Food insecurity (FI), the limited access to healthy food to live an active and healthy life, is a social determinant of health linked to poor dietary health and difficulty with disease management in the United States (U.S.). Healthcare experts support the adoption of validated screening tools within primary care practice to identify and connect FI patients to healthy and affordable food resources. Yet, a lack of standard practices limits uptake. The purpose of this study was to understand program processes and outcomes of primary care focused FI screening initiatives that may guide wide-scale program implementation.N = 19 healthcare staff. Intended program activities, outcomes, actors, implementation barriers/facilitators and overarching implementation themes were identified as a part of a cross-case analysis.This was an embedded multiple case study of two primary care-focused initiatives implemented in two diverse health systems in Chicago and Suburban Cook County that routinely screened patients for FI and referred them to onsite food assistance programs. The Consolidated Framework for Implementation Research and an iterative process were used to collect/analyze qualitative data through semi-structured interviews with Programs outcomes included: the number of patients screened, identified as FI and that participated in the onsite food assistance program. Study participants reported limited internal resources as implementation barriers for program activities. The implementation climate that leveraged the strength of community collaborations and aligned internal, implementation climate were critical facilitators that contributed to the flexibility of program activities that were tailored to fill gaps in resources and meet patient and clinician needs.Highly adaptable programs and the healthcare context enhanced implementation feasibility across settings. These characteristics can support program uptake in other settings, but should be used with caution to preserve program fidelity. A foundational model for the development and testing of standard clinical practice was the product of this study.The online version contains supplementary material available at 10.1186/s12889-021-12407-y. Food insecurity (hereafter FI) is a social determinant of health and economic condition where limited access to safe, high-quality, nutritious food prevents individuals from leading active and healthy lives . The WorPrior to the COVID-19 pandemic, approximately 33.5 million Americans experienced FI . U.S. hoStudies show that local and federal U.S. food assistance services remain underutilized due to limited awareness about their existence, the stigma associated with using welfare programs, and complex enrollment processes that can discourage use , 11–13. Among screening initiatives that exist, those implemented in primary care settings demonstrate the most potential to address FI because primary care practice is the most common form of health care delivery in the U.S. Moreover, primary care is recognized by professional and government healthcare organizations as the most typical setting where referrals to social and community resources often occur that connect patients to basic needs for disease management , 16–18.Existing literature points to FI screening practices that are largely guided by broad, national principles that have been interpreted in many ways—perhaps due to their rapid and organic evolution to fill a growing FI crisis. Evidence suggests that program activities, actors, implementation processes are driven by each healthcare contexts, program outcomes vary across clinical settings, and as a result, the long-term impact on health outcomes of screening programs cannot be determined , 19, 20.In implementation science, theory derived frameworks are used to study implementation context—specifically how multilevel system wide factors  and multisector factors  interact and determine the quality of implementation outcomes . FindingImplementation science research has been supported in several healthcare research studies, most notably by the National Institutes of Health for a variety of social and behavioral health research, such as tobacco cessation and diabetes prevention. The purpose of these studies was to understand how the complex and interdependent sociocultural, economic and political factors within the implementation context affected the process of program implementation. There is an opportunity to apply implementation science in the context of clinical FI initiatives because theoretical underpinnings of implementation have not yet been explored. Ultimately, researchers used findings to determine how to effectively disseminate and adapt these programs into other healthcare settings and contexts , 23.The Consolidated Framework for Implementation Research (hereafter CFIR) is an Implementation determinants framework comprised of theoretically derived domains and constructs as seen in Table The framework is broad with over 30 theoretically-derived constructs. When used to map implementation factors, CFIR can help researchers establish a foundation from which semantic relationships between implementation factors can be constructed. Hypothesized relationships between constructs can be used to develop a conceptual model that describes the implementation of a specific intervention. The framework is made up of implementation drivers that are categorized into five domains: 1) The intervention characteristics that point to the quality of the program, compatible design, its cost and adaptability across settings. 2) The inner setting, which directly relates to the physical and cultural setting where daily program processes occur. 3) The outer setting, which refers to any factor external to the program itself, including community needs, influences, local mandates, policies or regulations that affect implementation processes. 4) Characteristics of program staff/individuals, which are their knowledge and beliefs about the program from their own perspective. 5) Implementation processes, which include the steps used in planning, execution and ongoing management of the program .N = 19 healthcare staff participated in one-on-one interviews in this study to provide their perspectives about implementation. We used the Consolidated Framework for Implementation Research (CFIR) to identify common implementation barriers and facilitators from each interview as a part of a cross-case analysis. Findings from this study were used to develop a formative conceptual model that can guide the development, refinement and testing of standard screening practices in future research.The purpose of this study was to understand implementation processes and outcomes of two distinctively different FI screening initiatives. One program was implemented in primary care clinics located within the context of an urban, government funded health system. The other program was implemented in primary care clinics associated with a suburban, private, academic medical center. A total of Cook County is located in Illinois, a state located in the Midwestern region of the U.S. Within Cook County is a complex healthcare network that serves 5.2 million people. Two FI screening and referral programs were selected for this study using criterion sampling from a larger sample of 13 programs implemented within primary care settings identified in a previous study. The two programs selected for this study (hereafter Program A and Program B) differed in the type of setting . Distinct program differences listed in Table Inclusion criteria were based on previous research and national recommendations for clinical FI screening initiatives , 18, 27.An embedded multiple case study design was used to examine the phenomenon of primary care situated FI screening and referral processes , 29. TheFrom September 2019 to March 2020, an iterative sampling approach was used to recruit participants for this study from a convenience sample of implementation actors at each case until data saturation was achieved (N = 19). Through a purposive sampling process, implementation leaders, clinicians and other healthcare staff critical to program implementation were recruited for this study .The interview guides used with organizational leaders and frontline providers were developed for this study using the adapted CFIR framework  conducted semi-structured, key informant interviews for this study. The interviews were conducted face-to-face at each program site or over the telephone at the study participant’s discretion. Each interview lasted 30–45 min and were audio recorded for data analysis purposes. Participants recruited for the study were made aware of the audio recording at the beginning of each session and were required to provide verbal consent prior to participation in the study. This study and the verbal consent process were approved for a claim of exemption (Protocol # 2019–0610) from the University of Illinois at Chicago Office for the Protection of Research Subjects Institutional Review Board on August 30, 2019.The researcher took detailed notes during each interview that provided initial insights to the study. Revisions to the instrument guide were made after each interview for clarity and to collect additional program details.Data were collected, managed and analyzed concurrently over a period of seven months until data saturation was achieved. Transcriptions of the interviews were uploaded to Atlas.ti v.8 Qualitative Data Analysis Software for data management, coding and assistance with analysis. All personal identifying information was removed from the data prior to analysis. All data were stored on a password protected computer only accessible by the researcher. A codebook developed a priori based on the adapted CFIR framework for data interpretation was used during data collection and analysis  established interrater reliability of the coding process until 80% agreement was achieved as recommended for qualitative research . As dataFor each case, program activities, time of occurrence and implementation actors were confirmed. Implementation processes were also described as originally intended, as well as unanticipated implementation facilitators and challenges and the unique implementation context that resulted in program adaptations.Program outcomes were also collected to assess implementation feasibility, effectiveness, as well as overall program fidelity , 37. TheAtlas.ti v8 exploratory functions were used to further analyze and confirm findings, and for source triangulation between participants. Any overlap of themes helped to establish the semantic relationships between CFIR constructs. Prior to the finalization of study results, one program leader and one clinician from each case were asked to participate in member-checks. They each reviewed the results from their respective case, and provided feedback where necessary to ensure validity of study findings.Study findings revealed similar intended program activities and processes within and across cases illustrated in Tables Both cases intended to screen all of their patients for FI using their EMR systems and projected that 45% of their patient population would be identified as FI based on previous community-wide data . Across Clinicians across cases intended to use phone call reminders as an opportunity to remind and educate FI patients about the benefits of participating in the food distribution programs. Between 8 and 22% of patients received phone call reminders.Figure Clinicians across cases reported that physical space, clinician capacity, financial resources and EMR technology were resource challenges that inhibited program implementation. The study revealed a hierarchical relationship where barriers study participants identified trickled down from the organizational systems level that resulted in challenges with the delivery of care at the clinic level and ultimately affected how patients experienced FI screening and referral processes as seen in Fig. Study participants agreed that due to their health system’s pre-programmed EMR software, clinician prompts for FI screening and resource lists were not functional for the realities of day-to-day clinical care. Study participants reported that electronic screening tools were either unavailable or were only available intermittently (e.g. once per year), which did not allow for clinicians to capture the episodic and cyclical nature of FI. Resource lists were embedded so deeply within the EMR system that study participants also reported that they did not have time to navigate to those lists during patient visits.Limited financial resources that health systems could allocate to screening and referral initiatives negatively affected the frequency of food distribution, program sustainability and reach. Study participants reported that screening and referral programs were supported by a finite amount of in-kind donations from their community food assistance partner and local and federal grants. As a result, funding would last for only a fixed amount of time, and study participants reported that the money just did not pay for enough food meet patient needs. Moreover, grant dollars had spending restrictions, and required patients to be enrolled in SNAP benefits. Study participants reported that because of this spending rule, they had to turn several of their low-income patients away during program activities if they were not eligible for SNAP benefits, which negatively affected program reach.Rigid workflow processes across cases provided a small window of opportunity for FI screening and referral during the patient visit. Study participants said that check-in and intake were activities that occurred in settings with very little privacy, but indicated that this was typical for how clinic waiting room or nurse’s intake stations functioned. Physical space became a barrier to screening, referral and food distribution. Across cases, patients displayed discomfort when presented with FI questions, which study participants believed was because of the lack of privacy from other patients. Some patients commonly denied experiencing FI, even if clinicians knew that this was not the case. A lack of privacy could explain why a lower than expected number of patients were identified as FI, and were referred to and participated in the food distribution programs.Study participants reported that clinician capacity to deliver patient care was dependent on the health system’s workflow, and consistently reported that its rigidity did not provide enough time to distribute food assistance resource lists and counsel patients about FI. Clinicians also reported the inability to conduct patient outreach and phone calls for the purpose of increasing awareness about when food distribution was scheduled—an important component for increasing program reach. This finding could explain why there were lower than expected number of patients participated in the food distribution programs overall.Across cases, study participants reported that the support of community partnerships and the internal work culture created an aligned implementation context. As seen in Fig. Multi-sector networks supported inherent synergy with existing community initiatives, which gave each health system access to an existing program model, expertise and infrastructure. The local food justice organization and food depository that partnered with the health systems advocated for an equitable and sustainable food system through existing initiatives throughout the community and played a fundamental role in bringing together health systems, local food growers and other health and wellness community organizations; the collective strength and presence of which created a supportive implementation climate where study participants reported an activation of knowledge, awareness and advocacy work among clinical staff in preparation for program implementation.For example, study participants reported the presence of farm stands across the health system campus, medical and dietetics students involved in program activities, the use of offsite community centers to increase program participation and the assistance of local grant opportunities to increase food production and reach.A culture of clinic-level autonomy facilitated the equitable distribution of decision-making authority. “Managers need to take ownership because they know their patients and their staff,” said one study participant and in turn, when asked about this, clinicians responded with, “We do things differently here,” and “the way we do it is we want to reach everyone…” Statements of this kind referred to linkages, voucher activities and food distribution processes that study participants reported were adapted for universal distribution to reduce the stigma of FI. This adaptation could explain why the number of patients that participated in food distribution programs were much greater than the number of phone call reminders, and SNAP enrollment activities that clinicians actually engaged in.Study participants reported that program activities were highly adaptable and testable. Adaptability refers to the degree to which the core program components can be tailored to fit the implementation context . TrialabTable This is the first study, to this author’s knowledge, that applied CFIR to examine system-wide implementation factors of clinical FI screening initiatives within the context of healthcare settings and primary care. Empirically tested and theoretically derived CFIR concepts guided the development of a conceptual implementation model, while integrating program outcomes strengthened the interpretation of qualitative findings. The conceptual model in Fig. In this early stage of formative research, one optimal combination of clinical screening and referral activities did not emerge as generalizable for testing on a larger scale, which is a necessary step in the translational research pipeline . The U.SNevertheless, overarching themes that emerged across cases that maybe generalizable. Salient to this study were the CFIR concepts, program adaptability and trialability that made implementation feasible across both cases, while maintaining core screening and referral activities. This is consistent with the scalability and implementation framework literature that relies on assessing context, such as available human capital, technical resources, financial costs, and any other contextual factors that may not be replicable in a larger study, but that provide information about the authenticity and feasibility of delivering core intervention activities in clinical practice , 40, 41.Building on this concept, the proactive support of intervention modifications has been proposed in emerging health equity research as a way to address disparities in healthcare delivery, access, resources and outcomes in our most vulnerable populations . It requMoreover, adaptability and trialability highlighted the significance of the CFIR cosmopolitanism concept in this study. Specifically, the interaction between the inner culture and community context drove program design and filled healthcare resource gaps. This finding reflects the current literature on the existences of clinical-community linkages to address FI through clinical screening and referral mechanisms , 9. It aStudy findings resulted in the following recommendations for health systems: 1) Allow for adaptations with caution. Unique implementation contexts can foster implementation feasibility. Yet, considerations need to be made about how adaptations may negatively impact fidelity, reach and effectiveness. 2) Consider how the context can support intervention activities through clinician input about workflow, program responsibilities and time management. 3) Conduct asset mapping and outreach to potential community partners that have a strong presence in the community, aligned goals and objectives and resources that can be leveraged during program design and implementation. This recommendation raises its own challenges about whose responsibility within the health system it is to make community-wide connections and manage relationships, but is key for establishing a truly patient and community-centered medical home. 4) Consider non-traditional forms of staff support. In this study, allied health and medical students were motivated to work as interns in exchange for hands-on, experiential learning. Generally, students are subject to high turnover and may not always be the best solution to fill staffing shortages that require a long-term commitment. An alternative solution is to leverage the role and expertise of community health workers that are trusted sources of information for patients because they often live within the communities they serve.As a study instrument, the researcher was positioned alongside study participants during the process of information discovery during data collection and analysis. As such, this was a subjective process that may have been affected by the researcher’s own biases and experiences . The resWhile this study incorporated the perspective of multiple implementation actors representative of the implementation context, the sample size may be considered small at first glance. What is important to note is that data saturation was achieved, and that qualitative research of this nature requires the deep exploration of the context to interpret findings in a meaningful way. The scope of the study may have been expanded to incorporate more programs and program staff if time and resources to complete this study had not been limited.The study did not include patients’ perspectives or in vivo observations of screening and referral processes. Real-time data could have enhanced study findings, and patients’ perspectives could have provided insight about how screening and referral processes affected their clinical experience. The amount of time allotted for this study limited the scope of the study to the perspective of implementation actors only. Moreover, due to patient privacy laws, the study sites would not allow researchers to sit in during clinical visits. Future studies should consider patient interviews and immediate, post visit surveys to gauge a patient’s perspective about screening and referral processes.Due to time restrictions, data that were collected at only one point in time and relied on the memory of each participant. Future studies should consider the collection of data from participants at multiple time points to capture the dynamic process of implementation and to further validate findings.Lastly, this study is applicable only to the context of the U.S. healthcare system and characteristics of FI within the U.S. Nevertheless, a community-clinical integrated model may have the potential to address hunger in other countries.This study makes significant contributions to the limited body of literature in the emerging field of clinical FI screening programs in primary care practice. In particular, the proposed conceptual model is a foundation for the development of theory-driven standard practices. Though formative in nature the model identifies areas of exploration that have not been considered in previous research, such as intervention adaptability, internal work culture and the community climate.Study findings have implications for practice-based research. The exploration of external factors and creative uses of internal assets for program support should be considered due to the scarcity of funding for community-based interventions implemented in low-resource clinics. Future work should consider how these factors may enhance limited internal resources long-term. Community-engaged formative research with patients could help to tailor primary care focused initiatives to the realities of patient needs. Engaging the patient community could provide critical insights about stigma, privacy, trust and workflow processes from the patient’s perspective, as well as provide deeper understanding about the cyclical nature of household FI that may inform frequency of screening and can be used to advocate for additional health services. Study findings also have implications for ongoing policy work of universal social determinants of health screening practices supported by national healthcare experts.The key take away from this study is that due to limited healthcare resources, primary care practices that serve low-income communities need to be supported in their ability to adapt program activities to their specific context. While high program fidelity and intended program outcomes may not have been achieved in this study, findings demonstrate how implementation feasibility can be achieved when community partnerships and an internal resources are leveraged for program adaptations and support. With this in mind, future research may continue to build on the proposed conceptual model, which is formative in nature and sets the stage for development of standard screening practices. As our healthcare system continues its transition to a value-based model of care, we need to consider how primary care focused FI screening initiatives can effectively connect patients to food resources. If we can reduce the inequitable access to affordable and healthy food, we may eventually see long-term improvements in the quality of life of our most vulnerable populations.Additional file 1.Additional file 2.


ABSTRACT IMPACT: The Independent Investigator Incubator program provides 1:1 mentoring from ‘super-mentors’ to enhance junior faculty careers in research. OBJECTIVES/GOALS: In 2014, the Indiana University School of Medicine (IUSM) in collaboration with the Indiana CTSI established the Independent Investigator Incubator (I3) Program. The I3 Program is designed to provide 1:1 mentoring for new research faculty during the crucial early years of their careers. Our goal is to provide an overview of the I3 design and 5-year data. METHODS/STUDY POPULATION: The I3 Program employs a resource-sharing, centralized design that provides concentrated 1:1 mentorship from a senior faculty ‘super mentor’ as well as other resources, such as grant writing support. Unlike many mentorship programs, I3 mentors closely interact with the mentees within the School and are compensated for their efforts . The number of ‘super mentors’ has grown from 6 to 15 faculty over 5 years, and mentors typically serve 4 to 5 mentees. Mentee applications are accepted on a rolling enrollment basis. The I3 mentees represent a diverse group based on sex, ethnicity, terminal degree, academic track, and discipline. Mentors and mentees have annual reviews through the program. RESULTS/ANTICIPATED RESULTS: In five years, 110 mentees have enrolled in the I3 program. Upon entering, 53% had no external funding, 28% had internal funding, 12% had K-awards, 7% had R03/R21 awards. Over the first five years, 75% have received extramural funding. The median funding was $340,000 with nearly a third of mentees securing grants > 1 million in direct costs. For mentees who joined the program in its first three years (n=59), the average time to a notable extramural grant (defined as a NIH or foundation grant >$300K direct costs) was 2.2 years (median - 2.6 years). Nearly all mentees were satisfied with their mentor pairing based on the mentor’s ‘availability’ and ‘valuable feedback,’ and all mentees wanted the mentoring relationship to continue DISCUSSION/SIGNIFICANCE OF FINDINGS: Since 2014, the I3 Program has had a positive impact on the careers of junior faculty at IUSM as determined by faculty satisfaction and funding metrics. Future focus areas will include developing criteria/models for graduating from the program to balance fiscal sustainability with mentee needs during their transition to mid-career.


Outdoor adventure parks are highly important for contemporary society, having positive social, economic, and environmental impacts. Nevertheless, to fulfill their positive role in society, and to be economically sustainable, such parks need to nurture visitor loyalty. Drawing on previous fundamental research results that ascertain that customer satisfaction has a positive influence on customer loyalty, the objective of the current research is to explore the specific elements of outdoor adventure park visitors’ satisfaction, within an applied research framework, in order to emphasize those attributes that have a significant impact on visitors’ loyalty. For that, an online survey was conducted among the visitors of Arsenal Park, Romania, one of the largest adventure parks in south-eastern Europe. Data were analyzed using partial least squares structural equation modeling (PLS-SEM). Our results show that visitors’ satisfaction with respect to the safety and equipment involved in amusement services, the ambience of the park’s food and beverage facilities, and the quality of the food are the most important satisfaction constituents for enhancing visitor loyalty in the context of outdoor adventure parks. By formatively specifying the exogeneous variables of our model (in contrast with the omnipresent reflective measurements used in previous studies), and by employing the importance–performance map analysis (IPMA), we clearly emphasize those particular aspects that are under the control of outdoor adventure parks’ managers, which significantly impact their visitors’ loyalty, as well as the way in which managers can clearly identify those attributes that need improvements. Outdoor adventure parks are important for sustainable development in the hospitality industry, having positive social, economic, and environmental impacts.In relation to their social impact, by involving physical activities and social interactions in a natural environment, outdoor adventure parks positively affect their visitors’ well-being , life saFrom an economic perspective, it can be stated that outdoor adventure parks form an important segment of the hospitality industry, serving as economic engines for the local communities in which they operate . As reveRegarding the environmental role of outdoor adventure parks, previous studies have shown that the natural environment plays an important role in attracting adventure tourists, being a core component of their experiences . ConsequIn order for outdoor adventure parks to fulfill their social, economic, and environmental role in contemporary society, it is of the utmost importance that people  visit such parks and get involved in active leisure activities habitually and periodically, while also stimulating their friends and acquaintances to do so. In other words, customer loyalty—in this case, park visitor loyalty—needs to be developed and nurtured. Over the years, both practitioners and scholars have acknowledged that increasing customer loyalty can produce several relevant economic benefits. More specifically, retaining customers and stimulating positive word of mouth have been proven to be positively associated with economic sustainability, revenues predictability, and long-term profitability ,11,12. CTo date, several studies have been conducted to explore the factors that drive visitor loyalty for various types of leisure parks. However, as our literature review conducted within Clarivate’s Web of Science journals shows see , in mostThe current study explores the drivers of outdoor adventure park visitor loyalty, adopting a practical and applied approach, by taking into account a substantial set of industry-specific attributes as potential predictors of loyalty, related to the following two indispensable components of any outdoor adventure park: amusement services and food and beverage services, respectively. By formatively specifying the exogeneous variables of our model (in contrast with the omnipresent reflective measurements used in previous studies), and by employing the importance–performance map analysis (IPMA) within partial least squares structural equation modeling (PLS-SEM), we clearly emphasize those particular aspects that are under the control of outdoor adventure parks managers, significantly impact their visitors’ loyalty, and need to be maintained/improved. Moreover, the procedure used in this research can serve as a model/tutorial that can be used by the management of any outdoor adventure park in order to enhance visitor loyalty, and, consequently, improve the economic sustainability of the park’s operations.Outdoor adventure parks are a particular type of leisure park, in which risk, adventure, nature, and physical activity represent key features , a depicIn most cases, leisure parks are a capital intensive, highly developed, user-oriented, human-modified, and recreational environment . The modGenerically stated, adventure leisure activities utilize interactions with the natural environment that contain elements of real or apparent danger, in which the outcome can be influenced by the participant and circumstances . The devCustomer satisfaction, a concept that has been widely debated in the literature, and that has become a mantra in hospitality and tourism research, is traditionally associated with the difference between expectations and actual performance, with reference to a product or service. Thus, satisfaction can be defined as consumers’ response to the evaluation of the perceived discrepancy between prior expectations and actual performance, after the consumption/usage of the product/service . AccordiIn the specific context of leisure parks, previous research has investigated the following various relevant particular park-related attributes that are usually involved in the consumption experience, and that eventually form the overall measure of visitor satisfaction: the park’s physical environment, with attributes such as ambiance/atmosphere, cleanliness, equipment, etc. ,25,26,28Besides these directly observable and operationalizable aspects of leisure parks’ customer experience, previous research has also examined various emotional dimensions of the visitor experience such as immersion, fun, thrill, surprise, novelty, etc. ,24,25,26Simply stated, customer loyalty is a subjective behavior, resulting from complex psychological processes, which is expressed over time by consumers with respect to one or more alternative brands out of a set of brands . This usIt is, nowadays, generally acknowledged that satisfaction makes customers more psychologically attached to brands , and morIn the specific context of leisure parks, previous studies investigating the relationship between visitor satisfaction, on one hand, and behavioral intentions to revisit and/or recommend the park, on the other hand, have come to a similar conclusion: there is a strong positive influence of visitor satisfaction on visitor loyalty e.g., ,15,17). ,17. 15,1Considering the current’s research focus—outdoor adventure parks—and the two indispensable components of any such leisure facility—amusement services and food and beverage facilities, respectively—we issued the following research hypotheses:Hypothesis 1 (H1):Visitors’ satisfaction with the amusement services offered by an outdoor adventure park positively predicts visitors’ loyalty.Hypothesis 2 (H2):Visitors’ satisfaction with the restaurant services offered by an outdoor adventure park positively predicts visitors’ loyalty.The current research is aimed at identifying the most relevant constituents of visitor satisfaction for enhancing visitor loyalty, in the context of outdoor adventure parks. Drawing on previous fundamental research results that ascertain that customer satisfaction has a positive influence on customer loyalty, our goal is to explore the specific elements of outdoor adventure park visitors’ satisfaction, within an applied research framework, and to emphasize those attributes that have a significant impact on visitors’ loyalty.In order to accomplish our research goal, we focused on Arsenal Park, one of the largest adventure parks in south-eastern Europe. Arsenal Park was launched in 2009 after an investment of 25 million euros. Being built on the ruins of a former military base and munitions factory, the park has a military theme, occupying 88 hectares of land in the proximity of Orăștie, a city in the Romanian county of Hunedoara. Arsenal Park offers its visitors various amusement services related to adventure activities such as zip lines, power-fan jumps, armored rides, paintball, firearms shooting, etc., as well as a large military themed restaurant with mostly Romanian cuisine . The geoFurthermore, an online survey was conducted among the park’s recent visitors, targeted at assessing their satisfaction with and loyalty to Arsenal Park. The invitation to participate in the study alongside the link to the online questionnaire was disseminated via social media, in 2019, on the park’s Facebook page , as well as on various tourism/travel-related Facebook pages or groups. The invitation and questionnaire were only addressed to Romanian visitors, being available exclusively in Romanian. However, this did not significantly impact the representativeness of the study, as, according to the management of the park, the vast majority of the parks’ visitors come from Romania, of which more than half are from Hunedoara, the county where the park is located.More than 200 park visitors filled in the questionnaire. Only those who had experienced both the amusement and restaurant services offered by Arsenal Park were kept in the sample . Thus, the final validated sample included a total of 147 visitors of Arsenal Park  and TripAdvisor (about 80 reviews posted up to 2019). Only reviews including specific textual feedback were scrutinized, and, of these, only those reviews that specifically pointed out negative or positive aspects related to outdoor activities, or food and beverage were taken into account. Both positively and negatively described aspects of visitors’ experience were considered in order to draw-up the initial list of potentially relevant attributes from a satisfaction measurement perspective.In a second step, the drawn-up list was filtered by retaining only those attributes that were emphasized as potential satisfaction determinants in previous studies regarding leisure parks, as our literature review had shown see . For exaEventually, a shortlist comprising the most relevant elements was drawn up for measuring visitors’ satisfaction with the parks’ amusement services and its restaurant: cleanliness, equipment, prices, safety, staff, and waiting time, for the amusement services; ambience, food quality, menu, prices, staff, and waiting time, for the restaurant. All these elements were further included in the online questionnaire as satisfaction items with answering options ranging from one = very unsatisfied to seven = very satisfied. Consequently, visitors’ satisfaction was measured via two formative latent variables, each item/indicator capturing a specific constituent of satisfaction. Additionally, two single item questions were included in the questionnaire to reflect overall satisfaction with the park’s amusement and restaurant services, respectively, using similar answering options. These two additional questions were specifically included in the questionnaire so that we could afterward validate the two formative latent variables depicting visitor satisfaction. Visitor loyalty was measured reflectively using a scale with four items, each item with Likert answering options ranging from one = strongly disagree to seven = strongly agree, adapted from Ma et al.  and SlåtA detailed view of the items included in the questionnaire in order to measure visitors’ satisfaction and loyalty can be seen in Considering the exploratory and prediction-oriented nature of our research, a parsimonious path model for the impact of visitor satisfaction on visitor loyalty was proposed for further analysis using PLS-SEM .PLS-SEM was employed for data analysis for two reasons. Firstly, PLS-SEM integrates and handles reflective and formative latent variables within the same path model , our proFollowing the guidelines provided by Hair et al. , the meaWe firstly evaluated the construct of visitor loyalty, which was measured reflectively. Outer loadings produced by the PLS algorithm for all four loyalty items were above the threshold of 0.7 , suggesting high indicator reliability. Additionally, the loyalty construct exhibited very good internal consistency, with both Cronbach’s alfa (0.971) and composite reliability (0.974) values above the recommended threshold of 0.7. With respect to convergent validity, the average variance extracted value for the construct of loyalty (0.902) was above the cutoff point of 0.5, showing that the construct was convergent.Further on, we assessed the two formative constructs designed to measure visitor satisfaction. Firstly, in order to ensure that collinearity between the formative indicators was not an issue, we computed the variance inflation factor (VIF) for each indicator see . As all 2 values above 0.5. Hence, we concluded that the two formative constructs exhibit convergent validity.The next step in validating our formative measurements consisted of assessing their convergent validity. In the PLS-SEM context, the convergent validity of a formative variable reflects the extent to which it correlates positively with other measures of the same construct using different indicators. For this, researchers can conduct a redundancy analysis, testing whether the formatively measured construct is highly correlated with a reflective measure of the same construct. Using the single item questions included in the questionnaire to reflect overall satisfaction with the park’s amusement and restaurant services, we were able to run redundancy analyses for both our formative constructs. As can be seen in p values go beyond the cutoff point of 0.05, thus revealing the fact that the corresponding formative indicators’ weights are statistically nonsignificant. However, a nonsignificant weight is not indicative of poor measurement model quality, as long as the indicator’s absolute contribution to the construct, given by its outer loading, is high . In our case, all the outer loadings produced using the PLS-SEM algorithm, for all the formative indicators, were above the threshold of 0.5 . Therefore, we retained all the formative indicators in our model, and fully validated the two formative constructs as proposed.The next and final step of validating our formative constructs consisted of assessing the significance and relevance of their corresponding formative indicators. In order to do that, we employed the PLS-SEM bootstrapping procedure with 5000 subsamples; the results are shown in Before assessing the structural model, we checked for collinearity issues among the two predictor constructs. The variance inflation factor (VIF) value between amusement services satisfaction and restaurant satisfaction, as predictors visitor loyalty, was 2.65, clearly below the threshold of 5 , indicatWhen using PLS-SEM, meaningful practical implications can be considered valid only if the predictive relevance of the examined model is established . As the 2) for our target variable, with the results showing that a large proportion of visitor loyalty’s variance (76.9%) is explained by the two predictor constructs depicting visitor satisfaction.Firstly, we evaluated in-sample predictive relevance (or explanatory power), by examining the coefficient of determination , it can be stated that both satisfaction with amusement services (H1) and satisfaction with restaurant services (H2) have a positive and statistically significant impact on visitor loyalty, the impact of the two predictors being relatively equal.To test the hypothesized relationships, we used the PLS-SEM bootstrapping procedure with 5000 subsamples. The results, summarized in p values, we can outline those particular attributes of the amusement and restaurant services that are truly relevant for visitor loyalty. In the case of amusement services, the most influential satisfaction constituents are safety  and equipment , while in the case of restaurant services, ambience  and food quality  represent the most relevant satisfaction components for enhancing visitor loyalty. Additionally, analyzing the formative indicator’s weights and their corresponding p > 0.05). However, in the case of amusement services, visitors’ satisfaction with the staff and with the facilities’ cleanliness exhibit rather substantial weights , which, despite being unsignificant, suggest that these attributes might also play a role in boosting visitor loyalty, even though they are less important than visitors’ satisfaction with the amusement services’ safety and equipment.Visitors’ satisfaction, with the other attributes included in our construct, exhibits statistically unsignificant weights  point to a single-segment solution, we can conclude that heterogeneity is not an issue and does not affect our data. Therefore, the subsequent model estimates are robust , and theThe IPMA ,51 repreConsidering the parsimonious nature of our model, as well as the formative measurements of visitor satisfaction, we conducted the IPMA at indicator level, for the two satisfaction-related constructs, setting visitor loyalty as the target variable. The results are shown in Based on the IPMA results, we can emphasize that visitors’ satisfaction with respect to the safety provided by the adventure parks’ amusement activities, along with the ambience of the park’s restaurant, are the most important satisfaction constituents for enhancing visitor loyalty. Additionally, considering Arsenal Park’s performance for these two attributes, it can be stated that the management of the park is doing a good job, with the scores for both these attributes being above the average. However, in relation to the ambiance provided by Arsenal Park’s restaurant to its customers, there is substantial room for improvement.Visitors’ satisfaction with the food quality offered by the park’s restaurant, as well as with the equipment used for amusement activities, represent the next two satisfaction constituents that need to be carefully managed in order to boost visitor loyalty. As for Arsenal Park’s performance for these two attributes, even though both exhibit scores above the average, the management should consider substantial improvements with respect to the food quality offered by the park’s restaurant, in order to improve visitor loyalty.Visitors’ satisfaction with the cleanliness of the amusement services unit of the park, and with the staff involved in providing these services, represent other potentially important facets of satisfaction that need to be carefully managed in order to maintain or nurture visitor loyalty. Even though these two indicators were not found to have statistically significant weights after the bootstrapping procedure, their importance is substantially higher compared to the other remaining indicators. In relation to Arsenal Park’s performance for these two attributes, considering their relatively good scores, as well as their lower importance, the managerial recommendation would not involve investing in a significant improvement, but would imply maintaining their performance level.Surprisingly, visitors’ satisfaction with waiting time and prices, as well as with the restaurant’s staff or its food and beverage variety, represent unimportant facets of satisfaction, their improvement being technically unnecessary for increasing visitor loyalty. Consequently, despite Arsenal Park’s mediocre performance for visitors’ satisfaction with prices, as well as with the restaurant’s waiting time and menu, the management should not prioritize these aspects for future improvement intended at maximizing visitor loyalty.Our results have revealed that, despite an unanimously acknowledged strong, significant, and positive causal relationship between satisfaction and loyalty, the distinct visitor satisfaction constituents have different outcomes when it comes to visitor loyalty in the case of outdoor adventure parks.Thus, according to our findings, the most impactful satisfaction ingredients in the case of such leisure facilities are represented by the perceived safety of the amusement services, and the ambience of the food and beverage facilities. Regarding safety, our findings are in line with those of Milman et al. , who conIn relation to the ambience of the food and beverage facilities, our finding is rather novel, with previous studies being generally focused on the overall ambiance or atmosphere of parks, not being specific with respect to certain park units, areas, or services. For instance, Basarangil , as wellThe current study’s findings also revealed the following two other relevant constituents of visitor satisfaction that have a significant impact on visitor loyalty: the food quality offered by the park’s restaurant facilities, and the equipment used to provide amusement services. With respect to food quality, our results are in line with previous findings outlined by Geissler and Rucks , who poiRegarding visitors’ satisfaction with the equipment used to provide amusement services, which, in our research, was shown to have a significant influence on visitor loyalty, our results are compatible with those obtained by Wu et al. , who fouSurprisingly, our results revealed that visitors’ satisfaction with the staff, prices, or waiting time has no significant impact on visitor loyalty, regardless of whether the amusement or restaurant services are taken into account. Regarding the staff, our findings are contrary to those outlined by previous research. For instance, according to Milman et al. , park viIn relation to the prices charged within leisure parks, previous studies’ results have been inconsistent. For instance, Geissler and Rucks  found thLastly, considering visitors’ satisfaction with the waiting time, our results are inconsistent with those provided by Geissler and Rucks , and Wu Overall, our study partially confirms previous results obtained by researching the impact of visitors’ satisfaction and loyalty in the case of leisure parks. However, as this is, to the best of our knowledge, the first study to investigate the relationship in the case of outdoor adventure parks, in an applied manner, it emphasizes several satisfaction elements that have a distinct path of relationship with visitor loyalty, as compared to other types of leisure parks. These contradicting findings may be the result of the various particularities of such parks. Thus, one of the major differences between outdoor adventure parks when compared to other types of leisure parks is that they are basically much less crowded and more personal. Additionally, even though all types of leisure parks conduct regular inspections to keep their amusement infrastructure and activities safe, outdoor adventure parks need to use some of the most advanced safety equipment, as they need to provide a calculated level of risk and adventure. Additionally, while common leisure parks offer their visitors a mostly anthropic landscape, with acres of asphalt, and various human-made facilities, outdoor adventure provides visitors an environment that is as natural as possible, with as few as possible elements of built infrastructure.From a practical standpoint, our findings suggest that in order to increase visitor loyalty, outdoor adventure parks managers need to prioritize and carefully target their efforts towards improving their visitors’ satisfaction with respect to certain specific aspects of their operations, while maintaining a decent level of satisfaction with other attributes.Thus, with respect to the core operations of an outdoor adventure park, the focus should be on improving customer satisfaction with the perceived safety provided by the parks’ amusement services, as well as with the equipment involved. Safety represents an essential requirement in outdoor adventure parks; visitors expect leisure adventure and park experiences to have a calculable, predictable, and preferably, low risk. Additionally, having modern, up to date, and easy to use equipment for all the amusement services provided to visitors is of the utmost importance.Regarding the food and beverage services offered by an outdoor adventure park, as an integral part of the park experience, and often an attraction themselves, our findings emphasize the fact that to enhance visitor loyalty, park managers need to focus on visitors’ satisfaction with the ambiance and the food quality offered within their restaurant facilities.As for the remaining satisfaction constituents, such as those related to staff, waiting time, or prices, for amusement and restaurant services alike, they should be treated as secondary targets within outdoor adventure parks’ efforts to enhance visitor loyalty. However, despite not having a significant impact on revisit or recommendation intentions, these attributes should be monitored and maintained at a decent level of satisfaction, because an extremely low performance would pose the risk of ruining the overall park experience, and, eventually, losing repeat visitors.Other relevant practical implications result from our IPMA, which points out several satisfaction indicators that have a relatively high importance for predicting visitor loyalty, but do not exhibit a good enough performance in the case of the outdoor adventure park investigated within the current research—Arsenal Park. In order to increase visitor loyalty, Arsenal Park’s management should focus on improving the food quality and the ambiance provided by its restaurant, in which case, our results emphasized that there was room for substantial improvement. As for the other satisfaction constituents, the managerial recommendation for Arsenal Park would not involve investing in a significant improvement but would imply maintaining their performance level.Of course, the latter practical recommendations are specifically addressed to Arsenal Park and cannot be generalized to other players from the industry. Nevertheless, with respect to the IPMA, our general recommendation for outdoor adventure park managers, as well as for any leisure park manager, is to periodically collect visitor satisfaction and loyalty data, to perform IPMAs, and to prioritize future improvements appropriately, based on IPMA results, so that visitor loyalty can be enhanced. For this purpose, the procedure used in the current study can serve as a tutorial that can be used by the management of any outdoor adventure park.As a final remark, we need to point out that visitors’ loyalty cannot be nurtured while ignoring the online environment. The Internet has become an important communication media for tourism organizations, in which online travel communities significantly impact tourists’ choices . In suchTo fulfill their social, economic, and environmental role in the contemporary society, outdoor adventure parks need to constantly monitor and nurture their visitors’ loyalty, and to generate repeat-visit behavior and positive word-of-mouth. The current study emphasizes those particular attributes of outdoor adventure parks that can be managed and controlled, and that significantly impact visitor loyalty. By improving these aspects, outdoor adventure parks can effectively maintain and increase visitor loyalty, thus developing in an economically sustainable manner.Our results show that visitors’ satisfaction with respect to the safety provided by the adventure parks’ amusement services, along with the ambience of the park’s food and beverage facilities, are the most important satisfaction constituents for enhancing visitor loyalty toward outdoor adventure parks. Visitors’ satisfaction with the food quality offered by park’s restaurant amenities, as well as with the equipment used to provide customers the amusement services, represent another two satisfaction elements that can significantly boost visitor loyalty. Satisfaction with other outdoor adventure park aspects such as waiting time, prices, staff, or cleanliness were not found to be statistically significant in influencing revisiting or recommendation intentions. However, despite being statistically unsignificant, satisfaction with the cleanliness of the amusement services unit of the park and with the staff involved in providing these services, represent potentially relevant aspects for nurturing visitor loyalty, their importance being substantially higher compared to the other remaining attributes taken into account.By adopting a practical and applied approach, more specifically by taking into account a substantial set of industry-specific attributes as potential predictors of loyalty, the current research enriches the existing knowledge regarding the factors that drive outdoor adventure parks’ visitors’ loyalty, while, at the same time, provides meaningful and scientifically sound practical implications for park managers. By formatively specifying the exogeneous variables of our model (in contrast with the omnipresent reflective measurements used in previous studies), and by employing the IPMA within PLS-SEM, we clearly emphasized those particular aspects that are under the control of outdoor adventure parks’ managers, which significantly impact their visitors’ loyalty, as well as the way in which managers can clearly identify those attributes that need improvements.Evidently, the current research has certain limitations. Firstly, the size of the sample included in our analyses is not generous. Nevertheless, when all the respondents are recent visitors of a single outdoor adventure park, and when the data collection follows an ad hoc procedure, large samples are hardly realistic. Secondly, our data were collected in 2019, before the COVID-19 pandemic, which most probably affected people’s attitudes toward traveling, as well as toward leisure activities in general. The effect of such attitude changes is obviously not reflected in our research. Thirdly, the generalizability of our results is rather limited to the context of outdoor adventure parks.Each of our research limitations involves a suggestion for future research. Subsequent studies should process visitor data from several outdoor adventure parks, from various geographical regions. Future studies should also consider taking into account the effects of pandemic-based attitude changes regarding traveling and leisure activities, in the context of outdoor adventure parks. Additionally, future research could be conducted comparatively, using visitor data from several types of leisure parks , in order to point out potential significant differences, and to enable researchers to provide more generalizable results.


Hypertension is the leading single preventable risk factor for death worldwide, and most of the disease burden attributed to hypertension weighs on low-and middle-income countries. Effective large-scale public health hypertension control programs are needed to control hypertension globally. National programs can follow six important steps to launch a successful national-scale hypertension control program: establish an administrative structure and survey current resources, select a standard hypertension treatment protocol, ensure supply of medication and blood pressure devices, train health care workers to measure blood pressure and control hypertension, implement an information system for monitoring patients and the program overall, and enroll and monitor patients with phased program expansion. Resolve to Save Lives, an initiative of global public health organization Vital Strategies, and its partners organized these six key steps and materials into a structured, stepwise guide to establish best practices in hypertension program design, launch, maintenance, and scale-up. Hypertension is the leading single risk factor for death worldwide and accounted for an estimated 10.8 million 9·39–11·5) deaths in 2019 9–11·5 de.To reduce cardiovascular disease burden, the World Health Organization (WHO) and partners developed the HEARTS technical package to guide the management of hypertension and other cardiovascular disease risk factors in resource-limited settings . In 2021The first step in implementing a hypertension program is setting up an administrative structure. The administrative structure should include all relevant factors such as national or subnational ministry of health (MOH) focal points. It could also include representatives from the private sector and faith-based health care sector, non-government entities, and civil society.If the MOH  chooses to involve other partners, a memorandum of understanding (MOU) can be established between government entities and partner organization(s) that are collaborating on the hypertension control program Table , Step 1AA multi-stakeholder technical working group (TWG) should provide oversight and strategic direction for the program, contribute to technical decisions on programmatic aspects such as site selection, design of a treatment protocol, and establish a process for ongoing program monitoring and quality improvement. The TWG can include representatives from national non-communicable disease programs, supply chain logistics units of the government, health information departments, implementing partners, and civil society or patient representatives. The TWG should survey existing policies and guidance, determine where gaps exist and work with relevant MOH entities to update or create policies and guidance. For example, current government regulations may not support task sharing with nurses or other non-physician health workers for initiation and maintenance of hypertension treatment, a strategy that is feasible and effective . RegulatBefore the program starts, a needs assessment can utilize national and subnational data to better define disease prevalence, current numbers of patients diagnosed and on treatment, relevant national policies, and the regulatory status of key products.To understand the current level of resources available at primary health care facilities, program staff should conduct a baseline survey at a representative sample of health facilities. Program managers can use the baseline facility checklist to facilitate the documentation of existing human resources, medication and device availability and functionality, lab capacity, the quality of information systems, and how patients are managed Table —Step 1D.To ensure long-term hypertension control and patient retention in the program, the baseline situation analysis should also assess opportunities to implement differentiated service delivery as part of the hypertension control program. Differentiated service delivery means less intensive and/or community-based services for hypertension patients with stable controlled BP, freeing up clinic appointments for patients with uncontrolled BP .Program budgeting should be based on the needs assessment, current resources available, the development of a hypertension treatment protocol Table , and othThe choice of antihypertensive medications can vary by country, based on the population served, the availability of medications in the region, and medication prices. Simple drug- and dose-specific treatment protocols support efficient and standardized care, enable task sharing, and improve medication adherence . Simple To reach consensus on the drugs, doses, and steps in a simple treatment protocol, convene stakeholders at a consensus conference at the national or subnational level. This allows stakeholders to discuss various protocol options and agree on the best protocol for their country, province, or state . ProtocoThe 2021 WHO Guideline for the Pharmacological Treatment of Hypertension in Adults recommends a hypertension treatment protocol that initiates treatment with a calcium channel blocker or a single pill, dual-drug combination of a calcium channel blocker, and angiotensin receptor blocker . Both ofFinal approval of the treatment protocol is usually given by the MOH. The protocol can then be formatted, printed, and distributed to health care facilities. Facilities can choose to post it on the wall of the room in the primary health care facility where health care workers treat patients and/or distribute it electronically as a job aid.Medication and BP measurement devices are an essential part of launching a hypertension program. The BP device model chosen for a new hypertension program should be externally validated as accurate, come with multiple cuff sizes, and be durable and affordable for the program . TechnicDue to environmental concerns, manual mercury BP devices are being phased out globally . To replBefore forecasting the quantity of medications and BP devices that will be needed for a new hypertension program, program staff should conduct an inventory survey at facility level  session. Facility directors and program managers can participate in a ToT and in turn train health care workers in their respective facilities. Having in-country trainers who can conduct repeated training sessions ensures the training is sustainable.Once trained, supervisors can facilitate practical training for health care workers as part of in-service training. This training covers topics such as measuring BP, hypertension management, data collection, and data entry and reporting. Supervisors should conduct trainings at the facility-level whenever possible to include a wider range of health care workers and reduce disruption to service provision. Training aids have been developed by Resolve to Save Lives to support hypertension control programs Table —Step 4C.Facility-level supervisory visits are helpful for monitoring program quality. Program managers use a standard form to assess and record intervention fidelity, including proper BP measurement, workable equipment, availability of medication, completeness of registers, and data entry practices Table —Step 4D.An information system is crucial to a hypertension program as it facilitates the monitoring of patient and program progress and outcomes. Standard indicators enable programs to compare results across national, subnational, district, and facility levels, and to understand where program quality can be improved . WHO HEATo collect the data needed to calculate hypertension control and monitor program progress, each patient diagnosed with hypertension should have their personal identification and clinical information recorded on a portable hypertension card carried by each patient, in a facility-based longitudinal treatment registry, and as part of a larger registry maintained by local population health managers. If the program has a digital information system, a QR code can be included on the hypertension card to ensure accurate patient tracking if the technology allows Table —Step 5B.Monitoring and evaluation officers in countries that have paper systems may find calculating indicators manually a long and tedious process. If a hypertension program does not utilize electronic data, basic digital spreadsheet-based tools can aggregate data from paper patient treatment cards (or a simple random sample thereof; Table Facility managers, district health officers, and program officers should plan to regularly review data, examine trends in the key indicators, and establish feedback loops. Such regular review of data is critical to help identify program weaknesses and design quality improvement interventions.It is critical to ensure data security, privacy, and quality control when analyzing patient data. Resources on the security, confidentiality, and appropriate use of data are available from the US Centers for Disease Control and Prevention Table —Step 5C.Simple application, a mobile-based electronic information system designed for hypertension, have access to the Simple app dashboard, which allows program managers to view indicators across districts and over time, and generate monthly, quarterly, or annual reports [Programs using an electronic data collection system use computer software to automatically calculate program indicators and generate reports. For example, programs using the Resolve to Save Lives  reports  (Fig. 3;Regardless of how data are collected, monitoring and evaluation officers in facilities should prepare reports based on data aggregated manually, by a digital spreadsheet program, or via an integrated software program. At minimum, reports typically include data on number of patients enrolled, number of patients treated, proportion with controlled BP, and patient follow-up rates. Establishing a process and timeline for reporting will facilitate the analysis and interpretation of program results.An effective way to screen as many patients as possible is to set up opportunistic screening—that is, placing BP devices at registration and in well-trafficked areas, so that all patients entering the facility have their BP measured. In cases where initial screening identifies high BP in the community, care should be taken to make a rigorous BP measurement in a controlled clinic setting to confirm hypertension diagnosis.When patients are diagnosed and registered, facility staff must record their contact information accurately. This facilitates monitoring treatment and ensuring follow-up.Establishing a standardized system for patient follow-up is essential. Patients are lost to follow-up for various reasons, some of which include irregular availability of service providers, side effects of medications, medication stock-outs at the facility, distance to the facility, or preference for the private sector . StrategTeam-based care, including “task-sharing” among health care workers alleviates the shortage of medical doctors and nurses in many countries and allows more decentralized care that is delivered in the community where patients live. Team-based care occurs when all members of a multidisciplinary team engage in a patient’s care. This could involve training new staff to fill gaps in the team or building the capacity of existing team members so they can take on new tasks . Using aPatient-centered care can also involve hypertension screening by health care workers in the community—in well-trafficked locations, at events, or even house-to-house. Strong referral linkages must be established from the community to local primary care facilities so that individuals with high BP receive a formal diagnosis and treatment. Other health care programs, such as for diabetes or HIV, may already have established screening or treatment programs, therefore it may be efficient to integrate hypertension services into established practices Table —Step 6C This Six-Step Guide and best practice guidance was developed from implementation experience of 21 Resolve to Save Lives-supported national hypertension control programs. Despite successful enrollment and management of patients in these programs, there are continuing challenges to achieving and maintaining population hypertension control. Over time, country programs have developed solutions to address these challenges.It is essential that each country program integrates their own simple hypertension treatment protocol into national hypertension guidelines as part of national scale-up across all primary health care facilities. The next step globally will be to gather international consensus and converge on a universal simple treatment protocol shared across countries. A global standard hypertension treatment protocol can streamline global medication procurement for a short list of generic quality-assured preferred medications. Consolidating demand for antihypertensive medications across states or countries that are procuring the same preferred medications creates negotiation power with manufacturers which can lead to price reductions. Similar market-shaping interventions have been used successfully in the past to lower prices of medications for malaria and HIV commodities . While tAchieving hypertension control means utilizing programmatic data to inform program improvements and spark innovations that improve the treatment experience and health of patients. Resolve to Save Lives-supported hypertension control programs leverage individual patient and health care facility-level data to inform systematic quality improvement efforts. Systematic continuous quality improvement identifies program challenges on a regular basis and takes rapid actions to address them. Feedback loops that are integral to the quality improvement process are easier and faster to operate from an electronic health information system but can also be based on data from aggregating paper records on a monthly or quarterly basis.Lessons learned from the pilot stages of the hypertension program should be reviewed and considered before scaling the hypertension program to new areas. A situational analysis of the expansion areas may also be helpful to tailor the program to local contexts.A significant challenge that arises in many donor-led projects is how to transition from donor funding to government funding for the program . This haOther challenges and solutions have been identified through implementation of these hypertension programs in LMICs Table . PopulatStarting a large-scale, national public health hypertension control program can be broken down into six practical steps. Resolve to Save Lives’ practical Six-Step Guide to implementing hypertension control programs is a resource for governments and other implementers that establishes best practices in hypertension management and provides a roadmap for program launch, maintenance, and scale-up. The Six-Step Guide distills best practices from the WHO HEARTS technical package and the 2021 WHO guideline for the pharmacological treatment of hypertension in adults. Implementing and scaling up WHO HEARTS-based hypertension control programs in countries around the world will control high BP worldwide, and thereby prevent unnecessary deaths and disability for millions of people.United Nations Sustainable Development Goal 3 includes reducing premature mortality from non-communicable diseases by one-third.Hypertension, a non-communicable condition, is the leading risk factor for death worldwide; most of global hypertension-related disease burden occurs in low- and middle-income countries.Large-scale public health hypertension control programs must be prioritized to prevent hypertension-related disease burden in low- and middle-income countries.A practical, stepwise implementation guide to launch national hypertension control programs.Practical tools that can be adapted by countries to support hypertension control program implementation.


Both received 4 weeks of stress-related lessons. The EG received 60 additional sessions of APMR over 12 weeks. (3) Results: The program dropout rate of the participants was 1.3%. The EG’s program adhesion rate was 99.1%, and nearly half felt satisfied with the program. After adjusting for the BMI and the pretest in the ANCOVA, it was found that the CG had a greater change in HCC between the pre- and post-tests than the EG, while the PSS did not change significantly in either group. (4) Conclusion: APMR is a valid practice for physiological homeostasis of HCC for female adolescents, but it has no significant effect on perceived stress.(1) Background: A variety of stressors may be potentially harmful to adolescents’ health and well-being. Relaxation techniques have been recognized as a valid method for stress release, but the challenge is to apply them practically in schools to produce the desired effects. (2) Methods: This feasibility study used the Perceived Stress Scale (PSS) and hair cortisol concentration (HCC) to test the effects of an abbreviated progressive muscle relaxation (APMR) program on female adolescents. The participants were recruited from a high school and assigned by class cluster to either the experimental group (EG,  Adolescents often experience various kinds of pressure that come from the academic performance expectations of their parents or themselves or from emotional and interpersonal conflicts ,2. AcadeMany relaxation techniques have proven to be effective and are used by young people to relieve stress, such as progressive muscle relaxation (PMR) , meditatBoth subjective and objective stress level measurements are frequently used to evaluate the effectiveness of relaxation techniques ,17,18. TIt is well-known that stress is a behavioral and physiological response to stressors . The mosSaliva or serum cortisol can only measure the short-term effects of stress-related outcomes ,26. HairIn previous studies, the duration of PMR interventions for adolescents ranged from a single dose to 8 weeks, and each session typically lasted for 15 to 45 min, two to five times per week . RegardiThe purposes of this study were to test the feasibility of a 16-week school-based APMR program among female adolescents and to conduct a preliminary evaluation of its effects on the subjective and objective aspects of stress relaxation. Consequently, the following hypotheses were proposed: (1) school-based APMR is a feasible and acceptable relaxation technique for female adolescents; (2) the HCC in the experimental group (EG) will not change significantly  before and after the APMR intervention, whereas the control group (CG) will; (3) the perceived stress will change significantly for the EG after the APMR intervention, but not for the CG.This study employed a quasi-experimental design with a pre-test and post-test to evaluate the feasibility and preliminary effects of a school-based APMR program for female adolescent students.In the present feasibility study, a convenience sample of adolescents was recruited from a high school in southern Taiwan that had mostly female students. First, the researchers visited the principal to explain the research process and obtain approval for the APMR program.For the study, the participant inclusive criterion was having a hair length of more than 3 cm on the posterior vertex position of the head. The exclusion criteria were taking any corticosteroid medication within the past 3 months, applying hair dye or perm within the past 3 months, and/or experiencing major life events (the death or serious illness of a close relative or parents’ divorce)  within tThis study was approved by the Ethics Committee of Kaohsiung Armed Forces General Hospital . The research details were shared with the parents through a consent letter. The researcher explained the same information to the students from two classes during a classroom visit. All the participants and their parents provided written informed consent before participating in the study.The program’s objectives, approaches, protocols, and implementation process were developed by the partnership team consisting of the principal, deans, department heads, health promotion professionals, and school nurses. A school-wide assessment of the intervention was conducted subsequently.At least six team meetings were held to facilitate the development and implementation of the APMR program. In these meetings, the team discussed the intervention protocols for the actual course, analyzed the need for an intervention space, planned the course progression, and designed the methods to assist and monitor the participants in the intervention space. The intervention protocol was regularly modified and adjusted in close collaboration with the members of the school staff. The teachers for the two classes and the school nurses received a 2 h training course before starting the implementation to solidify their stress-related knowledge and skills, which were required to supervise the APMR practice during the intervention period.A 16-week APMR program was designed to help the students build stress-related knowledge and learn the APMR techniques to be practiced according to an assigned schedule.The lessons comprised four educational talks over four weeks, including topics focusing on the “concept of stress and stressors”, “biological process of stress”, “relationship between stress and physical and psychological health”, and “health benefits of APMR”. These were held as part of a health-related elective course between the 3rd and the 6th week of the semester. Both the EG and CG received these educational talks, but the EG received one additional class that introduced APMR. The program also provided the activity tutors with a 10 min CD as an assistive audio script to guide the implementation over the next 12 weeks to help ensure the quality of the APMR practice.Considering the limited time and the need to guarantee that the students’ formal curriculum and class time were not disrupted, the two 10 min practice sessions of APMR techniques were arranged during break times (during the morning break and after the noon nap). We treated academic exams as a significant real-time stressor for adolescents. Therefore, the practice sessions took place for 10 days before each monthly exam or professional certification exam, resulting in a total of 30 days of practice over 12 weeks.The APMR sessions were conducted by an expert and university trainer during the 6th week of this program. The muscle relaxation technique targeted the following major muscle groups: hands, arms, neck, shoulders, feet, and legs. Those in the EG were encouraged to focus their sensations on the release of muscle tension and the feeling of comfort. They were advised not to tense the muscle groups when they felt strained or aggravated pain. They learned about the steps of APMR: (a) secure a quiet environment in the classroom (this was carried out by the tutors); (b) assume a comfortable sitting position to eliminate muscular tension; (c) systematic tense up the muscles for 5 s, then relax the muscles for 10 s progressively; (d) focus on the comfortable and relaxed feeling as the muscles relax ,18. EachThe indicators of primary outcomes, including the program dropout rate, adherence, and activity satisfaction, were collected to assess the study’s feasibility ,33,34. AIn the present feasibility study, each group’s dropout rate was calculated by dividing the number of participants who quit the entire program by the total number of participants. Adherence to participation in the EG was assessed using the Person-Time Follow-Up Rate (PTFR), dividing the observed person-time by total person-time, excluding the dropouts. The EG participants were asked to rank their overall satisfaction with the APMR program from 0  to 4 (very satisfied). In addition, they were welcome to submit any comments or needs during the intervention.The primary outcome—feasibility—was defined as achieving the target sample size of at least 20 participants in each group, <10% dropout rate, >90% adherence  to the school-based APMR program, and >75% of participants being “satisfied” or “very satisfied” with the program. If the indicators failed to achieve these feasibility goals, a discussion and modification should be conducted for the research design, protocol, and intervention before conducting a randomized controlled trial in the future.The PSS is the most frequently used psychological instrument for measuring the perception of stress and is suitable for respondents with at least a junior high school education. The Chinese version of the PSS consists of seven positive and seven negative items. The participants were asked to rate each item’s occurrence frequency during the past month on a 5-point Likert scale ranging from 0 (never) to 4 (routinely). Higher scores indicate higher stress in the respondents’ daily lives. A confirmatory factor analysis corroborated the two-factor structure of the model. The positive and negative factors correlated significantly and negatively to a moderate extent. The instrument also had a high internal consistency reliability  .Previous studies have demonstrated that visual analog scales (VAS) have adequate psychometric properties to measure acute pain or level of relaxation  ,37. In t2) were calculated using anthropometric measurements after calibrating the equipment. The participants were asked to provide two 3 cm hair samples from different locations of their scalp. The research assistant was trained to cut 20–30 hair strands from the scalp’s vertex posterior, as close to the scalp as possible, using scissors. The most proximal 3 cm segment reflects systematic cortisol exposure over the previous 3 months. The level of HCC was measured according to the modified hair cortisol analysis protocol previously reported and analyzed on a salivary ELISA kit manufactured by Alpco Diagnostics for quantification [HCC is a stress indicator and mental health-related variable that can be significantly influenced by age, sex, hair treatment, body mass index (BMI), and major life events ,31. Bodyfication ,39,40,41t-test compared these characteristics between the EG and CG. To reduce the skewness to approximately twice the standard error or less, the HCC data used a log transformation to perform further analysis [t-test and ANCOVA were used to evaluate the effectiveness of the outcomes. Statistical analyses were performed using the statistical software package SPSS 24.0 for Windows.Frequencies and percentages were used to describe the participants’ body weight, body height, and BMI characteristics, and an independent analysis . A pairen = 40) and CG (n = 35). The two classes were located in two different buildings on the campus to avoid information contamination. The remaining eight students were excluded as they did not meet the inclusion criteria. Finally, the complete data from 23 participants in the EG (response rate: 60%) and 27 in the CG (response rate: 77.1%) were included in the analysis.The target sample size was obtained in 2 weeks. Seventy-four participants completed the research activities, and only one participant dropped out (1.3%) due to school transfer. The adherence (PTFR) was 99.1% for the school-based APMR program. Only one of the remaining 39 participants failed to complete the program activities, as she went on personal leave and missed 20 practice sessions. Nearly half (46.5%) of the participants reported that they were “satisfied” with this program. Some of the participants verbally stated that they felt relaxed after performing APMR.p = 0.59). However, changes in HCC were significantly greater in the CG (p = 0.02). There was a significantly larger HCC change in the within-group CG analysis (p = 0.001), but not in the EG. Additionally, the VAS revealed a significant increase in the relaxation rating of the EG (p < 0.001) (There were no significant differences in the baseline characteristics between the two groups . After a< 0.001) .The purposes of the present study were to test the feasibility of the school-based APMR program and to conduct a preliminary evaluation of the subjective and objective aspects of stress relaxation among female adolescents over a semester. Contrasting the results to the study’s a priori definitions of feasibility, we found that the dropout rate (1.3%) was lower than 10%, and the adherence to the program  was greater than 90%. However, a low satisfaction rate of 46.2% in the EG fell short of the goal of 75% satisfaction rate. Thus, while several indicators suggested that the program was feasible, there are still issues that require further investigation.A prior feasibility study of a 14-week school-based coping intervention with 2 h weekly sessions supervised by school nurses had a dropout rate, adherence, and response rate that were similar to ours, but with a higher satisfaction rate . RegardiWhile the target sample size was obtained, the response rate was low at 60% for the EG and 77.1% for the CG. This raised some questions about the school-based APMR program’s acceptability as a treatment option for this population. The current study’s low response rate is similar to what was observed in past studies ,42. NearFinally, we conclude that even though the satisfaction rate was low, having clear time restrictions, low time commitment, and practice with supervisors promote compliance and facilitate the program’s integration into the school environment without disrupting the students’ formal curriculum. Moreover, as educators are key partners who have a close relationship with adolescents, they are more suitable to deliver a stress reduction program and practice to promote mental health for adolescents .p = 0.02) in the CG, but there was no difference between the two groups in the PSS. Additionally, the VAS of relaxation rating showed a significant improvement for the EG (p < 0.001), implying that practicing with supervisors can ensure fidelity in the implementation of APMR. Furthermore, HCC results were reliable owing to the compliance of APMR and a steadier state in the EG during the school-based APMR program.The HCC results showed a more significant change (Pawlow and Jones  claimed p = 0.002) but not in the EG, implying that EG was in a steadier state throughout the APMR intervention in the school. A previous randomized control trial that evaluated the effect of an 8-week humanitarian intervention for war-affected adolescents showed that, regardless of whether one group had hyper- or hypo-secretion in HCC, the intervention could normalize HCC levels in either direction (up- or down-regulation) [HCC is a long-lasting accumulated biomarker that is more suitable for tracking long-term stress responses . The HCCulation) . In thatulation) ,45. ThusIn contrast, the subjects in the present study were healthy female adolescents who had not suffered any major early life stress events. Thus, the difference between these target populations results in a lack of benchmarks against which we can compare the results. Finally, self-regulation and normalization of HCC that are consistent with the hypothesis of physiological homeostasis have been proposed previously . The preBased on the mechanism of physiological homeostasis ,46,47,48In addition, a significant difference between the pre- and post-test results of HCC in the CG is required to determine APMR’s potential influence in the present study. A longitudinal study examined the levels of HCC when children transitioned into a more formal learning setting. The findings indicate that a larger increase in HCC is significantly associated with lower behavioral inhibition, which is the ability to regulate and control behavioral impulses . AdolescThere are several limitations to the present study. First, the target population was female high school adolescents, and thus, the findings cannot be generalized to other populations. Second, only 60% of the EG and 77.1% of the CG completed the PSS; such low response rates could have critically affected the study results. Third, several recent interventional studies have found that PMR could reduce saliva cortisol levels after the intervention ,19,50. HIn the present study, a significantly greater change in HCC was observed between the pre- and post-tests in the CG, while the PSS scores were not significantly different between the two groups. The school-based APMR program can be considered a potential relaxation technique to maintain the steady state for female adolescents, but it should utilize an audio script device to ensure adherence to all activities under tutor supervision.For future randomized controlled trials, this school-based APMR study suggests the following: (1) the duration of the program should be expanded; (2) the second practice session should be scheduled on the days when the break time is scheduled in the afternoon; (3) the outcome indicators should be repeatedly measured during the implementation period and the behavioral inhibition indicators should be considered; (4) the program should be expanded to other schools, different ethnic populations, and age groups; and (5) the research should further explore the possible reasons for HCC dysregulation among school adolescents.


OBJECTIVES/GOALS: Twenty years of evidence show CHW home-visits for asthma improve population health and lower overall health care system costs by reducing costly Emergency Department (ED) visits. We built a model to communicate these results to decision makers and demonstrate how program modifications can improve CHW program sustainability and long-term cost savings. METHODS/STUDY POPULATION: This CHW program simulation model (CHWsim) examines program level outcomes of sustainability and costs. CHWsim is populated with individuals in an asthma registry with frequent ED visits. The simulation shows the uptake of the CHW program, and the less frequent use of ED visits based on empirical data from a recent randomized controlled trial (RCT). CHWsim is interactive, allowing for parameter adjustments to programming and robust quantitative evaluation of those changes. We study sustainability using parameters based on number of CHWs, case load, frequency and duration of program. For cost outcomes, we use empirical data from a published return on investment study to demonstrate the cost of CHW programming vs. health care systems savings from reduced ED visits. RESULTS/ANTICIPATED RESULTS: We demonstrate a basic model that successfully simulates a recent RCT (n = 551), replicating the primary outcome of reduced ED visits within the Confidence Intervals. The model is validated by reproducing results of other RCTs. Results will also be presented from an in-process expanded model that simulates the intervention in a broader population (n = 4000). We test two programmatic changes and demonstrate how these modifications might improve health outcomes (reduced ED visits) that translate into cost savings to the system. 1) In the original trial, we served only one household member; in the model, we treat the full household, serving several individuals at the same time. 2) We also consider the assumption that a short annual visit might sustain the known 12-month health effect across many years. DISCUSSION/SIGNIFICANCE OF IMPACT: CHWsim uses individual level local data and patient characteristics to demonstrate the impact of program efficiencies to improve CHW program sustainability and reduce health care system costs without expensive new RCTs. CHWsim has the potential to improve CHW program delivery and influence funders to provide support.