Is the Strength at Home (SAH) intervention associated with reductions in intimate partner violence (IPV) in an implementation evaluation at 73 Department of Veterans Affairs (VA) health care facilities?This quality improvement study examined preintervention and postintervention outcomes from 1754 patients who participated in an implementation and training program. Results suggested that SAH was associated with reductions in IPV, posttraumatic stress disorder symptoms, and alcohol misuse.The findings suggest that SAH was associated with improvement in IPV behaviors and associated problems and that IPV intervention was successful as part of routine health care at VA facilities. Intimate partner violence (IPV) is a serious and prevalent public health issue that is interconnected with experiences of trauma, mental and physical health difficulties, and health disparities. Strength at Home (SAH) is a group intervention for persons using IPV in their relationships. Although previous studies have provided evidence of SAH’s effectiveness in reducing IPV, its patient outcomes as implemented within organized health care have not been examined.To evaluate patient outcomes from implementation of SAH in the Department of Veterans Affairs (VA) health system.This quality improvement study evaluated patient outcomes from a national implementation and training program conducted between December 11, 2015, and September 24, 2021. Data were collected as part of treatment and submitted by clinicians at 73 VA health care facilities. Patients were 1754 veterans seeking care aimed at addressing and/or preventing their use of aggression in intimate relationships. They completed 1 pretreatment assessment and 1 follow-up assessment in the immediate weeks after group completion.Strength at Home is a 12-week trauma-informed and cognitive behavioral group intervention to address and prevent the use of IPV in relationships.DSM-5, and alcohol misuse was measured with the Alcohol Use Disorders Identification Test.Changes in IPV were measured with the Centers for Disease Control and Prevention 2010 National Intimate Partner and Sexual Violence Survey. Changes in posttraumatic stress disorder (PTSD) symptoms were measured with the PTSD Checklist for g = 0.10), and alcohol misuse .The study included 1754 participants , of whom 1088 (62%) were involved with the criminal legal system for IPV charges. Analyses indicate that SAH was associated with reductions in use of physical IPV  and psychological IPV , coercive control behaviors , PTSD symptoms  health system. The SAH program addresses the influence of trauma exposure and core themes linking trauma to relationship problems and IPV, which is a unique program feature.22 An innovative aspect of the program is that participants’ partners are contacted via telephone by VA clinicians and are provided hotline numbers and resources and given the option to create a safety plan, which is an often overlooked gap in other intervention programs addressing IPV.23Strength at Home was initially funded by the VA and Department of Defense to be a model IPV intervention program for military and veteran populations. Strength at Home uses cognitive behavioral and motivational enhancement approaches within a closed-group format. Delivered over twelve 120-minute sessions, the content of SAH is grounded in the social-information processing model of IPV, which holds that trauma and PTSD bias perception of social information and choice of response in a way that can facilitate the use of aggression.27 A randomized clinical trial with 135 participants examined the effect of SAH compared with an enhanced treatment as usual waiting list condition. Results indicated significant reductions in physical and psychological IPV as well as in the use of coercive control behaviors after treatment and 3 months later as reported by both veterans and their partners.24 A follow-up effectiveness study examined the effect of SAH in the waiting list control group, and results again indicated significant reductions in the use of aggression.25 Recent studies have also observed significant reductions in aggression and PTSD symptoms among veterans receiving the program as part of a pilot implementation within the VA health care system,22 and the program has shown evidence of effectiveness among a sample of men in a non-VA setting.26 Although alcohol misuse is not an explicit target of SAH, its association with IPV is addressed clinically when it is an issue for participants, and effectiveness studies have demonstrated significant reductions in alcohol misuse from before to after treatment.26Strength at Home has demonstrated reductions in psychological and physical IPV in pilot, efficacy, and effectiveness trials.The primary goal of the present evaluation was to examine changes in the occurrence of IPV, PTSD symptoms, and alcohol misuse among 1754 veterans who received SAH at 73 VA health care facilities during a 6-year national implementation and training program for VA clinicians. It was hypothesized that participation in the SAH program would be associated with reductions in IPV, PTSD symptoms, and alcohol misuse.SQUIRE) reporting guideline.28The institutional review board at VA Boston reviewed the procedures and determined this evaluation of patient-level implementation outcomes did not meet the criteria for human research and was exempt from further institutional review board review. Individual patient data were deidentified. This quality improvement study is a nonrandomized evaluation of implementation outcomes and is not a randomized or experimental trial; therefore, it is reported in accordance with the revised Standards for Quality Improvement Reporting Excellence  were treated by VA clinicians participating in the SAH training program and were drawn from 73 VA health care facilities throughout the US between December 11, 2015, and September 24, 2021. The clinician training program included a 2-day experiential workshop, weekly clinical consultations, and monthly implementation consultations with national experts in SAH.Patients in this study completed 1 pretreatment assessment and 1 follow-up assessment in the immediate weeks after group completion. Patients were not required to have any primary diagnosis but to be interested in addressing and/or preventing their use of aggression in intimate relationships. Many were court ordered to receive IPV intervention or were otherwise involved with the criminal legal system. Clinicians used their clinical judgment in determining enrollment but received explicit instruction that almost all veterans referred to the program would be appropriate for SAH. The only exception was in the case of acute need for crisis stabilization, in which case the patient would be welcomed back once stable. Clinicians provided referrals for additional services as needed throughout the program. Baseline demographic and program completion data are presented in When patients completed release of information forms to allow hospital staff to conduct a partner outreach telephone call, a clinician attempted to contact partners up to 3 times around the beginning and end of the 12-week group. During these calls, all partners were offered hotline numbers and the chance to make a safety plan, and if they wished, they also reported measures of IPV they experienced by their partner, which were intended for use by clinicians to help understand the scope of the IPV reported and any differences in perspectives between partners and veterans. Clinicians reported that they completed 545 partner telephone calls: 381 partner intake calls and 164 partner posttreatment calls.All patients were seen for a baseline assessment and interview before starting an SAH group, during which they agreed to participate in the program, signed any appropriate release of information forms, and completed baseline self-report measures of IPV, PTSD symptoms, and alcohol misuse. Participants also self-reported their age, gender identity, era of military service, and race and ethnicity during the intake interview. These variables were collected to understand the reach of the program across demographic groups of veterans. After the baseline assessment, participants were seen for up to 12 sessions of the SAH group. The same measures, plus a posttreatment satisfaction measure, were completed after session 12. Attendance in 9 of 12 sessions (75%) was considered completion, and those who attended at least 9 sessions also received a certificate of completion. Clinicians submitted deidentified scale scores and patient demographic characteristic information to program evaluation staff as part of the training program.30 which included 30 items assessing 4 subtypes of IPV behavior: (1) psychological aggression , (2) coercive control , (3) reproductive control , and (4) physical aggression . At 2 time points (before and after treatment), veterans reported whether they had engaged in each IPV behavior in the past 3 months on a dichotomous scale, with 0 indicating no and 1 indicating yes. Prevalence scores were calculated by summing the number of positive responses for each subtype of IPV and converting the sum into a dichotomous variable representing the presence or absence of each type of IPV in the past 3 months.31 Summary scores representing the total number of subtypes of IPV  were also computed .Intimate partner violence was measured using questions from the Centers for Disease Control and Prevention 2010 National Intimate Partner and Sexual Violence Survey,Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5).32 Participants indicated how often they were bothered by each symptom in the past month on a 5-point Likert scale , and participants reported symptoms based on “a very stressful experience.” Items were summed, with higher scores reflecting more severe symptoms. A cut score of 33 is suggested as indicative of probable PTSD.33 The measure evidences good reliability  and discriminant and convergent validity.Posttraumatic stress disorder symptoms were measured with the 20-item PTSD Checklist for the 34 The AUDIT is a 10-item screener with 3 questions on the amount and frequency of drinking, 3 questions on alcohol dependence, and 4 questions on problems caused by alcohol; responses  were summed, with higher scores reflecting greater levels of alcohol misuse. A cut score of 8 is suggested as indicative of problem or hazardous drinking.35 The AUDIT has a reported median reliability coefficient of 0.83 and adequate construct and criterion-related validity.36The Alcohol Use Disorders Identification Test (AUDIT) was used to assess alcohol misuse over the past year.2 tests for binary variables and 1-sided t tests for the interval and count variables. Effect sizes were calculated as odds ratios (ORs) for the binary variables and as Hedges g for the interval and count variables. Significance was set using the Benjamini-Hochberg method with a false discovery rate of 5%.37Data analysis compared pretreatment and posttreatment IPV, PCL-5, and AUDIT scores. The sample included all participants who completed at least 1 in-person SAH group session and had nonmissing IPV, PCL-5, and AUDIT scores. The pattern of missing data was predominantly missing posttreatment data  completed an intake for the SAH program (see g = 0.10) and alcohol misuse  and medium for the number of IPV subtypes reported .We conducted several additional analyses to assess whether court referrals, race and ethnicity, and age were associated with both the prevalence of IPV and the likelihood of completing SAH. None of the variables were associated with the prevalence of IPV. Only court referrals were significantly associated with the likelihood of completing SAH. The OR was modest , indicating that the veterans mandated to participate in the program were more likely to complete it. However, the modest effect size indicates that being mandated to participate in the program was not strongly associated with graduation from the program.In this article, we report implementation outcomes from a sample of veterans who received SAH during a 6-year national implementation and training program for VA clinicians. Results from 1754 veterans indicate that SAH was associated with significant pretreatment to posttreatment reductions in the proportion of veterans who reported using physical, psychological, and coercive control IPV toward a partner and in the number of types of IPV used. The effect sizes for these changes were medium. In addition, small but significant reductions in PTSD symptoms and alcohol misuse from before to after treatment also suggest that the program may be helpful in reducing PTSD-associated distress and symptoms. There was no change in reproductive control behaviors; however, there was little opportunity to examine changes in these behaviors due to the low prevalence of this type of IPV at baseline (3% of the sample).16 In this study, court involvement was modestly associated with completion rates, and the noncompletion rate (attending <9 sessions) was 32%. This rate is lower than the 37.8% to 50.8% overall attrition rates reported in meta-analyses39 of the factors associated with attrition in community IPV intervention programs, which are typically comprised entirely of court-mandated participants who are more likely to complete the intervention. The lower noncompletion rate observed in the present study is notable considering that 37% of the sample participants (641 of 1754) were self- or clinician-referred, and they were a clinical sample not excluded for any psychiatric or substance use disorder. The rate is also notable because 62% of the sample participants were court-involved veterans, a group known to have high rates of substance use and psychiatric difficulties and to experience significant barriers to continuous treatment, such as homelessness.41A common criticism of IPV programs is a high attrition rate, even among veterans mandated to participate.Partner outreach telephone calls to address the unmet safety planning and mental health needs of partners who have experienced IPV are an important emphasis of the SAH program and receive considerable attention in the training program. Data from the present study indicated that 31% of partners (545 of 1754) were successfully reached but that the data were limited with respect to the content of the calls as well as reasons for nonresponse. Future research could examine how to improve rates of completed calls and safety plans made by examining barriers and facilitators to successful partner outreach from the perspectives of veterans, partners, and clinicians.42 In addition, the PTSD33 and alcohol use36 measures used have also demonstrated excellent construct and criterion validity with other measures. Finally, the set of patients in this study was not drawn for representativeness of the veteran population; specifically, results may not be generalizable to women. We also cannot use these data to examine changes in the proportion of veterans engaging in IPV at a population level. The data available were limited with respect to examining factors associated with noncompletion, which should be explored in future analyses.The strengths of this study include the large sample size, diverse veteran subgroups, numerous sites, and routine clinical settings and patients. Despite these strengths, results must be considered against several important limitations. First, because the data were obtained from clinical practice, there was no comparison group or follow-up data to assess whether gains were maintained over time. Future research on the sustainability of SAH is needed to assess whether intervention effectiveness is maintained over time. Another potential limitation is the exclusive use of self-report measures, which raises concerns of self-reporting bias, including underreporting of IPV, but also alleviates concerns of clinician bias. Mitigating this concern is prior work showing that, unlike data from civilians, veterans disclose a greater amount of their own use of IPV compared with what their partners report about them.Intimate partner violence is a serious, prevalent, and costly public health problem that has traditionally been stigmatized and most often addressed within the criminal legal system. The recent effort to implement access to comprehensive IPV programming at every VA hospital in the country is an alternative model for addressing violence as a public health issue. Data from this study suggest that participation in the SAH program delivered within routine care at VA facilities was associated with reductions in IPV, PTSD symptoms, and alcohol misuse. These results suggest that IPV intervention as part of health care at VA facilities was successful and that its extension to other organized health care systems may be warranted.


Borehole strain monitoring plays a critical role in earthquake precursor research. With the accumulation of observation data, traditional data processing methods struggle to handle the challenges of big data. This study proposes a segmented variational mode decomposition method and a GRU-LUBE deep learning network based on machine learning theory. The algorithm enhances data correlation during decomposition and effectively predicts borehole strain data changes. We extract pre-earthquake anomalies from four-component borehole strain data of the Guza station for two major earthquakes in Sichuan (Wenchuan and Lushan earthquakes), obtaining more comprehensive anomalies than previous studies. Statistical analysis reveals similar abnormal phenomena in the Guza station’s borehole strain data before both earthquakes, suggesting shared crustal stress accumulation and release patterns. These findings highlight the need for further research to improve earthquake prediction and preparedness through understanding underlying mechanisms. Considerable work remains to be done in the study of earthquake precursors. Pre-earthquake anomaly extraction is a prerequisite for earthquake precursor analysis. Over the past few decades, a significant volume of earthquake precursor observation data has been accumulated worldwide, thus providing a solid data foundation for earthquake precursor research.Large earthquakes are driven by continuously changing tectonic stresses, which occur after a long-term preparation phase composed of different stages of seismic activity evolution2. De Santis et al. analyzed electron density and magnetic field data measured over 4.7 years by the Swarm three-satellite constellation to identify possible in-situ ionospheric pre-earthquake anomalies of large earthquakes from different angles, and they determined that in-situ ionospheric anomalies were correlated with earthquakes3. Skelton et al. analyzed the stable isotope ratios and dissolved element concentrations of groundwater obtained from a borehole in northern Iceland between 2008 and 2013 and found that changes in groundwater chemistry were associated with earthquakes4. Hattori et al. used principal component analysis to analyze the pre-earthquake anomalies in ULF geomagnetic data, and the results showed that these features are likely to be correlated with large earthquakes8. Fan et al. used a nonnegative tensor decomposition (NTD) approach to analyze the Swarm Satellite magnetic field data for the 2015 Mw 7.8 Nepal Earthquake and had extracted anomalous phenomena related to earthquakes9. Additionally, research has been conducted on other areas like groundwater11, gravity12, ozone anomaly indices13, and outgoing long-wave radiation (OLR) data14, all of which have produced significant findings.Investigating precursory data of earthquakes holds significant importance in enhancing our understanding of seismic activities and their potential consequences. By meticulously analyzing patterns and trends, researchers can identify early warning signs that may offer valuable insights into impending seismic events. Moreover, the continuous advancements in data analysis techniques contribute to refining predictive models, fostering collaboration among scientists, and ultimately improving global seismic hazard assessment and management. Worldwide, many scholars have utilized various earthquake precursor data to analyze specific earthquake cases in academic research. Wang et al. compared theoretical and observed GPS values to identify the geodetic anomaly pre-ceding the Lushan earthquake and verified that the pre-earthquake anomalies in GPS data were related to the Lushan earthquake17. In ground monitoring systems, crustal deformation observations rank among the most crucial precursor observation items. Borehole strain observations represent an important method of studying crustal deformation and changes in the in-situ stress field. Crustal deformations can be observed under the action of a regional stress field. Installed deep within bedrock, borehole strainmeters can record both continuous stress and strain measurements, establishing themselves as essential tools for monitoring crustal deformation. High-resolution records provided by borehole strainmeters allow for the detection of subtle strain variations.Since the “Plate Boundary Observatory” (PBO) was launched in the United States, borehole strain observations have received unprecedented attention because of their high resolution and high sensitivity18. Chi and Yu et al. used PCA19, state space equation20 and VMD21 methods to remove the strain response due to air pressure, solid tides and changes in water level to preferentially isolate non-tectonic disturbances. Qiu et al. used high-pass filtration and overrun rate analyses to remove the long-period signal and extracted borehole strain anomalies before the large earthquakes20.Borehole strain observations can record the strain changes related to earthquakes, thus providing a possible method of extracting strain anomalies before earthquakes. However, borehole strain observations are susceptible to interference from the external environment because of their high-accuracy and wide-band characteristics. Researchers have studied the removal of external interference from borehole strain data. Ren et al. studied the influence of water level fluctuations of the Dadu River on a Guza borehole strainmeter and provided a basis for removing the influence of borehole strain data22. Gong et al. studied borehole strain data and analyzed the seismogenic structure of the Hutubi earthquake in detail23. Chi et al. used VMD and PCA to detect the pre-earthquake anomaly of the Wenchuan earthquake and verified the correlation between the earthquakes and anomalies24. Zhu et al. detected the pre-earthquake anomaly of the Lushan earthquake by calculating eigenvalues and eigenvectors25.On the basis of removing interference, scholars have conducted pre-earthquake anomaly analyses of borehole strain data for different earthquakes. Shi et al. observed the variations of co-seismic static stress deviations and showed for the first time that they are consistent with theoretical predictions by observing borehole strain, which is of great significance for earthquake predictionAs the accumulation and complexity of earthquake precursor observation data continue to grow, traditional signal processing techniques are becoming overwhelmed. Conventional filters, due to variations in data frequency and dynamic shifts, often omit or blur critical information. The VMD technique, employed for data decomposition, frequently encounters memory overflow issues with large datasets. This paper introduces the SVMD method, designed to circumvent memory limitations while preserving data correlations.28, neural networks38, a random forest (RF) model40 and decision trees41 have shown potential in enhancing seismic event prediction, such as estimating time, location, and magnitude, while also reducing false alarms. While significant progress has been made, challenges remain in terms of data quality, scarcity and heterogeneity. The ongoing development and refinement of machine learning models, alongside the increasing availability of high-quality data, aim to improve the accuracy and reliability of earthquake forecasting.In recent years, machine learning techniques have emerged as promising tools for studying earthquake precursory data. Current research leverages algorithms like support vector machinesIn this paper, a GRU-LUBE network was proposed to extract pre-earthquake anomalies from borehole strain data and this article takes the Wenchuan earthquake and Lushan earthquake as examples to analyze the data of Guza station and compare the analysis results of other two stations to determine the effectiveness of the algorithm. The GRU-LUBE network utilized in this study is not only adept at capturing the characteristics of the borehole strain data but also excels in constructing prediction intervals by calculating the upper and lower bounds of the forecasted data, enabling efficient anomaly detection. Through this study, more accurate pre-earthquake anomaly information can be provided for earthquake warning systems, improving the accuracy and timeliness of earthquake prediction. The flow of this paper is shown in Fig. As is shown in Fig. 42. VMD is adaptive to the processing of nonlinear and nonstationary signals, it transforms the data decomposition problem into a variational problem. The resulting constrained variational problem is as follows:Variational mode decomposition (VMD) is based on solving the variational problems of classical Wiener filtering and Hilbert transform, it can adaptively decompose signals into several finite-bandwidth intrinsic mode functions by iteratively searching for the optimal solution of the variational modelk-th intrinsic mode function (or mode). It represents one of the decomposed components of the original signal, which is a band-limited oscillatory function centered around a specific frequency; k-th mode uk and their corresponding center frequency In Eq. , \documeHowever, the VMD method conducts a global search and solves variational problems, which may cause computational challenges, such as slow processing speed and computer memory limitations, due to the large amount of data involved. Conventional data segmentation approaches can be employed, but they may result in the loss of data correlation between segments. To address these issues, we propose a Segmented Variational Mode Decomposition (SVMD) method. The underlying principle of the SVMD method is illustrated in Fig. As shown in Fig. In recent years, the application of advanced machine learning techniques has significantly improved our understanding and prediction of natural disasters, including earthquakes.The activation function of 43.The Lower and Upper Bound Estimation (LUBE) method is a nonparametric method that directly constructs prediction intervals and offers significant advantages in extracting anomalies from earthquake precursor data. LUBE is a statistical approach used for anomaly detection and outlier analysis by calculating the lower and upper bounds within a dataset, thereby identifying anomalous points. Accurate detection of anomalies in earthquake precursor data is crucial for improving the precision of earthquake early warning systems. In this paper, the GRU neural network is applied to the LUBE method and the two outputs correspond to the upper and lower bounds of the intervalThe mode of the GRU-LUBE is shown in Fig. In this paper, the input to the GRU-LUBE network is the pre-processed borehole strain data and the output is the predicted upper and lower threshold values. Data from relatively stable time periods are used as training data, with a data length of at least 6 months.The execution speed of the algorithm proposed in this paper is primarily influenced by the SVMD decomposition phase and the training phase of the GRU network. It's recommended that, with the advancement of computer hardware as a prerequisite, the time consumption caused by the SVMD decomposition and the data training of the GRU network should be addressed using a distributed computing framework to distribute the computational load. Additionally, performing calculations on GPUs will further enhance the processing speed.44.Borehole strainmeters are designed to place sensors within boreholes to monitor deformation. In comparison to the Earth’s size, the deformation observed in the crust represents a minute portion, which can be approximated as the deformation observation result of a singular point. Four-component borehole strain observations represent a type of relative observation, capable of detecting changes in the target observation but not providing a complete measurement of the target observation. This characteristic is determined by the underlying principle of its modelWith one additional measurement, a simple relationship between the four measurements can be obtained using Eq. :8\documeOnly three independent variables are considered under plain strain conditions at or near the Earth’s surface. Therefore, we can derive various strains from the Guza recordings. The formulae used are as follows:We looked into the Wenchuan earthquake and the Lushan earthquake for this essay. Wenchuan County, Sichuan, experienced a Ms8.0 earthquake on May 12 at 14:28 (UTC + 8). 31.01 N and 103.42 E were the coordinates of the epicenter. The focal depth was roughly 14 km, according to data released by the China Earthquake Networks Center of the China Earthquake Agency. On April 20, 2013, at 08:02, a Ms7.0 earthquake struck Lushan County in Ya'an, Sichuan. 30.277° N and 102.937° E were the coordinates of the epicenter. The Chinese Earthquake Administration's China Earthquake Networks Center reported that the earthquake's Ms7.0 magnitude and roughly 13 km focal depth.As is shown in Fig. We selected borehole strain data from Guza station from 2007 to 2008 and from 2011 to 2013 for anomaly extraction before Wenchuan earthquake and the Lushan earthquake, respectively. The data met the self-consistent coefficient k ≥ 0.95 criterion; therefore, we believe that the data are reliable. First, we converted the four-component borehole strain observational data into one areal strain  there must be at least 15 anomaly points within a 30-min period. (b) The difference between the center point of the upper and lower bounds interval and the actual value of the anomaly point must be greater than 1.5 times the interval width and there must be more than three such points within that 30-min period.In order to better express the changing characteristics of abnormal days, this article calculates the cumulative number of abnormal characteristic values over time, the formula is as follows:Figure 20. Wang et al.45 employed a method based on the inversion of regional seismic source mechanisms to quantitatively determine stress tensors for the Wenchuan earthquake. Their analysis indicated that from June 2007 until the main Wenchuan earthquake, there was a notable increase in local stress levels. This suggests a predominant accumulation of stress before reaching its peak, followed by a stable release after the peak. Shi et al.46 calculated the pre-seismic b-value changes for the Wenchuan earthquake and observed a continuous declining trend from mid-2007 until the earthquake. The rate of this decline accelerated, with a significant drop in the b-value at the beginning of 2008. These research findings align well with the anomaly periods identified in our study and we extracted similar abnormal change processes and also extracted more abnormal days.The sigmoidal temporal behavior, as shown in Fig. 20 used the approximate negentropy (ApNe) and b value to analyze the Lushan earthquake, their results showed an abrupt acceleration followed by moderate acceleration, which indicates that non-Gaussian changes in the borehole strain data began to appear. Xu et al.47 analyzed the time series of GNSS baseline length changes prior to the Lushan earthquake. Their findings revealed abnormal deviations in the trend of GNSS baseline changes between September and December 2012; Qiu et al.48 concluded that the abnormal changes observed at the Guza Station  should be related to the Lushan earthquake. Chi et al.49 also observed abnormal strain 5 months before the Lushan earthquake that lasted for 3 months. The aforementioned results are consistent with the anomaly periods identified in this study. This also proves the effectiveness of the method in this paper.In this study, a strikingly similar phenomenon was observed prior to the Lushan earthquake. As illustrated in Fig. . suggest that interactions between various segments of a fault cause these regions to evolve from acting independently to displaying coordinated behavior. The extent of this coordination in fault activity serves as an indicator of the fault's stress condition. The progression of this coordination typically encompasses a deviation from the linear stage and meta-instability stage50. As depicted in Fig. 50. We plotted the anomaly rate chart. As shown in the Fig. As depicted in Fig. 51 conducted calculations and analyses on the earthquake monitoring capability of borehole strainmeters. Through empirical formulas, he deduced that for earthquakes above magnitude 7, the range over which precursory signals of borehole strain observations spread is: 210 km for long-term precursors and 472 km for short-term precursors. The two comparison stations are most likely to detect short-term precursors. Short-term precursors generally refer to anomalies that appear within 3 months of the earthquake. Therefore, this study only selected data from the year of the earthquake at the two stations for comparison.The results of our analysis using the same hypothesis for the data from Xiaomiao and Renhe stations for the Wenchuan and Lushan earthquakes are displayed in Fig. As is shown in Fig. The Guza station exhibited similar anomaly variations before both earthquakes. To rule out the possibility that this phenomenon occurs periodically, we analyzed the data from 2009 to 2011 using the same network and parameters, as shown in Fig. As illustrated by Fig. 52. Furthermore, the observation of pre-earthquake anomalies at distant stations, such as Xiaomiao and Renhe, supports the validity of the Guza station’s findings. Zhu et al., by comparing the temperature, atmospheric pressure, rainfall and borehole water level data during the two earthquakes, concluded that the anomalies before the two earthquakes were not related to these influencing factors53.The analysis of the anomalies extracted from the Guza station's borehole strain data during the Wenchuan and Lushan earthquakes reveals several key insights. The presence of similar S-shaped rising trends in the cumulative anomaly days preceding both earthquakes suggest a commonality in the pre-earthquake stress accumulation and release processes55:Shared patterns in crustal stress accumulation and release: The observed pre-earthquake anomalies may reflect a general pattern in the crustal stress accumulation and release process, which could manifest in different earthquakes, leading to similar anomalies observed at the Guza station.Proximity of earthquake epicenters: The relatively close proximity of the Wenchuan and Lushan earthquakes may imply similarities in their causation or seismic mechanisms, potentially resulting in similar pre-earthquake anomalies.Comparable geological settings: The Wenchuan and Lushan earthquakes may share similar geological settings, which could cause the crustal stress accumulation and release processes to exhibit similar characteristics, thus, similar pre-earthquake anomalies.Consistency in monitoring techniques and methodologies: The techniques and methods employed at the Guza station for monitoring the Wenchuan and Lushan earthquakes are consistent, resulting in the extraction of similar anomaly features during data processing and analysis.Coincidence: Although several potential reasons have been identified, it is still possible that the similar anomalies observed at the Guza station before the two earthquakes are coincidental. Further analysis of additional earthquake events and long-term monitoring data is required to validate the generality of this similarity.Several factors could contribute to the observed similarities in pre-earthquake anomalies at the Guza station for the Wenchuan and Lushan earthquakesFrom the research presented in this paper, the significance of long-term monitoring becomes evident: The accumulation of stress and strain in the Earth’s crust is a gradual process, and it's only through sustained observation that these subtle changes can be accurately captured. Such changes might be indicative of potential seismic activities. Long-term observation provides continuous underground strain data, crucial for understanding and predicting crustal dynamics, seismic precursors, and the cyclicity of seismic activities. Moreover, extended observation data aids seismologists in refining and improving earthquake prediction models, enhancing their accuracy. However, with these benefits come associated challenges. Equipment maintenance: even though borehole strainmeters are relatively stable, regular maintenance and calibration are imperative to ensure the precision and reliability of the data. Data volume: extended monitoring generates vast amounts of data, necessitating robust storage, processing, and analysis capabilities. Data interpretation: long-term strain data can be influenced by a myriad of complex factors, which elevates the intricacy of its interpretation. In essence, while the prolonged monitoring of borehole strainmeters brings forth invaluable insights, it also introduces its set of challenges that must be adeptly managed.In conclusion, the similarities in pre-earthquake anomalies at the Guza station for the Wenchuan and Lushan earthquakes may be attributed to shared patterns in crustal stress accumulation and release, proximity of earthquake epicenters, comparable geological settings, consistency in monitoring techniques and methodologies, and coincidence. A more comprehensive understanding of this similarity can be achieved through the analysis of more earthquake events and continuous monitoring of pre-earthquake anomalies in different regions and earthquake types. This will help enhance our understanding of earthquake mechanisms and improve the accuracy of earthquake prediction.In this paper, we propose an anomaly detection method based on SVMD and GRU-LUBE. SVMD preserves correlations between data and significantly reduces the time needed for data decomposition. GRU, with its unique structure, can effectively learn and predict data, while LUBE efficiently extracts data anomalies. Statistical analysis of the borehole strain at the Guza station revealed that anomalies prior to the Lushan earthquake were similar to those observed before the Wenchuan earthquake. By comparing the results from Xiaomiao Station and Renhe Station, we demonstrate that the pre-earthquake anomalies extracted by the Guza station are linked to both earthquakes. This suggests that the effective anomaly extraction method employed at the Guza station has successfully identified pre-earthquake anomalies in borehole strain data. The similarity of the cumulative anomaly days graphs for the Wenchuan and Lushan earthquakes, characterized by two S-shaped rising trends, implies the presence of common pre-earthquake characteristics or a shared pattern in crustal stress accumulation and release. This study highlights the importance of further investigation into the underlying mechanisms of pre-earthquake anomalies and the development of advanced techniques for better earthquake prediction and preparedness.


M = 44.67, SD = 11.80). Telephone interviews were conducted and the data were transcribed and analyzed using thematic analysis. Qualitative data analysis revealed that most participants had multiple reasons for discontinuing the program. They identified both barriers and facilitators to using the program, which could be categorized as either personal or program related. Personal aspects included life circumstances, personal characteristics, and psychological responses to the program. Program-related aspects encompassed technical factors, program content, and the level of support provided. The findings of this study can enhance our understanding of why people stop using guided internet-delivered programs. We discuss the practical and research implications, with the ultimate aim of improving the design and efficacy of internet interventions.Internet-delivered cognitive behavioral therapy (ICBT) interventions can be as effective as traditional face-to-face therapy for various mental health conditions. However, a significant challenge these online interventions face is the high rate of people who start but then stop using the program. This early discontinuation can be seen as incomplete treatment and can reduce the potential benefits for users. By exploring why people stop using ICBT programs, we can better understand how to address this problem. This study aimed to examine the experiences of healthcare workers who had stopped using a therapist-guided internet-delivered stress recovery program to gain deeper insights into usage attrition. We conducted semi-structured interviews with twelve participants who were female healthcare workers ranging in age from 24 to 68 years ( •Most healthcare workers had multiple reasons for discontinuing the internet-delivered stress recovery program.•Personal and program-related barriers and facilitators of program usage have been identified.•Personal usage aspects included life circumstances, personal characteristics, and psychological responses to the program.•Program-related usage aspects included technical factors, program content, and the level of support provided. To datePeople may discontinue using internet mental health interventions for various reasons. Firstly, the use of such interventions may vary depending on the individual's motivation , specifiICBT program-related specific intervention factors may also contribute to usage attrition. First, there is evidence that guided online interventions have higher rates of program module completion compared to unguided interventions . The absHealthcare workers face difficult working conditions that can lead to mental health problems such as burnout, anxiety, and depression . HoweverTo improve the development and updating of ICBT programs, it is essential to actively involve clients by seeking and incorporating their feedback. By examining why participants drop out, researchers and clinicians may gain valuable insights that can be useful for intervention design, engagement strategies, and retention. The aim of this qualitative study was to analyze the experiences of healthcare workers who had discontinued an internet-delivered stress recovery program. For this purpose, a semi-structured interview was developed based on previous qualitative research on the experiences of ICBT participants . Two mai22.1www.clinicaltrials.gov (NCT05553210) and was approved by Vilnius University Psychology Research Ethics Committee (Reference No. 2021-03-22/61). All participants provided informed consent to take part in both the quantitative and qualitative research at the pre-intervention assessment. The current qualitative study was reported following the COREQ  guidelines.The qualitative study is associated with a two-armed randomized controlled trial assessing the effectiveness of a tailored internet-delivered stress recovery intervention. The trial was registered on 2.2n = 45), 2) tailored intervention plan group . Participants who started but then stopped using the program were included in the qualitative study. Eligibility criteria: 1) completing fewer than 4 modules (< 4 weeks), 2) at least one login to the program. Researcher AN manually reviewed the login details of all participants to the program modules and screened eligible participants for the study. A total of 24 participants had dropped out of the program by week four, 4 of whom have never logged in to the program. Of the 20 participants that met eligibility criteria, 12 were interviewed . Participants who did not agree to participate in qualitative interviews indicated that they did not have time for it or had little involvement in the program and therefore did not want to talk about it. The study flow is presented in Appendix 1.Healthcare workers were invited to participate in the internet intervention through national media, social network groups, healthcare institutions, and email databases. The RCT involved 91 healthcare workers who were randomly assigned to two study groups (ratio 1:1): 1) standard intervention plan group . More than half of those included (n = 7) in the study were nurses or assistant nurses (58 %), three of them were doctors of medicine (25 %), and two were clinical psychologists (17 %). No significant differences were found between subjects included and subjects excluded from the qualitative study (Appendix 2).The characteristics of the participants included in the qualitative study are presented in 2.3The 6-week therapist-supported internet intervention CBT program FOREST+ for healthcare workers , which iParticipants' usage of the program is shown in 2.4nm = 3), 6 prompting questions np = 6), e.g., What do you think made you stop using the program?); (B) factors related to the program and to its use ; (C) personal characteristics and life circumstances ; (D) recommendations and other observations . The protocol provided the interviewer with a flexible interview structure with guidelines for prompting questions or phrases . For each question, an area was marked to highlight information that had already been heard so that the interviewer would not repeat questions. In addition, the interviewer had space in the interview sheet to take notes during the interview. Interviewers also had the opportunity to ask open-ended prompting questions of their own devising if they felt the interviewee had not adequately covered the topic and there was no such question in the protocol.The semi-structured interview protocol was developed by the authors of this study (see Appendix 3). The interview structure was based on the analysis of literature, which revealed several broad topics: participant expectations for the program, motivation to engage, experience of using the program , life circumstances, and personal characteristics that may have influenced the use of the program. The semi-structured interview comprised 10 mandatory questions and 20 prompting questions divided into four categories: (A) overall experience of using the program . Prior to this, a call was made to arrange a suitable time for the participants to be interviewed so that they were in a private place where they could safely share their experiences. During the main interview, the interviewer introduced themselves as the program researcher and his/her name. The participants were informed that their honest answers were very important for the development and research of the stress recovery program for HCWs. Interviews were audio recorded. Consent to record the interview was obtained before the interview was started. The interviews ended when the interviewer felt that the topic of dropout from the program had been sufficiently covered and when the information obtained was repeated, or when the interviewee expressed that they had nothing more to add.Semi-structured interviews were conducted by telephone from 5 to 16 December 2023 and lasted between 10 and 34 min . Given that AN contributed to the development of the program and studied the outcomes of the FOREST+ program as part of her dissertation research, AN only conducted the first pilot interview with one of the participants and did not conduct further interviews herself. Also, the master's program student interviewers were involved in the research process of the program as a part of their master's thesis but had no direct contact with the participants before the interviews. AN  and DZ  conducted the thematic analysis. For both coders, this was the first qualitative study conducted. However, the team of auditors was made of two senior researchers that are leading researchers in the field of internet interventions , and of two senior researchers, who are experienced in qualitative research . Thus, the research group had strong base for discussing the content of the interviews.2.7The data analysis was based on the thematic analysis method as described by 33.1M = 8.05, SD = 3.68). The most common first-mentioned reason given by five participants  was lack of time and busy pace in life. Three participants indicated that they did not like the format or nature of the program . Few participants encountered technical difficulties when accessing the program . Several participants were also unable to use the program because they were away at the time . Two participants indicated that they felt too fatigued to use the program after work . Finally, one participant stated that she had stopped using the program because she had already participated in the program before (P1).The results of the qualitative analysis of the first mentioned reasons and the number of times the reasons for discontinuing participation in the internet-delivered stress recovery intervention were mentioned are presented in 3.2The full model of barriers and facilitators in relation to program use is presented in 3.2.1Such disappointment with my own... It is a bit disappointing that I can't manage my time so that I can't find fifteen minutes or half an hour for it.” [P4]. Meanwhile, other participants noted positive experiences using the program, such as optimism and better self-awareness.A theme named psychological response to the program emerged during qualitative analysis, reflecting participants' subjective experience of the program. Some participants experienced negative emotions while using the program, such as anxiety, irritability, anger, guilt, loneliness, sadness, and self-pity, which acted as a barrier to continue participation. For example, one participant who indicated that she was currently being treated for depression stated that during the program she experienced: “Maybe my expectations were higher and just too high. I was expecting to see someone who would explain, who would... It would be interesting to listen to, and it's so... It's dull like a textbook.” [P6]. Other expectations indicated by the participants were that the program could be more interesting and engaging, more professional, and more able to help them improve their well-being.Participants were also asked about their expectations regarding the program and if they were met. We noted that some participants stopped using the program because it did not meet their expectations of having a live interaction with a therapist: “3.2.2I think it started during the pandemic, and I think it's the third time that I've shared it and then I thought I should register myself and see what you're offering and what it's all about and I'd be interested in that too... In terms of information and maybe something for myself or my work.” [P8].Certain personal characteristics were identified as barriers or facilitators. Users indicated that a lack of motivation led to non-use of the program, while others felt motivated to use the program for reasons such as the desire to help themselves or even professional interest: “Existing knowledge about stress reduction methods also hindered the use of the program, as participants felt that the information presented was already known to them. In addition, the use of the program was complicated by personal characteristics such as a lack of concern for one's own well-being and difficulty in revealing oneself to others. On the other hand, being open-minded  acted as a facilitator.3.2.3Even, for example, in workplaces, to initiate some kind of hour, or not, like, five-minute periods, for example, and to organize something like that at that time.” [P3].Participation barriers related to life circumstances included lack of time, private space, energy or extrinsic motives, stressful life experiences, or crises. Also, participants indicated that they had stopped using the program because of improved psychological well-being. Participants reported a lack of time for a variety of reasons, such as a heavy workload, childcare, household chores, obligations to others, social activities, travel, or difficulties with time management. Difficulties in accessing the program without a suitable and private location were also experienced. Moreover, participants often reported not using the program due to a lack of energy, e.g., feeling fatigued after a long working day. Several participants reported experiencing stressors or crises while using the program, such as illness, illness or loss of a loved one, difficult and stressful working conditions, and household stress. Finally, one participant felt a lack of extrinsic motives, such as incentives from the healthcare institution: “In addition, some indicated that life circumstances acted as facilitators to use the program. Extrinsic motives such as information about the program from their healthcare institution, colleagues, relatives, and social media acted as facilitators to start using the program. While having free time and a suitable private place to use the program helped them to be more engaged.3.2.4Well, that's the kind of feedback that's missing... The feedback would be, well, it seems that when you're there, you could immediately ask. Or the person who is communicating with you, they would feel your well-being even the next time without asking, wouldn't they, from the behavior, from the eye contact, from the facial expressions, and all the other empirical things that, well, you just see it visually and it's... I think obviously live contact would be the best thing (laughed).” [P3] On the other hand, some participants mentioned that they had developed a therapeutic alliance during the program, which encouraged their further involvement.Participants indicated that their experience using the program may have been influenced by the support they received from the therapist or study administrators. Some felt a lack of support from their therapist: “…in my case, these reminders make me... Aaaa works in a more stressful way (laughed)” [P9]. For two participants, there were too many reminders . Meanwhile, two users indicated that there could have been more reminders . Lastly, one participant indicated that the timing of the reminders was unsuitable (P2).Technical support was also important for participation. One participant (P5) stated that when she had technical difficulties, the study administrator helped her to solve them which was very helpful. On the other hand, one user (P7) indicated that there was a lack of technical support while using the program. In terms of support by email or message reminders, the reminders were unsuitable for some users but suitable for others. Most participants felt that reminders to use the program were important. But few participants (P8 and P9) were dissatisfied with the reminders received: “3.2.5In fact, as we are now in the last few years, there are so many internal stressors, and not only internal but also external... So maybe I think it's really worth it.” [P2]. It was also important for participants that the format of the program was appropriate. They liked the psychoeducational texts, tasks, and length of the program. In addition, it was noted as important if the program was presented in an uncomplicated and coherent way and whether the content of the program was engaging and attractive.The content of the program was also an important factor, acting either as a facilitator or as a barrier. Participants were motivated to use the program if it was perceived as professional and reliable, or if it was relevant to them and healthcare professionals in general: “On the other hand, the same factors were seen differently by other participants. Usage was reduced if the content was considered unengaging, boring, or irrelevant to the user or healthcare professionals in general. Some users found the content of the program unsuitable because of an inappropriate format of communication with the therapist, tasks, redundant information, and bad timing of the program or program reminders. In addition, the content of the program was too difficult to use for some participants . It was also noted that the program reminded them of a test situation.3.2.6Well, I was supposed to go away for two weeks, and there... Well, there's the forest, there's this... You know, there's no internet, nothing. I tried, I tried. After that, I realized that I had blocked your connection somehow. I've tried for the last time and nothing.” [P5].Technical aspects may also have influenced the use of the program. For some participants, online access to the program was convenient and acted as a facilitator. For others, the log-in method was challenging and inconvenient, and there were some technical issues: “4This study specifically focused on qualitative data regarding the experiences of healthcare workers who had discontinued the use of internet-delivered stress recovery program. The aim was to get a deeper insight into the usage attrition phenomenon. The thematic analysis showed that healthcare workers who stopped using the therapist-guided program tended to have more than one reason to do so. Discontinuation was motivated by lack of time, busy pace of life, travel, fatigue, previous participation, or more program-related factors such as technical difficulties in accessing the program or simply the unsuitable nature of the program itself. The analysis of identified barriers and facilitators faced by the participants while using the program revealed the importance of both personal and program-specific factors. Personal aspects included a psychological response to the program, personal characteristics, and life circumstances. Program-related aspects included the level of support received, program content, and technical aspects. The results of the study are discussed below in more detail.Overall, the results of our study are consistent with other qualitative studies of internet interventions. Person- or program-related facilitators or barriers to internet program use have been reported in several other studies . HoweverSome of the most important personal factors determining engagement in online psychological support may be related to the participant's intrinsic motivation, such as the desire to help oneself or even a professional interest. The current study highlights that a lack of intrinsic motivation can act as a significant barrier for engagement in internet intervention. A previous qualitative study on treatment completers of an online program showed the importance of fostering participants' intrinsic motivation to use the program . MotivatIntrinsic motivation to participate in the program can also be influenced by how the program is perceived. In the current study, some participants indicated that they found the program professional, which acted as a facilitator. However, some participants saw the program as irrelevant and unlikely to help them, which acted as a barrier. Therefore, the proper initial presentation of the program to participate may be an important aspect to consider. Similar themes emerged in a study by In this study, we observed that a negative psychological response to the program may also lead to usage discontinuation. Some participants indicated that they experienced anxiety, self-blame, guilt, or even increased stress due to the program. Similarly, a qualitative study of an internet-based mindfulness program for healthcare workers by User expectations are also among the personal factors that influence program use . Some ofGiven that research shows that ICBT programs can be beneficial, it is important to look at what works for whom. For some individuals, even a brief engagement in intervention can be sufficient to achieve the expected benefits . It is pIn our study, we noticed that program-specific aspects can also be important in hindering or prompting the use of the program. High workload and associated fatigue were found to make it difficult to implement an internet intervention for workers in a healthcare institution. Similar results have been noted in a previous qualitative study, which showed that participants may perceive the use of the online program as difficult and demanding . HoweverIt is also important to find ways to make internet interventions more engaging and user-friendly. The results of this study are in line with those of This is to our knowledge the first qualitative study to explore reasons for usage discontinuation in an online stress recovery intervention for healthcare workers. Moreover, as the participants were informed about the qualitative study at pre-intervention assessment, it was possible to successfully recruit most of the program dropouts. Another advantage of the study is that the participants were interviewed immediately after the end of the program, which allowed us to capture their experiences less distorted by time. However, the results of this exploratory study need to be seen in the context of the limitations of qualitative research . Firstly5The results of this study will hopefully increase our knowledge about factors that can influence usage attrition from internet-delivered mental health interventions for healthcare workers. We recognize that there is usually no single reason for discontinuing a program, thus a holistic approach to fostering program engagement is important. The themes identified illustrate that participants face both personal and program-related facilitators and barriers to using the internet-delivered psychosocial program. The results indicate that factors that are important in face-to-face therapy may also be important in internet interventions – where unrealistic expectations and doubts about the effectiveness of treatment can lead to an early withdrawal. However, some of the methods currently used to encourage participation in such programs can also act as barriers for some people. This points to the need to move towards a more personalized and patient-driven approach to psychological treatment. Therefore, the technical features of the program should act as more engaging and stimulating depending on the needs of the client. The role of the institution behind the treatment, which ensures support and facilitates the use of internet programs for healthcare workers, is also important and should be further investigated.10.13039/501100008530European Regional Development Fund (project No: 01.2.2-LMT-K-718-03-0072) under grant agreement with the Research Council of Lithuania (LMTLT).The project has received funding from The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Inadequate prescription of antibiotics has been recognized as a public health problem by the World Health Organization. In this context, antibiotic stewardship programs have been implemented as a tool to mitigate its impact.To describe the changes in clinical outcomes after the implementation of an antibiotic stewardship program in a level IV hospital.We conducted a unique cohort study of patients hospitalized for infectious pathologies that were treated with antibiotics in an advanced medical facility. We collected the clinical history before the implementation of the antibiotic stewardship program (2013 to 2015) and then we compared it to the records from 2018 to 2019 collected after the implementation of the program. We evaluated changes in clinical outcomes such as overall mortality, and hospital stay, among others.We analyzed 1,066 patients: 266 from the preimplementation group and 800 from the post-implementation group. The average age was 59.2 years and 62% of the population was male. Statistically significant differences were found in overall mortality , mortality due to infectious causes , and average hospital stay ; we also observed a tendency to decrease hospital re- admission at 30 days for infectious causes .The antibiotic stewardship program implemented was associated with a decrease in overall mortality and mortality due to infectious causes, as well as in average hospital stay. Our results evidenced the importance of interventions aimed at mitigating the impact of inadequate prescription of antibiotics. These interventions mitigate the harms of the inadequate prescription of antibiotics -In Colombia, several studies have assessed the effects of antimicrobial stewardship programs in terms of restricting the use of certain groups of antibiotics based on the local epidemiology, hospital stay, cost reductions, and the incidence of multidrug-resistant bacteria isolates. These programs encourage results and have no negative effects on patients’ evolution. However, none of them has focused specifically on evaluating the impact on clinical outcomes In this sense, our study aimed to describe the change in clinical outcomes after the implementation of an antimicrobial stewardship program in a level IV hospital.We conducted a single cohort study with addressed patients before and after the antimicrobial stewardship program implementation. The program intervention included a prospective post-audit model in charge of a surveillance committee of specialists in infectious diseases, internal medicine residents, and nursing groups. This committee used a database of antibiotic initiation formats focused on broad-spectrum antibiotics and did not include restricted drugs. The committee also consulted clinical histories and held counseling with the medical staff providing feedback on antibiotic prescriptions and promoting educational awareness campaigns on the rational use of these drugs, including information on the institutional guidelines for infectious diseases.In cases where the inadequate prescription was detected, we consulted with the Infectiology Department to select the appropriate medication, dosing, and administration pathway. Additionally, the antimicrobial stewardship group programmed visits to the intensive care unit and the emergency department to review specific cases and check the proper filling out of the initiation format.We included patients over 18 years of age, diagnosed with infectious diseases requiring antibiotic treatment, and enrolled in the institution’s antimicrobial stewardship program database, from January 2018 to January 2019. We did not use data from 2016 and 2017 considering this a prudential time to consolidate the implementation and stabilization of the program.We selected a control group from the hospital’s microbiology database, which included patients from 2013 to 2015, before the implementation of the antimicrobial stewardship program. Patients who died 72 hours after hospital admission were excluded as the time was insufficient to evaluate the effect of the program interventions on clinical outcomes. We also excluded those records that did not have all the clinical variables of interest.We evaluated the following clinical outcomes: overall mortality, mortality due to infectious causes (grouped among the institution’s top ten causes of morbidity due to infection), hospital stay length (days), hospital readmission due to infectious causes in the 30 days following discharge, and average duration of antibiotic therapy.Urinary infection was defined as urinary tract symptoms with positive microbiological isolation from urine culture. Pneumonia was defined by new or persistent radiographic features with no other obvious cause and two of the following findings: leukocytosis or leukopenia, cough or sputum production, fever or hypothermia, abnormal lung examination, or increase of oxygen requirements. Sepsis of unknown origin was considered in patients with organic dysfunction defined by a Sequential Organ Failure Assessment (SOFA) score greater than two points, secondary to a presumably infectious cause without an evident focus of infection after a rationale clinical study. Bacteremia was diagnosed with a positive blood test culture associated with sepsis without potential infectious foci.Hospital Militar Central approved the study.The antimicrobial stewardship program active surveillance also considered the population’s sociodemographic characteristics, the most frequent pathologies with the wrong prescription of antibiotics, and the proportion of patients whose antimicrobial therapy was adjusted as part of the program. The research ethics committee of the Considering a minimum of 252 in the before-implementation program group and a 774 after-implementation program group, we calculated a proportion difference of 7%, a sample size ratio of 3, a confidence level of 95%, and a power of 90%.First, we described the obtained data in terms of frequencies and percentages for the qualitative variables. For the quantitative variables, data distribution was expressed as mean and standard deviation or median and interquartile range.We analyzed two groups of patients: from 2013 to 2015  and from 2018 to 2019  to evaluate potential differences between them (p<0.05 was considered significant) . All cliNumerical differences were explored with a bivariate analysis to look for differences between proportions. Quantitative variables were cross-checked with Student’s t test when they presented a normal distribution, and with the Mann-Whitney U test when they did not. The most frequent infectious pathologies requiring the prescription of antibiotic therapy were described and analyzed according to the original strata and expressed as total values and percentages. The hospital’s group of specialists on infectious diseases also described the relationship between infections and inadequate antibiotic prescription regarding the relevance, dosage, and route of administration .We compiled information on 1,546 patients. Of these, we excluded 483 from the analysis: 431 because all the clinical variables of interest were not registered, and 52 died within 72 hours of hospital admission. We finally included 1,063 patients in the study: 266 in the before-implementation program group and 800 after its implementation .No statistical differences were found regarding the age of both groups (p=0.387). The average age of the sample was 59.2 years and 62% was male. The distribution of the infectious etiology was similar in both groups except for osteomyelitis and febrile neutropenia, which were less frequent in the group before the program implementation. The most frequent etiology was urinary tract infection (30%), followed by pneumonia (16%), and sepsis of unknown origin (11%). A statistically significant reduction in the average duration of antibiotic therapy was found after the program implementation  with a total difference of 2.75 days between the two groups.As for the clinical outcomes evaluated, there were statistically significant differences after the implementation of the antimicrobial stewardship program in overall mortality , mortality due to infectious causes , and average hospital stay  with a tendency to decreasing hospital re-admission after 30 days due to infection .The analysis of mortality due to infectious causes, classified among the five most prevalent etiologies in the hospital, showed a statistically significant difference in the after-implementation group mortality in urinary tract infection , pneumonia , and soft tissue sepsis , but no statistically significant difference in mortality due to bacteremia  and gut-origin sepsis .The infectious pathologies mostly associated with an inadequate antibiotic prescription, defined by the antimicrobial stewardship program surveillance committee, were superinfected ulcers (28.5%), urinary tract infection (20.3%), and pneumonia (14.1%).As a result of the antimicrobial stewardship program active surveillance, antibiotic therapy (suspension or drug change) was modified in 23% of the cases (187/800 patients) in the after-implementation program group.,-The conduction of this study addresses inadequate antibiotic prescription, a public health problem that has grown exponentially and requires a measurable impact mainly on microbiological results but also on clinical outcomes In the present study, we reduced the average duration of antibiotic therapy by 2.75 days. According to previous studies, this translates into cost reduction, lower antibiotic use, and lower bacterial resistance selection pressure because of reduced antibiotic exposure The main reasons for therapy modification were an inadequate prescription, treatment adjustment to the microorganisms isolated from cultures, dosage or incorrect route of administration. These factors were discussed in educational sessions in our institution as part of antimicrobial stewardship program feedback. The population characterization allowed us to identify the most prevalent infectious pathologies needing antibiotic treatment and those with a higher proportion of cases receiving an inadequate prescription. These data are relevant to consider in subsequent analyses.Considering that 25 to 40% of hospitalized patients received antibiotic therapy as part of their treatment, our results will help improve and adjust the medical personnel’s training processes and awareness as part of the derived plan from the antimicrobial stewardship program ,Regarding the observed mortality, discriminated by infection, it is known that adherence / the accomplishment of antimicrobial stewardship programs represents a reduction in mortality in specific clinical scenarios et al. included a large number of studies about antibiotic stewardship programs and assessed their impact in terms of clinical and economic outcomes. The research reported decreases in total antibiotic consumption, length of hospital stays, use of restricted antibiotics, and nosocomial infections by some multidrug-resistant bacteria. However, overall mortality and mortality due to infection were not significantly different after the program implementation. The authors concluded that studies with longer follow-up periods and antimicrobial stewardship standardization are required to draw more precise conclusions et al. claimed that the absence of studies with better methodological quality is the main limitation in determining the impact of this type of program on clinical outcomes. Mortality and length of hospital stay did not adversely vary with the introduction of the antimicrobial stewardship program The impact of the antimicrobial stewardship program implementation on the different clinical outcomes yielded diverging results due to some methodological limitations Regarding the study’s limitations, we acknowledge an absence of standardization in the clinical variables of interest that forced us to discard a significant group of patients registered in the database, which prevented a more precise analysis of the results. The average age of the analyzed population (59.3 years) implies higher overall mortality rates, comorbidity rates, and a higher probability of adverse effects related to the prescription of antibiotics, which can limit results interpretation. The study’s hospital is the healthcare referral center for all military forces in the country, which can impact on the complexity of the observed clinical cases as reflected in the high mortality related to most of the infectious etiologies evaluated.Despite the observational type of the study and its potential risk of inherent bias, our data suggest that antimicrobial stewardship program implementation favorably impacts the evaluated clinical outcomes, such as overall mortality, mortality due to infectious causes, length of hospital stay, and average duration of antibiotic therapy. There was also a quantitatively though not statistically significant difference in the reduction of hospital readmission for infection.However, these results should not be explained exclusively by the program implementation since the strategy was accompanied by other interventions that may have influenced the results, such as stricter handwashing policies, systematic visits of infectious disease specialists to the intensive care unit to provide counsel on the best alternatives for antibiotic therapy, training processes and socialization of clinical practice guidelines, and stricter policies on antibiotic prescription processes. These factors should certainly be considered when interpreting these findings.Our results should be interpreted with caution. We emphasized that the impact on clinical outcomes was probably a consequence of the overall care quality improvement of infected patients in this institution and that the antimicrobial stewardship program was an adjunct tool in this enhancement plan.The inadequate prescription of antibiotics is a latent threat to public health. Hence, we must intensify the search for tools to mitigate its impact. Antimicrobial stewardship programs are part of the available strategies with scientific support. However, its standardization and generic introduction into health systems should be encouraged to allow the development of studies with bigger sample sizes and better methodological designs to enable precise conclusions on their impact on clinical outcomes.