Background: Despite increased support for voluntary medical male circumcision (VMMC) to reduce HIV incidence, current VMMC progress falls short. Slow progress in VMMC expansion may be partially attributed to emphasis on vertical  over more integrated implementation models that are more responsive to local needs. In 2013, the ZAZIC consortium began implementation of a 5-year, integrated VMMC program jointly with Ministry of Health and Child Care (MoHCC) in Zimbabwe.Objective: To explore ZAZIC’s approach emphasizing existing healthcare workers and infrastructure, increasing program sustainability and resilience. Methods: A process evaluation utilizing routine quantitative data. Interviews with key MoHCC informants illuminate program strengths and weaknesses.Methods: A process evaluation utilizing routine quantitative data. Interviews with key MoHCC informants illuminate program strengths and weaknesses.Results: In start-up and year 1 , ZAZIC expanded from two to 36 static VMMC sites and conducted 46,011 VMMCs; 39,840 completed from October 2013 to September 2014. From October 2014 to September 2015, 44,868 VMMCs demonstrated 13% increased productivity. In October, 2015, ZAZIC was required by its donor to consolidate service provision from 21 to 10 districts over a 3-month period. Despite this shock, 57,282 VMMCs were completed from October 2015 to September 2016 followed by 44,414 VMMCs in only 6 months, from October 2016 to March 2017. Overall, ZAZIC performed 192,575 VMMCs from March 2013 to March, 2017. The vast majority of VMMCs were completed safely by MoHCC staff with a reported moderate and severe adverse event rate of 0.3%.Conclusion: The safety, flexibility, and pace of scale-up associated with the integrated VMMC model appears similar to vertical delivery with potential benefits of capacity building, sustainability and health system strengthening. These models also appear more adaptable to local contexts. Although more complicated than traditional approaches to program implementation, attention should be given to this country-led approach for its potential to spur positive health system changes, including building local ownership, capacity, and infrastructure for future public health programming. As voluntary medical male circumcision (VMMC) safely –13 reducSlower than anticipated progress in VMMC scale up may be attributed to several factors including lack of consensus on whether to implement VMMC programs as vertical  or horizontal (integrated) models. Currently, vertical programs predominate as they were perceived to facilitate faster service expansion during the global, rapid scale-up phase by relying on donor-dedicated funding, workers and work spaces for VMMC –23. VertIn contrast, integrated VMMC services may operate in multi-purpose, public service delivery points where other health services are provided by the same healthcare workers . IntegraIn Zimbabwe, the Ministry of Health and Child Care (MoHCC) adopted a national strategy for VMMC scale-up for males ages 10–49 in 2009. Initially, vertical VMMC services were largely implemented in urban areas by one non-government organization employing a predominantly outreach model with independent, VMMC-focused teams, campaigns, and stand-alone VMMC clinics ,30. EarlIn 2013, the International Training and Education Center for Health (I-TECH) at the University of Washington, was funded by the Centers of Disease Control and Prevention, USA (CDC) through the US President’s Emergency Plan for AIDS Relief (PEPFAR) to try an additional VMMC approach: employ local partners and build health system capacity through integrated VMMC program delivery in direct partnership with the MoHCC, simultaneously promoting health system strengthening and community engagement. The ZAZIC consortium (an acronym developed with letters from each implementing partner’s name) is composed of three, local implementing partners . ZAZIC wZAZIC conducted a process evaluation of routine program implementation to assess the program during the first 3 years of operation, aiming to understand if the program was implemented as planned and if the results can be reasonably attributed to the ZAZIC model . This paZAZIC routine data collection, including program monitoring and evaluation (M&E) data used for this paper, comes principally from MoHCC VMMC monitoring tools, described in detail previously ,36. In bTo complement the quantitative data, additional information on the implementation model come from data collected, but not published, in a qualitative study of the influences of the performance-based financing (PBF) incentive conducted in October 2015. The overall PBF study methodology and the broader results from the PBF-focused research were published previously . In brieWithin the ZAZIC consortium, Zimbabwe-based implementing partners have primary responsibility for managing program activities, thereby encouraging local ownership through our country-led approach. ZAZIC works closely with Provincial Medical Directors (PMDs) and District Medical Officers (DMOs), those primarily responsible for health services delivery, to conduct VMMCs. These provincial and district leaders are integral to the development and adaptation of the model to meet community-level needs, in accordance with guidelines for differentiated care. For example, the mix of MoHCC doctors, nurses, and other auxiliary staff involved in VMMC service delivery may differ by district or by site and over time, conforming to changing needs and priorities. As each district and site has autonomy to operate the program and deploy staff based on facility needs, staffing is highly variable by site or day. ZAZIC estimates between 180 and 540 staff across districts may be involved with VMMC program in addition to other facility duties at any time. ZAZIC supports districts and sites with VMMC roving teams to fill staffing gaps when possible. Additionally, demand creation teams are members of the communities in which they work. They mobilize their communities using demand creation strategies (messages) and activities  adapted for the specific communities or age groups with whom they live and work.ZAZIC, in partnership with the MoHCC, implements standardized VMMC trainings in line with international best practices –44 incluFor service delivery, routine VMMC using surgical or PrePex device-based VMMC is managed by districts as part of routine service delivery and provided free to clients. Districts have between one and five static sites with outreach performed at distant satellite health centers or diverse community settings. The MoHCC’s national supply chain program largely provides VMMC-related supplies and commodities, including VMMC kits. VMMC services and supervision are implemented predominantly by existing healthcare staff. Health facility leadership work closely with DMOs to determine site-specific VMMC service availability at static and outreach sites complemented by occasional community-based campaigns. All men who come for VMMC are strongly encouraged to test for HIV by MoHCC counseling staff in the same clinic location prior to VMMC. HIV-infected patients are linked to care. MoHCC adheres to the WHO-recommended package of VMMC services ,46 when At all sites, ZAZIC uses national MoHCC forms for VMMC reporting through the district and provincial surveillance systems. During the first year as the program grew to scale, MoHCC and ZAZIC worked closely to develop and disseminate new MoHCC VMMC M&E tools which streamlined data collection to reduce redundancy and encourage data completeness. A register job aid contains clear instructions to help ensure correct form filling, including AE classification and severity. The Monthly Return Form simplifies national and donor reporting with fewer, targeted indicators that are integrated into the District Health Information System. Annual data quality audits (DQA) are conducted at a sample of ZAZIC-supported VMMC facilities to assess data quality , using aThe national VMMC program adopted a $25 per VMMC performance-based financing (PBF) system  to offseblended implementation model that employed additional non-MoHCC mobile and outreach staff to support MoHCC staff performing VMMC in a variety of locations, and enabling extended or weekend hours for VMMC service delivery. Third, VMMC trainings for additional personnel were expanded to increase the number of trained VMMC providers in priority districts. Fourth, ZAZIC expanded the reach of VMMC services by adding more outreach sites and reassigning vehicles from non-priority to priority districts, maintaining the proportion of VMMCs occurring in outreach sites at approximately 85%. Last, demand creation efforts were prioritized in rural areas, focusing on community-based entertainment activities such as soccer tournaments and music galas with a VMMC focus. New payment modalities for mobilization efforts were developed to incentivize mobilizers. Non-priority districts were not eligible for PBF payments and largely did not maintain VMMC services.In October, 2015, PEPFAR global strategy changed to focus on high HIV burden districts; in Zimbabwe, programmatic activity would focus only within the 36 sub-national units that, together, accounted for 80% of people living with HIV/AIDS . TherefoDuring the integrated implementation phase, from March, 2013 through September, 2014, ZAZIC expanded from 2 to 36 static VMMC sites and conducted 46,011 VMMCs: 39,840  were conducted from October 2013 to September 2014 (FY14). Over FY14, ZAZIC completed an average of 2654 and 3985 VMMCs/month in the first and second 6-month period, respectively, an increase of 50%. Subsequently, in FY15, an additional 44,868 VMMCs were performed (including 3452 PrePex), demonstrating a 13% increase in annual VMMC productivity. In the blended period, from October 2015–September 2016, productivity increased further with 57,282 VMMCs ), reflecting an overall 27.7% growth over the previous 12-month period with VMMCs performed at approximately 18 static sites. ZAZIC ramped up again from October 2016 to March 2017 and conducted 44,414 VMMCs in just 6 months by increasing the static sites to 24, adding additional demand creation officers and focused community engagement using soccer tournaments and music galas. This achievement exceeding higher donor targets and marked ZAZIC’s most productive 6-month period. Overall, ZAZIC safely performed 192,575 VMMCs from March 2013–March, 2017 during its first 3 years of operation .Table 3.Safety of VMMC clients was assured during this period of scale-up and transition with reported rates of adverse events (AE) remaining under 0.5% over the first 3 years  36]..36].The 14 MoHCC key informant (KI) interviews included: 1 Senior Health Promotion Officer; 2 Matrons; 5 Provincial Medical Directors (PMD); 4 Medical Superintendents; and 2 District Medical Officers (DMO). Results highlighted several strengths and challenges of the integrated implementation model.[VMMC] is a Ministry of Health program and in our case as local authority we have to toll the policy of the central government. The ministry took the program on board, and we also have to take the program on board. We have to create demand for the program and also create awareness in the community to increase the uptake of the program.First, it appears clear that local MoHCC staff feel ownership over the program. When asked their roles, responses were similar to this PMD who noted that his role was ‘the overall in-charge of all the programs in the district and one of them being the Voluntary Medical Male Circumcision.’ KIs were also likely to mention their primary roles in the entire VMMC process.Our partners think they are overall responsible for all the activities because they have got money, but we think that we should be overall responsible. We should decide how the program runs.Another KI noted his authority and ownership of the VMMC program more bluntly:The VMMC program is part of the Ministry of Health program so we make sure that everyone understands that [VMMC] it is part of hospital business…This means that we have integrated circumcision to our health services.Second, it seems that ZAZIC’s model is integrated into routine service delivery. KIs generally noted that, ‘integration of the program is not a problem. We will do as we normally do with other programs.’ The linkages with other HIV-related services is also evident as men found HIV-positive through testing as part of VMMC, ‘they can be easily referred and commenced on ART.’ Several KIs also noted similar directives to this respondent:[The VMMC program] it’s working very well, I think the team is working very well. There is lots of team work. We have many nurses who are trained in VMMC. It’s more of team work at the hospital because we have the nurses, clerks, administrators, and quite a number of people in the hospital involved.Last, MoHCC staff benefit from the VMMC trainings. One KI explained that staff VMMC training ‘is an additional skill and qualification’ while another mentioned that a program ‘advantage is that a number of staff has trained in this [VMMC] skill which is a lifetime skill.’ Others may believe similarly to this KI who noted the reach of program training and involvement:[VMMC] can be integrated with HIV testing and counseling since HIV testing and counseling is the main entry point to circumcision... Also circumcision is an HIV preventive measure. We could also take advantage of the STI clinics to talk about circumcision.KIs also provided several key insights into program challenges. First, several KIs suggested that further synergies between VMMC and other health interventions could be advantageous to demonstrate full integration of VMMC into routine service delivery. Recommendations included rolling VMMC messages into scheduled health education talks and encouraging providers in other clinic service areas to actively refer eligible men to VMMC as part of standard practice. Others suggested similarly to this KI:that we have done the job since anyone can access [VMMC] at anytime.’ A number of other KIs also mentioned VMMC decentralization efforts to extend routine service availability to more lower-level facilities.The biggest challenge is that this VMMC thing is outreach based. We want it to become part of the day to day business of every facility. If a nurse can do it from the hospital and go for outreach why can’t a nurse at that outreach clinic do it on a daily basis?Moreover, additional improvements in client access to VMMC were noted. One KI recommended that VMMC access should be available at all lower-level, static healthcare clinics, since that would demonstrate ‘There is staff attrition, a lot of movements among health personnel. You find that all trained doctors for VMMC…have gone so we need to re-train other doctors.Last, although KIs believed that the VMMC program strengthened staff skills, the related issues of worker attrition and staff movement reduced the effects of capacity building. To sustain a more full and consistent integration of VMMC services, several KIs noted the need for continuous opportunities for VMMC trainings to compensate for staff turnover. Additional trainings could also extend access by ensuring VMMC capacity at more rural static sites.This process evaluation helps demonstrate that ZAZIC largely implemented its model as planned and suggests that ZAZIC results may be attributable to its integrated and blended implementation model. ZAZIC successfully and safely conducted 192,575 VMMCs during its first 3 years of implementation. ZAZIC weathered an intense shock to the integrated model, resulting in a successful transition to a more blended program approach, demonstrating immense flexibility and adaptability. During implementation, ZAZIC also partnered with local government leaders to support service delivery with periodic community-adapted campaigns, demonstrating a collaborative, contextual approach to implementation in line with guidance for HIV-related differentiated care. Employing this model, overall ZAZIC performance these first years appears similar to early VMMC productivity from other predominantly vertical programs including Kenya, Tanzania, and South Africa ,50 and aVertical VMMC programs are often justified to achieve results quickly; however, ZAZIC shows that a more sustainable, integrated (or blended) model may achieve similarly. According to routine M&E data, ZAZIC’s recent achievements continue to demonstrate excellent progress towards MoHCC targets: by March, 2017, ZAZIC reached 90% of its semi-annual target as compared to 56% of the semi-annual target achieved by the other large-scale partner organization in Zimbabwe . ZAZIC aAmong the greatest accomplishments of the integrated and blended approach is that district teams independently completed approximately 85% of VMMCs due, in large part, to broad support from the district and provincial health leadership. Although additional mobile teams using non-MoHCC staff contributed to the success of the transition to only 10 districts, MoHCC appears to demonstrate program ownership and improved sustainability for the future. Demand creation adapted to local community engagement complemented this approach. Moreover, key VMMC indicators were incorporated into the national District Health Information System, showing integration of this program into routine service delivery and reporting requirements. Also, in 2014, the MoHCC adopted a task shifting approach to promote nurse-led VMMC for both surgical and device-based services, improving provider coverage for integrated VMMC activities. From DQA implementation and reported AEs, it appears ZAZIC oversight in combination with district-based implementation helped ensure progress towards greater protocol adherence, infection prevention, quality improvement, and compliance with safety standards in a manner that encourages sustainability of these efforts .Moreover, for routine service delivery, the integrated and blended model’s heavy reliance on the existing facility, staff, commodity and supply infrastructure, supplemented by PBF, appears to help reduce donor costs and incentivizes providers to incorporate VMMC into their schedules. The integrated model also relies on cost sharing: the healthcare workers who perform VMMCs and supportive services, facilities for service delivery, and logistics systems for supplies are provided by the MoHCC. Management and supervision, after start-up, are a stable ZAZIC investment to promote quality service delivery. Last, the PBF component, supported by donors and MoHCC, and managed by ZAZIC, encourages productive service delivery from local clinic teams as part of routine duties. Keeping healthcare workers in their workplaces potentially reduces disruption to district healthcare staffing or decreased clinic productivity.ZAZIC success is not without some formidable challenges, some due to its integrated model. First, we had a slower pace of scale-up than might be anticipated in a vertical approach due to the need for local buy-in, ownership, and intensive participation. The first 9 months of critical partnership building reflect this slower start-up period. Second, with the integrated model, physicians and nurses have multiple competing demands and equipment may be shared across departments. VMMC capacity is growing; however, staff training achievements are challenged by attrition and staff mobility. Reliance on practicing providers is also less well suited to the campaign approach that may generate large numbers in a short time period. Also, the integrated model largely relies on the existing health system for strategic information; revisions in the national VMMC reporting tools were needed to improve initial data quality and aggregation flow . For botWe qualitatively compare our integrated and blended program productivity to that of other more vertical VMMC programs in Zimbabwe and in the region, suggesting the success of this innovative model. We do not detail program implementation of a vertical model. More rigorous quantitative comparison between integrated and vertical programs was not undertaken as part of this process evaluation of routine program implementation. As an implementing partner working at scale, we are restricted from engaging in formal research comparing models. Moreover, the qualitative data used for this study was collected during the integrated, but not blended, implementation period. Furthermore, although we report on the use of the PBF, analysis of VMMC program costs are outside the scope of this paper. Despite these limitations, this process evaluation of the ZAZIC VMMC program and its results is the first to provide insight into this innovative program model.This process evaluation shows that ZAZIC’s integrated, blended approach to VMMC demonstrates a productive pace of scale-up and client safety while likely encouraging simultaneous health system strengthening. Although local leaders note that improvements could be made in program reach, additional staff training, and decentralization efforts, the model appears to work well to leverage and augment existing VMMC capacity across multiple sites in 21 districts. ZAZIC’s locally led consortium also successfully transitioned its broader program to meet changing PEPFAR priorities by focusing in depth on 10 priority districts. Throughout the transition, ZAZIC continued to safely improve productivity, further suggesting advantages of the ZAZIC approach. ZAZIC also sets an example of a successful MoHCC partnership with MoHCC receiving implementation support and gaining VMMC capacity through this joint, country-led implementation. As recent HIV combination prevention trials highlighted the importance of community-based adaptations to extend the reach of public health programs , this loIn the future, ZAZIC aims to evaluate the program more rigorously through both qualitative and quantitative methods. Greater understanding of the implications of transition from integration to blended implementation on VMMC service delivery, including the effects on other routine services within health facilities where VMMCs are performed, would provide insight into the model’s impact. Moreover, as additional VMMC roving teams were added to meet targets, assessment of the effects of these supplemental teams on site engagement and VMMC program sustainability, overall, would be informative. Furthermore, considering the continued HIV epidemic and the fiscal challenges of PEPFAR, PEPFAR should facilitate more rigorous, independent, qualitative and quantitative research comparing vertical versus integrated/blended programs with respect to acceptability, performance and sustainability. Continued consideration for VMMC program integration efforts and support for blended delivery models, in the near and long terms, are warranted to reinforce commitments to VMMC targets and to support health systems in Zimbabwe and the region.


Patient perspectives on new programs to manage metabolic syndrome (MetS) are critical to evaluate for possible implementation in the primary healthcare system. Participants’ perspectives were sought for the Canadian Health Advanced by Nutrition and Graded Exercise (CHANGE) study, which enrolled 293 participants, and demonstrated 19% reversal of MetS after 1 year. The main purpose of this study was to examine participants’ perceptions of their experiences with the CHANGE program, enablers and barriers to change.n = 164), with insights from focus groups (n = 41) from three sites across Canada. Qualitative data were thematically analyzed using interpretative description. Insights were organized within a socio-ecologic framework.A convergent parallel mixed methods design combined patients’ perspectives collected by questionnaires , inter-individual factors  and organizational factors .Results revealed participants’ overall support for the CHANGE program, especially the importance of an extended program under the guidance of a family physician along with a skilled and supportive team. Team delivery of a lifestyle program in primary care or family medicine clinics is a complex intervention and use of a mixed methods design was helpful for exploring patient experiences and key issues on enablers and barriers to health behavior change.The online version of this article (10.1186/s12875-018-0837-z) contains supplementary material, which is available to authorized users. In Canada, 19% of adults have metabolic syndrome (MetS)  exhibitiBuilding on promising results from previous studies –11, the Evaluation of patients’ perspectives is particularly important for lifestyle programs, as programs vary widely and attrition can be substantial , 14. MixThe main purpose of this study was to examine participants’ perceptions of their experiences with the CHANGE program, enablers and barriers to change. Participants were from all three sites .A convergent parallel mixed methods design was used , with quThe questionnaire was a tool for assessing patients’ experiences with lifestyle programs in primary care. It was developed through input from primary health care providers regarding the critical issues to be assessed for quality improvement purposes in primary care, based on a review of key indicators of primary care service quality . ContentQuestionnaire administration and data collection was managed by research coordinators (RCs) from each of the three sites. Each RC had options for getting the questionnaires completed. They could complete with patients in-person or mail paper questionnaires in the languages appropriate for their site along with pre-stamped return envelopes. The French and English paper questionnaires also included a web address to the online questionnaire so that participants could complete the questionnaire online if they wished. The online questionnaire was not translated into Russian, as the RC at the site opted to translate and complete questionnaires with participants in-person. All paper questionnaires were transcribed and downloaded into Microsoft Excel for descriptive analysis. Comments written were content analyzed for themes by one researcher (DR) and reviewed by two members of the team for consensus on theme content (PB and DR).Focus group participants consisted of individuals currently participating in the CHANGE study and were recruited through a mail-out to all participants, outlining the purpose of the study. In addition, flyers were posted in the clinic, inviting people to participate in the study. Potential participants were asked to contact the researcher either by phone or email. Focus groups took place in all three cities. An experienced qualitative researcher experienced in facilitating focus groups (JK) established a relationship at the beginning of the sessions outlining the purpose of the research, her role in the project and then moderated the English sessions. The focus group in French was led by a francophone researcher (AT) who established a relationship at the beginning of the sessions with participants, outlining the purpose of the research, his role in the project and then facilitated the discussion, with input from the original facilitator (JK) who is bilingual, but had French as a second language. Open-ended questions were used to explore participant perspectives.  of 293 potential recipients (56% response rate); 76% as paper questionnaires and 24% online responses. Of the 164 responses to the survey, 27 (19.4%) respondents reversed their metabolic syndrome. This is consistent with the 19% reversal found in the entire study population (11). Therefore, the survey response reflects the population included in the larger study. Most questionnaire respondents (89%) had completed the one-year program; thus, results mostly reflect their perspectives. Numbers were inadequate to conduct subgroup analysis on the drop-outs.Results of the quantitative aspects of the questionnaire and the dimension being assessed are shown in Table They provided me with the confidence and knowledge to succeed”. Further, patients commented that their behavior, health, and well-being had improved . Several patients noted reduced medication use or decreased blood pressure.Over 150 positive qualitative comments from the questionnaire, representing more than 80% of the comments, indicated patients felt the personalized program was motivating and had increased their awareness and knowledge of what to eat and how to exercise. Increased self-efficacy was often mentioned such as: “Some challenges with the program emerged. For example, 32% indicated they ‘sometimes’ or ‘often’ had problems getting to appointments due to time or cost. Only 62% felt they knew what to expect at the start of the program and 23% felt they had been involved in setting goals only to some extent.“It’s hard to stick to a Mediterranean diet when you live in Alberta”. The most common barrier to physical activity was chronic pain due to arthritis and other health issues.Many participants  reported sometimes not trying the recommended diet or activity changes because something got in the way, while only 6–7% reported that this happened often  who participated in 6 focus groups across 3 clinics, each consisting of 6–10 participants. The focus group participants reflected the larger study population, including mean age of 60 (range 45–68 years), mean BMI 32, majority Caucasian along with some participants of Asian, Russian and Arabic ethnicity.“a privilege” to be part of the program and reported the program had changed their life by educating, supporting, and implementing realistic lifestyle changes.Similar to the questionnaire, focus group participants reported very positive feedback about being a part of the CHANGE program. Many shared they felt it was “structured, yet flexible” enough to meet a variety of dietary, exercise, and lifestyle needs.“It’s a very structured approach to changing your diet and exercising…yet it’s so flexible. The diet is about what I wanna eat and not about what somebody else is shoving down your throat.” (Participant 12)Individualized gradual approach to care. Participants emphasized the personalized and gradual approach was the biggest asset of the program and helped to differentiate it from other diets and programs previously tried as it was realistic and conceivable to adapt to individual needs. The program was reported to be providing gentle discipline…without being viewed as pushy”. Many comments were made that staff were not judgmental. “They didn’t sit there and judge you, and say ‘oh you shouldn’t be drinking all that wine or having all that red meat…I know I was doing things wrong and I think we all know we have to make changes in our lives’”.Personalities and approach of the staff. The support and enthusiasm of the staff were key factors in the adherence and success of participants. Staff reportedly created a relaxed atmosphere, never making participants feels rushed, yet ““I think if the doctor is suggesting it, that probably was one of the most powerful incentives.” (Participant 27).Physicians as motivator and trusted mentor. Physicians played an important role in participants registering for the program. Several participants said they would not have registered independently, but did so on recommendation from their physician. Participants also spoke of adhering to the program, as they felt accountable to their physicians.The first three month period is very good. Reinforces everything. Kind of kick starts you.”Frequency of meetings for the program. Surprisingly the intense weekly visits for the first 3 months were not seen as a barrier and were very well received. Not one participant felt it was too much. “Accessible supervision by expert team. Participants appreciated that there were expert health professionals to guide them. Several mentioned they were apprehensive to try new lifestyle changes due to their lack of knowledge in the realms of healthy eating and exercises and/or implications of lifestyle changes on their illness or recent surgeries. Having the team involved provided confidence for them to implement the changes. Participants appreciated the open access to the dietitians and kinesiologists at all times.Social aspect. The social aspect of the program was prominent.“I can say coming to exercise in a group helped me because I think when you just do it by yourself or with your instructor you don’t feel as much part of something that’s going on, so it was always kind of neat to come to the gym and see other people that were on treadmills… That were all at different stages… that helped because I think I had felt for a long time there was no way I was ever gonna get any success out of weight loss program.” (Participant 3).My wife got on board so that it became a family-oriented thing rather then just an individual thing”. Participants spoke of the program influencing family members and friends, which was a great motivator.Impact on significant others. Participants spoke of the impact of the program was not just individual. ““I shared information with two colleagues. There were family members who wanted to ride with me, who wanted to exercise. It’s inspiring to them. There is an impact on the family. The meals are no longer the same. There are no hamburgers and fries anymore…people around me also changed their habits. You can change the habits of 10 people through only one person.” (Participant 12).While participants were very positive about their experiences, several challenges were shared. These were divided into personal and program-based.Controlling your diet is harder than quitting smoking”. Several participants spoke of the difficulties of maintaining their health goals when family members were not supportive. “My biggest challenge has been trying to make the food changes with the rest of my family, who are not in the CHANGE program, and don’t want to change”. Similar to the questionnaire findings, many participants shared that the lack of time to participate in exercise was challenging.Personal. The biggest challenge was the psychological barrier to changing personal habits and maintaining self- discipline. As one participant declared, “Program. There was a minimal amount of support to address mental health issues. Participants mentioned there had been a small assessment with the nutritionist, but would prefer a larger focus in this area. Offering access to a mental health professional early on in the program was deemed helpful.“Those services take a long time to get. The assessment was done and the expectation was that your family doctor followed up on that but who do family doctors refer to? Psychologists, psychiatrists, so you’re just putting another stumbling block of time and energy. Here I am on month 6, finally mentally in the game. The year’s half done.” (Participant 34).In addition, several participants suggested more variety in the exercise programs and increased focus on incorporating specific health issues . The program offered appointments and services only during the weekdays. Several participants requested evenings and weekend access due to conflicts with work schedules.Despite the questionnaire and focus group questions being framed differently, similar issues emerged from participant’s responses. The focus groups elicited more reflection on intra-personal issues, while organizational issues were more prominent in the questionnaire results.Published literature reports the most prevalent and important barriers to lifestyle change, from participants’ perspectives, are ‘lack of willpower’, self-discipline, and personal agency or self-efficacy, depending on the theoretical model being used , 23. LacIn the current study, changing habits was personally challenging, but participants shared that the program mitigated some of the challenges listed above. Comments on the individualized aspects of the program, the supportive and knowledgeable personalities of the providers and the social aspects were all seen as important to promote ongoing motivation and participation.Results from both the questionnaire and focus groups reinforced the well-known challenges with maintaining changes, even after a one-year program. While over 60% were totally or very confident to maintain both diet and physical activity changes, there was a subgroup of about 10% who were less confident in maintaining physical activity changes and 4% for dietary changes. Optimal program length for the majority of people to maintain new lifestyle habits remains controversial and has implications for program delivery costs and sustainability.Trust has been found to be an important element to consider in patient assessment of services . Focus gWhile the family physician plays a key role as a coordinator and mentor, team functioning is also known to be very important in delivery of complex interventions . This waPeople enjoyed socializing with other participants during the program. While most health counselors are trained on motivational interviewing and other counseling techniques, they may not understand the importance of, nor have been formally trained on the social benefits of the program. Since, providers in this study usually counseled one-on-one, the social aspects of the program should be further enhanced. The importance of having significant others as part of the program was mentioned both in the questionnaire comments and in the focus groups. Greater appreciation for health behavior change influencing the whole household has implications for further development of the CHANGE program.Mental health is a significant factor impacting behavior change programs . In bothSeveral comments support a need to tailor the CHANGE program to various subgroups. Many middle-aged participants were still in the workforce, so time limitation was a key barrier. Offering more evenings and weekend programming would be beneficial for this group. At the organizational level, patients often advocate for increased flexibility regarding accessing services including increased flexible clinic hours. Through the development of primary care reform, clinics are starting to address this need by hosting clinics on evenings and weekends. However, allied health services need to be expanded as well. The older adult population had more flexibility in their time, but had higher levels of social disconnectedness and perceived isolation, which are independently associated with lower levels of self-rated physical health . SeniorsThemes from the focus groups frequently complimented the questionnaire. There were no direct contradictions in comparing the results of questionnaire and focus groups; rather different aspects emerged as important. The key role of the family physician and importance of the social aspects emerged in the focus groups, while the questionnaire confirmed the trust they had in the team. Both methods revealed trust with their health professionals, along with an individualized realistic gradual approach led to the general support for such a lengthy and intensive program. Findings that a longer and more intensive program was preferred were unexpected and needs to be further explored.Further validation of the questionnaire is needed including assessment of test-retest reliability and convergent and divergent validity. While we sent out the questionnaire to all participants in the study, the response rate of 56% is likely not representative. In addition, as the focus group consisted of participants self –selecting and were only offered in French or English, not Russian, there is potential for further bias. Extra concerted efforts would be needed to elicit perspectives from participants, who declined to participate in the questionnaire and focus groups, which was beyond study scope. We also have no knowledge of the needs of the wider group of people with MetS who did not agree to undertake the CHANGE intervention. Different approaches are needed to determine how to reach and promote lifestyle change among other subgroups in the population. Likely multiple strategies are needed, including web-based approaches, group programs, and programs with a stronger mental health focus. Further work is required to explore the 10% of participants who noted they were less confident in maintaining physical activity changes and 4% for dietary changes.This research provides insight into patients sharing their experience of the CHANGE lifestyle program in family medicine clinics and generally confirms a large body of literature on the major enablers and barriers to lifestyle change. Overall participants’ experiences were very positive especially as they emphasized the importance of participating in an individualized program led by family physicians and a skilled and supportive team. The role of the family physician as a trusted mentor is likely a key factor to the success of the program.Due to the personalized supports, participants’ confidence in maintaining the changes long term was high. Specific recommendations provided by participants  may further improve the CHANGE program and its long-term success and sustainability.Implementing complex behavioral interventions such as lifestyle modification in primary care is challenging. Although intrapersonal issues  often dominate peoples’ perceptions of the success of such an intervention, modifying aspects at the interpersonal  and organizational level  can ultimately improve the effectiveness of a program. The positive participant experiences shown in our current work enhance the evidentiary basis of the CHANGE Program and supports the wide spread implementation of CHANGE in primary care. Multiple approaches may be needed to obtain future participant experiences to inform ongoing program improvements.Additional file 1:Survey questionnaire. (DOCX 228 kb)Additional file 2:Focus Group questions. (DOCX 13 kb)Additional file 3:Examples of Emergent themes and sub-themes based on analysis of focus groups. (DOCX 15 kb)


The aim of this paper was to review the recent international developments in health promotion and wellness initiatives targeting chronic disease prevention and management for adults with intellectual and developmental disabilities (IDD) targeting type 2 diabetes (T2D).There has been one diabetes prevention program (STOP) and two self-management T2D education programs  adapted for this population. All three programs have been adapted from other theoretically informed and tested programs developed for the general population. Each program has employed co-design and co-production techniques with all stakeholders. The three programs all target the high-risk lifestyle factors that can lead to T2D and contribute to poor glycaemia control, and have undertaken randomized-feasibility studies, the results of which are promising.This paper shows that any health promotion and wellness initiatives need to be tailored and reasonable adjustments made in order to address this population’s cognitive impairments and communication difficulties. Wellness initiatives can prevent the onset of many chronic health diseases, and can also assist individuals to cope or manage when they have developed a chronic health condition. That said, it can also be challenging to promote wellness in light of also having a chronic health condition. This paper reviews the most common chronic medical condition in adults generally, as well as in those with an IDD, type 2 diabetes (T2D), from a wellness standpoint. We were interested in exploring what is known about efforts to promote wellness to prevent diabetes onset as well as efforts to promote wellness for individuals with IDD who have a T2D diagnosis.T2D is a universal chronic health condition, and figures are predicted to increase as the world’s population continue to age . It is eBeing diagnosed with a chronic health condition such as T2D, it is therefore important to ensure that you maintain both good physical, and psychological, wellbeing in order to prevent developing complications, leading to other chronic health conditions. Promoting wellness and health promotion initiatives to prevent T2D developing is based upon targeting unhealthy lifestyle risk factors. Similarly, managing T2D is also based upon targeting healthy lifestyle modifications  , 5. HoweSupporting people to have better control of their diabetes has been shown to decrease their risk of developing complications, which in turn can diminish the financial and human costs of diabetes , 7. For Genetic: specific genetic/chromosomal conditions (e.g. Down syndrome) are more likely to be correlated with higher obesity levelsLifestyle: people with IDD are more likely to have poorer diets, be less physically active, lead more sedentary lifestyles and have higher levels of obesityHealth related: higher levels of multi-comorbidity, high levels of anti-psychotic medication prescription, greater dependence on family/paid carers, lack of uptake of health screenings/surveillance and a lack of reasonable adjustments being made by healthcare and specialist diabetes services [services –13.People with IDD are also living longer and it is projected that this longevity will continue . As a coMacRae et al. 2015)  found th  found tThere have been few theoretically informed and robustly evaluated interventions that focus on health promotion and well initiatives to prevent people with IDD at high risk from developing T2D , 16–19. The aim of this paper was to review the recent wellness initiatives in diabetes prevention and T2D management for adults with IDD. The paper found one diabetes prevention program (STOP) and two recently published self-management T2D education programs  adapted for adults with an IDD. We reviewed the theoretical underpinnings of each program, the program development and content, and the current state of the evidence concerning these programs.The ‘STOP Diabetes’ program was developed as a multi-component lifestyle behaviour change initiative for the prevention of T2D targeting cardiovascular risk factors in adults with IDD –25. A muThe first phase of development combined (1) stakeholder interviews, conducted with service users/carers and health professionals; and (2) reviews of key IDD-specific research, existing interventions and behaviour change literature. The second phase of development involved two pilot cycles of testing, evaluation and refinement of the curriculum. Modifications made to the curriculum content, delivery and resources were based on observations made during sessions and qualitative feedback. During this pilot phase, a quality development process was also developed for assessing intervention fidelity . The thiThe theoretical underpinning of the STOP program  was infoThe behavioural goals and lifestyle messages included in the STOP program were based on two existing prevention programs –33 that 2). Participants needed to be willing/able to attend group education sessions and able to walk for at least short distances . The program consists of one initial carer session, followed by seven joint education sessions for the person with IDD and their carer/spouse/partner . The sessions were designed to be delivered in a community setting by two educators  and one support person. The initial carer session provided an overview of the program, allowed the carer to meet the educators, explored their role in supporting the service user and ask any questions they may have. The curriculum for the participant and carer sessions together explored different topic areas  each week, and builds on/consolidates learning from earlier sessions   undertooFeedback and observations collected during the pilot phases suggested that the program was acceptable to both the adults with IDD and their family/paid carers , 24, 32.DESMOND-ID is an adaptation of the original DESMOND (Diabetes and Self-Management for Ongoing and Newly Diagnosed) structured self-management T2D education program , 35. TheThe adapted DESMOND-ID education initiative was a 7-week program designed to be delivered in two parts. The first part (session 1) was for family/paid carers and spouses/partners only, and delivered 1-week in advance of the commencement of the main program. This 2-h session focused on what is T2D, introducing the aims of the DESMOND-ID program and role of carers in supporting the person with an IDD over the forthcoming 6 weeks. The second part of the education program (sessions 2–7) was delivered over 6 weeks, two and a half hours per session, 1 week apart and is for both the person with ID and their carer/spouse/partner together. Table The program is based on a series of psychological theories of learning and education: Leventhal’s Common Sense Theory , Dual Process Theory (process of learning) and Social Learning Theory (i.e. self-efficacy). The philosophy of the program was founded on patient empowerment, as evidenced in published work , 34. DevN = 19) versus standard routine care (N = 20) in Northern Ireland, Scotland and Wales. All the participants had T2D, mean age was 54.7 years. Most participants (69%) were supported to attend the DESMOND-ID program with a family/paid carer. Over 90% of adults with an IDD attended between 4 and 6 sessions and 94% of carers attended between 6 and 7 sessions. Biomedical data  were collected at baseline and 3 months follow-up.Taggart et al. (2017)  undertoop < 0.05), compared to an increase for those participants in the control group (61 mmol/mol to 65 mmol/mol).This study found that with reasonable adjustments, it was possible to identify, recruit and obtain consent from adults with a mild to moderate ID, and deliver the DESMOND-ID education program. Taggart and colleagues found that for those participants in the DESMOND-ID group, their HbA1c reduced statistically from 66 mmol/mol to 57 mmol/mol , were discussed initially by the research team. Finally, we considered guidance on reasonable adjustments to healthcare designed to ensure access for people with an IDD. At each stage, there were regular consultation meetings with service users, carers and their representatives.The program had four standardized components with associated materials, delivered by diabetes specialist nurses. How they were delivered depended on participant and supporter characteristics and preferences   undertooRecords of program adherence were kept . Of the Although the primary aim of the study was not to assess efficacy, clinically important outcomes, as part of determining the feasibility of a definitive trial, were collated. Six-month outcomes were obtained from 94% of participants. In the OK diabetes program, 35% of those who received supported self-management either lost > 5% body weight or dropped HbA1c > 5.5 mmol/mol. House et al. (2018)  results There have been strong criticisms that many health promotion and wellness initiatives targeting any chronic disease prevention and management targeted at people with IDD have little, if any, theoretical underpinnings and are not robustly evaluated . This paThe STOP program focused on the prevention of diabetes; this program used a group education format over a 7-week period. The DESMOND-ID and OK diabetes programs both focused on the self-management of this chronic health condition; the former initiative was based on a group format over a 7-week period whereas the Diabetes OK program was based upon a 1–1 format over four sessions. All three programs used health professionals as the educators, and all three programs involved family/paid carers/spouses/partners. The results of all three programs are very promising in terms of their adaptation processes, program content, delivery and in their evaluations. However, The STOP program had only a sample size of five adults with an IDD whereas the DESMOND-ID and OK diabetes programs had 39 and 82 adults with IDD prospectively: further research is still required regarding their clinical and cost-effectiveness.As the aetiology of T2D can be multi-causal , any health promotion and wellness initiatives, and chronic disease management initiatives, must be tailored to the specific needs of the target population to improve a number of target outcomes . However, for those adults with IDD who have a cognitive impairment and communication difficulties, the development of such prevention and self-management initiatives is much more complex. Research also clearly illustrates that many adults with IDD are dependent upon family and paid carers to support them to make healthier lifestyle choices on their behalf –19. All Diabetes self-management education programs can be observed as complex regimes of self-care practices  in order to achieve optimal glycaemic control, and reduce potential acute and long-term complications. It can be questioned whether individuals with IDD given their cognitive impairments and communication challenges can adhere to such regimes. The studies by Taggart et al. (2017)  and HousAll three programs are limited to people with mild to moderate IDD, and who have a family/paid carer or spouse/partner who can provide support for them, although those with a more severe/profound IDD would not necessarily be able to engage: but their carers could still be involved to learn how to manage the person’s diabetes. Despite the favourable accomplishments of these three innovative health promotion, wellness and management initiatives targeting diabetes , 37, 40,This paper provides a review of three promising theoretically informed health promotion and wellness and self-management initiatives. The three programs have successfully adapted and made reasonable adjustments/amendments for the cognitive and communication needs of this population that can be translated into other chronic disease conditions such as arthritis, asthma, cancer and coronary heart disease.Recognizing and understanding the specific cognitive impairments of this population  and communication difficulties is essential in adapting/modifying or developing any new health promotion and wellness initiatives. Lessons learnt from these programs include breaking the aims and objectives of such programs into understandable and achievable chunks; using concrete kinaesthetic and observational methods of learning; modifying the curriculum content, delivery and resources using easy read and pictures/symbols; self-monitoring (i.e. through pedometers and/or food diaries); and exploring barriers and solutions to making lifestyle changes. All three programs also understood the role that family/paid carers play in supporting the person with ID to interact in the health action plans of these programs between each session. The good management of T2D can lead to better glycaemia control and thereby diminish potential complications from occurring and preventing premature deaths .Greater emphasis should be placed upon wellness and health promotion initiatives that can prevent people with IDD developing chronic health conditions such as diabetes, coronary health disease and cancer. Efforts should be placed upon wellness initiatives that promote healthy diets, increase physical activity and reduce sedentary behaviours, thereby targeting one of the significant health hazardous risk factors—obesity , 12. Thi


Living and geographical conditions in Bangladesh expose children to a high risk of drowning. Two programs operating in the Barishal Division of Bangladesh aim to reduce drowning risk through the provision of crèches  and swim and rescue classes (SwimSafe). Anchal provides a safe environment with early childhood education to children aged 1–5 years old, while SwimSafe teaches children aged 6–10 years old basic swimming and rescue skills. Despite evidence for their effectiveness, it is unclear under which conditions these programs best operate. This protocol describes a project that seeks to conduct a process evaluation and gender analysis to identify implementation inefficiencies and contextual considerations for improved sustainability of the programs. A mixed- method approach using both qualitative and quantitative data will be used. Quantitative program data will be analysed to measure program utilisation, delivery and reach, while qualitative data will be collected via key informant in-depth interviews (IDIs), focus group discussions (FGDs) and observations. The process evaluation of the Anchal and SwimSafe programs provides an opportunity for implementers to identify practical strategies to improve program delivery and improve contextual adaptability of these programs. Furthermore, the findings may provide guidance to other implementers aiming to deliver community-based programs in rural lower-middle income contexts. Globally, children aged 1–14 years in lower-middle-income countries (LMICs) are at the greatest risk of morbidity and mortality from drowning. This burden is particularly significant in Bangladesh, where 43% of deaths in children aged 1–4 years occur from drowning . The ratThe World Health Organization has recommended the implementation of four community-based interventions that reduce drowning in rural LMIC contexts in response to the United Nation’s Sustainable Development Goal 3 to reduce preventable deaths of children under the age of 5 years to 25 per 1000 live births . CurrentBHASA drowning reduction program based on these identified effective interventions in an effort to reduce the burden of drowning in Bangladesh. Two of these effective interventions within Project BHASA are Anchal and SwimSafe [In 2016, the Centre for Injury Prevention and Research, Bangladesh (CIPRB) developed the Project SwimSafe . The AncBHASA intervention upazilas (sub-districts) in the Barishal division: Kalapara, Taltoli and Betagi upazilas. Evaluation will be conducted across all intervention sites. Upazilas are the lowest level of administrative units in Bangladesh, and typically have a population between 250,000 to 400,000 people. There are three Project upazilas. Each Anchal Centre is managed by a trained Anchal Maa (caregiver of a crèche) and Anchal Assistant (caregiver’s assistant) who supervise 20–25 children from 9 a.m. to 1 p.m. six days a week. During this time, children are involved in early childhood development (ECD) activities aimed at stimulating children’s physical, intellectual, linguistic, social and emotion development. Children aged 1 to 5 years old are eligible to attend. Anchal centres are held in a suitable room in the Anchal Maa’s home, which is equipped with educational materials for child stimulation and barriers to create an enclosed space [upazila. There are 400 Anchal centres under the program across all three intervention ed space . Table 1upazila. The SwimSafe program provides children aged 6–10 years of age with a 21-step swimming course delivered in 12 sessions aimed at teaching basic swimming and rescue skills. The program was developed in collaboration with experts from The Alliance for Safe Children, UNICEF and Royal Life Saving Society Australia (RLSSA), catering for contextual requirements . Each seupazila, managed by an overarching Program Coordinator. Program trainers are also employed to provide initial and ongoing training to Anchal staff and CSIs. All AMOs and three of the supervisors are female.Both Anchal and SwimSafe programs are managed at the field level by three levels of staff. Firstly, a total of 20 Supervisors directly manage CSIs and Anchal Staff within their communities. Each Supervisor manages 25–35 Anchal centres or 10–15 ponds and receives a one-day orientation to the program on joining. The ECD component of Anchal is additionally monitored by Anchal Monitoring Officers (AMOs) and an ECD specialist. An Area Coordinator oversees the programs’ operations in each CIPRB has also founded Village Injury Prevention Committees (VIPC) in each community. These committees are comprised of local formal and informal leaders. VIPC committees facilitate interactions and engagement between CIPRB and members of the community. VIPC members also oversee the programs’ implementation within the community and participate in recruitment of Anchal Maas and CSIs. They are also tasked with raising awareness on drowning prevention in their communities. Committees meet monthly to discuss these issues. Although both Anchal and SwimSafe have been found to be cost-effective in reducing drowning within communities  analysisRealist theory posits that programs may have differing effects across contexts and participants. To understand this dynamic, the underlying mechanisms behind the effect of a program requires examination ,17. UndeIn addition, comprehensive process evaluations that seek to understand unintended consequences, such as on gender norms and behaviours, are better able to adapt to contexts and ensure maximal effectiveness, while also considering the equity of outcomes ,21. GendA mixed- method approach using both quantitative and qualitative data will be used to triangulate the program monitoring data with key informant in-depth interviews (IDIs), focus group discussions (FGDs) and program observations. As part of the enrolment process for the programs, staff visit all households in the community and conduct a baseline survey to gather information on the community’s demographics. Program monitoring data are also collected, including participant demographics, participant attendance, graduation rates, dropout rates and standardised monitoring forms completed by supervisors. This data is collected and managed using REDCap electronic data capture tools through hand held tablets.Quantitative data from across the Anchal and SwimSafe programs will be analysed to gather metrics such as child attendance and dropout rates, staff retention and age and gender differences in enrolment. upazilas. IDIs will provide an understanding of individual-level responses to the programs, while FGDs will provide insights to wider community perspectives and cultural norms [The methodology used will be guided by the COREQ guidelines for qualitative research . Qualitaal norms . ObservaThe exact sample size for each participant type cannot be determined a priori. Data collection will cease once saturation has been reached . This wiImplementing staff from CIPRB will introduce the data collectors to the community. Communities will be purposively selected to ensure that the evaluation includes sites with a variety of geographic, demographic and program characteristics. Within communities, parents and children will be randomly selected by data collectors, while program staff will be purposively selected based on their roles. The interviews will last between 30–60 min and be conducted in a quiet place such as a participant’s home or local office. Only data collectors and participants will be present. Each FGD will comprise of 6–8 participants and will last for 40–60 min. Researchers will purposively select program staff or randomly select children and parents for FGDs and then use snowballing to identify further participants. FGDs will be homogenous and comprise of one type of participant of the same gender, such as mothers of participating children, or male CSIs only. FGDs will be held in a neutral place such as a school or community hub. There are four major components of the programs that will be observed by the research team, which are (1) review of the programs’ documented SOPs; (2) program delivery venues; (3) delivery of programs to children; and (4) supervision visits of the Anchal Maas, Anchal Assistants and CSIs.The observations will incorporate shadowing techniques where data collectors will use prompts to ask participants their motivations behind behaviours when feasible to do so without interrupting the session . Female data collectors will conduct observations of Anchal centre operations from 9 a.m. to 1 p.m. or SwimSafe classes from the side of the pond. They will note observations in an observational checklist, which will be developed based on program SOP requirements and monitoring outcomes such as venue suitability and maintenance, Anchal staff and CSI behaviour with children, and child responsiveness to the program. Data collectors will be present at the venue before the sessions start and will remain throughout to minimize interruption.The IDIs and FGDs will take a semi-structured format using interview guides that will be developed in accordance with the study objectives and field-testing. See All IDIs and FGDs will be first transcribed in Bengali and then translated to English. 20% of translations will be checked by the data collectors for quality assurance. Transcriptions will not be returned to participants due to limitations in literacy of participants and logistical constraints in re-visiting communities and locating individuals. Free and informed written consent will be sought from all participants. All participants will be informed that the data will be used to improve the delivery of the Anchal and SwimSafe programs. The voluntary nature of the study will be emphasised. Participants will also specifically indicate that they consent to being audio recorded. Written consent for child participants will be obtained from their parents or guardian. The primary aim of the process evaluation is to understand who benefits from the programs and under what conditions. Accordingly, the process evaluation will answer key questions about the barriers and enablers for the implementation and uptake of the programs in the Barishal division. These will be structured around context, implementation and mechanisms of impact as per the United Kingdom’s Medical Research Council guide to process evaluations . These cTo identify unexpected benefits (or harms) related to gender, this process evaluation will be seeking to identify how the programs have affected the gendered roles and relationships within the communities in which they operate, including impacts for parents, program staff and other community members. Gender analysis provides insight into benefits of programs beyond the targeted effect, and can lead to the identification of possible opportunities to promote gender equity in both the program implementation team and targeted communities .We will undertake a gender analysis informed by the Gender Integration Framework by FHI 360 upon which questions will be developed for IDIs and FGDs . SpecifiIt is important that gender analysis be accompanied by action to address imbalances in gender power relations. We will use the findings from the gender analysis to identify how gender inequities can be addressed through practical strategies in the programs which will be implemented in mid-2019.Quantitative data collected from program records will be analysed to determine specific process measures such as reach, fidelity and dose. Descriptive analysis such as counts and percentages will be conducted for this data to identify demographic differences between outcomes such as attendance and graduation rates. Differences in rates and proportions between groups will be analysed using bivariate Pearson Chi-squared tests and trends analysed using Chi-square linear-by-linear associations. The SPSS statistical software package will be used to conduct the analysis .Analysis of the transcribed qualitative data will be assisted by NVivo 12 software . A frameQuantitative and qualitative data will be presented together to illustrate program implementation status, encompassing both key successes and issues in regards to program delivery, management and community response. Quantitative data will provide insights into the current status of these implementation components, and the qualitative findings will identify the mechanisms behind these and potential strategies for improvementAll data will be stored and shared via secured servers. All files will be de-identified before sharing with translators or being used for analysis. Data will be stored for five years in the secured servers and physical cabinets for 5 years, as per Australian research ethics requirements .Local ethics approval from the ethics committee of CIPRB has been granted (Memo no: CIPRB/ERC/2017/24). Ethical approval was also obtained from the University of New South Wales Human Research Ethics Committee (HC: 180608). Written informed consent will be obtained from all participants for qualitative data collection. Consent will be taken from parents or guardians of minors participating in the study.The findings of the analysis will be presented in a report to the funder of the programs and CIPRB program staff. Findings will also be verbally shared with community VIPC members by Supervisors to gain their assistance in improving implementation. The results will additionally be published in peer-reviewed journals and presented at academic conferences.This protocol outlines in detail the methodology, methods, and analyses that will be used to conduct a process evaluation of the Anchal and SwimSafe drowning reduction programs in the Barishal division of Bangladesh. This process evaluation will explore the implementation of these programs through analysis of its delivery and effect on gender roles and responsibilities ,22. The The results may additionally guide other organisations seeking to implement community-based drowning reduction programs in LMICs by providing insights into key considerations and challenges when delivering these programs.This project will engage a variety of relevant stakeholders, from participants to program delivery staff to supervisory staff, to obtain a thorough representation of the current implementation status of Anchal and Swimsafe programs. Furthermore, the incorporation of the Gender Integration Framework in the analysis allows for a more holistic view of unanticipated benefits and harms, beyond the scope of traditional process evaluations.A key challenge for this study will be the translation of qualitative responses into English for analysis, introducing the possibility of incorrect semantics and meaning being represented in the transcripts. It is essential that key findings be compared to field notes and corroborated with Bengali-speaking data collectors to ensure no mistranslations have occurred. Data collectors will crosscheck a random selection of translated transcripts (20%) against their notes to ensure that appropriate meaning is being conveyed ,36. The


N = 101) or in specialized service teams ; and second, to compare IPC associated variables in MH-PCTs vs MH-SSTs.This study has two aims: first, to identify variables associated with interprofessional collaboration (IPC) among a total of 315 Quebec mental health (MH) professionals working in MH primary care teams  was significantly and negatively associated with IPC in SSTs.Improving IPC and making MH teams more successful require the development and implementation of differentiated professional skills in MH-PCTs and MH-SSTs by care managers depending upon the level of care required . Training is also needed for the promotion of interdisciplinary values and improvement of interprofessional knowledge regarding IPC. Interprofessional collaboration (IPC) is defined as a process by which professionals from multiple disciplines share roles and tasks in order to respond in a coherent and integrated way to the needs of patients, their loved ones and the community , 2. IPC Despite abundant evidence for the positive effects of IPC, studies have shown that the uptake of IPC in organizations remains weak; IPC is also inadequately practiced in healthcare teams , 9. Inad. Individual characteristics include demographic variables  and personal attributes  and gender . The mean age of study participants was 43 years for the total sample, 41.7 years in MH-PCTs, and 44.1 years in MH-SSTs. Mean seniority on the teams was 3 years for the total sample, 2.25 years in MH-PCTs, and 3.44 in MH-SSTs. Most participants in both the total sample and the two subsamples were psychosocial professionals (77.2% in MH-PCTs vs. 44.4% in MH-SSTs); while the rest were medical professionals (15.8% in MH-PCTs vs. 43.5% in MH-SSTs) or general professionals (7.9% in MH-PCTs vs. 12.1% in MH-SSTs). IPC had a mean score of 8.022 (SD = 3.751) for PCTs, and 19.931 (SD = 3.747) for SSTs. Participant characteristics are presented in Table Three hundred fifteen (315) MH professionals working in PCTs (SSTs N = 14 partic2), and had acceptable goodness-of-fit. In the MH-SSTs, four variables were independently and positively associated with IPC, of which two related to Interactional characteristics (knowledge integration and team climate), one related to Structural characteristics , and another related to Professional role characteristics . The single variable related to Individual characteristics, age, was significantly and negatively associated with IPC. This model explained 55.0% of total variance (adjusted R2), and had acceptable goodness-of-fit.The multiple linear regression models are presented in Table This study was to our knowledge the first to compare variables associated with IPC in MH-PCTs and MH-SSTs. The findings revealed three variables independently and positively associated with IPC in both PCTs and SSTs ; whereas knowledge sharing correlated with MH-PCTs only, and two other variables  with MH-SSTs only. Therefore, in terms of variables significantly associated with ICP in MH-PCTs and MH-SSTs, there were as many differences as similarities, contrary to our hypothesis. This may be explained by the differences in teams working in primary care as compared with specialized care, described in the introduction, and by the fact that most PCTs were formed following the MH reform with staff from former SSTs. The increased promotion of integrated care among professionals from both PCTs and SSTs aimed at accommodating patients who need service at both levels of care may also explain our results. Moreover, while the proportion of medical professionals was greater among SSTs, and psychosocial professionals more prevalent among MH-PCTs, inter-professional collaboration (IPC) was not associated with type of professional in either MH-PCTs or MH-SSTs.In addition, all four blocks in the conceptual framework were represented for MH-SSTs, whereas only two blocks represented MH-PCTs. No Individual or Structural characteristics variables were associated with IPC in MH-PCTs. This result may be explained by the recent nature of professional transfers to the new multidisciplinary MH-PCTs, and the early stage of team operations in terms of staff acquisition, the transfer of task-related knowledge, skill development as well as team support . The embTwo variables related to Interactional characteristics (knowledge integration and team climate) were associated with IPC in both MH-PCTs and MH-SSTs. A high degree of knowledge integration and positive work environment are particularly important in managing most common MH problems, but also in treating severe and enduring MH problems such as schizophrenia and bipolar disorder. Studies have shown that IPC would be limited without knowledge integration from different disciplines and a positive working environment , 41; whiThe multifocal identification variable under Professional role characteristics was also associated with IPC in both MH-PCTs and MH-SSTs. This underlines the importance of professional identification for improving IPC in MH teams practicing from a multidisciplinary model of care, such as those responsible for expert assessments, case reviews and management of individuals with complex needs. Indeed, professional identification was experienced as a great source of satisfaction and motivation for workers whose professional skills were valued by other team members . MoreoveThe knowledge sharing variable under Interactional characteristics was associated with IPC in MH-PCTs only. This suggests the particular importance of knowledge sharing in the newly formed MH-PCTs dealing with patients mainly affected by common mental disorders and substance use disorders as well as multiple biopsychosocial needs that require sharing of information, skills, and expertise , 82. Con, a climate conducive to the development of good team working relationships [Organizational support has also had positive effects for reducing staff turnover [Organizational support, a Structural characteristics variable, was associated with IPC for MH-SSTs only. Organizational support entails multi-level leadership in overseeing the provision of team resources, adequate space for patient care, clear rules and procedures , 30, a cionships , as wellionships . This suionships , 88. Speturnover  and on jturnover .Regarding Individual characteristics, our study identified a negative association between age and IPC, unlike some previous research (e.g. ), but onFinally, some independent variables identified as significant in other studies were not related to IPC in this research, whether for MH-PCTs or MH-SSTs, which may be partly explained by the study context. However, some variables that were not in collinearity with others, but measured different dimensions, may have been relatively close in meaning . Most astonishing was that type of profession  was not related to IPC in our study. This result may have occurred because teams were too similar in terms of their mix of professionals to be differentially related to IPC, or perhaps due to the way in which each individual team was regrouped in terms of PCTs or SSTs.Despite some important findings, this study had certain limitations. First, the study used a cross-sectional design, which did not permit the formulation of cause and effect inferences about the data. Second, the research did not include a control group, which would have allowed for comparisons. Third, MH-PCTs and MH-SSTs represented a diversified range of teams such as assertive community treatment teams, emergency department teams (SSTs), single access point or psychosocial teams (PCTs), that were not treated as specific team types in the analyses. Treating each team subtype separately may have produced different IPC associated variables. Studying specific teams with a complementary method such as case study analysis may also have brought additional information concerning team processes and dynamics to the results. In addition, there were more SST than PCT teams, and for some, such as emergency department teams, response rates were relatively low. Fourth, some variables identified as key variables in earlier ICP research  were not investigated in the present study , 28. FifThis study was innovative in a number of ways. First, it included a large sample of professionals working in MH-PCTs or MH-SSTs located in four Quebec MH networks. Second, the study tested numerous variables previously identified as strongly related to IPC and organized within a conceptual framework. Moreover, it identified variables associated with IPC in both MH-PCTs and MH-SSTs, comparing IPC associated variables for the two practice settings. The two multivariate regression models identified three independent variables related to Interactional characteristics, and one each for Individual characteristics, Structural characteristics, and Professional role characteristics, respectively. Three independent variables were associated with both MH-PCTs and MH-SSTs, and three were specific to either MH-PCTs or MH-SSTs; as such, they reveal some variation in IPC across levels of care. This suggests the need for managers to promote the development and implementation of differentiated professional skills on teams, depending upon their required level of care provision. Surely, the maintenance of IPC depends upon the contributions of all team members; whereas their effectiveness may be directly influenced by managers themselves. Thus, at the level of specialized services, managers might focus their attention on organizational support without neglecting other variables identified in association with IPC in both MH-PCTs and MH-SSTs . At the primary MH level, managers should focus on the development of knowledge-sharing competencies. Finally, more outreach activities and training of MH professionals are needed to promote interdisciplinary values and skills as well as interprofessional knowledge and IPC. All in all, MH professionals working as members of multidisciplinary teams need preparation and support to know how to work more effectively and collaboratively.