People living with cancer face numerous psychosocial challenges, including cancer-related fatigue, fear of recurrence, and depression. There is a lack of digital interventions tailored to the needs of people living with all types of cancer. We developed a 6-week, digital, peer-delivered, self-management program: iHOPE . The program is underpinned by positive psychology and cognitive behavioral therapy to meet these psychosocial challenges.This study aimed to assess the feasibility of the iHOPE program among people living with cancer. Program adherence and satisfaction along with changes in psychological distress and positive well-being were measured.worry or fear of cancer recurrence, positive mental well-being, hope, gratitude, and health status. The website’s system recorded data on the usage of the program. Satisfaction with the program was also measured.A pre-post, acceptability, and feasibility design was used. People living with cancer (N=114) were recruited via a national cancer charity in the United Kingdom and were given access to the iHOPE program. Demographic and other participant characteristics were recorded. Participants completed digital measures at baseline and the end of the 6-week program for depression, anxiety, cancer-related fatigue, cancer P<.001) and increased for positive mental well-being (P<.001), hope (both P<.001), and gratitude (P=.02).A total of 114 participants completed the baseline questionnaires. Of these, 70 people (61.4%) participated in all 6 sessions. The mean number of sessions undertaken was 5.0 (SD 1.5). Moreover, 44.7% (51/114) of participants completed at least three sessions and end-of-program outcome measures. A total of 59 participants completed the satisfaction questionnaire, where ≥90% (54/58) of participants reported that the program was easy to navigate and was well managed by the peer facilitators, and that they found the social networking tools useful. Preliminary efficacy testing among the 51 participants who completed baseline and postprogram outcome measures showed that postprogram scores decreased for depression, anxiety, cancer-related fatigue, and fear of recurrence (all The feasibility evidence is promising, showing that the peer-delivered digital iHOPE program is acceptable and practical. Implementation of the iHOPE program on a wider scale will incorporate further research and development to maximize the completion rates of the measures. Initial effectiveness data suggest positive impacts on important cancer-related quality of life and mental well-being outcomes. A randomized controlled trial design with a longer follow-up is needed to confirm the potential of the iHOPE program for improving mental and physical health outcomes for cancer survivors. Globally, there were an estimated 18.1 million new cases of cancer in 2018 . Globallsafety net they felt they had during treatment ; (2) you felt fatigued; (3) you did not have energy to do the things you wanted to do; and (4) you felt tired a lot. Fear of cancer recurrence is measured by the following 4 items: In the past four weeks… (1) you worried about dying from cancer; (2) you worried about cancer coming back; (3) whenever you felt a pain, you worried that it might be cancer again; and (4) you were preoccupied with concerns about cancer. Each item in these 4-item subscales is scored from 1 to 7 . Items are summed to give an overall score of 4 to 28 for each of the 2 subscales , with higher scores indicating greater difficulties.The quality of life in adult cancer survivors scale (QLACS)  is a valOver the past two weeks, how often have you been bothered by any of the following problems... (1) little interest or pleasure in doing things; (2) feeling down, depressed, or hopeless; and (3) poor appetite or overeating. Responses to each of the 9 items range from 0 to 3 , leading to a summed score between 0 and 27, with higher scores indicating greater severity of depression. Scores of 10 or more are presumed to be above the clinical range, and so, scores of less than 10 are classified as cases of depression. Recovery rates were calculated as those patients who scored ≥10 (cases) before treatment and scored <10 posttreatment.The patient health questionnaire-9  is a 9-iOver the past two weeks, how often have you been bothered by the following problems… (1) feeling nervous, anxious, or on edge; (2) trouble relaxing; and (3) becoming easily annoyed or irritable. Responses to all 7 items range from 0 to 3 , providing a total score of 0 to 21, with higher scores indicating greater anxiety. Scores ≥8 are classified as cases of generalized anxiety disorder. Recovery rates were calculated for those patients who score ≥8 (cases) before treatment and <8 post-treatment.The generalized anxiety disorder scale  is a 7-iBelow are some statements about feelings and thoughts. Please tick the box that best describes your experience of each over the last two weeks… (1) I have been feeling optimistic about the future; (2) I have been thinking clearly; and (3) I have been feeling love. Participants rated each of the 14 items on a scale of 1 to 5 , providing a total positive mental well-being score ranging from 14 to 70, with higher scores representing greater positive mental well-being. A change of three or more is seen as clinically meaningful change . Participants scored each item from 1 to 7 , giving a total score of 6 to 42, where a higher score indicates more gratitude shown [The gratitude questionnaire-6-item form  is a selde shown .P<.05. Owing to some deviations from the normal distribution in follow-up gratitude, anxiety, and depression scores, all variables were analyzed using Wilcoxon signed-ranks for paired samples. We report the means with SDs and medians with a range of scores. As recommended for nonparametric paired data, we report r as the effect size estimates (r=z/√n), where z is calculated through the Wilcoxon test and n is the number of observations (n=102) [r were used to determine small (0.1), moderate (0.3), and large effect sizes (0.5) [All statistical data analyses were conducted using IBM SPSS Statistics 25 . The sample was not powered to detect significance in the outcome measures; nevertheless, we present changes in the scores to aid understanding of the potential effect of the program and to provide data on which to base a power calculation for a larger study of efficacy. The level of statistical significance was set at  (n=102) . Recommees (0.5) .A total of 114 participants completed the baseline questionnaires, and those who also completed the postprogram questionnaires were included in the analysis (n=51). Participant characteristics are shown in Examining baseline depression, anxiety, well-being, quality of life, cancer-related fatigue and worry, hope, and gratitude scores between those who did and did not complete postprogram questionnaires revealed no significant differences . The mean number of sessions was 5.0 (SD 1.5), and 61.4% (70/114) of participants attended all 6 sessions. Half of those who completed 3 or more sessions of the program (n=51) went on to complete the outcome measures, giving a 50% response rate to questionnaires at the end of the program.strongly agreed or agreed that the program and its delivery were positive and activities in the program were useful.The 59 participant responses to the satisfaction questionnaire are detailed in recovery from depression  and anxiety , respectively .At the end of the iHOPE program, participants reported statistically significant improvements in depression and anxiety, with moderate effect sizes. Before the program, 47% (24/51) of participants exceeded the clinical cutoff scores for depression, and 43% (22/51) of participants exceeded the clinical cutoff scores for anxiety. At the end of the program, 31% (16/51) and 29% (15/51) of participants had scores that indicated a z=−4.421; P<.001; r=−0.44) and worry or fear of recurrence , with moderate effect sizes.At the end of the iHOPE program, participants reported statistically significant improvements in cancer-related fatigue  and hope , with a moderate effect size for well-being and a large effect size for hope. Participants also reported statistically significant improvements in gratitude , but with a small effect size  completing at least three of the six sessions. Feedback from the participants who completed the satisfaction questionnaire was overwhelmingly positive for many aspects of the content and design. Preliminary efficacy testing had positive results, with generally moderate-sized effects in the expected direction.The majority of the participants were female, white, married, employed, and educated. Although this may present a limitation in terms of generalizing the study results to other demographic groups , a recent systematic review has reported that the majority of participants in self-management cancer programs are indeed women , and so,Reporting rates of cancer sites were suboptimal, and data collection procedures should be improved, perhaps with a user-friendly checklist of cancer sites. Furthermore, collection of data on time since diagnosis and/or stage of treatment will allow us to verify in future studies if those recently diagnosed with cancer will show the same postprogram improvements in outcome measures as those who have survived cancer (or are coming to the end of treatment). Of those providing data, the largest group was breast cancer, reflecting national data. Gynecological cancers were reported by 11.4% of participants, which is greater than the estimated 5% of the population incidence . HoweverThe implementation of the program had positive results—89% of the participants completed the program  , and thedropout attrition where participants do not fill in questionnaires  and nonusage attrition where participants stopped using the program  [nonusage participants in this study may be e-attainers (as described in [There is a distinction between s study) . High ras study) , are coms study) . It is pribed in ), where ribed in . A higheribed in , using bribed in , and redribed in  could imThe program was acceptable and appears to be practical, with positive feedback on program activities. The program uses peer support features and is supported by a facilitator with personal experience of cancer. There is a growing evidence base showing that trained peers can respond safely and therapeutically to distressing issues that often arise during self-management programs . This stAcknowledging the significant limitations owing to the 50% completion rate of postprogram questionnaires, the findings show that scores for depression, anxiety, well-being, cancer-related fatigue and worry, hope, and gratitude were improved postprogram for those who completed the questionnaires. Moderate effect size improvements were achieved for most of the outcomes, which is consistent with other self-management research for long-term conditions involving self-selecting participants . The facThe need for better care for comorbid depression in cancer survivors has been called for ,19. Manyrecovered from depression and over a quarter  had recovered from anxiety. These results are encouraging, compare well with general data on short-term psychological interventions [By the end of the iHOPE program, the scores indicated that nearly one-third  had ventions , and sugventions . The iHOventions . To dateventions , supportOur findings from this study are limited by the lack of a control group; lack of longer-term follow-up; small sample size; and a sample mainly of white, married women with a high level of education. Participants were recruited via the MCS charity website, Facebook, and other social media sites. This is likely to have attracted highly motivated cancer survivors, with good health and digital literacy skills, compared with cancer survivors who do not access health websites. Further studies of the feasibility and acceptability of the iHOPE program could utilize recruitment strategies aimed at widening participation for male cancer survivors ,73 and pThere was a low response to the postprogram questionnaire. It is possible that there is a bias in responding to those who did find the program useful. The results of this study should be considered with caution, particularly in relation to the generalization of data. However, this feasibility testing suggests there is acceptability and practicality to our program, but there is a further requirement to support retention to complete research measures in future programs. This study used a crude usage attrition assessment. Future studies would benefit from using more sophisticated tracking tools and data analysis to reduce usage attrition and improve engagement and outcomes. Future research should now be a randomized controlled trial, powered to detect significant changes, a longer follow-up, and continued measurement of health and well-being related outcomes, satisfaction, and program usage.We have shown that a digital self-management program, iHOPE, has the potential to improve several common and pressing unmet needs of cancer survivors, including fatigue and worry, depression, and anxiety. These improvements need to be further tested using a more robust research design involving a much larger sample over a longer time frame within a randomized controlled trial.


We can learn valuable lessons from program efforts that at first glance may seem to be far removed from our own work. Duttine et al..See related article by Global Health: Science and Practice describes efforts recently undertaken in Brazil to develop and test an approach to supporting parents of young children affected by Zika. For the vast majority of GHSP readers, we suspect that this topic is not directly relevant to their work. Nevertheless, we believe we can learn valuable lessons from program efforts that may seem, at first glance, to be far removed from our own work.The article by Duttine and colleaguesa clearly defined need, and (2) a potentially relevant model. The need was for effective, formalized support of caregivers of community-living children with mild to moderate Zika-related impairments. The model was a caregiver education and support program first developed in Bangladesh and subsequently adopted in many other countries: Getting to Know Cerebral Palsy.The authors describe their process in the development and initial testing of a community-based support program for parents. Their starting points were: (1) needs assessment, which included a review of relevant literature and consultation with stakeholders, both experts and parents of affected children. On the basis of this input, the developers then crafted an initial version of the program design and materials  and an associated theory of change (a theory of how they thought the intervention would work).With this identified gap and a potential solution, the next step was a iterative rounds of piloting to assess relevance, usefulness, and feasibility. Adaptation and refinement of the program was done not only at the end of each of these rounds; the developers also pursued an intentional approach of fast-track learning—eliciting feedback on an ongoing basis from participants and facilitators and making real-time changes, as necessary, in content, approach, and logistical arrangements.The program developers then tested the program in 2 diverse sites, going through 2 As they explain, not only was the program itself iteratively adapted and modified, so too was the theory of change. In the course of trying out the intervention, the investigators formed a better sense of how it worked and, in turn, made revisions to their theory of change.learning from neighbors, drawing on an approach developed in another context for a somewhat different need  and adapting it to their setting to address their specific problem. We encourage you—our readers—also to learn from neighbors, drawing from examples like this of how to address a public health problem by:Listening to stakeholdersBeing flexible and prepared to revisit assumptions and early design choicesBuilding learning and adaptation into your routine ways of doing businessThe authors modeled


However, since there are limits on how much 2H-water can be administered and since some metabolic processes may be slow, it is possible that one may be challenged with measuring small changes in isotopic enrichment. We demonstrate an advantage of the isotope fractionation that occurs during gas chromatography, namely, setting tightly bounded integration regions yields a powerful approach for determining isotope ratios. We determined how the degree of isotope fractionation, chromatographic peak width and mass spectrometer dwell time can increase the apparent isotope labeling. Relatively simple changes in the logic surrounding data acquisition and processing can enhance gas chromatography-mass spectrometry measures of low levels of 2H-labeling, this is especially useful when asymmetrical peaks are recorded at low signal:background. Although we have largely focused attention on alanine (which is of interest in studies of protein synthesis), it should be possible to extend the concepts to other analytes and/or hardware configurations.Stable isotope tracers can be used to quantify the activity of metabolic pathways. Specifically,  In fact, one expects that a longer dwell time will result in better ion statistics since more time will be spent collecting a signal, however, sitting on one ion will immediately limit the collection of signal from another ion . In our  alanine A. Studie alanine  and demo2H1]alanine we could achieve ~9-fold amplification whereas when analyzing alanine we could achieve ~189-fold amplification  but noticeable asymmetry  . The linear response in the M:E isotope ratio of the standards demonstrated that one could detect the 2H-labeling; however, the marked variation with the “AutoIntegrate” routine made it difficult to resolve small changes between these standards  A. We comtandards B. In contandards C and allm/z 100 at scan 0 is ~50 times its baseline) and more marked asymmetry   D. We reatandards E. Howeveurements F.2H-water. Regardless of the integration method, we could detect the presence of 2H-alanine in animals given 2H-water vs. naïve controls . Although one can visualize an expected apparent stimulation of protein labeling in fed vs. fasted rats in cases where the entire peak is integrated, the data become tighter when integrations are restricted to a smaller boundary . Using this approach, we did not detect any influence of positional labeling on the degree of isotope fractionation (not shown); therefore, it appears that the number of isotopic substitutions and not the location of 2H influences isotope fractionation.First, does the positional location of 2H-water and measure the labeling of product molecules in the M+1 species 2. It appears that for the assay of alanine reported here, we are at/near the limit of resolution. Namely, we tested the “methyl-8” derivative on a 30 m vs. a 50 m DB17ms column , but we could not observe a substantial effect on fractionation of unlabeled and [2-2H1]alanine. Presumably this is expected since the oven temperature gradient is already slow, namely, increasing at 5 °C per minute. Subsequent tests compared the fractionation of the unlabeled and [2-2H1]alanine on 30 m column with a more polar phase . That test resulted in substantially less fractionation , suggesting that less polar columns and/or derivatives may increase the fractionation.Second, we tested whether we could modulate the fractionation of singly-labeled alanine. As noted earlier, we often administer 2H-water (99.9 atom percent excess), [2-2H1]alanine (98.9 atom percent excess) and alanine (98 atom percent excess) were purchased from Cambridge Isotopes . GC-MS supplies were purchased from Agilent . Standards containing unlabeled and labeled molecules were prepared by mixing known quantities of the respective compounds.Unless specified, all chemicals and reagents were purchased from Sigma-Aldrich . 2H-water (20 uL per g body wt) at ~3 PM animals were then randomized to subgroups that were either allowed free access to food overnight or maintained in cages with no food overnight. The following morning (~9 AM) all rats were euthanized, and blood and tissue were collected. The 2H-labeling in total liver protein was determined following homogenization in 10% TCA. Protein pellets were transferred to a new tube and spun at 10,000 rpm at 4 °C for 10 min, samples were washed two times with 10% TCA to remove all free amino acids and dried under a stream of warm nitrogen. Samples were then resuspended in 250 uL 6 N HCl and heated at 85 °C overnight. A 25 uL aliquot of the protein hydrolysate was transferred to a new tube and dried under a stream of heated nitrogen. GC-MS analyses were performed as described below using the “methyl-8” derivative. Studies were approved by the Merck Research Laboratories Institutional Animal Care and Use Committee (#2020-601166-Aug); note that these animals are controls not published previously [Metabolic labeling was achieved in fasted vs. fed Wistar Han rats by administering a bolus of 2H3]leucine . The mice ate ad libitum. Comparable studies administered 2H-water to 12 week old mice  to enrich the body water to ~2.5% 2H. Mice were returned to their cage and 5% 2H-water was added to their drinking water, mice drank ad libitum to maintain the enrichment at ~2.5% 2H in total body water. After 14 and 10 days, respectively, the mice were anesthetized with isoflurane and euthanized by cervical dislocation and exsanguination. Hearts were excised, flash frozen in liquid nitrogen, and stored at −80 °C. Studies were approved by the Institutional Animal Care and Use Committee at University of Vermont (#19-032) and were in accordance with the guidelines listed in the Guide for the Use and Care of Laboratory Animals published by the National Institutes of Health. The review criteria are consistent with the “ARRIVE guidelines” that are endorsed by Metabolites. In other studies, metabolic labeling was achieved by feeding 12 week old male mice a diet containing 99%  and alanine, respectively, with a dwell time = 10 ms per ion. Note that the fragment at m/z 99 represents the base ion in the spectrum, whereas the molecular ion (m/z 158) accounts for ~15% of the intensity of the base ion. In studies where 2H-water is used to quantify protein synthesis, this derivative and fragment provide an advantage since the background isotope abundance has limited influence by any extraneous signal, and the use of DB-17ms column facilitates a good separation between alanine and glycine . Th. Th(1)y=The effect of isotope fractionation on the amplification of the M:E isotope ratio was simulated using two assumptions. First, we assume that the model peaks represent the elution profiles of the labeled and unlabeled molecules. Second, for simplicity, we assume an equal proportion of labeled and unlabeled molecules, i.e., in all cases the expected ratio of the peaks is 1. Simulations were performed under conditions where the unlabeled peak remained fixed and the labeled peak was shifted by −5, −15 or −45 scan units on the x-axis . The ratio of the peaks was then determined over a small region of the leading edge of the fixed peak, e.g., when the signal representing the fixed peak was ~−1 to ~−20% of its maximum  covering ~500 scans of baseline before the peak elutes and ~800 scans after the maximum peak height. The exact range is not critical, one should include enough data points to describe the peaks; output files are in the form “.csv”.The data were exported using the Agilent Chemstation feature “Export 3-D data”, unless specified, the range was set to export the necessary ions for alanine  were then imported to a MS Excel spreadsheet.Before proceeding with the integration, all chromatograms were manually inspected to determine whether the abundance of alanine was similar . Under good analytical conditions , the maximum peak heights of 2H-labeling. Since the fractionation that occurs during gas chromatography is highly reproducible and apparently not affected by the positional location of 2H substitutions, our studies suggest that strategies which optimize the degree of isotope fractionation should provide a useful means of increasing the detection of 2H-labeling when samples are analyzed using more conventional mass spectrometers. Our logic may help circumvent a reliance on more traditional IRMS in certain cases. In summary, the isotope fractionation that occurs during gas chromatography can be used to enhance the detection of 2H-labeling. For example, one can use smaller regions of the leading edge of the peak while still including a reasonable number of data points in the calculation. Lastly, when using our biased integration logic, it is imperative to include known standards if the goal is to correct the data and obtain true enrichments; one can obtain relative differences between groups without the use of known standards , the labeled and unlabeled molecules simply need to behave in a comparable fashion. We should also emphasize that although the absolute retention of an analyte of interest will certainly vary across injections , the fractionation of labeled and unlabeled molecules shows virtually no variation under the conditions applied herein . As implied, the stability of isotope fractionation is imperative for guiding peak integrations. Although we found that one can rely on a single dwell cycle to determine the ratio of unlabeled to labeled molecules , we do not advocate using such an extreme slice of the data; nevertheless, our observations make the case that isotope fractionation is remarkably consistent. In addition, we expect that the ability to detect ions at greater frequency will also improve the use of isotope fractionation as a means for amplifying the apparent ds e.g., B. Based on the experimental data presented here, it appears that there is a need to develop alternative software to process data obtained during GC-MS assays. We should note that our studies are not meant to suggest that GCMS analyses can be a substitute for IRMS analyses. Although our data suggest that one can blur the lines between the analytical methods, a head-to-head comparison would be necessary to identify true limits. We should also add that advances in high-resolution mass spectrometry can offer novel advantages in cases where one aims to quantify low levels of labeling , especia2H species, each mass isotopomer was normalized to its maximum peak height. As expected, in a control animal  the mass isotopomers are superimposed on each other (Panel A). However, the administration of [2H3]leucine or 2H-water results in marked shifts of the labeled species . We expect that one should be able to capitalize on this isotope fractionation in cases where 2H-labeled tracers are administered.Our simulation and modeling studies support the notion that partial integrations would be applicable to other analytical formats and instrument configurations e.g., liquid chromatography-mass spectrometry. In fact, We should note that attention towards integration strategies is not limited to studies involving fractionation, this has merit for various chromatographic applications ,18.Finally, we have not commented on how data are used in different metabolic flux models; indeed, this is very context-dependent. Fortunately, there is strong interest in developing tools for supporting related areas of tracer-based research ,26,27.


We conducted a focus group discussion with bus workers to evaluate their experiences and perceptions, as well as their reasons for participating in a program for vulnerable workers. The study also sought to identify the strengths and weaknesses of the program. A total of nine bus workers participated in the focus group discussion. The focus group discussion was conducted based on a semi-structured guide, which was developed from discussions among the researchers and a review of major preliminary studies. The verbatim transcriptions were analyzed using content analysis. The sole existence of a health promotion program for vulnerable workers in Ulsan was sufficient to attract participants who had not been involved in other health management programs. Participants reported that participation in the program mitigated some of their musculoskeletal symptoms, which are often faced by bus workers. The findings of this study may contribute to the expansion of the health promotion program targeting workers in vulnerable working environments in Ulsan and other places. In order to increase users’ satisfaction and the sustainability of the program, it is necessary to develop a strategy to increase the accessibility of the program and enhance the self-efficacy of participants. A vulnerable worker refers to a laborer whose well-being is at risk as a result of being involved in the labor market . VulneraTransportation workers, including bus workers, are exposed to risk factors such as vibration, noise, and hazardous chemicals. Moreover, they are often required to work for long hours without guaranteed breaks in a cramped and small working space . They foThe Ulsan Metropolitan City Bukgu Contingent Workers Center has been preparing to embark on a project to create an environment in the Ulsan area where small-scale workplaces with less than 50 employees can labor in good health, by bridging resources such as health, medical care, and safety preparations. It is part of the activities for the revitalization of the regional labor, management, citizen, and government cooperation project since 2014 . NotablyThe present study focused on the third program—health promotion program for bus workers. In 2018, the program offered stretching training for musculoskeletal disorder prevention, exercise prescription, and counseling based on the results of a general medical examination for about three months. Rehabilitation specialists provided stretching training and internal medicine care, and other specialists referred to the medical examination results. The specialists regularly visited the main bus garages in Banguhjin, Nongso, and Yuli, Ulsan to provide direct services. In addition, the program provided self-exercising tools to encourage self-stretching, brochures containing healthcare guidelines for promotional and educational purposes, and posters with stretching instructions, which were installed in the employee area. Moreover, a stretching promotional video was created and distributed to bus drivers.For this study, a focus group discussion with bus workers was conducted to evaluate their perceptions of, and experiences with, the program, motivation for participation, and the strengths and limitations of the program. The findings of the present study are expected to provide a better understanding of the program, which can help to enhance it in the future, as well as understand its implications for other similar programs in Ulsan.In this qualitative study, a focus group discussion was conducted with bus workers to evaluate their perceptions and experiences of the program, in order to explore strategies to further improve the program. The consolidated criteria for reporting qualitative research were applied to describe the qualitative research process using a focus group discussion .A total of three analytical and four auditing researchers constituted the research team. The analysis team comprised of one preventive medicine specialist, one researcher, and one clinical nurse with 11 years of experience. The audit team included one occupational environmental medicine specialist, one rehabilitation medicine specialist, and one small-scale business executive. Two of the researchers in the analysis team have extensive experience in qualitative research; they are experienced in reporting qualitative studies in research papers and theses, have attended seminars and conferences, and have conducted lectures related to the method.Nine bus workers attended a focus group discussion. The small-scale business executive contacted them individually to explain the purpose and content of the study. Then, those who agreed to participate were selected. Response bias, which refers to the tendency of respondents to respond according to researchers’ intentions, is likely to be low, given the research topic and purpose.The focus group discussion was conducted according to a semi-structured guide developed from discussions among the researchers and a review of major preliminary studies. The guideline comprised the following four aspects: bus workers’ awareness of the health promotion program; motivation for participation in the program; perception of the contents of the program; opinions and suggestions for the improvement of the program. Prior to the discussion, participants were fully informed about the purpose of the study, and therefore, verbal consent was obtained. One researcher conducted the discussion, which took about two hours. The discussion was recorded and transcribed for analysis. Content analysis was performed to analyze the data . The traA detailed analysis was performed, and concepts were derived by a researcher through repeated reading of the transcribed contents and notes of the focus group discussion. The derived concepts were then reviewed by another researcher, and conflicting opinions among the two researchers were resolved through sufficient discussions. Another researcher examined the concepts derived by the two researchers, who participated in the primary analysis and categorized similar concepts from among the ones resulting from agreements. All researchers then examined the results of the analysis, focusing on the framework of the entire category. The participants did not review the results of the analysis, and four supervisors finalized the assessment of the analysis results.The characteristics of the study participants are shown in A total of 100 concepts were derived and categorized into the four themes: obstacles to the healthcare of bus workers; the first positive impression of the health promotion program; satisfaction and changes after participating in the health promotion program; improvement of the health promotion program. In general, bus labor is characterized by working in the same position for a long period of time in a limited space (a bus) . This woThe participants were not able to consume meals regularly due to the two-shift working system and the short dispatch intervals. They had two meals per day and failed to establish a regular meal schedule . Moreover, it had become normal for the participants to rush meals due to the tight dispatching interval time. This resulted in chronic indigestion (participant 2) and abdominal obesity  among the participants, which eventually deteriorated their health.Participant 9: As you know, we have a designated amount of time to eat. There should be at least 20 to 30 min to eat, but we only get ten minutes sometimes.Participant 6: I eat in two minutes.Participant 9: I pour water into my rice bowl—that is the environment (where I work at).Participant 8: ... We do not have time to eat. We just scoop out the rice out and eat it. It’s like when we ate rice when cannonballs were falling during the Korean War.Participant 8: In the morning, when I say (to my wife) that I working the afternoon shift, I get a meal at 7 or else 10 or 11 AM.... Then I return from the shift, and I eat around 3 or 3:30 PM… then, I eat at 7 PM.… and I eat again at 11 PM.…I need to be on a diet. I mean, my belly is sticking out. If you go through this (schedule) for three months, you will get this stomach too; it is for real. I have no other choice because it is all in the contract.The majority of the participants complained of sleep disturbances due to the shift-work system . It was a major predicament, as their daily lives could only function by receiving psychiatric counseling or taking medication (participant 9). In addition to the work schedule, having a direct association with passengers, which was a job characteristic, was also a factor that impaired the mental health of the participants. They stated that they experienced significant difficulties due to inappropriate reproach and verbal abuse in an environment directly disclosed to the passengers, which made them want to quit their job, ultimately . Participant 6: I have a sleep disorder.Participant 9: One time I could not sleep for three days because I did not take the pill. I take zolpidem or something… I know I should not, but I need to work. I have to sleep in some way - I called in sick too… I do not want to take it either.Participant 5: I see myself as a disabled person. I have been suffering from insomnia. It has been a few years now. The more you take it, the more damaged you are.Participant 1: A friend my age, who has similar characteristics as me, could not ignore and let go of the wrongdoings of passengers. I heard he received psychiatric treatment and eventually quit. What I am saying is that, these things made me extremely stressed; bus driving is not only a physically strenuous labor but also a mentally stressful job…The participants continued to maintain a naïve attitude towards health issues, despite their declining physical and mental health. Most participants acknowledged the necessity of healthcare but continued being negligent of their health due to lack of time (All participants). Furthermore, they were not aware of the accurate figures for their blood pressure and blood sugar levels, to prevent cardiovascular diseases, which are likely to be caused by their work environment  . Moreover, they recognized the discrepancy in their knowledge on basic self-healthcare, although they made very few attempts to ameliorate it. They believed that perceptions of healthcare vary with age and willingness . That is, the higher the age, the more interested in health status one is. Engaging in health-related behaviors depends on the will of a person. Therefore, they anticipated that positive reformation of a work environment would not have any effect on their health (participant 7).Participant 8: It is no fun when you do it alone.Participant 4: I use the gym equipment on the riverside when I have the time, but to be honest, I do not really work out at home.Participant 8: I must do it when I have time, but I just do not. Twenty-four hours is not enough.Participant 5: I do not have the time for it.Participant 3: Younger people in their 20s and 30s are not interested at all. They are reluctant and feel awkward to get involved in a program like this.Participant 7: I personally think that the will of a person is the most important regarding matters of health, whether it is about using a handbook or an app (smartphone application) on health. I think that no more than 30% of workers will use it.The participants did not have any previous experience with other health promotion programs, despite their extensive career (All participants). Some participants  engaged in exercise as a hobby and managed their health without considering the health issues arising from work. Under these circumstances, the present health promotion program was sufficient to attract the attention and involvement of the participants in the program .All participants recognized that their physical and mental health was deteriorating due to the detrimental working environment. Some of the participants managed their health through fitness and soccer during their days off . These activities, however, did not contribute to the improvement of the musculoskeletal symptoms, a constant inconvenience sustained by their work. None of the participants had any prior experience of participating in health promotion programs, including programs held by public health centers or employee health support centers.Moderator: Have you ever tried a similar program like this? Have you tried it before?All participants: No, I have not.Moderator: You are aware of a public health center or an employee health support center, I assume? Have you ever participated in any similar programs there?All participants: No, I have not.Participant 9: This is the first time…the first time since 1991, when I started my job.There were various reasons for participants to join the health promotion program. Most of them took an interest in the program after seeing the promotional banner or promotional articles on social networks . In addition, some voluntarily joined in hopes of relieving their physical pain .Moderator: How did the rest of you hear about the program?Participant 6: I saw the banner.Participant 5: … It could be spotted at the garage.Participant 6: I received a text message.Participant 3: There was an announcement in my company, and for some other companies, a union leader posted the announcement on the union social network.Participant 9: I thought I should give it a try. When I saw it, nobody told me about it, but I wanted to give it a shot when I spotted it.Participant 6: I thought it could be helpful because my neck and shoulder ache…Participation in the program was an opportunity to reassess the health problems that the participants had been neglecting . Participants reported experiencing positive changes and significant satisfaction . They were able to gradually relax the persistent pain through quick stretching and understood their current health status through various medical examinations . The lack of publicity for the program, however, generated a low participation rate. This phenomenon was regarded unsatisfactory, which led to the participants encouraging their peers to join .The numbers of involvement in the health promotion program varied by the participants from one to eight-time involvement, but they experienced a positive transformation from the stretching skills they acquired. The most significant change was that the stretching skills enabled them to take health-related actions in daily life . In the long-term, it is expected to improve their healthcare behavior and health status. They also recognized a shift in their perception of the working condition after participating in the program . Before the program, they considered the working environment and the short dispatch intervals to be the significant factors, which forced them to feel helpless about healthcare. However, they learned to utilize the workspace to stretch efficiently for a short amount of time. From this understanding, they established a routine, which comprised stretching, and observed improvement in their physical discomfort. This encouraged them to participate in other available health promotion programs .Moderator: Is it better after the stretching? Can you feel it?Participant 5: I had some shoulder pain, and there were two physical therapists; two of them gave me shoulder massages, and I got them about three times. Then, I did it at home, and it was quite pleasant.Participant 9: (I have a) frozen shoulder. I have terrible shoulder pain, and I felt great relief doing it.Participant 2: Yes, it felt untangled.Participant 9: They also gave tools. If you do what you learn from them, you could actually pull it through. Because my body is in pain…Participant 1: I do it whenever I start the engine.Participant 9: Yes, it helped a lot.The program primarily focused on the prevention of musculoskeletal disease through stretching and exercise and included examinations of the body fat, body mass, osteoporosis, blood pressure, blood sugar, and cholesterol. Such a comprehensive healthcare program resulted in high satisfaction among the participants (All participants). Furthermore, considering the lack of free time, they were content with the availability of health counseling and individualized posture correction for painful areas from professionals, in their workplace (bus garages) . Moreover, they were satisfied with the strategy to associate the stretching tools, compensation of the program involvement, engaging in a daily healthcare routine, and the companionship of colleagues throughout the engagement (participant 8).Moderator: You have had various experiences. You underwent blood drawing and stretching exercises, but which one was the best of all?Participant 2: It was the body fat analysis.Participant 1: I went for that  to see the body fat percentage and to be assessed. I wanted to know my body measurements, and therefore, I was recommended to colleague.Participant 3: Things you could conveniently do, like stretching, by seeing a doctor. You feel like a patient when you visit a hospital, but you could go there (garage) without any pressure. I can casually go there, and at the same time, I can receive professional diagnosis and treatment.Participant 1: I had easy access. For so-called-hospitals, you have to visit deliberately and that is inconvenient. However, there (garage), you could just do it for just being there.Participant 9: I tried the gift (stretching tool) at home, and it was really good. It stretched my back, and I experienced immense relief.Participant 7: I used to have shoulder pain when exercising. It was damaged, so I stopped it, but the pain did not subside. Therefore, I went to an orthopedic, but the doctor told me that nothing was wrong with me. So I just let it slip. … I clearly did not know how to treat it…during the stretching activity, I was informed about an injured area that I was not aware of. It was not the most impactful exercise, but I wish they taught me muscle or ligament stretching movements…because lately, it has made me feel much better.The participants expressed great satisfaction with the program but noted the limitations as well. One of the most mentioned points was the lack of program publicity . Participants who reflected on their health and experienced improvements through the informative sessions despite the short-term period felt sorry for their colleagues, who could not get involved due to the lack of publicity . Moreover, some of them worried that the unmodifiable working environment would eventually worsen the symptoms regardless of the stretching skills and felt unsatisfied with an insufficient health consultation .Participant 9: I think with good PR (public relations); I mean many workers did not do it simply because they did not hear about it. But if you were to recommend it to your co-workers by saying “It is really nice when you actually try it out” and “Just try it! It is truly helpful!” then they might become willing to participate. But the PR was almost invisible, which made the workers hesitate. You need proper promotion for this.Participant 3: It is a good idea to hop on a car and stretch. However, the unpleasant part, rather than feeling better from the exercise is that… if you get an old car, you would feel the symptoms worsen quickly, rather than improving.Participant 8: I benefitted from the exercising or other activities, but I did not benefit from, for example, finding out how good or bad my health was.The great fulfillment of the program led to participants recommending the program to other colleagues . Participants shared their positive involvement in the program with their peers who could not join because of insufficient advertising. They believed that those who have experienced the program should enthusiastically inspire others to participate .Moderator: What would be a good PR strategy for this (addressing the low participation rate)?Participant 6: We should actively promote it.Participant 1: People who have participated in this program can spread the word, but people who have not cannot; if more people participated in the program, then the word would have traveled faster.Moderator: Would you consider recommending this program to others?Participant 1: Yes. If your body gets better, of course, you will recommend it.Participant 5: I encouraged a lot of them by saying things like “It is nicer than I expected.”Participants mentioned several aspects of the program that could be enhanced. The current program manages only physical health. They emphasized the importance of sleep disorders and mental predicament as a result of their work environment and the inclusion of a mental health consultation session in the program . Moreover, they asserted that the continuity of the program would amend the core of the problem lied in health . Furthermore, the persistent obstacles as a result of the two-shift work system and short dispatch intervals were other compelling reasons for the low participation rate . They highlighted the necessity of adopting a unique shift system for a smooth implementation of the program . They also noted that maintaining a health handbook or distributing health-related posters could serve as adequate substitutes in case of participation failure . They also stated that not only should the program be expanded to other regions, but also small establishments with less than five employees should be prioritized for the program . Mental health problems were an imperative factor deteriorating a healthy routine. The physical pain and mental difficulties could remain unaddressed and eventually threaten the responsibilities of the worker . Chronic pain and fatigue accumulation from working in such an environment can decrease the concentration level and increase sleep disturbances . In addition, unfair treatment and criticism from passengers could trigger mental stress, which could hinder bus operation . They therefore strongly argued that mental difficulties should be managed to avoid operational complications .Participant 1: We (workers) talk a lot about grievances when we take a break in the employees’ room. This has something to do with psychological wellbeing as well … it might be quite helpful to get some counseling or… Because I am extremely stressed out, bus driving is not only physically taxing but also psychologically stressful. Therefore, psychological counseling is needed.Participant 9: It might be because of my age, but I have not been able to sleep since last March; sleeping does not work on me anymore. So I consulted a few psychiatrists… strangely, if I wake up in the middle of the night, I cannot go back to sleep. Moreover, I have been suffering for one year and seven months. I am seeing a counselor too……There are more ways than I thought. They just keep their mouth shut and keep it to themselves. Rather than just telling us to lower the accident rate, I wish we could have some peace of mind. Loss of sleep is often directly associated with accidents, as you know.Many participants pointed out the inevitable need for a regular program rather than a one-time event . A sudden healthcare event is not practical under circumstances where it is challenging to transform the working condition (participant 8). They also claimed that there is a need for permanence to understand their health status and maintain a proper stretching posture .Participant 8: It is an only a one-time thing if you do it for a week and you rest a bit. … I want the current program to be gradually developed and continued for a longer period of time.Participant 6: I wish it became a long-term program.Participant 3: I think it would be appropriate to make things like this last for a while…Participants’ irregular working hours and short dispatch interval times hindered program engagement . Participants whose pain improved through the program attempted to get more involved in the program . However, inconsistent working and program hours led them to neglecting their health again . They inquired about operating hours at various times and wished to be informed of the program’s location and schedule through social networks . They presented a positive response to a healthcare handbook as a way to self-manage health . Considering the relatively high age range of the bus workers, they expected that the handbook would suit them better than an unfamiliar smartphone application and that it would provide them an opportunity to manage their health without being involved in the program . Furthermore, some considered that the posters at the workplace would naturally encourage stretching activities, which would enhance the effectiveness of the program (participant 8).Moderator: What do you think about being provided with a health handbook so that one can keep a record of their health?Participant 9: It would be nice if you could give it out.Participant 6: It is good to keep a track; I will know when and what I did, and I can reflect on it too.Participant 2: I will have the “Ah ha! I got it!” moments.…Moderator: What about a smartphone application? Do you generally use it well?Participant 2: It is okay, but I would prefer a handbook.Participant 5: Me too.Participant 6: People like us do not really know…youngsters do though…Participant 8: Remember when there was a national gymnastic exercise or some sort of an event with instructions? I think it would be more effective if you stick a poster on a wall and follow it regularly whenever you have the time.Moderator: Are you suggesting making a poster about it?Participant 8: Indeed. Even I would follow it naturally if it was in the office.The participants felt positive about the expansion of the program. They suggested prioritizing small-scale businesses with less than five employees as the companies often do not provide proper healthcare for financial reasons . Moreover, they recommended the expansion of the program to other regions .Participant 5: Where should it start… There are tons of small businesses. Regular small businesses go through a health checkup process once a year. But smaller ones hardly do it. There are just thousands of them out there.Participant 8: You have no idea how many companies with three to four people are there… Never in their wildest dreams would they go to a hospital.Participant 5: No, never.Participant 2: I wish other regions will get a chance to experience it too… The good part of the program is that stretching is essential, but it is not so easy to do it as you picture it in your head. If you squeeze it in every second, I think it would be nice to see the program in every region.A focus group discussion of bus workers was conducted to examine their experiences and perceptions of the health promotion program, in order to gain a better understanding of the program and improve it. The health problems of transportation workers was highlighted for select periods. Precisely, it was reported that the likelihood of experiencing physical disorders such as cardiovascular diseases ,14, muscFour themes were obtained in this study: obstacles to the healthcare of bus workers; the first positive impression of the health promotion program; satisfaction and changes after participating in the health promotion program; and improvement of the health promotion program. First, based on previous studies, it was confirmed that bus workers are at risk for several health problems. In particular, many of these health problems are caused by the working environment of bus workers. Participants complained of severe digestive problems and sleep disorder due to the tight working hours and the two-shift working system. They also mentioned mental stress caused by conflicts with passengers. They were aware of their healthcare needs to some extent, but lack of time was one of the reasons for neglecting their health. As the health of the bus workers is directly related to passenger safety, it is necessary to pay more attention to improving the working environment, which can fundamentally solve the health problems of bus workers . It is aThe present health promotion program was reported to mitigate some of the health problems faced by bus workers. It was found that stretching exercises for bus workers, who are required to work in minimal space, could prevent musculoskeletal disorders ,28, and The suggestions for the improvement of the health promotion program could be categorized as content- and operation-related improvements. Suggestions for content-related improvements included adding more health promotion activities to address various other health problems. Notably, it was found that there was a high demand for activities for sleep disorder and stress management. Stress management of bus workers is essential in situations where there is always a risk of traffic accidents, and the possibility of conflict with passengers and other workers . As bus Regarding suggestions for operation-related improvement, participants stated that the core health problems could be addressed if the program was implemented continuously rather than as a one-time event. The continuous implementation of the program is also crucial for building rapport with the participants and also for expanding the range of participants. Moreover, considering participants’ work environment, it is necessary to improve the program’s accessibility by, for example, providing more program hours and introducing a reminder system via social network. Unfortunately, due to time and budget constraints, it might be challenging to considerably increase the accessibility of the program. Thus, developing a strategy to increase the accessibility of the program in order to increase participation and satisfaction with the program is required; it is necessary to develop strategies to improve bus workers’ the self-efficacy for healthcare. For example, it is crucial to consider how to incorporate various activities into the program, such as providing a healthcare handbook that allows participants to track their healthcare behaviors, or reminding participants, directly and indirectly, about the necessity and methods of stretching before work.A limitation of this study is that it could not quantify the effects of the health promotion program. Based on the findings of this qualitative study, it is expected that this health promotion program will help to mitigate musculoskeletal symptoms of bus workers, prevent symptoms from worsening, and lead to a higher participant satisfaction. Nevertheless, an understanding of the quantitative effects and satisfaction is necessary for the expansion of the program. Therefore, in the future, it is essential to evaluate the effectiveness of the health promotion program based on the contents and measurements of the questionnaire before and after participation in the program. Another limitation is that the study did not confirm the opinions of bus workers who did not participate in the program. In order to enhance the accessibility of the program, future studies should include bus workers who have not participated in the program previously. This study had only one female participant, which is also considered to be a limitation. Although the experiences and awareness of female bus workers in a male-dominated workplace are expected to vary, it is difficult to analyze and interpret different results given the small sample size in this study. In future studies, it is necessary to examine the perception of healthcare of female bus workers.This qualitative study provides an understanding of the extent of bus workers’ health problems and their healthcare status as well as the effectiveness of the program, and provides information on how it can be improved. The study findings are expected to explain the importance of workers’ health problems and to expand health promotion programs targeting workers in vulnerable working environments in other regions.


Heated Humidified High Flow Nasal Cannula Oxygen Therapy (HHFNC) is increasingly used on the paediatric wards and High Dependency Units (HDU) for different types of pathologies and different age groups. We aimed to describe current practice related to the use of HHFNC on the paediatric wards and HDUs, weaning practices and preferred outcome measures for future research.We carried out a cross-sectional online survey of UK paediatric consultants or their delegates working on the paediatric wards. Descriptive analysis of their geographical, and organizational characteristics, their specialties, and their level of experience was investigated. Reasons for HHFNC initiation, weaning criteria, patients’ characteristics and their primary pathologies were also analysed.P < .001). HHFNC was reported by nearly two-thirds (68%) of the practitioners who used it on the wards to be as effective or superior to CPAP (Continuous Positive Airway Pressure) with fewer complications. Failure rate while on HHFNC was identified as the most important outcome measure in any future research followed by the length of need for HHFNC support .Participation of 218 paediatricians from 81 hospitals  was registered. HHFNC was provided in most of the surveyed hospitals . A High Dependency Unit (HDU) was available in 47 hospitals (58%); less than a third of those have a dedicated paediatrician. Decisions around HHFNC were made solely by paediatricians in (75%) of the cases, mostly at hospitals with no HDU compared to those with dedicated HDUs (70.3% VS 36.6, 95%CI:22.6–50.4%, This survey showed support for developing paediatric-specific national guidance on the use of HHFNC on the wards. Our list of defined research priorities may help guide further collaborative research efforts in this field. Heated Humidified High Flow Nasal Cannula Oxygen Therapy (HHFNC) has become increasingly popular as an option for non-invasive respiratory support of infants and children in critical care . More reThe primary mechanism of action for HHFNC is not well known but has many theoretical ones by which it reduces the work of breathing and improves efficiency of ventilation , 7 by waBecause of the uncertainty surrounding the use of HHFNC in paediatric practice, we aimed to survey the UK paediatricians with the following objectives: a) to describe the current practice related to the use of HHFNC on the paediatric wards and HDUs for different age groups and different pathologies; b) to describe weaning practices and supportive care during HHFNC, and c) to define research priorities and preferred outcome measures for any future randomised controlled trials.onlinesurveys.ac.uk, Jisc software, UK) to elicit their responses regarding practice related to HHFNC and their perceptions regarding research priorities. The survey covered four main domains:general information about the respondents,their wards and their patients’ characteristics including their primary illnesses,information about the use of HHFNC in practice including responses to two case scenarios, comparison with both low flow oxygen therapy (LF) and CPAP.finally, the respondents’ opinion of future trials on HHFNC and the key priorities in any further research.We carried out a cross-sectional online survey of UK paediatric consultants using the Online Survey Software  in three regions across the UK and these responses were used to inform the final questionnaire used in this survey  and Microsoft Excel 2016 .A total of 218 respondents participated in the survey, representing 81 hospitals across the 12 regions in the UK   had dedicated HDUs, with more than a third  were with an on-site Paediatric Intensive Care support (PICU). Twelve HDUs 12/19, 63%) were solely managed by the intensive care team and only seven HDUs (7/47 ≈ 15%) had a dedicated paediatrician. The majority of HDUs provided all types of non-invasive ventilation  and long-term invasive ventilation (LTV) . Table /19, 63% Respondents reported using HHFNC in a variety of illnesses on their wards particularly where HDU and intensive care facilities are not readily available . Respiratory diseases collectively accounted for more than 75% of the reasons to start HHFNC Fig. .Fig. 2IThe most common clinical indication for HHFNC initiation was hypoxia (oxygen saturation < 92%) not responding to LF  Fig. .Fig. 3IPaediatric wards were the primary location to start HHFNC according to the majority of respondents . Other locations such as the emergency department were also considered an option when a ward bed was not immediately available. Six respondents representing 5 cardiology wards from 4 different regions reported using HHFNC for cardiac patients with different pathologies (pre- and post-heart surgery). Most respiratory physicians in this survey  considered their respiratory wards as HDU-acuity level therefore HHFNC became a standard therapy on these wards. HDU and PICU were the primary locations to start HHFNC therapy in 8/218 responses (3.6%).Starting HHFNC therapy on the ward was overall a paediatric team-led decision, and similarly modification and weaning off HHFNC  particularly in hospitals with no HDU compared to hospitals with dedicated HDUs {24/34 (70.3%) VS 17/47 (36.6%), 95%CI: 22.6–50.4%, P: .002}.Relevant guidance on HHFNC was more available in hospitals with HDUs compared to hospitals with no HDU {36/47, (77%) VS 17/34 (50%), 95%CI: 5.9–45.6, P: .012}  and then gradually weaning the flow rate afterwards (75.7% of respondents).Respondents were asked to compare between CPAP and HHFNC on the wards, nearly two-thirds of them (67.9%) said HHFNC is either the same or superior to CPAP with fewer complications Table .Table 4Clinicians were asked to rank their three most important outcome measures on the use of HHFNC therapy in any future research Fig. . HHFNC FOverall, 187 clinicians (85.8%) supported the idea of developing national guidance on the use of HHFNC in general paediatric practice. A small number of respondents said that such guidance is not necessary  and the remaining respondents were not sure if such guidelines might change current practice.This study is the first and the largest national survey to review the current practice around HHFNC on the paediatric wards in terms of the number of responses, the geographical areas that have been covered across the UK and the use of HHFNC in many paediatric illnesses other than bronchiolitis, in addition to discussion about the supportive therapy while on HHFNC.The study period was intentionally meant to span as many seasonal variations as possible to reflect practice and to minimize recall bias when HHFNC use is at its nadir in the summer.In this survey, we noticed many areas of controversy and variation in clinical practice around HHFNC. As a non-invasive therapy, HHFNC is considered safe , easy toDetermining the initial HHFNC rate and the escalation strategy is still controversial as shown in this survey. While most respondents focused on 2 L/kg/min as a start-up flow, others tried a range of 3-4 L/kg/min in cases of bronchiolitis and pneumonia. Using the actual patient’s weight is a useful guide that most units have agreed on, however, it is worth mentioning though that most devices that deliver HHFNC are capped at < 2 L/kg/min for larger children with a maximum flow of 60 L/min. Majority of the surveyed units had criteria to determine HHFNC failure and an escalation strategy to an appropriate level of support demonstrated in the two case scenarios . It could not be ascertained, however, if oral feeding was only allowed in the weaning phase or administered throughout therapy. In general, keeping patients NBM while on HHFNC was the least favourable method as demonstrated in this survey Table .Nearly 80% of the respondents said they either never used sedation or used it sometimes for establishing HHFNC Table .HHFNC was generally assessed by 68% of our respondents to be either equal or more effective than CPAP with fewer complications . Other sAs a word of caution, this is a description of the current practice around HHFNC in the UK at the time the survey was conducted. We acknowledge that the total response rate in this survey is not large enough to make firm suggestions, however, we believe that this survey has served its purpose of highlighting the real need of further consolidated research and probably to work on developing a national guidance on the use of HHFNC on the paediatric wards similar to other countries .HHFNC is a rapidly evolving therapy with little data that supports its benefit in many of the paediatric diseases that have been discussed in this survey. Our survey indicates that there is growing confidence amongst paediatricians around HHFNC that may justify its increasing use in children. The key research priorities that have been identified by our respondents may help guide future studies to answer these concerns and support their clinical decisions.Additional file 1. Survey questionnaire.


Despite significant recent reforms, Australia’s mental health system faces substantial service and workforce shortages, and progress on the reorientation of services to a recovery focus is also slow. Implementing recovery-focused programs led by mental health peer workers is one way of addressing these issues, but uptake of these programs in Australia is patchy and not well evaluated.This project will investigate the implementation of a peer-led mental health self-stigma program across three diverse settings in an Australian capital city. The project aims to (1) examine the processes and contextual influences on successful implementation of peer work roles and (2) evaluate the impact a peer worker-led program has on individuals and services.The project will use an interventional implementation science approach: small-scale, researcher-led implementation of the Honest, Open, Proud program to explore contextual influences, and implementation, service and individual outcomes. The Consolidated Framework for Implementation Research (CFIR) will be used to guide investigation of contextual factors. Implementation outcomes  and service outcomes  will be examined in interviews with a range of staff within the services, checklists of adherence to program protocols and analysis of administrative data. Individual quantitative outcomes will include self-stigma, recovery and quality of life, measured at baseline, end of program and follow-up. Qualitative enquiry will focus on experiences with the peer worker and program.Quantitative analyses will comprise change scores on service and individual outcome measures. Where possible, differences between settings and the effects of potential confounds will be tested using multi-level linear models, which will account for clustering of individuals within programs and settings. Qualitative data will be analysed using a framework approach, which is an effective way of combining inductive and deductive coding to test and refine a thematic frame.Recovery-focused, peer-led programs have the potential to provide a unique contribution to the management of mental health issues. Currently, there is little information to guide successful implementation of these roles. This project will provide important preliminary data on the factors that affect implementation and the impact peer workers can have.ACTRN12619001312134. Registered 26/09/2019ANZCTR - Trial Registration ID:  Contributions to the literatureResearch indicates that peer work can have a positive impact on outcomes and satisfaction with care for both the consumers and the peer workers.The potential for augmenting the workforce with peer workers has strong potential to improve current services’ focus on recovery and alleviate substantial burden on the mental health system.The current protocol outlines a project that will provide critical evidence using implementation science methods that can ensure the optimal delivery of peer work in the Australian context.The Australian mental health system is undergoing a significant period of reform and change. Government reforms are shifting service delivery from a one-size-fits-all approach to a stepped-care model, and the recent roll-out of the National Disability Insurance Scheme (NDIS) has changed the funding and availability of many support programs. Increasing the capacity of mental health peer workers has been identified as a key strategy to support the mental health workforce and to improve continuity of care in this time of change –4, makinPeer work is a rapidly growing area that can have a positive impact on both consumer outcomes and satisfaction with care, as well as for the peer workers themselves –7. InterPeer work is a rapidly growing industry internationally , 9, 10. However, peer workers can also be employed in unique, peer-specific roles, in which they use their own lived experience to promote recovery through mutuality, reciprocity and role-modelling . In thesOne way in which peer work has progressed in recent years has been through the development of manual-based peer-led programs that specifically target peer worker outcomes such as stigma, empowerment and recovery. Honest, Open, Proud is one such program, developed by renowned mental health consumer and principal investigator on the National Consortium for Stigma and Empowerment, Professor Patrick Corrigan. Originally called Coming Out Proud due to its strong basis in the gay and lesbian movement, the program focuses on identity and disclosure as a means for reducing internalised stigma and promoting empowerment . ConsistEarly randomised controlled trial evidence from diverse populations, including adolescents  and adulExamine the processes and contextual influences on successful implementation of peer work roles; andEvaluate the impact the peer worker-led recovery program, Honest, Open, Proud has on individuals and on services.Thus, the current study has two primary aims:This study protocol addresses the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist  and the The project will use an interventional implementation science approach: small-scale, researcher-led implementation of the Honest, Open, Proud program to explore outcomes and contextual influences . ConsistBetter Together is being conducted according to the principles of community-based participatory research, which are particularly appropriate in implementation research that focuses on the relevance and uptake of interventions. The investigators all identify as mental health consumers and work in peer-identified roles and the research questions were developed by consumers and carers . The intResearch protocols and materials were co-developed with stakeholders via the ACACIA Consumer and Carer Advisory Group to ensure the nature and style of questions is appropriate for participants. In particular, consistent with consumer and carer preferences , qualitaA pilot study focused on testing methods and measures for the individual level outcomes and preliminary investigation of selected implementation outcomes will be conducted with university students prior to commencement of the main study.Data collection is planned for three distinct settings within one Australian capital city: community-based public mental health services, a university and a recovery-focused adult mental health learning organisation (Recovery College).Peer workers have recently been introduced into the city’s public mental health system, with positions in a variety of hospital and community-based settings. Group-based programs are already undertaken by at least one peer worker and opportunities exist to extend implementation to other peer workers. The program will be delivered and evaluated during usual peer work sessions.The second planned setting is a university. The investigator team, who are all peer researchers and educators, will facilitate the Honest, Open, Proud program for staff and students of the university as part of the wellbeing program. The program will be held on campus at times agreed with participants to accommodate study and work responsibilities.The third planned setting is a mental health Recovery College. The investigators and/or peer educators within the Recovery College will facilitate the program as part of 2019 second semester course offerings. The Recovery College has a specific focus on co-production and the importance of peer-led recovery, making it an ideal comparator for the other settings, in which these concepts are being introduced retrospectively.Honest, Open, Proud consists of nine tasks in three lessons, plus a follow-up booster session  .n = 72). Data collected during pilot testing of the intervention will also be included .The third key group is people with lived experience of mental illness. As an exploratory study, no specific sample size calculations have been undertaken for individual outcomes. Based on medium-sized effects observed in previous studies trialling the Honest, Open, Proud program , we willThere are no specific exclusion criteria. However, the program and associated research project measures are all in English and approach the issues from a Western conceptualization of stigma and mental illness. As such, this may prove challenging for people from different cultural or language backgrounds. We will not specifically exclude these people from participating, but they may require extra assistance to take part.Intervention characteristicsOuter settingInner settingCharacteristics of individualsProcessThe primary outcome is the success of the implementation of peer work roles across the settings. This will be investigated using the CFIR , which pwww.cfirguide.org, including the interview guide builder, specific constructs of focus to investigate contextual influences for the current study across the five domains will be selected in collaboration with the ACACIA Consumer and Carer Advisory Group. Expected constructs include adaptability and complexity of the intervention, external policy and incentives, inner setting culture and implementation climate, individual stage of change and all process constructs.Using the tools provided at http://www.comingoutproudprogram.org/images/Honest_Open_Proud_Fidelity_2.9.2017-min.pdf), scored by one investigator at each session.Measures of specific implementation outcomes (feasibility and acceptability) to be completed after program delivery are provided in Additional file Integral to the participatory nature of both the program and the project is information about the peer delivery. The project investigators will record notes and reflections on their own experiences delivering the program as part of data collection. Other peer workers involved in program delivery will be invited to do the same and to participate in an interview at the completion of each Honest, Open, Proud program to generate rich, cumulative data on the implementation process.At the service level, outcomes of interest are safety, person-centeredness and effectiveness. These will be investigated via interviews with staff and analysis of administrative data, including quality and safety monitoring, and routine outcome measurement statistics such as service level consumer experience data [e.g. the Your Experience of Service (YES) questionnaire ] to asseTable Figure Table Baseline measures including demographic and limited clinical data will be completed upon recruitment to the study and return of the consent form, prior to commencing the Honest, Open, Proud program. Questionnaires will be available both on tablets managed by the research team  and in paper form, according to participant preference. To avoid error introduced by participant management of codes, questionnaires will be identified by participant first name (or pseudonym) and last initial. Participants will be advised about the use of names during the initial contact about the program so that they may elect not to participate if uncomfortable with identified data collection. Names will be removed and replaced by a code after matching of questionnaires is complete. Outcome measures will be completed at the conclusion of Lesson 3 (3 weeks) and again at the conclusion of the booster session (6–8 weeks after baseline).A brief feedback session  will be conducted at the end of the booster sessions to gather additional information on participant experience. People who did not participate in the outcome measurement may elect to participate in the feedback session by completing written informed consent at this point of the study. Participants may take part in a face-to-face discussion or elect to answer the same open-ended questions in a brief, online survey.Total participation time, including program sessions, outcome measures and the feedback session is approximately 10–12 h across 8 weeks. Data collection is anticipated to commence in October 2019 and be completed early in 2020.Data for peer workers facilitating the program will comprise reflective notes on experiences of delivering the program and 30-min interviews conducted at the conclusion of each Honest, Open, Proud course (after the booster session). Peer workers will be asked to keep written or typed notes on their experiences to be submitted for inclusion in the research data at the conclusion of data collection. Interviews will follow a semi-structured protocol, guided by the CFIR constructs, and will be digitally recorded for professional transcription. Willingness to continue participation will be checked with peer workers at each participation occasion. Participation may extend for 6 months from October 2019 and comprise three to four interviews in that period. Facilitation of the program will take approximately 8 h plus preparation time. Estimated research data collection time is approximately 2 h of notes per course  plus up to 2 h of interview time (30 min per interview).Data for staff in the settings in which the program will be delivered will comprise one interview of approximately 60 min. Interviews with up to five staff members at each site will follow a semi-structured protocol, guided by the CFIR constructs, and will be digitally recorded for professional transcription. Participation for staff members will be on a single occasion only. Data collection from staff is anticipated to commence late in 2019, after at least one Honest, Open, Proud course has been completed at the site.During study setup, a request for aggregated administrative data on quality, safety and consumer experiences will be made to the data governance bodies of each location. To minimise issues of confidentiality and delays due to complex permissions, these data may be restricted to publicly available reports on performance. The purpose of examining administrative data is to supplement primary data from staff observations of service-level changes and individual participant outcomes.Quantitative data will comprise program scores of fidelity, overall service scores on measures of safety, effectiveness, patient-centeredness and experience, and individual measures of self-stigma, empowerment, recovery and quality of life. Due to the exploratory nature of the study, it is expected that quantitative data will be primarily descriptive and comprise change scores across time. Where possible, differences between settings and the effects of potential confounds will be tested using multi-level linear models, which will account for clustering of individuals within programs and settings.All qualitative data will be analysed using a framework approach . FramewoThe current protocol describes a study that uses an implementation science approach to evaluate a small-scale implementation of a program in three distinct settings in an Australian context. The primary aim of the study is to evaluate the success of the implementation of the program, with secondary aims to examine other related implementation factors including feasibility, fidelity, acceptability and sustainability of the program, service-level outcomes of safety, person-centeredness and effectiveness of the program, and individual-level outcomes for the effectiveness of the program on aspects such as self-stigma, recovery and quality of life. Peer work can have a positive impact on both consumer outcomes and satisfaction with care, as well as for the peer workers themselves –7. FurthAdditional file 1. SPIRIT 2013 Checklist: Recommended items to address in a clinical trial protocol and related documents.Additional file 2. Standards for Reporting Implementation Studies: the StaRI checklist for completion.Additional file 3. Evaluation questions (for discussion or written response).


Since 2019, aiming to eliminate periodic rubella outbreaks, the Japanese government has provided a rubella immunization program targeting men born in fiscal years 1972 to 1978, who lacked the opportunity to be vaccinated against rubella in childhood. This study aimed to explore the factors associated with participation in the rubella vaccination program among the first-year target population in 2019.A total of 11,754 adult men in Japan born in fiscal years 1972 to1978 living in seven rubella epidemic areas  were selected from a list of a survey agency and invited to complete an Internet questionnaire in March 2020. Recruitment ended when the participants reached 1680 individuals. Multivariable log binomial regression analyses were performed to explore the association between awareness of rubella prevention and rubella antibody testing in fiscal year 2019, adjusting for social characteristics.Of the 1680 men aged 41–47 years who completed the survey, approximately half (51.3%) said that they had received a voucher for the rubella antibody testing and vaccination program. One-quarter (25.9%) of the respondents had used the voucher for rubella antibody testing in 2019, and 6.0% had used the voucher for rubella vaccination in fiscal year 2019. Respondents who understood the government recommendation for rubella antibody testing and vaccination for men of their generation , those with acquaintances who had undergone rubella testing , and those who knew that about their lack of opportunity for rubella vaccination  tended to undergo rubella antibody testing. Receiving the most recent seasonal influenza vaccination  and being able to confirm a rubella vaccination history  were also associated with rubella antibody testing.The ongoing Japanese test-and-vaccinate rubella program has yet to achieve its participation rate goal for 2019. Further dissemination of the government recommendation to the population is necessary, along with improvements in the accessibility of the rubella vaccination program.The online version contains supplementary material available at 10.1186/s12889-021-10340-8. Japan periodically faces rubella outbreaks among adult men who did not have the opportunity to be immunized against rubella in childhood . In 2013Strengthening the immunization system is critical for eliminating rubella, but many countries continue to struggle with improving vaccination uptake. Rubella elimination can be achieved through a combination of routine childhood immunization and the vaccination of people in older age groups who are susceptible to the virus (“speed-up” campaigns) . AlthougRecently, the Japanese government decided to implement a unique rubella immunization program in response to the rubella outbreak in 2018–2019, targeting susceptible men born from fiscal years 1962 to 1978, who did not have the opportunity to be vaccinated against rubella as children . BeginniTo accelerate rubella vaccination coverage among the susceptible population in Japan, it is necessary to identify the barriers to this population’s participation in the vaccination program. Therefore, our study aimed to explore the factors associated with participation in the rubella vaccination program among the first-year target population in 2019: men born from fiscal years 1972 to 1978.n = 6.46 million), with 95% confidence intervals.A total of 1680 adult men were recruited for this study from the registry of a web-based survey company . In late March 2020, this survey company randomly selected persons from a list of 11,754 individuals (1) aged 41–47 years and (2) who lived in one of seven prefectures in Japan  then invited them to participate in the study. We selected these prefectures with large metropolitan areas, because the latest rubella epidemic impelled their local governments to actively promote rubella countermeasures in the target population. Those who agreed to participate were subsequently directed to complete an anonymous online, self-administered questionnaire. Registrants were provided with financial incentives for their participation. Recruitment ended when the number of participants reached approximately 1600 individuals. The sample size was calculated if the margin of error was 0.5, proportion of rubella antibody testing was 0.21, and response rate was 0.15 among the population , highest level of education completed , household income , number of children ≤ 1, or > 1), and occupation . Participants were also asked about their smoking status . To assess partner’s current desire for pregnancy, each participant was asked the following question: “Does your spouse (partner) currently have a desire to become pregnant?” with the response options of , or > 1,yes, no, do not know), “Did you receive an antibody test for rubella using the voucher?” , and “Did you get a rubella vaccination using the voucher?” .To determine the respondents’ rubella testing and vaccination history from February 2019 to March 2020 , they were asked, “Did you receive a voucher for rubella antibody testing and vaccination from your residential local government?” . To determine whether an individual’s rubella vaccination history could be confirmed, we asked, “At present, do you have access to your records such as the Maternal and Child Health Handbook (not including your parents’ recollection) to confirm whether or not you have previously been vaccinated against rubella?” . Each participant was also asked, “Do you have acquaintances who received a rubella antibody test from February 2019 to March 2020?” to determine whether the respondents’ acquaintances were tested for rubella antibodies in fiscal year 2019. The responses were categorized as none no or yes in the analysis.To assess the respondents’ understanding of the government recommendation regarding rubella vaccination for men of their generation, we asked, “Are you aware that it is recommended that men born from fiscal years 1962 to 1978 receive a rubella vaccination?”  and “Are you aware that babies carried by mothers who are infected with rubella may develop a serious condition called congenital rubella syndrome?” .The participants were also asked the following questions to measure their perceptions of the risks associated with a rubella outbreak: “Are you aware that men in your generation, born from fiscal years 1962 to 1978, had no opportunity to be vaccinated against rubella?” (response options: P < 0.05) in the univariate analyses were included in the primary model, and the variables that remained significant were then selected for the final model. Using a similar model, we also assessed receipt of a voucher for the rubella antibody testing and vaccination program as the dependent variable. All analyses were done with Stata/MP, Version 16.1 . Statistical tests were two-sided and regarded as statistically significant at P < 0.05.The proportions of the participants who received a rubella voucher, underwent rubella antibody testing, and were vaccinated against rubella in fiscal year 2019 and the 95% confidence intervals (CIs) were calculated by the assessed participant characteristics. Log binomial regression analyses were performed to explore the associations between participants’ awareness of the rubella prevention program and their history of rubella antibody testing in fiscal year 2019, adjusting for social background characteristics. All demographic variables (except for gender and age) and variables shown to be statistically significant .Table Of a total of 1680 men aged 41 to 47 years, approximately half (51.3%) said that they had received a voucher for the rubella antibody testing and vaccination program Table . One-quaThe percentages (95% CIs) receiving a voucher, undergoing rubella antibody testing, and receiving the vaccination varied by subgroup Table . Those wTable n = 104), 90% had already received their vaccination at the time of the survey.Table Approximately one-quarter of the men born from fiscal years 1972 to 1978 responding to the survey had participated in the Japanese government’s rubella catch-up program from February 2019 to March 2020. A national-level report for the same period  shows a The present study suggests that men’s understanding of the necessity of rubella vaccination for their own health promotes their participation in the rubella prevention program. However, such knowledge is not yet widespread among men born from fiscal years 1972 to 1978 Table . Being aAlthough the participation rate of Japan’s new rubella vaccination program remains low, the public recognition of the new rubella vaccination policy has slightly changed. We found evidence that knowledge is increasing regarding the need for adult men to be vaccinated against rubella, rather than only women and babies needing vaccination. The present study found that partner’s current desire for pregnancy did not affect adult men’s participation in the rubella catch-up program. This finding is in contrast to our previous study conducted in 2014, which found that partner’s current desire for pregnancy was a major factor associated with adult men’s voluntary rubella antibody testing and vaccination [The present study revealed two steps that may present obstacles for the rubella catch-up program; 1) receipt of the voucher and 2) taking action using the voucher. The most straightforward strategy to increase the vaccination program participation rate is providing reminders to the target population by telephone, letter, or text message, as a Cochrane meta-analysis has suggested . The remImproving access to vaccines is essential for removing barriers and increasing vaccination coverage . Among tOur study had a few limitations. First, as an Internet survey population sampled from urban areas, our sample cannot be considered representative of the general Japanese population; thus, the results should be interpreted carefully. The present survey shows a higher participation rate (25.9%) in the rubella catch-up program, compared with a national-level report for the same period (21.2%) . This diThe ongoing Japanese test-and-vaccinate rubella program has yet to achieve half its participation rate goal for 2019, the program’s first fiscal year. Further dissemination of the government recommendation to the population is necessary, along with improvements in the accessibility of the rubella vaccination program, including through incorporating the program in the workplace health check-up setting.Additional file 1. The research questionnaire translated in English . The original questionnaire in Japanese was developed for this study.