and added sugars have shown great promise in control of obesity and type 2 diabetes (T2DM). In a meta-analysis of randomized controlled trials of 15 plant-based diet interventions, Barnard et al. found that adherence to the diet for at least four weeks was associated with a mean weight loss of −3.4 kg [p = 0.011), pesco-vegetarians , vegetarians , vegan . In a Southern California sample of Mexican Adventists [2 , and (2) significant decreases in waist circumference , and fat mass . Lastly, LLU faculty adapted Adventist Health Study findings to the design of a pilot plant-based diet intervention trial that enrolled 32 Mexican T2DM patients from community clinics in a federally designated medically underserved area of Southern California (San Bernardino County) [1C of 1.2%) [For the purpose of systematically adapting a plant-based diet intervention for Hispanic/Latino patients at high risk for cardio-metabolic disease, our group at Loma Linda University (LLU) undertook a series of pilot studies ,7,8,9 toventists , the Advof 1.2%) .p < 0.001) [For the scalability of interventions in disparate populations, the National Institute of Minority Health and Health Disparities proposes a conceptual framework that involves engaging multiple domains of influence over the lifespan , sociocultural, and health care system ) . For the< 0.001) .The overall aim of our mixed methods evaluation of the adapted HELP program  was to assess programmatic effectiveness and sustainability in reducing pediatric obesity by educating children ages 5–12 and their families about plant-based eating habits and physical activity . The specific aims are as follows: (1) To examine whether the HELP intervention prevented an increase in adiposity levels in obese/overweight children, (2) To examine whether the HELP intervention decreased adiposity in obese/overweight parents, (3) To determine strengths, weaknesses, opportunities, and threats to the HELP program effectiveness and viability through a stakeholder analysis of program staff.In 2010, the Department of Family Medicine and Diabetes Education of Adventist Health White Memorial (AH-WMMC) Medical Center adapted and implemented HELP to be a culturally tailored plant-based diet and physical activity intervention for pediatric obesity in Hispanic/Latino families. At AH-WMMC, HELP was delivered through a highly successful model of culturally responsive care that was developed, implemented, and disseminated by AH-WMMC in 2008 ,22. We wAH-WMMC created an innovative modular curriculum for training of providers , medicalStudy Population. Participants were enrolled in the HELP program using the following inclusion criteria: (1) a child ages 5–12 years, with body mass index (BMI) percentile ≥85% by CDC guidelines , (2) oneDuring 2010–2018, children and their family members were encouraged to participate in the program together. No family members were excluded. During this period, three hundred and forty-eight children participated in the program along with an additional 194 non-referred children . Curriculum and data collection methods changed post 2015; hence, only participants enrolled in the HELP program from 2016–2018 are reported (52 referred children and 98 adults). Of the 52 children who were referred to the program due to meeting inclusion criteria, two were measured at < 85th percentile at the baseline visit but were not excluded from the program evaluation.The HELP Intervention was adapted to deliver culturally tailored plant-based diet guidance. The 5 month intervention included an intensive 6 week educational phase (6 lifestyle change modules) followed by a 3 month maintenance phase and program graduation. The dietary intervention consisted of cooking instruction and supermarket tours to implement a four tiered  food guide to plant-based eating . The fooA further adaptation of the original HELP program consisted of interactive hands-on cooking classes conducted by expert bilingual staff (three registered dietitians/certified diabetes educators) from the local community. The programs focused on teaching culturally tailored plant-based nutrition: how to eat a healthy diet and how to cook plant-based healthy recipes. The interactive cooking classes allowed the participants from the community not only to learn about healthy eating, but experience it by participating in the cooking process, touring the supermarkets, and tasting the samples as part of the education. All of the program educational materials were specifically developed for the targeted community with language considerations.Furthermore, all cooking demonstrations were designed with the target population in mind, where recipes were carefully aligned with the traditional fare of this community. The educators took special care to ensure that the recipes taught in the program included only those ingredients that were easily accessible in the local neighborhood markets, making the program recommendations easily attainable. This means participants did not have to alter their shopping habits and go out of their community to go grocery shopping. This is of particular importance as many in this community do not own a car, therefore having to drive or take a bus to a whole foods store would create an additional burden for this community. Instead, they could shop in the same neighborhood markets. The resources for healthier meals were easily available in their own community.The physical activity intervention included a physical activity pyramid and pedometer measures that were designed to help parental/guardian participants monitor their and their child’s progress toward achieving pedometer goals . For each parent–child dyad, height (by stadiometer) and weight was measured during program sessions (six times during the 5 month follow-up). A food and activity diary was recorded by the parent to monitor their and their child’s progress towards improvement as measured by the tiered food guide . The metThe HELP Quantitative Outcome Measure is described. The goal of the HELP program is healthful lifestyle change. We tracked BMI by taking each child’s and each adult participant’s weight and height. HELP is a 6 consecutive week program with a 3 month break between week 6 (module 5) and graduation (module 6). We take their weight and height at either Orientation or module 1 (week 1 or 2), and at module 5.Participants. During May 2018, semi-structured interviews were conducted with six key informants who possessed valuable insight about the HELP Program at White Memorial Medical Center (WMMC). These six key informants consisted of an interdisciplinary team . Four of the team members  had specifically designed, culturally tailored, implemented, and modified the intervention during 2010 to the present. The two remaining team members  were chosen for their technical knowledge of diet and diabetes in patients in the catchment area.Interviews. All participants provided written informed consent. The following four interview questions were developed by the Center for Health Research at School of Public Health, Loma Linda University to evaluate the sustainability of the HELP Program: (1) What are the strengths of the programs to introduce more plant-based eating into the diets of Hispanic/Latino obesity or T2DM patients being treated at AH-WMMC? We would like you to refer to cooking classes, supermarket tours, and diet counseling if possible, (2) What are the weaknesses of the programs to introduce more plant-based eating into the diets of Hispanic/Latino obesity or T2DM patients being treated atAH-WMMC? (3) What opportunities are present and need further development in the programs to introduce more plant-based eating into the diets Hispanic/Latino obesity or T2DM patients being treated at AH-WMMC? (4) What are the threats that exist to continuing development of the program to introduce more plant-based eating into the diets of Hispanic/Latino patients with obesity or T2DM being treated at AH-WMMC? The interviews with consented participants were held over the telephone during business hours and lasted 20–40 min. All interviews were digitally recorded (with participants’ consent) and transcribed verbatim. The interviewer reviewed the transcripts to ensure no content was lost during the transcription and to clarify any questions.Qualitative Analysis. We used classic grounded theory to design a qualitative program evaluation that followed a minimally prescriptive approach that allowed themes to emerge from the data. Our rationale was that a family-based, culturally tailored, plant-based diet approach to treating pediatric patients with obesity is quite novel. Our qualitative evaluation of the HELP program will allow us to gain an in depth understanding of how this type of novel intervention can be implemented in a series of RCTs at the T2 to T4 level of intervention. The interview transcripts were entered into QSR International’s NVivo 11 qualitative data analysis software. Open and axial coding was used to analyze the data and identify emerging themes.Outcomes. To assess the effect of the intervention on adiposity in the child and adult we conducted a quasi-experimental, one group evaluation to measures changes in BMI from baseline to week 6 . The primary outcome was the modified CDC Z-score for a child’s BMI . Since 2Analysis. Linear mixed models with main effects of time, gender, age, cohort year, gender by time interactions, and subject-level random intercepts were used to model the change in BMI in adults and BMI z-scores in children from baseline to post intervention. BMI and BMI z-score contrasts from these models were computed to specifically investigate the main effect of follow-up time (baseline to post intervention). Interactions of this main effect with gender were also considered in exploratory analyses. All analyses were done using SAS Software (version 9.4)  and R version 3.1.1 .Ninety-eight adults  and 52 children  were referred to the HELP program from 2016 to 2018. Ninety-three of the adults (98%) were classified as overweight or obese BMI ≥ 25) when measured at baseline. Fifty of the children (96%) were classified as overweight or obese (BMI ≥ 85th percentile or BMI Z-score > 1.04 by CDC guidelines [ when mean = 50), there was a slight decrease in modified BMI Z score  from pre- to post-intervention . No significant effects were found for gender, age, cohort year, or a time by gender interaction.For children who were ages 5–12 years and overweight or obese (n = 93), there was a slight decrease in BMI (p = 0.06) from pre- to post-intervention of 0.21 kg/m2. No significant effects were found for age, gender, or cohort year, but we did find a significant interaction of time by gender (p = 0.047) that is depicted in 2, 95% CI for the difference (−1.33 to −0.18), p = 0.01), as compared to women , p = 0.30).For adults who were overweight or obese  of the participants highlighted that a plant-based diet is not common in this community. This presents challenges and opportunities of getting the community members to accept the plant-based diabetes education and to buy into a plant-based diet program considering how presently the community residents are not inclined to the vegetarian diet. Despite this, the key informants felt that the past experience with the program being well tailored to the community resulted in a positive response from community members: Subtheme #1b: Positive community response to the current program.“I get families telling us how thankful they are and how they benefited, how they didn’t know that what they were giving to their children was bad. How kids are now telling the parents how to eat better or not to buy certain products because that’s what they learned in class… Children are at a time in their life where the changes are going to be more permanent if we reach them, because they are more willing to learn.”Four of the participants referred to the positive response from community members to the program being offered. One of them who is involved in coordinating the program shared positive feedback she received from the program participants, expressing gratitude: Theme #2: Lack of awareness among community members about the program offeredFour of the participants shared that one of the challenges of the program was that the community members were not well informed on the availability of classes or on what diabetes education entails. Patient education on diabetes and obesity, while available on a one-on-one basis, may not reach every patient. Two participants stated that not all patients have the access to providers who know about the program and can provide a referral to take the diabetes education classes.“Anybody can get that (diabetes education) as long as they have some sort of insurance coverage…Whichever patients have access to the educators, they will get the … education.”“I think maybe the only struggle would be to get the word out there, (get) people informed so we get bigger classes, a bigger population coming to get educated”.One key informant who is among chief instructors for the programs expressed that classes have room to grow so more of the population would be able to benefit from them: Theme #3: Lack of teen-focused programs“I wish I had a teen program because ours (program) only runs from five to twelve…. I am a true believer of children’s programs because I think children are at a time in their life, for their changes are going to be more permanent if we reach them because they’re more willing to learn. The adults aren’t but children are more open and teens because there is a really, really great need that’s when a lot of the social the environment comes in and they really, really need that help.”One of the key informants expressed a concern that there is not a next level of the child obesity program for this community, so that as the children transition in age, they could remain in the chronic disease prevention program and continue getting this support: Theme #4: Culturally Tailored Interactive Program Conducted by Competent StaffIt’s not only good for me, it’s easy to cook, it tastes good, and I am able to purchase the items at my local market.”Another emerging theme was that culturally tailored interactive programs conducted by competent staff, as is done at AH-WMMC, resulted in greater acceptance by the community. As one of the participants stated: Subtheme #4a: Cultural Tailoring“I did a lot of recipes that were familiar; they were Latin recipes they would bring to me, and I would turn them into healthier versions of their favorite recipe…I believe, that was well accepted.”Five of the key informants discussed in detail the cultural tailoring of the program and this appeared to be one of the largest reported strengths of the program. This means they could continue to enjoy familiar foods but now made with healthier ingredients: Subtheme #4b: Tailored Educational Materials“they are easy to follow”.In addition to cultural sensitivity, the educational materials developed for these programs reflected the low literacy level of the targeted population and included pictures, and as one of the participants stated: Subtheme #4c: Competent personnelTwo of the key informants felt that having competent experienced staff  conducting the programs contributes greatly to the overall strengths of the HELP program.Theme #5: Administrative and Financial Support is Necessary for the Success of Community ProgramsAnother important emerging theme that has the potential of becoming a barrier or the advantage to the diabetes prevention programs at AH-WMMC is related to the administrative and financial support of the programs.Subtheme #5a: Leadership Support“it’s the first time that the hospital has really taken on to fund our programs, in the past it was all done by grants…. The hospital is pretty much on board that this is an extremely important program and that diet definitely makes an impact for diabetes and pre-diabetes.”. On the other hand, a third respondent felt less certain about internal funding for the future of the program and emphasized the importance of recognizing the importance and challenges of lifestyle interventions for disparate populations  when making decisions on resource allocation and marketing. For marketing the hospitals nutrition programs for pediatric obesity, the third respondent expressed the opinion that a more hospital-specific plan  would help them get the availability of the nutrition program better disseminated to the community being served.Two of the respondents identified an important source of support provided by the hospital administration for the nutrition program: Subtheme #5b: Financial Support“Can we have more diabetes educators, can we even keep the ones that we already have and then the ancillary staff that we need to run these types of programs”.All six responded reported that a lack of consistent funding to the programs was a key weakness/threat to the programs. As community health programs do not bring in revenue, all the key informants expressed concern about their sustainability. Lack of funding for space rental and materials as well as inability to expand programs were among some of the reported concerns. One of the participants was encouraged about the hospital providing the program funding for the first time during this year, as in the past traditional grant funding resulted in lay-offs once the funding ran out. More diabetes educators are needed to sustain and expand quality programs, but the current staff’s concern is whether they will be able to keep who is there now: Given the type of programs offered, two of the key informants referenced the use of grants for past funding and felt that there are multiple grants that could be sought after to sustain these programs in the future. The concern however, expressed at the same time, is that when the programs are funded by grants, it means the funding is limited to a time-period, and once it runs out, the programs may have to stop.Our findings from the HELP program indicate that for Hispanic/Latino children who were overweight/obese and lived in a medically underserved region of East Los Angeles, a culture-specific, family-tailored plant-based diet intervention prevented a significant increase in adiposity as measured by BMI Z-score. The family-based intervention also helped with weight management in their overweight/obese parents/caregivers, particularly in the males. Several aspects of HELP program findings reported here are noteworthy: (1) The plant-based diet intervention was not based on enforcing a strict adherence to vegetarianism, but instead promoted a tiered approach to following a pattern that emphasized incorporating whole plant foods with minimal processing , (2) The intervention allowed semi-vegetarian patterns, (3) The intervention improved weight management outcomes in both child and parent, (4) The plant-based diet intervention was administered by a multidisciplinary team that worked within a culturally responsive intervention model that made the intervention diet both culture-specific and family-tailored .Promoting Culture-specific Plant-based Diet Choices without using Dietary Pattern Labels (“Vegetarian”)Our findings indicated that completion of the adapted HELP program that included a component that promoted increasing plant-based food choices  was an eFrom the standpoint of translation to a high risk disparate population for cardio-metabolic disease, we note that our findings move beyond promoting plant-based dietary pattern labels  into the potentially more impactful domain of promoting culture-specific, familiar choices of whole plant foods with minimal processing from the tradition of pre-Columbian Mesoamerican Diet ,28. This1c in T2DM patients [Our qualitative work with the HELP staff identified the positive effect of a cultural tailoring of the choice of plant foods that was implemented through culturally responsive staff and family-tailoring of the recipes. This finding is consistent with findings from other interventions for Hispanic/Latinos. For example, Santiago-Torres et al. developed a “Traditional Mexican Diet Score” (MexD) that quantified a three sisters pattern  from dietary survey data from Mexican women and found the MexD score to be inversely related to inflammation (hsCRP) and insulin resistance . In theipatients . Studiespatients .Household/Family Tailoring of the Diet to affect the Household Context of the Patient: The “Familismo” Effect ,32,33p = 0.043) over time for behaviors such as self-managements in diet, exercise, and diabetes care compared to the control group (based on Diabetes Self-Care Activities Questionnaire) [The “Familismo” Effect  in the Honnaire) ,34. Thisonnaire) ,34.T2DM patients who specified family participation as a motivating factor for making healthier lifestyle choices experienced a 1.4%–1.7% reduction in HbA1c in diabetes self-management studies . AdditioWe note the major limitation of our evaluation is the quasi-experimental design in a small sample where we do not have a control arm to isolate the dietary treatment effect. The findings herein need investigation in a randomized controlled trial that has a sample size that allows consideration of individual and family effects. Additionally, we note the issues of validity and reliability of the diet and physical activity measures.Findings from HELP provide preliminary evidence that a culture-specific, family tailored intervention delivered in the context of culturally responsive care by a health care organization can be an effective intervention for pediatric and adult obesity in Hispanic/Latino families in a medically underserved region. HELP intervened on multiple domains across the life course of the NIMHD Research Framework: Biological (caregiver-child interaction), Behavioral , Built Environment (Supermarket Shopping), and Health Care System (Provider–Patient) . Further


Physical activity (PA) is recommended for people living with heart failure (HF). Despite evidence of its benefits, participation in PA is low in this population, putting them at risk for loss of functional independence and additional health burdens. The aim of this pilot study was to ask older adults living with stable, chronic HF to identify strategies to support regular PA. Patients in an outpatient HF rehabilitation program were recruited to participate in focus groups about their PA knowledge, attitudes, and preferences as part of a stakeholder engagement project. At the beginning of the focus group, participants completed a questionnaire listing 8 potential strategies to optimize PA, and were asked to identify the top 4 strategies that they thought would be most beneficial to support regular PA participation. This was the focus of the current analysis. Thirteen adults with HF  were enrolled. Top-rated strategies endorsed by participants to support long-term adherence to PA included provision of an exercise guide to support home-based exercise and supplement health provider-supervised exercise sessions (69%), group education classes (64%), completion of fitness assessments at regular intervals (62%), and provision of a transition pathway from an exercise rehabilitation program to a community-based exercise program (62%). The remaining strategies were endorsed by fewer than 50% of participants, and included remote delivery and support options. These results have important implications for future program development and implementation efforts to support PA among older adults with stable, chronic HF.


China has initiated a tree planting program in epidemic regions of schistosomiasis as a part of efforts to eliminate schistosomiasis. More than 518,900 ha of tree plantations have been planted through the program between 2006 and 2015. However, whether the planting program has fulfilled its mission or not is an open question. In this study, we intended to get the answer from the main stakeholders of the planting program through a large-scale survey. Based on interviews with 80 administrators of the planting program and 1440 farmers in 24 counties and districts in four provinces, we found that most stakeholders viewed the planting program positively. Nearly 92% of farmers and all administrators believed that the planting program had reduced snail densities, while 94.3% of farmers and all administrators believed that the program had lowered the incidences of schistosomiasis. In addition, they reported that the impacts on farmers’ living and local environments by the tree planting program were mainly positive. Based on the stakeholders’ responses, we conclude that the tree planting program has been perceived by the main stakeholders as an effective environmental control measure of schistosomiasis. However, certain places and people that may be impacted negatively by the program should be given more attention when implementing the program. Schistosomiasis is a parasitic disease that affects millions of people worldwide. According to the World Health Organization (WHO), schistosomiasis was reported in 78 countries, and 220.8 million people required preventive treatment in 2017 .Schistosoma japonicum). Before that, the parasites infect certain types of freshwater snails  as miracidia hatched from eggs contained in feces of patients and sick animals [Currently, the WHO is leading a preventive chemotherapy campaign globally to control schistosomiasis. However, to eliminate schistosomiasis requires effective means to stop the transmission of the parasites (Schistosoma) besides chemotherapy . People  animals . Various animals ,7. In ad animals ,9. Other animals . For exa animals ,12. Ther animals ,14. A mo animals ,16. They animals .While significant progress has been made in controlling the transmission of schistosomiasis, some issues also surfaced during this process. Applying chemicals to kill snails and cercariae carries the risk of increasing chemical resistance of the vector and the parasite  and the Populous spp.) or Chinese wingnut (Pterocarya stenoptera). The site-preparing activities and growth of trees can change the microclimates and soil moisture conditions in snail habitats. Researchers observed the lowered water table, changed light conditions, and restricted growth of weeds in plantations in field experiments [An environmental control measure that was officially started in China in 2006 has the potential to address these limitations. The government supports local farmers and private enterprises to grow tree plantations in epidemic zones of schistosomiasis in China. Species used for planting usually are fast-growing timber or pulp tree species such as poplars  What were the stakeholders’ views on the effectiveness of the program to lower the snail density and the incidence of the schistosomiasis? (2) How did they view the impacts of the program on farmers’ living and the environment? (3) What factors would affect farmers’ participation in the planting program? Through the study, we found that the planting program was generally viewed as an effective way to control snails and reduce diseases. It had positive impacts on farmers’ incomes and local environments. The financial statuses of farmers affected their participation in the program significantly. In the rest of the paper, we presented the details of our study and the main findings.We chose Hunan Province, Hubei Province, Anhui Province, and Sichuan Province as the study area. All four provinces have been classified as schistosomiasis epidemic zones by the Chinese health administration. By the end of 2015, 408,559 ha of tree plantations have been planted by the program in these provinces, accounting for 73.8% of the total areas planted nationally. We selected six counties or districts that have implemented the planting program from each province to survey .Two questionnaires consisting of multiple-choice and open-end questions were designed in this study: one for administrators and one for local farmers. The interview questions for the administrators included three sections. In the first section, administrators were asked about their positions and knowledge of schistosomiasis. In the second section, they were asked questions on the primary control measures of schistosomiasis used in their counties or districts. Questions on the effectiveness of the tree planting program were asked in the third section. Administrators were asked to assess the impacts of the planting program on snails, schistosomiasis, the environment, and local farmers’ incomes.Interview questions for farmers also included three sections. Demographic and socioeconomic information about the participants was collected in the first section. In the second section, the participants were asked about their knowledge of schistosomiasis and controlling measures. In the third section, the participants were asked questions about the planting practices and the effectiveness of the planting program.We tested the two questionnaires in four counties in Sichuan Province before the formal survey. These counties were different from the counties included in the formal survey to avoid biases. Based on the responses from the investigators and participants in the pilot study, we modified the questionnaires to remove questions that could lead to ambiguous or uncertain answers. The final questionnaire for administrators had 11 questions, while the final questionnaire for local farmers contained 18 questions  using the survey data of farmers. The family’s participation in the planting program was treated as the response variable, which has values of 1 (participated) and 0 (did not participate). The number of labors, family incomes, knowledge of schistosomiasis, participation in other controlling measures, and the use of lands prior to tree planting was treated as explanatory variables . Since tt = -0.809, df = 22, p-value = 0.4271).Between 2006 and 2015, a total of 143,294.7 ha of tree plantations have been planted in these counties and districts. The average area of plantation planted in a county or district was 5970.6 ha . Snail habitats in 17 counties and districts have declined, while an opposite trend was observed in seven counties and districts . The PeaIn total, we interviewed 80 administrators and 1440 local farmers in 24 counties and districts. After the quality check, we kept all 80 forms for administrators and 1218 forms for local farmers for further analysis. Among the 1218 local farmers, 707 has participated in the planting program. The demographic and socioeconomic characteristics of the local farmers were summarized as follows . The numAmong administrators, 42.5% indicated that they were very familiar with schistosomiasis, while 33.75%, 21.25%, and 2.5% indicated they were familiar, relatively familiar, and less familiar with schistosomiasis, respectively. Among local farmers, 59.52% of respondents could correctly identify all five prevention measures of schistosomiasis. The percentages of farmers that could correctly identify four, three, two, and one prevention measures were 20.03%, 13.05%, 6.07%, and 1.31%, respectively.The administrators and local farmers primarily expressed similar attitudes toward the effectiveness of the tree planting program .The farmers’ answers to the question regarding the primary benefit and issues of the planting program concentrated on several items . Fewer p2 (random effect) was 0.662, while the marginal R2 (fixed effect) was 0.08. All these indicated that the odds of participating in the planting program was affected more by the county than by other explanatory variables.The result of the GLMM model showed that the family income and the farmer’s belief that plantation could effectively reduce grazing significantly influenced a farmer’s participation in the planting program . The varThe changed inputs in fertilizers, pesticides, and use of machinery reported by farmers who have participated in the planting program showed a mixed pattern .Snail habitats in most counties and districts have declined between 2006 and 2015. There were seven counties and districts that had the opposite trend. A close look showed that the adjustment of administrative boundaries of these counties and districts during this period was the main reason for this countertrend. Villages or townships with areas infected with snails were later put under their administration. The correlation coefficient indicated a negative but not statistically significant association. The lack of significant association between the areas of plantations and changes in snail habitats was expected because the program was only part of an integrative package of measures used to control snails. The finding supported our early suggestion that it is inappropriate to simply attribute the declination of snails or incidences of disease in these counties or districts to the planting program.Our results showed that the participants in our survey had a good knowledge of schistosomiasis diseases. Around 76% of administrators were very familiar and familiar with the matter, while around 80% of local farmers had good knowledge of disease prevention. This result showed that the education and outreach program on schistosomiasis has achieved good results in these counties and districts. This observation supported an early finding that health education on schistosomiasis prevention in China is effective . It alsoThe majority of administrators and farmers believed that the planting program has helped to lower snail densities and incidences of schistosomiasis diseases. The farmers’ answers regarding the main benefit of the planting program further corroborated this point. “Reduce disease” and “Reduce snails” were ranked as the third and the fourth among all citied primary benefits. Lowering snail densities and incidences of schistosomiasis are two main justifications proclaimed for the planting program . The perIn addition, the majority of the administrators and farmers believed that the planting program has reduced grazing in the infected areas. This observation was further verified by the farmers, as they ranked “Difficult for grazing” the third place among main problems caused by the planting program to farmers. Raising livestock in the infected areas, especially buffalos, constitutes a significant contributor to the epidemic of schistosomiasis in China . The treOn the ecological impacts of the planting program, the administrators again held a more favorable view than the farmers. More than 80% of administrators believed that the main impact on floods was to protect dikes, while only more than 60% of farmers had the same view. The view on the impact on wildlife showed a similar pattern. Furthermore, more than 20% of farmers did not select any of the three impacts of the tree planting program on floods. The same number of farmers did not think that the planting program has caused changes in wildlife. These divergences can be caused by the different availability of information to administrators and farmers. It could also be caused by the lack of professional knowledge needed for judging these benefits among farmers, e.g., wildlife identification skills and knowledge of flood engineering. A small percentage of administrators and farmers reported that tree planting could affect the flood flow path and caused sand sedimentation. However, a field study found that poplar plantations actually caused less sedimentation than reeds , which wThe main benefits and problems of the program expressed by the farmers were mostly in agreement with their choices above. One notifiable point is that farmers listed “Improve the environment” as the top benefit and ranked “Improve air quality” in the fifth place. These are co-benefits of the planting program. Several studies have shown that tree plantations planted through the program can help to improve environments and clean air ,27. ThesThe GLMM fitting result showed that the random-effects variance (between counties) was more than the fixed-effects variance. This was understandable because each county made their own policies to decide who could participate in the planting program and the level of subsidization given to participants. However, two factors were significant at the individual level, i.e., the annual family income and the perception of tree plantations as the most effective way to control grazing in the infected area. Growing tree plantations requires investments in tree seedlings, fertilizers, pesticides, and management. Comparing to conventional farming, the upfront cost of tree planting was much higher. In addition, due to the long growing time of trees, farmers cannot get immediate returns. These factors were displayed in farmers’ ranking of the main problems of the program. “Reduce income or slow return” and “Need investment” were ranked as the top and the fifth place, respectively. There is a danger that the planting program may favor families in better economic situations more than poor families. Especially when the poor families relied on the land for incomes, the program might deepen the income inequality by denying them the access to the land. Other large-scale afforestation projects have already been found to contribute to income inequality in rural China . This isThe number of labors in a family did not have a significant effect on farmers’ participation in the planting program. This indicated that the program would not increase labor demands from the participated families significantly. In contrary, “Lower labor intensity” was ranked the sixth among all benefits. Knowledge of schistosomiasis and participation in other controlling measures also did not affect the participation significantly. This might suggest that farmers’ participation in the planting program was more from a utilitarian view rather than a disease prevention view. The negative association between the participation in the program and the number of use types of the lands for other purposes, even though not statistically significant, added supports to this observation. All these observations attested to the importance of economic factors in schistosomiasis control .The changes of agricultural inputs by farmers who have participated in the program showed a mixed pattern. Almost an equal number of farmers reported increased or decreased use of fertilizers and pesticides. This seemly contradicted pattern reflected the diverse uses of the lands before planting trees. For families that used the lands for low-intensity production activities such as for animal grazing, growing tree plantations would increase their inputs. However, for those who used the lands for more extensive farming activities such as growing crops and vegetables, conversion to tree plantations could lower the inputs of fertilizers and pesticides. The more uniform opinion that the tree planting program could reduce the use of machinery was due to the fact that machinery was less needed when trees grow up.In summary, by surveying the main stakeholders of the tree planting program, we found that their responses support the justifications used to initiate the program. The program has been perceived to reduce snail densities, incidences of schistosomiasis, and grazing in the infected areas. While achieving these goals, the program was reported to have mostly positive impacts on the farmers’ income and environments. However, our study also revealed some impacts that require more attention. The negative impacts on floods and wildlife observed by some stakeholders need to be further studied. The significant influence of the annual family income on participation in the program brought the concern on whether the program will increase income inequality in rural areas. While these are not significant issues for the program as a whole, they might cause adverse impacts to certain groups of people and planting sites.As the first large-scale study on the effectiveness of the tree planting program, our study has provided vital information to gauge the success of the program and its potential inclusion as a tool for controlling schistosomiasis. However, our study has limitations. First, we were only able to conduct a cross-section study. A longitude study tracking the before-and-after changes will be more ideal. We wish that the government will consider setting up a longitudinal study in the next stage of the planting program. Second, we have to rely on the administrators’ and farmers’ observations to assess the impacts of the planting program. This will inadvertently add subjectivity to our results. It will be more rigorous to quantify the impacts of the planting program through controlled studies. Nevertheless, to conduct controlled studies will be a real challenge, because it is unethical to prevent people from using other means to control the vectors and diseases other than planting trees.To eliminate schistosomiasis is a health goal set up by the international community. Environmental controlling measures play an essential role in realizing this goal. In this study, we assessed the effectiveness of using the tree planting program to control schistosomiasis in China through a large-scale survey. Our results showed that the majority of stakeholders viewed the tree planting program as a success. The program was credited for lowering snail densities and incidences of schistosomiasis in places where it has been implemented. The program was also found to increase farmers’ incomes and improve environments. While the mainstream view toward the planting program was positive, there were also concerns about its adverse impacts on environments and income inequality in certain places. More attention needs to be paid to these impacts in the future. Overall, our study showed that the tree planting program had addressed a number of limitations associated with the existing environmental control measures. Other countries and regions that face the challenging task of eliminating schistosomiasis may consider adding this control measure to their arsenals.


The movement of evidence-based interventions into routine institutional settings like nursing homes is challenging. Among non-pharmacological interventions to address behavioral problems of residents with dementia, Music and Memory (M&M), a popular individualized music listening program, has been shown to have potential to improve quality of life among residents. To examine facilitators and barriers to implementation and sustainability of the M&M program in nursing facilities, a statewide (online and mail) survey of nursing homes was conducted in Wisconsin where the statewide implementation of the program occurred. The response rate was 41% (N=161). Descriptive statistics and content analysis were conducted. Over 80% of facilities provided the M&M program, and 86% of them planned to continue the program. The majority of respondents found the M&M to be beneficial to residents but also reported that the program was not equally effective for everyone, and M&M was time and labor intensive. Barriers to sustainability were: lack of buy-in by direct care staff, use of technology, costs of equipment, inconsistent volunteers, and families not supportive or helpful. Facilitators were: support of facility personnel, family, and volunteers; observing positive effects of program, M&M training provision and support, family involvement, and accessibility of equipment. Targeted resident selection is needed to identify the residents most likely to benefit from the program to avoid possibility of increased agitation or discomfort. Careful consideration is needed for facilities to identify realistic costs, labor, and staff buy-in to promote success.


To address scholarly activity (SA) accreditation standards, the Michigan State University’s College of Osteopathic Medicine Statewide Campus System has offered the Association of American Medical Colleges’ (AAMC) Teaching for Quality Program for two cohorts of community-based faculty. The purpose of this paper was to describe the design and delivery of the customized program, the authors’ initial lessons learned, and their plans for further evaluation and dissemination.The authors customized the program to overcome the barriers typically faced by community-based program faculty learners through a graduate medical education (GME) consortium model. This was the first time this program was delivered in this mannerThe authors’ initial cohort of 19 learners successfully developed 15 projects, with two pairs of learners collaborating on projects. The second cohort of 15 learners developed 11 projects, with one pair of learners collaborating. The authors present a series of principles for community-based GME leaders striving to develop SA projects in their respective GME environments.The “consortium advantage” derived from entities such as the SCS may prove integral to efficiently coordinating SA project resources and knowledge across diverse GME systems. During recent years, graduate medical education (GME) in the U.S. has continued to experience substantial changes, most notably moving to a single accreditation system. Under this new system, graduates of both allopathic and osteopathic medical schools complete residency and/or fellowship training in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME).Many community-based residency programs have experienced considerable challenges meeting these new ACGME requirements, particularly those related to increased faculty and residents scholarly activity (SA) project expectations and compliance with the Clinical Learning Environment Review (CLER).To address SA accreditation standards, the Statewide Campus System (SCS) at Michigan State University’s College of Osteopathic Medicine (MSUCOM)The purpose of this paper is to describe the design and delivery of the program, the authors’ initial lessons learned, and their plans for further evaluation and dissemination. The authors will conclude with a series of general principles for GME leaders striving to develop projects at their respective SA environments.The SCS was founded in 1989 as a statewide consortium to improve the quality of Michigan osteopathic GME.The Te4QIdentify a gap in their QIPS education;Design a feasible QIPS project to address that gap;Conduct the project and assess its impact; andProduce a SA poster, article, or presentation concerning their project results.This overall training program sequence is illustrated in Figure 1.During the original planning process, the SCS Office of Faculty Development recognized that program implementation through a consortium would present unique challenges  for both SCS “coaches” and faculty learners. Additionally, the authors recognized that the program would need to be customized to overcome the barriers typically faced by community-based clinicians conducting SA projects. Therefore, they proposed the following modifications to the delivery of the program to central AAMC office faculty who were especially supportive:Program resource identification. The authors customized the Te4QArticulation of program time commitment. The SCS leadership presented to its Education Standards Committee and Governing Board a detailed timeline, complete with monthly time estimates to which learners would need to commit. As both committees were comprised of leadership from each member hospital, this step was essential to ensure that learners’ institutional leaders would understand and be supportive of the commitment required for their faculty to complete the program. Program applicants were then required to complete a four-page learning contract, committing to the program time expectations.Common QIPS knowledge base. Acknowledging that learners would attend this program with a variety of pre-program experiences, the authors devised a plan to establish a common QIPS vocabulary for program communications. Learners were encouraged to complete two Institute for Healthcare Improvement (IHI)SCS faculty coaches. The SCS Office of Faculty Development quickly recognized from learners’ pre-workshop self-assessment statements that most learners had never developed a prior SA project. The authors therefore identified themselves to serve as learner coaches for different projects based on the project focus and the coach’s areas of expertise.Narrowed project focus. SCS required program learners to select one CLERCommunication and resource accessibility. The authors worked to help ensure that learners would each have: 1) ready access to resources and materials for future projects, 2) a place to archive important project-related documents, and 3) a feasible mechanism to communicate with other learners and coaches. We therefore created an online course using Desire2LearnThis online course site became a repository of recent articles concerning SA in GME settings, resources related to IRB application and project design, project timeline and deadline templates, discussion boards for frequently asked questions, and drop boxes for important project documentation. The drop boxes also enabled coaches to offer ongoing guidance, consultation, and feedback based on what learners had submitted.The recruitment of Te4QWe have concluded that the overall process of promoting the program as an appealing GME investment primarily involved two simultaneous processes: a) obtaining “buy-in” from multiple system and residency program stakeholders, and b) adequately customizing the program to prove more feasible/appealing to potential community-based GME learners.In January 2015, applicants were notified of their program selection and provided a packet of pre-workshop assignments with completion deadlines and the contact information of their assigned coach. AAMC faculty primarily taught the workshop in March. Learners then worked with their coaches to refine their project, evaluate project feasibility, and prepare appropriate IRB applications.A follow-up webinar occurred that August with AAMC faculty, SCS coaches, and learners to provide a 10-minute status report on their projects. At the end of the program in May of the next year, learners disseminated their SA project findings at a regional poster day to earn completion certificates from both the AAMC and MSU.Our initial 2015-2016 cohort of 19 learners developed 15 projects, with two pairs of community-based faculty collaborating on two separate projects. Two learners withdrew from the program, one leaving the area for another GME position. Our second 2017-2018 cohort of 15 learners developed 11 projects, with one pair of participants opting to collaborate. Three learners withdrew from the program due to positional changes or competing GME position demands.To date, about 50% of program projects have been specifically oriented to testing the implementation, delivery, and evaluation of QIPS curricula and content for either residents and/or faculty. The remaining projects addressed specific aspects of healthcare delivery processes such as surgical suite waiting times, postoperative patient follow-up calls, opioid prescribing patterns, cross-shift resident handoffs, timely reporting of critical patient lab results, assessing patients for severe sepsis, and implementing a series of group visits for patients with complex diabetes management needs.Two projects involved education of residents concerning osteopathic manipulative medicine treatments. Those SA projects involving any protected patient health information were designed to have system Quality Improvement department personnel de-identify patient data to avoid HIPAA-related infringementsWe have identified the following principles for GME settings:1. Compiling resources and streamlining project design processes can reduce learner time commitment and increase their SA project engagement.Since community-based faculty are so often busy with patient care demands, prospective QIPS projects can be perceived as “just one more thing to be done”.In hindsight, it appears that those learners who utilized available program-related resources tended to have smoother project design experiences. It was, however, also especially evident that sizable variations existed across systems  which either facilitated or impeded successful project completion.The SCS Office of Faculty Development also reviewed overall differences in project design needs between primary care and specialist providers, the extent to which different learners wanted to obtain (or avoid using) protected patient health data. The authors have concluded that regularly assessing such differences across learners’ healthcare systems will be helpful for future Te4Q cohorts. Clearly, some learners preferred to be left alone after being provided a “critical mass” of project support materials, while others preferred to exchange project updates or engage in ongoing problem-solving discussions with coaches and colleagues.2. Helping learners attain a solid QIPS knowledge base may make them more confident and capable of completing SA projectsMost learners stated that the assigned pre-workshop IHI3. Providing assigned coaches with compatible project-related skills can serve to keep learner SA projects moving forward.The provision of coaches with compatible osteopathic provider, educational specialist, and project design expertise appeared to be critical for many learners during their early project planning. Similar to other settings, several program learners indicated that they appreciated most coach feedback, as well as the accountability they felt to complete project developments to provide periodic updates for their coaches.This paper summarizes the authors’ experiences of delivering the AAMC Te4QIt will very likely take several additional cohorts of learners for the authors to determine the sustainability of programs such as Te4QSeveral groups have suggested that the “consortium advantage” from such entities as the SCS may prove integral to more efficiently sharing SA resources and capitalizing on project-related expertise across diverse GME settings.The authors declare no conflict of interest.


Fall related fractures in elderly are one of the most serious health problems in the world. Due to the rapid aging of the elderly in Korea, elderly falls has emerged as a very important social health issue. Falls can result in injuries, a loss of confidence and a subsequent reduction in physical activity and community participant. This work was conducted by the Busan Metropolitan International Safe Community Program in 2018. Purposes The purposes of this study were to develop a community-based fall prevention program and to test the effects of the program on the postural balance and fall efficacy for elderly people.36 elderly were recruited from the community in Dong-gu district of Busan Metropolitan City. The program consisted of balance exercises, elastic resistance exercises and prevention education. Postural balance and fall efficacy were evaluated before and at the end of the intervention, using the Functional Reach Test (FRT), Timed Up & Go test (TUG) and the fall efficacy scale-K. The intervention was performed for twice a week in the senior center for 12 weeks. Data were analyzed using paired t-test using the SPSS program.Developed program was based predominantly on the social cognitive model of behavioral change to successfully increased activities participation in elderly. This program is very useful because it not only focuses on exercise, but participants also learn fall prevention strategies. There were significantly improved in postural balance  and fall efficacy (p<.001). This study suggests that this program can improve postural balance and fall efficacy in elders. Therefore, this program is recommended for use in fall prevention programs for elders living in the community.Injury, Aged, Accidental falls, Postural balance


The program is in its third year of implementation with the broader goals of enhancing resident knowledge of normal cognitive changes and cognitive impairment including risk factors for dementia. The emphasis is on engaging residents to improve brain health. With staff, goals are to enhance their capacity to understand, identify, refer, and support residents with cognitive impairment. This is done with case conferences, consultation, lectures, and workshops. For residents, the program provides lectures, interactive workshops, films, as well as periodic “Ask the Doc” individual meetings where residents can discuss cognitive and related concerns. A geriatrician and geropsychologist conduct these activities with invited guest speakers including geriatric fellows. Yearly, approximately 180 unique individuals are served in this program. Resident program satisfaction surveys were favorable. For example, 80% of residents replied “a lot” to the question, “Did you find this presentation interesting?”, in the past six months of programming. Building on these efforts, we conducted a formal survey with 249 resident participants of one NORC that found: 15% have dementia/experience memory loss; 12% live with someone with dementia/ memory issues; 16% identify as a dementia caregiver; and 75% are concerned about developing dementia. We then hosted a community-wide forum to discuss survey results. Our experience has underscored the need for expansion of our efforts. Future plans include creating a “dementia friendly” NORC. Funded by the UJA-Federation of New York.


Immunization program monitoring includes numerous activities, some of which include monitoring of vaccination coverage, surveillance performance and epidemiological patterns. The provision of timely, high quality and actionable feedback is an essential component of strengthening health systems. Within the African region of the WHO, various bulletins are produced and disseminated regularly to provide feedback on the performance of immunization programs and vaccine preventable disease control initiatives.The 2019 annual national immunization program managers’ meeting for countries in the eastern and southern African subregion was held in Asmara from 18 - 20 March 2019. A survey questionnaire was administered to the participants representing the national programs and in-country partners across the 20 countries.On average, the 75 respondents receive 1.8 e-mailed feedback bulletins monthly. Twenty-three (31%) respondents receive 3 or more written feedback bulletins per month, and 72% receive the bulletins regularly. On a scale of 1 - 5 (from lowest to highest), 87% participants rated the relevance of the bulletins they receive at 4 - 5. Only 19% of the respondents responded that the results are discussed within the national immunization program, and 14% stated that action points are generated based on the feedback received. Fifty-nine (79%) respondents want to receive more frequent feedback on routine immunization performance. Among the EPI program managers and the EPI program data managers, the access to these feedback bulletins was quite limited. Even though the primary objective of the bulletins is to initiate discussions and action based on the provided feedback, such discussions do not happen regularly at country level. The programmatic use and advocacy value of the bulletins is not optimal.We recommend integrating program feedback, regularly updating the distribution lists, the additional use of instant messaging platforms for distribution, as well as online posting of the bulletins for wider availability. The African Regional Strategic Plan for Immunization 2014 - 2020 (RSPI) maps out ambitious goals for improving access to vaccines and to eliminate targeted vaccine preventable diseases. The plan acknowledges the need to position strong immunization systems as an integral part of well-functioning health systems, and recommends corresponding actions for countries, one of which is to enhance the collection, triangulation and use of administrative, surveillance, risk assessment and vaccine safety data to improve performance of immunization services and complementary actions in tackling the disease burden . The devUsing programmatic data generated at the national level, the WHO African Regional immunization and polio eradication programs provide regional programmatic overview and feedback to national immunization programs during annual meetings, and periodic monitoring and evaluation exercises, in the form of written program summaries, presentations and reports. In addition, regular feedback bulletins are produced to monitor country progress against the targets and to present a comparison of performance between different countries. The primary aim of these bulletins is to provide a regular and transparent assessment of country performance, with a view to encourage progress, and indicate the need for course correction where needed. Within the African region of the WHO, the provision of written surveillance feedback is a recognized legacy of the polio eradication program –14. VariNational immunization and disease control programs regularly share immunization coverage and disease surveillance databases with WHO. Country program data on acute flaccid paralysis (AFP) surveillance, polio virology laboratory as well as measles case-based surveillance and serological lab data is shared weekly, while other vaccine preventable disease (VPD) surveillance databases  and immunization coverage monitoring data is shared monthly. The immunization program data management team at the sub-regional office of the WHO aggregates, cleans and analyses the data regularly with the relevant program officers in order to provide interpretation, prepare and disseminate feedback bulletins. These bulletins include tabulation, maps and charts as well as narrative descriptions covering data quality, immunization coverage, surveillance and laboratory performance, as well as epidemiological trends.The WHO African regional immunization program develops and disseminates more detailed and specialized feedback bulletins summarizing Regional performance across the 47 countries. These comprise of the weekly feedback from the polio program on the Acute Flaccid Paralysis surveillance performance and Polio Laboratory performance, monthly feedback on the measles and rubella surveillance performance, and the monthly routine immunization newsletters. While there may be some differences in the target audience of these feedback bulletins, the national immunization and disease surveillance program staff remain at the primary targets. Every year, the WHO and UNICEF Regional offices jointly organize a meeting of national immunization program managers, to share programmatic information and experiences, monitor performance against regional and global targets and goals and discuss scientific updates. These annual sub-regional level meetings are also attended by global and regional partners. The 2019 annual national immunization program managers’ meeting for 20 countries in the Eastern and southern African subregion was held in Asmara, Eritrea from 18 - 20 March 2019. The participants included immunization program managers, data managers, other national program team members, as well as national level partners from the 20 countries. A survey questionnaire was administered to the participants representing the national program and in-country partners across the 20 countries. The questionnaire focused on the programmatic feedback provided to countries from the WHO regional and sub-regional levels. The data was entered and analyzed using MS Excel.The questionnaire was distributed to 91 persons, and responses were received from 76 participants. One questionnaire was discarded because of incompleteness. Participants from all 20 countries in the subregion provided responses to the survey questions, with at least 2 respondents from each country in the subregion except Mozambique, which had only one response submitted. The 41 participants from various in-county partners were from WHO, UNICEF, John Snow Inc. (JSI), Clinton Health Access Initiative (CHAI), PATH and Aspen Management Partnership for Health . A third of the respondents had 10 years or more of experience with the immunization work at the national level. On average, the respondents receive 1.8 e-mailed feedback bulletins at least monthly. Twenty-three (31%) respondents receive 3 or more written feedback bulletins per month . The 15 The majority (72%) of the respondents receive the feedback bulletins quite regularly, while 18 get them irregularly. On a scale of 1 - 5 (from lowest to highest), 47 of 54 (87%) participants rated the relevance of the bulletins they receive at 4 - 5, while 42 (91%) of 46 respondents stated that the feedback bulletins were detailed enough in their content and rated them 4 - 5. With regards to how the feedback bulletins are received at the country level, only 19% responded that the results are discussed within the national immunization program, and 14% stated that action points are generated based on the feedback received . In the A major objective of providing written feedback to national officers, tabulating and mapping performance across multiple countries, is to allow immunization program managers at subnational and national levels to see their work within the bigger context of the Regional and global goals. In this regard, it is critical that they get accurate, timely, relevant feedback that also provides programmatic guidance and is followed up with the appropriate technical assistance. Currently, all of the immunization program feedback bulletins from the WHO African regional and sub-regional levels that are provided to the national level are shared by e-mail, and none of these bulletins are posted online, which limits the audience of the bulletins. The participants in this survey are the technical leaders and partners for immunization and VPD control work in their respective countries. Given that most of the respondents have been responsible for immunization activities for a number of years, it is expected that they are already familiar with the feedback processes and products. The majority of the respondents rated the feedback bulletins they receive as relevant and detailed enough. Despite this, our study has highlighted needs for improvement in the distribution and utilization of the feedback bulletins. Even among the EPI program managers and the EPI program data managers, the access to these feedback bulletins was quite limited. Only a third of the total respondents receive three or more feedback bulletins a month. The primary objective of the feedback is to monitor performance across multiple countries, with a view to initiate discussions and action as necessary. However, only 17 (23%) responded that such discussions happen regularly at country level. Only 21% of the participants responded that these bulletins are brought to the attention of higher-level decision makers, limiting the advocacy value of the bulletins.Periodically, countries are supported to do immunization program and/or surveillance reviews, and other similar in-depth program assessment activities to identify their strengths and weaknesses, and address gaps that hinder the attainment of program objectives. However, such exercises are resource intensive, conducted once every 3 - 5 years and cannot replace the frequent provision of program feedback. In many countries, the national immunization program and the surveillance / disease control program are in separate divisions within ministries of health. In such cases, the responsibility for VPD surveillance exists in a program outside of the immunization program. It is expected that these two programs work closely in terms of planning interventions, data sharing and impact monitoring among others. However, multiple national program reviews have identified gaps in information sharing and use in such contexts . In the With the adoption of Demographic Health Information Systems (DHIS2), countries are preparing to move into web-based real-time data entry and data management platforms that provide the functionality of generating automated dashboards as well as alerts and reports. However, the linkage of data outputs with programmatic guidance will continue to be relevant and will not replace the need for high quality program feedback . This isWritten feedback is a critical element for strengthening public health programs. The written feedback provided by the WHO on the immunization and vaccine preventable disease efforts in the subregion can be improved through the use of updated distribution lists, the additional use of instant messaging platforms for distribution, as well as online posting of program feedback bulletins for wider and longer periods of availability. In addition, bulletins should be better integrated and regularly shared with the inclusion of programmatic guidance to better guide countries towards the RSPI targets. National programs should create regular platforms to review performance widely across the immunization and surveillance programs, and explore ways of utilizing the feedback to improve data quality and overall program performance.Monitoring and use of data for action is one of the five pillars of the “Reaching Every District” approach;The provision of timely, high quality and actionable feedback is an essential component of strengthening health systems;The WHO Regional and Sub-regional levels share various emailed program feedback bulletins covering immunization and vaccine preventable disease control initiatives regularly.The various feedback bulletins from the WHO regional and sub-regional levels are not reaching all the key program staff at country level;All the national immunization programs are not regularly discussing the feedback results and generating action points based on the findings;There is a need to explore different approaches to widely sharing the feedback, and making it more useful and actionable for countries.The authors declare no competing interests.