Mass communication is one component of effective public health program implementation . It inclFrom 2014 to 2017, the Centers for Disease Control and Prevention (CDC) funded 88 communities through Racial and Ethnic Approaches to Community Health (REACH) and Partnerships to Improve Community Health (PICH). REACH funded local health departments, tribes, universities, and community-based organizations to reduce racial and ethnic health disparities in their communities . PICH suMany REACH/PICH programs had limited experience using mass communication to support public health efforts in rural or small towns. In response, CDC provided individualized training, guidance, and technical assistance. This included developing a communication plan, identifying and understanding key audiences, developing and pretesting messages and materials, selecting communication channels  and categories , providing spokesperson training, conducting audience research, and evaluating communication activities.To understand what contributed to successful communication efforts in nonmetropolitan regions, we conducted individual, 60-minute telephone interviews with personnel overseeing programmatic activities (“program managers”) and mass communication activities (“communication leads”) in 6 REACH/PICH programs. These programs achieved or exceeded annual communication objectives and dedicated at least 10% of annual funding to mass communication. Each interviewed program worked in municipalities with populations of 250,000 or less across multiple US Census regions. Two were tribal programs. By uing a semistructured interview guide, programs were asked open-ended questions about the challenges, opportunities, and promising strategies they encountered when implementing mass communication in small and mid-sized communities. Inductive qualitative analysis identified 4 emergent themes.For most interviewed programs, the perceived value and role of communication activities grew over time. Hiring communication staff or consulting services built long-term communication capacity. Increasing program capacity for mass communication had the potential to inform the organization more broadly, especially when staff who had gained communication training and experience advanced within the organization or worked across programs or grants.Audience research helped programs develop communication materials for priority populations. Audience research and message testing helped programs define discrete audiences, better understand their messaging needs, and determine which channels were appropriate and accessible to audiences served.Several programs felt prepared to continue their communication efforts after REACH/PICH funding because of the experience that had been gained. Programs also felt their communication efforts brought attention to the larger organization. Programs primarily conducted mass communication activities without direct involvement from their organization. CDC technical assistance and funding allocations provided support to help organizations understand and appreciate mass communication efforts.I think [the recommendations are] really important because it tells the awardee how important communication efforts are. . . . I think at the start of [the funding period] if you looked at [the program and] all the partners, there is no person who [was] designated to doing communication work. In a small community, that skill set and capacity wasn’t there, so what was really great about the [award] requiring that communication work, we put time and energy toward it to the point where now there’s a full-time person designated to work toward it. — Communication leadIt all depends on who you have on staff. . . . [Our communications person] knew a lot before coming here so she led the way with the communications without needing much hand-holding. — Program managerWorking with [the communication consulting firm] has massively increased our organizational capacity because we’ve learned so much about how formative research happens and about identifying what outlets we should be using, [and skills such as] plain language writing. . . . We’ve learned so much that we can use going forward about how to do our own messages. — Communication lead[Hiring our communication lead] paid off tenfold. He created stuff and it was amazing. We needed that person. I think it should be [required] that you have a media person. — Program managerBefore PICH, we usually just relied on earned media and press releases. What would get picked up would get picked up, either for a news interview or an article in the newspaper. With the PICH funding, it has allowed us to have the staff time to put together our own commercials and then also pay for commercials to air on our local TV stations. — Program managerI did communications plans with each of the program managers to get a little more detailed about who they needed to reach. . . . We had some nice audience worksheets that we were provided through the grant so I had worked through those, [and] message mapping. . . . They helped you really target in on identifying who those audiences were, what they did, what they looked like, in creating those nice personas. I think they work. I think they helped [program managers] say, “I get it. I don’t need to talk to everybody. I really need to talk to the people at the town who are doing this, or the human resources people at the businesses.” — Communication leadOne of the ways that we save money is that we did the focus groups ourselves. . . . Communications are very expensive, so making sure that we have the resources allocated to designing great messages that work with the community [was a consideration]. . . . We did a little backend testing with [materials], which actually was so helpful especially when making sure the language was appropriate. — Communication leadWe did a communication survey [in our community], which was great. We asked, “Where do you get your news from?” I think that’s something that every [program] should do. Because you have to know where your people get their information. I was surprised with our survey how many people still watch the news. — Program managerI liked the materials we came up with. We worked really hard to get the messaging right, around not just healthy behaviors, [but] more around these environmental changes. . . . We spent a lot of money on that internal learning. — Communication leadThe things we’ve learned through PICH, we will be able to apply to our ongoing communications with the public we serve [as a health department]. — Communication leadMaybe a year and a half, almost 2 years into the project, all of the sudden . . . the light went on. We realized how sustainable communication objectives can be and how much of a difference just communicating a message can make in the community. . . . [The organization is] supportive, but I don’t think we had the knowledge as an organization. We didn’t do [message] testing of any sort. That was really eye-opening. We actually had a couple of staff . . . get trained in plain language writing. . . . We run everything through them now. — Communication leadWe have a visioning session and we do this once a year just to talk about what’s coming down. Even when REACH goes away, what’s next? Where do we go? How do we keep this momentum? We’ve been doing this for a couple of years and as part of this process we start every session with a SWOT analysis — the strengths, weaknesses, opportunities, the whole bit. It was interesting to me that yesterday, one of the things that was noted as a strength was communication . . . [and] it was also listed as an opportunity to get better. — Program managerThe structure that this [REACH funding] was able to bring in regards to the amount of communication that had to be put out and the focus on a certain population made our organization realize, “Oh, we’re getting notoriety among partners and even community members.” . . . People knew, at the end of the day, that everything was linking back [to our organization]. — Communication leadCommunity-based organizations, local agencies, hospitals and educational systems, nonprofit entities, and local businesses may partner — formally or informally — to complement one another’s efforts. Programs worked with existing partners to increase the reach of communication efforts. Program partners were reliable and motivated to work with programs to promote messages and materials. Improving the communication capacity of partners was viewed by some as a method to achieve sustainability of program efforts.Determining a core vision and aligning communication strategies advanced efforts of partner coalitions. Programs noted that many key partners for communication efforts were unpaid but shared similar goals. These partners frequently shared messages on behalf of the programs, expanding reach to audiences that may otherwise be less accessible.We didn’t have too many paid partners. It was more of “grassroots for the betterment of the community” partner, or it was an initiative that directly benefited their audiences or their membership or their group. — Communication leadI was thinking . . . “How can we support our partners in getting a skill set that allows them to do their own communication work in the future?” Some of that is leading by example. Some of that is drawing partners into our work. For example, for making a video, making sure that partners who are interested in learning how to make videos are a part of that. We’d hold digital storytelling workshops, we’ve brought community partners to work with our media contractor. . . . That, to me, is another really strong way to sustain our effort. — Program manager[Communication as a coalition] does require a conversation. The conversation needs to focus [on the fact that] this is not one organization presenting these things. This is about getting a group of organizations to work together. Every single organization that’s in that room has branding rules and logos. . . . We’ve worked hard to rebrand ourselves as the coalition. — Communication leadYou have to be okay in your communication efforts knowing that sometimes when the partner is the carrier of the message, that as long as the community is becoming aware, you’re doing your job. Even if your name’s not the final one on it, the goal is that community awareness increases. — Communication leadAccording to programs, operating in a less populous area has advantages for mass communication. Programs felt it was relatively easy to access existing networks for communication activities in nonmetropolitan regions using existing networks to involve partners and access channels for mass communication. In small, close-knit communities, these relationships were frequently useful and reliable avenues for message dissemination.Special considerations apply to the selection of communication channels in nonmetropolitan regions. Programs serving rural areas noted that channels designed to maximize reach in larger markets  need to be carefully considered in less populous regions. For example, billboards lack exposure if placed in areas without heavy traffic flow, transit advertising is not relevant in areas with limited to no public transportation, and television and radio broadcasts may reach beyond the key population or geographic region, or alternately, may not reach isolated areas. Programs frequently used alternative, often economical, channels to communicate to these audiences, including social media posts and paid messaging on social media platforms, local-access or cable-access television or radio, internet radio programs, podcasts, newsletters, and mass mailings. Almost all refined and expanded their social media presence during the funding period. Programs found opportunities to promote their activities by using earned media through local publications and news stories. Programs also observed that earned media coverage generated interest and encouraged the replication of program activities by other small communities or neighboring regions.Most people within the health care arena are aware that we’re here. [It] is maybe easier than some of the bigger markets where there are just so many layers of . . . providers. You just know each other here. — Communication leadI haven’t run into a situation where someone has said no. That’s [attributable to] size. Even in large cities and large communities, there are niches and there are smaller communities. . . . There is just an ease [in these clusters]. — Communication leadHow we handle communications within [our city] is different than how we handle it within a rural community. , that’s going to our radio stations or our TV outlets. . . . Now that we’ve reached out to the smaller communities, we’ve had to learn the ropes for small towns. — Program managerThe thing we started doing this year, as well, is Facebook paid messaging. . . . What I really liked about the Facebook option, when you do a newspaper ad, you can’t say “I only want to reach 18 to 25 [year old] African Americans that live in this zip code.” It ends up [being] whoever picks up the newspaper, which sometimes is our population and sometimes it’s not. [Facebook] allowed me to really tailor down. — Communication leadRadio, in particular, is effective. I know, having lived in the city in the past, it’s not a target or a way to reach everyone, but here, with a few stations you can really reach a huge number of people by getting on a few key radio programs of that sort of thing. — Program managerWhen we look at a limited budget [next year], our focus will definitely be on more social media because that’s what we’re hearing constantly. . . . It’s really realizing and accessing your audience exactly where they are. Had all projects in the past had someone in communications, that would have continually been the focus. — Program managerOne of the foundations of our [communication] plan that I think has been most successful is the social media work. — Program managerIt seems like when there’s a rural community that’s doing something, there’s another community that hears about it. Then they may want to do it because the other community did it. By having the media pick up on it and say, “Hey, this is what small town ABC is doing,” I think that has helped persuade other small towns to decide . Then they’re more willing to participate in some of our initiatives. — Program managerREACH programs emphasized the importance of allowing cultural contexts to guide program planning, implementation, and mass communication when addressing health disparities. Celebrating and embracing the cultural roots of the community can empower and encourage community members in the process of communicating about public health programs. According to interviewees, consideration of cultural and spiritual aspects like language, ethnic background, church events, and cultural practices reinforced powerful community connections and improved message dissemination. Programs valued the involvement of community members in the cocreation and testing of messaging, particularly when program staff were not from the same social and cultural backgrounds as audiences. The tribal programs emphasized the importance of considering the unique attributes and infrastructure of tribal communities in all aspects of program planning and implementation, including approaches to mass communication.I think the other reason why this has been so successful is the [production] company we chose to work with made a huge difference. . . . They’re Native. . . . Before I got into this, I knew if we did our media right, we could impact a lot of people nationwide in Indian Country. I do wellness and healing all across Indian Country. I know the importance of striking that emotion. — Program managerYou have to look at the heart of the people you’re working with. You have to connect at where they’re at. If the majority of your people are Latino then you have to connect with their culture. If the majority of your people are Black, then you have to connect with their culture. That’s what I think is our biggest takeaway from this. — Program managerWe tried to get into the community as deeply as we could. That really guided a lot of what we did, especially because we realized how much culture was playing into the mix. . . . I think it really came down to the nuances between those 2 cultures [and that] changed the way we did everything. . . . What we realized is, we needed to go to places that were either designed to be culturally specific or naturally became culturally specific locations. We could really tailor the intervention to each of the communities a little better. — Communication leadPeople were shocked to see a billboard in Spanish, but there’s the benefit of shock value and catching someone’s eye and realizing that message is solely for them. . . . Even now there’s been commercials in Spanish on English-[language] TV stations, because it communicates, “We know you’re watching too.” It’s a respect value and having the [platform] to say, “We know you’re [in] the minority, but we care enough to ensure this message reaches you.” — Communication leadSmall- to mid-sized public health programs may be unsure of the feasibility of using mass communication in their program activities. REACH/PICH programs in nonmetropolitan regions demonstrated the successful use of mass communication strategies to promote and support programmatic efforts. The experiences suggest that nonmetropolitan communities can achieve communication objectives through various adaptive approaches, frequently leveraging local partners, networks, and resources.Undertaking mass communication for public health programs requires defined objectives, understanding the audiences to reach and the best channels and strategies to reach them, and evaluation methods to track changes over time — each grounded in health behavior change and communication theory . To implAudience research using established methodologies — such as focus groups, in-depth interviews, or surveys — supported the creation of mass communication approaches that reflected the local contexts of the communities in which the programs operated. Culture has been identified as an influential factor in how message content, structure, sources, and channels are perceived and received by key audiences, and is associated with multiple facets of health behavior . Health These examples illustrate that it is feasible for public health programs in nonmetropolitan regions to increase internal capacity for mass communication to reach target audiences. CDC provides resources on health communication and social marketing for public health programs that are applicable in nonmetropolitan settings . These p


Increasing children’s physical activity (PA) at school is critical to obesity prevention and health promotion. Implementing novel, low-cost PA programs offers potential to contribute to children’s in-school PA, particularly in resource-constrained schools. This evaluation describes implementation fidelity, reach, and dose of two PA programs in the Fueling Learning through Exercise (FLEX) Study.n = 7) or CHALK/Just Move classroom activity break PA program (n = 6). Intervention programs were delivered across two school years. Surveys with program champions/teachers and children, in-session measurement of children’s PA by accelerometry (Actigraph GT3X) in a subset of schools, and key informant interviews were used to collect information on implementation, including fidelity, dose, reach, and sustainability, and to calculate an implementation score.Thirteen diverse, low-income Massachusetts elementary schools were recruited and randomized to the 100 Mile Club walking/running program  compared with CHALK/Just Move schools  (13.6 min vs. 2.7 min per session). A slightly higher proportion of eligible children participated in CHALK/Just Move compared to 100 Mile Club (54.0% vs. 31.2%). Both programs were well received by champions/teachers and students.Six CHALK/Just Move schools implemented the program in both years. Two schools randomized to 100 Mile Club did not implement at all, and only three schools implemented both years. Implementing schools had similar implementation scores  but fidelity to core and enhanced elements differed between programs. In 100 Mile Club schools, dose of program delivered was greater than in CHALK/Just Move schools (34.9 vs. 19.7 min per week). Dose of PA received per session was also greater in 100 Mile Club schools  contains supplementary material, which is available to authorized users. Physical activity (PA) plays a critical role in childhood obesity prevention in addition to conferring a number of other important health benefits –3. HowevExperts have recently called for a “whole school” approach to increasing children’s PA , in whicNovel strategies are needed to increase PA opportunities for children at school, particularly among low-SES children. Teacher-developed, champion-led school-based PA programs may have unique advantages with respect to acceptability, feasibility, and sustainability, compared to programs developed by researchers outside the school environment . DocumenThis paper describes the implementation of two innovative school-based PA programs in the Fueling Learning through Exercise (FLEX) study , a clustUsing a mixed methods approach, we aimed to understand key elements of implementation, including program reach, dose, and fidelity by engaging direct implementers and participants. In addition, we sought to identify barriers to and facilitators of program delivery to inform opportunities for future dissemination.n = 7), or CHALK/Just Move (n = 6), or control (n = 5). Randomization occurred after schools agreed to participate and to implement the program to which they were assigned. The interventions were delivered across two school years (2015–2016 and 2016–2017) for children in grades 3 through 5. One 100 Mile Club school opened the program to all grades. Programs were available to all children in participating grades/classrooms regardless of whether they were enrolled in the trial. Table Detailed methods for FLEX are described elsewhere . Eightee100 Mile Club  is a proCHALK/Just Move  is a proFLEX study staff trained champions, who were typically tapped by the principal, and classroom teachers to implement the programs in both study years. In 100 Mile Club schools, study staff offered a 30–40 min training at school at baseline (year 1) to explain the program, helped champions identify the best outdoor and indoor routes, and delivered printed program guides and other materials. At the start of year 2, study staff conducted check-ins via phone to re-engage champions, helped troubleshoot any barriers that surfaced during the first year, and offered support and/materials as needed. In CHALK/Just Move schools, study staff offered 10–20 min trainings annually to classroom teachers who would be implementing the program and delivered program guides and activity cards. Study staff provided support to champions and teachers throughout the two-year intervention, including regular check-ins via email. All schools received a $1000 stipend to support their respective program.The primary aims of the evaluation, informed by a process evaluation framework , were toChampions and teachers were asked to complete brief online surveys at midpoint, to report details of year 1 implementation and post-intervention, to report details of year 2 implementation and plans for continuing programming). For 100 Mile Club schools, surveys included questions about scheduling of program sessions, numbers of participants, and methods for tracking and displaying mileage. For CHALK/Just Move schools, surveys included questions about the number and duration of daily breaks, use of activity cards, and integration of PA breaks with academic material. Champions and teachers were sent links to online surveys via email. Study staff sent reminders to non-responders.Consented child participants randomized to 100 Mile Club or CHALK/Just Move were asked to complete a brief post-intervention survey to assess their participation in and feelings about the program. Questions asked children to report whether or not they participated in the program, whether they liked it, and whether they would participate again.In spring 2017, assessments were conducted in a subset of implementing schools to measure the time children spent engaging in PA during program sessions (dose received). All program schools were invited to participate. Prior to conducting assessments, research staff sent information letters home to parents explaining the evaluation and providing them the opportunity to “opt out” for their child. Likewise, children were given the opportunity to decline to wear an accelerometer prior to the start of assessments. Children who agreed were outfitted with waist-worn accelerometers  by trained study staff according to a standard protocol  19]. In. In19]. In Fall 2017, after completion of the study, semi-structured interviews with champions and teachers at schools randomized to either 100 Mile Club or CHALK/Just Move were conducted by telephone by a trained research assistant . This was based on study staff’s direct contact with school staff and inquiries regarding PA program implementation. For the next evaluation level, implementation metrics were applied to schools that implemented any program elements during the first year of FLEX (implementation cohort); metrics assessed the two-year average fidelity and dose of the program and the maximum reach for either year for each program Descriptive analyses were used to summarize implementation results for both programs.For the implementation cohort, data from champion and teacher surveys were extracted from Qualtrics and analyzed using Microsoft Excel. Implementation details and dose were reported for 100 Mile Club schools by champions. CHALK/Just Move implementation details and dose were reported by teachers and averaged across classrooms to create school-level metrics to parallel 100 Mile Club. Interview and observation data were used to supplement incomplete survey data.We estimated the percentage of schools that offered core elements of the PA program over two years as well as the percentage of schools that offered any enhancements. An implementation score was created that ranged from 0 to 3. This score is comprised of the sum of two separate scores: fidelity to core elements (0–2) plus the use of enhanced program elements (0–1). Schools could receive a score of 0 for not implementing at all, a score of 1 for not implementing core elements to standard, or a score of 2 for fully implementing both core required elements . A score of 0 was assigned if no enhancement was used at least “most of the time” and a score of 1 was given when at least 1 enhancement was used “most of the time” or “always.” A key rationale for developing an overall implementation score was to have a metric to compare these two programs, however different, across the entire study to quantify delivery and explain primary outcomes discussed in separate manuscripts.Dose of programming delivered was defined as minutes per week per school. Champions and teachers were asked to report the minutes per week that they offered PA programming at midpoint (year 1) and post-intervention (year 2) as categorical responses. For 100 Mile Club, champions selected the response that reflected total minutes of PA programming offered each week across all sessions. Categories, in minutes, were 0–15, 16–30, 31–45, 46–60, 61–75, 76+. CHALK/Just Move teachers were asked to report sessions offered per week and minutes per session. To estimate total PA minutes per week, the medians of the selected categorical response for each question were multiplied to determine an estimated PA program minutes per week. Responses for sessions per week were 0–2, 3–4, 5–6, 7–8, 9–11, 12+. Minutes per session responses were 0–2, 3–4, 5–6, 7–8, 9–10, 11+. For example, if a teacher reported 3–5 (median = 4) sessions per week and 7–8 (median = 7.5) minutes per session, then 30 min of weekly PA programming was estimated. If 12+ sessions or 11+ minutes were reported, 12 sessions and 11 min were used as there was no median value.Dose received was determined by average minutes children engaged in light PA (LPA) and MVPA in program sessions, measured by accelerometer, in the subset of participating schools. Accelerometer data were processed using a 15-s epoch to more accurately record short, intermittent bursts of activity common among children . Data weTo measure program reach, information reported in champion and teacher surveys was used. 100 Mile Club champions reported the number of students regularly participating across all grades including those either eligible for or enrolled in FLEX during year 1 (grades 3 and 4) and year 2 (grades 4 and 5). For one 100 Mile Club school where participant numbers were not provided on the survey, session participation observed and documented by research staff was used. CHALK/Just Move teachers reported whether their class was participating and the number of students in their class.Reach was calculated by dividing the number of participating students by the total number of students in the eligible grades. The number of students in each grade at each school was obatined from publicly available data from the Massachusetts Department of Education (DOE) . Reach wTo better understand program receptivity and potential for sustainability and scalability for future dissemination, as well as barriers to and facilitators of implementation, we evaluated champion/teacher and student attitudes toward the programs. For champions/teachers, we defined receptivity as the percent who indicated on surveys at the mid-point and post-intervention time point that they would implement their respective program again. Children’s receptivity to the program was determined by both the percent of children who indicated on surveys that they liked the program and the percent of children who indicated that they would participate in the program again. Additional information on program sustainability was gathered from key informant interviews with champions and teachers from all schools randomized to the programs. Common as well as program-specific themes from the interviews were identified and refined by study staff familiar with program implementation.Demographic characteristics of the FLEX schools as randomized are presented in Table Table Of the seven schools randomized to 100 Mile Club, five (71.4%) schools in year 1 and three of these schools (42.9%) in year 2 implemented the program to some extent. Two schools (28.6%) did not implement the program either year. Six of six schools assigned to CHALK/Just Move implemented the program to some extent in each of the two years.The implementation cohort consists of the five 100 Mile Club schools and 26 classrooms from all six randomized CHALK/Just Move schools. Implementation metrics, reach, and dose, as well as teacher/champion and student receptivity to the programs, are presented in Table Schools implementing the programs had overall similar implementation scores (100 Mile Club = 2.0 vs CHALK/Just Move = 1.9). However, fidelity to core and enhanced elements was different between the two programs. Champions at 100 Mile Club schools were somewhat more likely to report fidelity to core program elements (40.0% of respondents) than were teachers in CHALK/Just Move schools (19.2% of the respondents). However, about 65% of CHALK/Just Move teachers (17 of 26) offered at least one program enhancement, compared with 60% of the 100 Mile Club respondents. One 100 Mile Club school implemented fully to standard, with both core and enhanced elements. By comparison, no CHALK/Just Move school implemented fully to standard.Champions in 100 Mile Club schools reported offering a higher dose of PA programming than did teachers in CHALK/Just Move schools. 100 Mile Club champions reported offering about 35 min per week. On average, 100 Mile Club schools held 3.4 sessions per week (data not shown). CHALK/Just Move teachers reported offering about 20 min per week per school. On average, across all CHALK/Just Move schools, teachers reported offering 3.6 sessions per week (data not shown).n = 55) from the two 100 Mile Club schools engaged in an average of 13.6 min (SD = 5.0) of PA per session. 100 Mile Club sessions were, on average, 25.0 min long (range: 20.0–30.0). In the two CHALK/Just Move schools, children (n = 160) from eight classrooms, engaged in an average of 2.7 min (SD = 2.2) of PA per session, with an average of 1.5 sessions (range: 1–3) per day. The average length of sessions was 6.2 min (range: 3.0–11.0). The impact of the programs on children’s overall PA will be presented in a separate manuscript.100 Mile Club sessions were measured at two schools. In both cases sessions were held before school in a drop-in format where children joined as they arrived to school. Children (n = 67 students per school) than 100 Mile Club .We estimated that the FLEX PA programs reached about one-third to half of all eligible students in participating schools at some point during the two years of implementation. A somewhat higher proportion and number of students participated in CHALK/Just Move  of CHALK/Just Move teachers, compared with 67% (2 out of 3) of 100 Mile Club champions reported that they would do the program again. Among children who consented to take part in the trial and who participated in the programs, 100 Mile Club was received somewhat more favorably with 72.7% responding that they liked the program compared with 69.2% of children who said they liked CHALK/Just Move. Children participating in CHALK/Just Move reported being more likely to do the program again compared with those who participated in 100 Mile Club (91.6% vs. 80.8% respectively).Table Key themes specific to each program emerged from the interviews. Champions in 100 Mile Club schools indicated that before-school sessions were most successful and well attended, and a positive outcome of the program was that it promoted school community by facilitating interaction among children from multiple grades and encouraging participation of other school staff and/or parents, caregivers, and other family members. Teachers from CHALK/Just Move schools noted that the program was easy to integrate into the classroom and was often used as a transition between subjects. They also observed that integration of an online or video component could be beneficial, and having activity cards in additional languages would help engage students whose first language is not English.This evaluation was conducted to describe the extent to which two school-based PA programs designed to increase student’s access to PA in school were implemented in FLEX, and to understand key factors associated with implementation that could inform future dissemination of the programs. The 100 Mile Club and CHALK/Just Move programs were identified through a nationwide crowdsourcing competition for their potential for scalability, including cost-effectiveness and flexibility  and deteResults from this evaluation indicate that among our sample of diverse, low-to-moderate income schools that even when provided external resources and support to implement these programs, not all schools can or will do so. Among the seven schools randomized to 100 Mile Club, over a quarter of the schools did not implement the program at all, and among those that did there was erosion over the two years from 5 to 3 schools. Only one 100 Mile Club school champion implemented fully to standard and included enhancements in both years, like displaying children’s mileage progress outside the gym where they and others could see it, and recruiting parent volunteers (2–3 per session) to help with tracking and provide encouragement to the children during 100 Mile Club sessions . This per session finding should be interpreted cautiously, since CHALK/Just Move sessions were delivered up to three times per day and up to five days per week, whereas 100 Mile Club sessions were usually delivered once per day and up to three times per week. Nevertheless, these findings suggest that both programs provided additional weekly PA minutes. Both programs were generally liked by the champions and teachers implementing the programs and by the children participating in them.Despite the mixed results of implementation, among schools that implemented the programs, there was a reported additional dose of total school PA minutes delivered and received per week. This reported dose delivered was higher among 100 Mile Club schools (~ 35 min per week) than CHALK/Just Move schools (~ 20 min per week). Likewise, the measured average total PA dose received By design the FLEX Study was framed to evaluate two distinct PA programs chosen for their flexibility and adaptability to a range of school settings. The 100 Mile Club is a school-level, voluntary program typically held before school, while CHALK/Just Move is designed to be classroom-based. As a result, the two programs had differing reach in terms of number of children and, potentially, differences in participants by sex, weight status, and/or fitness. Unfortunately, we were not able to collect detailed information on all participating children. While the 100 Mile Club relied on a single champion to implement and maintain, responsibility for delivering CHALK/Just Move was spread across multiple teachers. Our evaluation found that because 100 Mile Club typically relied on one person to implement, champions were more likely to have either fully implemented or not implemented the program according to protocol; CHALK/Just Move had more teachers involved, but delivery of program elements was less uniform. As a result, the programs were offered in different ways across schools, and it was difficult to capture perfectly parallel implementation information for the two programs. Nevertheless, we collected enough similar information that we were able to compare and contrast the two programs. Inherent differences in the programs may therefore make one or the other more suitable to particular school environments or allow them to complement each other if implemented in tandem.A key strength of this evaluation of the real-world implementation of the PA programs is that it was included as part of a large, randomized controlled trial. This allowed for collection of program implementation data from a range of school environments and, in the case of child survey data, from a large sample of participants.Another strength of the FLEX evaluation is that the intervention programs were developed by schools and teachers and because participating schools were randomized to either 100 Mile Club or CHALK/Just Move, we were able to evaluate delivery of the programs in a quasi-real world setting. This is notable because though we assume that the schools that agreed to participate had at least some willingness to implement a new PA program, they were randomly assigned to the program, rather than choosing the one that might best fit their school environment or culture. The fact that schools were randomized to the programs allowed for opportunities to understand school- and champion/teacher-level factors that influenced delivery and may be critical for sustainability and scalability.Additionally, a strength of this evaluation is the mixed methods approach. The use of both quantitative and qualitative methods allowed for a more detailed examination of the various aspects of implementation. Multiple dimensions of process evaluation were used at multiple time points during the study.A limitation of this evaluation is that the sample of champion and teacher respondents to surveys and interviews was limited and did not capture demographic characteristics of the respondents themselves . That information may be valuable in understanding how to develop champions in the future for these kinds of interventions . FurtherIn addition, though accelerometry provided an objective measure of in-session PA, the waist-worn device may not be sufficiently sensitive to record many of the CHALK/Just Move activities, particularly semi-stationary movements like stretches and yoga poses. Though schools that agreed to participate in the accelerometry sub-study were not necessarily representative of all schools, the sample was small, and data collected only one time, they did represent a range of implementation scores. Nevertheless, these data provide a picture of how much and what types of activity children engage in during the programs. In addition, by being integrated into the classroom setting, CHALK/Just Move may provide benefits beyond additional minutes of MVPA. Forthcoming analyses as part of FLEX will look at the impact of both programs on other aspects of children’s overall health and well-being, including cognitive function and academic achievement.The primary aim of the FLEX Study was to evaluate the impact of two different school-based PA programs on children’s PA and to explore their feasibility for dissemination and scalability, particularly for resource-constrained schools. This evaluation demonstrates that overall both programs were overall well received by schools, including both champions/teachers and students. Some schools were able to implement the programs with minimal resources and without extensive support from researchers, particularly in the first year. However, schools may need additional financial and human capital investment and/or policy support to promote long-term sustainability. Researchers must be cognizant of the fact that schools, with finite resources, are by necessity making tradeoffs in choosing to implement one program or another. The results of this evaluation suggest that both programs, if implemented, can enhance opportunities for PA at school. The 100 Mile Club shows potential for providing meaningful increased PA minutes for children, but may have limited reach as a voluntary, before-school program and the burden for implementation falls to one champion. CHALK/Just Move, as a classroom-based program, has the potential to reach a large number of children, with the burden for delivery spread across multiple teachers, but likely offers more limited benefits in terms of MVPA. Identifying the program or programs that best fit individual schools is necessary for securing the buy-in critical to their success. Future work should evaluate how multiple PA programs can be put in place in schools simultaneously to increase children’s opportunities for PA throughout the school day.Additional file 1:FLEX Key Informant Interview Guide – 100 Mile Club. Key informant interview objective and guide for FLEX Study 100 Mile Club schools. (DOCX 18 kb)Additional file 2:FLEX Key Informant Interview Guide – CHALK/Just Move. Key informant interview objective and guide for FLEX Study CHALK/Just Move schools. (DOCX 21 kb)


Pediatric blood and marrow transplantation (BMT) is one of the most challenging allopathic treatments a patient and family can be faced with. A large Midwest academic health center, and leader in pediatric BMT, made the decision in 2013 to incorporate integrative nursing as the care delivery model. Nurses trained in advanced nursing practice and specialized in integrative health and healing performed a deep-dive needs assessment, national benchmarking, a comprehensive review of the literature, and ultimately designed a comprehensive integrative program for pediatric patients and their families undergoing BMT. Four years after implementation, this paper discusses lessons learned, strengths, challenges and next phases of the program, including a research agenda. The authors conclude that it is feasible, acceptable and sustainable to implement a nurse-led integrative program within an academic health center-based pediatric BMT program. Integrative nursing has emerged as a framework for delivering sound patient care over the past five years. Principles closely aligned with the Institute for Healthcare Improvement’s (IHI) Quadruple Aim can be used to help clinicians work with their patients to achieve better outcomes at lower costs, while at the same time tending to clinician well-being . In the A team of advanced nursing practice leaders with specialty training in integrative health and healing performed a four-month long deep-dive needs assessment in order to develop a customized integrative program to complement the pediatric BMT program. Otto Scharmer’s Theory U  served aThe principles of integrative nursing  informedStakeholder dialogue—Interviews were conducted with clinical and administrative leadership as well as with frontline clinical staff.Shadowing practice—Current state of nursing and supportive care staff practice was observed to identify areas of opportunity.Prototyping—Experiential and educational sessions were conducted to engage staff and enhance their understanding of integrative modalities.Benchmarking—Other pediatric integrative therapy programs were examined through site visits, phone interviews, and extensive internet searches. These were reviewed for best practices.N = 32) on the unit were surveyed to assess the knowledge, perceptions and comfort level with integrative modalities and care delivery.Staff survey—Nursing staff  the first year of the program, there was only one full-time clinician dedicated to providing integrative services to patients and families. Currently, there are two-and-a-half full-time equivalent employees providing integrative services. (2) Patients and families affected by childhood cancer, and other rare diseases for which BMT is utilized as a treatment, are very well connected to one another. Patients and families now report having heard about the benefits of integrative therapies from people in their disease-specific communities before ever arriving to the facility. (3) Clinicians have indubitably become more skilled at applying integrative therapies to unique patient populations. Clinicians are skilled at assessing the root cause of a patient’s symptom and applying the therapy that will modify the root cause rather than simply eliminating the symptom. For example, young children often experience nausea and/or vomiting before or after medication administration or in anticipation of chemotherapy. It is important to assess the characteristics of and the circumstances surrounding the nausea and/or vomiting. Often, it is anxiety or anticipatory anxiety that leads to sudden onset nausea and/or vomiting . Mind/boThe BMT program treats approximately 80 patients per year. Patients are engaged in treatment for a minimum of three to four months. Some patients remain in the system and seek in- and outpatient care intermittently for up to two years. Year one of the program, 51% of BMT patients engaged in integrative therapies. By year two, that number increased to 70%, and at the conclusion of year three, approximately 94% of patients participated in integrative therapies throughout their BMT experience. Patient and family engagement with the integrative therapy team ranges from a one-time consult to daily sessions of 30–60 min. The average patient is seen two or three times per week for approximately 30 min. Over the course of hundreds of integrative therapy sessions over the past four years, the program reports no adverse events. Practice guidelines and safety recommendations have been developed based on available literature, clinician experience, patient report, and occasionally “near misses”.Establishing a research program was one of the eight original goals. This has been the most challenging goal to accomplish and was, by design, delayed for the first few years. Infrastructure needed to be built before clean data collection could occur. Now that a consistent set of services is offered by experienced clinicians, the program is ripe for an integrative research agenda. Several quality improvement surveys and one qualitative study have been completed and played an important role in shaping the research agenda. The first study published by the program examined themes around the usefulness of music therapy . Table 2The integrative therapy program is entering into its fifth year of existence. It has grown and matured since the original design, but remains true to its initial mission, vision and goals. By all objective measures, the program has been deemed a success. Rates of patient engagement and utilization, increase in grant funding and institutional support, and provider and front-line clinician acceptance all speak to the accomplishments of the program over the past four years. The authors conclude that it is both feasible and acceptable to implement a nurse-led integrative program within an academic health center-based pediatric BMT program.The success and sustainability of the program may be in large part due to nursing leadership. Nurses are uniquely positioned to assess and treat patients from a whole-person, whole-system framework. Nurses are by nature nurturing, caring and attuned to using their own self as a therapeutic intervention. Furthermore, by having advanced nursing practice consultation available, the model is more financially sustainable than a physician-centric integrative consult service. Patients receive competent assessment and continuity of care with nurses trained in integrative modalities accessible to them on a daily basis.The work over the past few years has demonstrated that there is a strong clinical and business case for implementing integrative nursing within an acute-care pediatric setting. Patients and families are voicing a desire for this approach to care and there is increasing evidence that integrative approaches can improve clinical outcomes including symptom management . If embe


The Encore Fellowships Network (EFN) began as a pilot program in 2009 to match mid- and late-career for-profit employees in the San Francisco Bay Area to non-profit organizations seeking their skills and experience. After a successful pilot, the EFN expanded nationally, reaching 26 states and placing close to 2,000 Fellows in 10 years. This presentation will reveal analysis from more than 1,400 linked surveys of fellows and their organizational hosts both pre- and post-fellowship, totaling more than 350 observations. Results indicate a high sense of program satisfaction and enduring impact on the work of the non-profits. Further, the efficiency of the matching process was positively associated with fellows’ recommendation of the program to friends or colleagues and a higher sense of enduring impact among fellows was positively associated with the likelihood of pursuing post-fellowship non-profit work. Implications for the EFN and the broader nonprofit sector will be discussed.


Program attrition is a major problem in substance use treatment. It is not clear which client and treatment variables are related to successful completion. This study aimed to identify client variables associated with Therapeutic Community (TC) completion. A secondary aim was to investigate changes in entry and exit scores on psychosocial outcome measures.Retrospective quantitative analysis of data collected from 193 Australian TC residents, over 3.5 years. Variables measured included: demographics; Depression, Anxiety, Stress Score (DASS-21) and World Health Organisation Quality of Life 8 questions (WHOQOL-8).Completion rates were 30.6%. High Money WHOQOL-8 scores, suggestive of minimal financial stressors, positively predicted completion. Multivariate analyses showed that negative predictors of completion were: amphetamine being primary substance of concern, aggression, high Relationship WHOQOL-8 scores, suggestive of positive relationships, and younger or older age. Those in the program demonstrated clinically significant psychological improvement and significant improvement in all quality of life scores over time. The degree of psychometric improvement was most pronounced in those who completed the course, with the exception of depression, stress, and money problems.The findings provide an understanding of specific predictors of program completion which may help to identify high-risk clients and inform program improvement. Early attrition rates may be reduced by monitoring and supporting high-risk clients. Overall, psychometric improvement occurred amongst both completers and non-completers overtime but is most prominent amongst course completers, with the exception of depression, stress, and money problems. Future research could potentially focus on amphetamine users and shortened TC programs, focusing on acute psychosocial intervention. In Australia, substance use is conservatively estimated to cost $55 billion annually, in terms of lost productivity, health impacts, crime, road accidents and fires . InternaTherapeutic Community (TC) programs are used in numerous countries around the world as a means to help individuals to maintain abstinence and enable social rehabilitation . TCs shaEffectiveness of TCs can be measured in terms of initial and ongoing engagement with the program, completion of the program, short-term change in wellbeing and long-term outcomes in terms of functioning after program completion. Factors affecting completion rates of TCs are important for two reasons. Firstly, although TCs have been shown to be effective in the treatment of substance use disorders, completion rates are low, ranging from 9 to 56% . Low comThere are several factors previously found to be positively associated with TC completion. A meta-analysis found that those who were relatively older were more likely to complete, however age groups varied across studies and mean ages of participants were relatively young, in the 20s to 30s . AdditioPsychosocial change in clients of TCs has been previously investigated by one systematic review and two additional studies , 19, 20.‘The Buttery’ is a drug free, not-for-profit, charitable TC in Northern New South Wales, Australia. It provides residential substance use rehabilitation for male and female adults who are addicted to drugs, alcohol or both. Clients must be clean and free from drugs and alcohol for at least four days prior to joining the community. Its guiding philosophy is that addiction is not a consequence of choice, but rehabilitation is. The program is not affiliated with any religious or political group. It offers support in early recovery from substance use disorders of an understanding group of people through its TC, in a home-like rather than institutional-like environment.It utilises a peer-based hierarchy, whereby clients take on additional group responsibilities as they progress through the program. Clients participate in evidence-based structured group and individual learning and therapy. The program consists of three phases, totalling seven months. Early withdrawal can be voluntary or involuntary. There is zero-tolerance to substance use relapse, which results in involuntary withdrawal. The service has a high demand, with waiting lists typically exceeding 12 months.There is a need for further research examining client characteristics that predict completion rates, and short-term wellbeing outcomes for clients using the TC model of treatment. While TC approaches have local variability in content, their core approach of having a safe community as the primary therapeutic agent is consistent. Therefore, the systematic study of program outcomes in terms of completion rates and outcomes for clients of TCs will help to build knowledge regarding the efficacy of the TC model of treatment for improving the wellbeing of those with substance use disorders. Because substance use disorders affect the whole person, it is necessary to assess both psychopathology and multi-faceted quality of life to assess change associated with interventions. Additionally, it is likely that some client factors, for example, the main substance of concern, relationship factors, symptom profiles and socioeconomic factors may show common patterns across TCs in terms of predicting engagement and completion.The primary aims of this study were to identify factors associated with TC completion as well as investigate the change measured in entry and exit psychometric data and quality of life (QOL). These outcomes will add to the body of evidence of TC completion. This information will also provide an understanding of specific predictors of program completion, facilitate identification of high-risk clients and inform program improvement.A further aim was to investigate the psychosocial outcomes of clients with SUD. This will highlight any psychosocial differences in non-completers versus completers.This study considered data routinely collected from TC clients admitted between January 2013 to July 2016. The data was collected via face-to-face interviews by TC staff and use of a computer based questionnaire upon program entry and exit. Consent for the data to be used in research was obtained and recorded during the admission interview. Ethical approval was granted by Western Sydney University (H11353) and University of Wollongong (NSA16/009) Ethics Committees.The primary outcome measure was course completion. This is defined as completion of the third phase of the program. This typically occurs at 217 days; however, clients can progress more slowly if program goals are not achieved. To ensure measures were clinically relevant to SUD treatment and met Australian standards; outcome measures were used from Network of Alcohol and Other Drugs Agencies (NADA) ‘Client Outcomes Management System’  and WorlThe DASS is a quantitative assessment tool which measures psychological distress in three domains: Depression, Anxiety and Stress. It has been validated for use in drug and alcohol services as well as across culture and age groups , 22. It WHOQOL-8 is a shortened adaptation of the WHOQOL-100, and has been validated for substance use and mental health disorders, cross cultural and Australian contexts . It consOther NADA measures used include primary substance of use data and a categorical (Yes/No) questionnaire on other self-reported issues . Additionally, rurality data was collected (residence prior to program commencement) as rural health is an Australian national health priority . RuralitExclusion criteria were clients who did not consent to the research and clients who had not completed or exited the course at time of data analysis. A total of 257 clients were admitted to the program over this period, of which 44 did not give consent and a further 20 had not yet completed or exited the course; resulting in a sample size of 193. For a logistic regression a priory power analyses, assuming an odds ratio of 1.5, a power of 0.8, a probability of a completer prevalence of 0.3, alpha of 0.05 and a one tailed test, requires a sample size of 190.All data were analysed using SAS 9.3 . Descriptive statistics were calculated for sample characteristics, psychopathology, quality of life and completion rates. This included before and after measures of psychopathology and quality of life, to gain an understanding of change in wellbeing from entering to exiting the program.Chi squared tests were used to determine whether completers differed from non-completers in terms of important categorical demographic characteristics. Data were categorically grouped prior to univariate analysis to provide clinically meaningful outcomes. Age in years was categorised as: < 25, 26–50, > 51. DASS domains were categorised as: Normal-Mild, Moderate-Very Severe. Similarly, Primary Substance of Use was tested in a series of major substances  individually against ‘not using the substance’. Sub categories of the NADA self-reported issues were grouped so that a positive response to any sub category was recorded as a positive category response. T-tests were used to determine whether completers and non-completers differed in WHOQOL-8 scores as this tool is not validated for classification into categories of severity (21).p < 0.25 in univariate analyses were entered into a logistic regression model. Stepwise multivariate logistic regression was performed to determine odds ratios for factors associated with completion. For the multivariate modelling, DASS scores were considered as continuous variables to allow for maximum use of distribution information given the relatively small sample. Age was entered into the model as age and age*age to allow for the U-shape distribution to be modelled.Variables that had an association with completion at Repeated measures analysis of variance (RMAV), using PROC MIXED, was used to assess the psychometric measurements (DASS and WHOQOL-8 scores) over time (entry compared to exit) where the time by group interaction indicates a difference over time between completers and non-completers. An unstructured covariance model was used.P = 0.038) and reported higher self-satisfaction scores (P = 0.0018) on program entry than women. Most clients were from urban areas with the highest level of access to health care (MMM1). The most common primary substance of use was alcohol, with amphetamines being second most common. The mean DASS scores upon admission were suggestive of Moderate Depression, Anxiety, and Stress levels. The most common other self-reported problems were risky behaviours, self-harm or suicidality issues and aggression.Client characteristics are presented by gender in Table Treatment retention data are presented in Table P = 0.026). Those less than 25 years (n = 16) only had an 11.19% completion rate; those greater than 50 years (n = 18) had an 11.19% completion rate. Non-completers had a higher incidence of self-reported aggression problems (p = 0.006), self-reported current or previous self-harm or suicidality issues (P = 0.017), and lower Money WHOQOL-8 score (P = 0.011) on entry. Whilst not achieving statistical significance, non-completers also had higher rates of categorical (P = 0.062) and mean Depression (P = 0.065) on entry, were more likely to come from rural areas with reduced health care access  and have amphetamine as the primary substance used (P = 0.052).Data showing differences between completers and non-completers are presented in Table Results from the multivariate logistic regression predicting completion are presented in Table P < 0.001). Overall, the completers had better psychometric ratings than non-completers (completion effect) with the most notable differences found for Money (P < .001). The completion*group effect demonstrated that the improvement of psychometric outcome measures was greater in those who completed the course, with the largest completion*time effect being for improved relationship ratings for those who completed the course compared to non-completers (P < .001). However, no significant differences were found for Depression (P = 0.230), Stress (P = 0.098), and Money (P = 0.343) when comparing the change scores from entry to exit between completers and non-completers.Table Table P < .0001). The effect of time was also significant, but the group*time interaction was not significant, suggesting that money concerns improved across both groups overtime.Within the QOL domains, Money showed the greatest initial difference between the two groups  had lower odds of program completion. Further, our study showed that the TC program improved psychological and quality of life scores among residents, as measured by clinically significant clinical improvements in DASS and WHOQOL-8 on exit irrespective of program completion. The degree of psychometric improvement was most pronounced in those who completed the course, with the exception of depression, stress and money ratings. This suggests that the improvements in ratings for these factors did not differ significantly between completers and non-completers.Previous studies have demonstrated mental health and QOL improvement during follow up post-TC attendance , 19, 20.This study provided additional insight into some other complex areas. While the attrition rate is lower beyond 12 weeks, there is still a large (30%) exit rate after 12 weeks but prior to program completion. These figures are similar to other studies. This delayed attrition occurred despite clients successfully overcoming initial withdrawal symptoms and early adjustment issues. It may be that the delayed attrition in the program is due to social stressors, such as employment and finances or separation from positive relationships (partner or children). Indeed, those who reported higher levels of satisfaction with relationships upon entry were less likely to complete the program. It may be that clients with delayed attrition differ from individuals with early attrition in other important ways. Future studies are needed to investigate whether this is the case.The results are consistent with previous research suggesting that individuals were more likely to leave treatment prematurely if their primary drug of concern was a stimulant . The assHigh attrition rates are expected in the first few weeks as SUD clients experience withdrawal effects and adjustment issues, and the current completion rate results are consistent with findings in previous TC studies . The preThe delayed attrition of clients, in which 30% prematurely exited the program after three months, is likely to be due to broader mental health issues or social factors, as these clients overcame the initial withdrawal and adjustment issues. Our results suggest program improvements could include financial counselling services. Clients with financial stress (low Money satisfaction in WHOQOL-8) were less likely to complete the program, as demonstrated in multivariate analyses. Further, Money was the only WHOQOL domain that did not show improvement in completers compared to non-completers over time.High Relationship satisfaction (WHOQOL-8) on entry was negatively associated with completion, presumably reflecting distress with separation from loved ones. Improvement to support clients with existing relationships external to the course, such as partners and other family, may be warranted. TCs require clients to have very restricted contact with people beyond the TC as part of the recovery process, to separate from existing patterns and habits and to focus on personal recovery and growth. A desire for contact with significant others beyond the program may contribute to early departure in some clients with strong bonds. Indeed, a recently completed qualitative study investigated reasons for early withdrawal from the TC program through semi-structured interviews with residents in 2017–2018. A recurring theme for early withdrawal was residents’ relationships . It is aOur assessment of short-term outcomes identified that non-completers may show significant improvements in wellbeing even though they did not complete the entire program. The introduction of a short SUD interventional program, conducted in addition to the existing course could be considered. The short course could be utilised in combination with pre-admission screening, whereby those at higher risk of non-completion attend the short course as an introduction or acute intervention. This could further improve the psychological and social wellbeing for those unable or unwilling to complete the course, and potentially also lead to higher completion rates of the full course. The concept of a short interventional program is also supported by existing evidence, as higher completion rates and improved long-term outcomes are found in shorter TC programs . PreviouThe lower completion rates in those clients at the younger and older ends of our sample may indicate that they did not feel the same levels of peer support or belonging in the TC, possibly due to being of a different age to others in the group. Further, qualitative, research is warranted to determine if this is the case.P = 0.052) so only this primary drug group was included in the multivariate analyses. It is important to note that while the numbers are small for amphetamine relative to other drugs of concern at present, the use of amphetamine is a currently increasing problem [The relatively small sample size limited the ability to compare several subgroups against completion. In univariate analyses only amphetamine was trending towards being significantly different ( problem . Early p problem . MissingQualitative studies into the causes of early exit are rare. One qualitative study has been conducted , howeverIn conclusion, those who reported higher satisfaction levels in relation to money had higher odds of program completion. Those who used amphetamines as primary substance, self-reported aggression, those who reported positive relationships on entry into the program and those who were at the younger or older extremes of the sample had lower odds of program completion. Additionally, our study showed that the TC program improved psychological and quality of life scores overtime. These were clinically significant clinical improvements. The degree of psychometric improvement was most pronounced in those who completed the course, with the exception of depression, stress, and money problems. Early attrition rates may be reduced by improved recruitment, monitoring and supporting high-risk clients. Future research could potentially focus on amphetamine users and shortened TC programs, focusing on acute psychosocial intervention.


This article presents updated and unified Poissonian earthquake and focal mechanism catalogs for the United Arab Emirates and its surroundings. Data were compiled from different local, regional, and international sources. Several magnitude-conversion relationships have been applied to obtain the unified moment magnitude estimates for the final datasets. Dependent earthquakes were identified and removed from the compiled data via a declustering process to ensure a time independent Poissonian distribution of seismicity. The final compiled earthquake catalog is comprised of 1464 mainshocks, which span the time period of 658–2019 [1]. The range of their spatial region is 21°–31°N on the latitude and 47° to 66°E on the longitude. Additionally, an overall number of 583 focal mechanism solutions spanning the time period of 1923–2015 were acquired [1]. Such datasets are compatible with other published catalogs from across the globe which provide a basis for the estimation of seismic hazard and risk, as well as, the establishment of a unified seismic action representation in the building codes for the United Arab Emirates. This paper and its dataset are a companion for a published article in the Journal of Asian Earth Sciences under the title “A State-Of-The-Art Seismic Source Model for the United Arab Emirates” [2]. The rawA: YEAR; B: MONTH; C: DAY: date type variables indicating the date for each earthquake.D: HOUR; E: MINUTE; F: SECOND: date type variables indicating the time for each earthquake.G: LONGITUDE; H: LATITUDE: double type variables  indicating the location (longitude and latitude) for each event.I: DEPTH: double type variable  indicating the depth of each individual earthquake.J: Mw: double type variable  indicating the final considered moment magnitude for each earthquake included in the catalog.L: Strike 1; M: Dip 1; N: Rake 1; O: Strike 2; P: Dip 2; Q: Rake 2: these columns represent the two nodal planes for the focal mechanism solution for each earthquake; each column contains a number for each mentioned individual parameter .K: Code; R: Code: these two columns refer to the source of the moment magnitude value and the focal mechanism solution parameters , respectively.The second Microsoft Excel file in the Mendeley Data repository includes the focal mechanism solutions dataset . It inco2A spatial region spanning longitudes between 47° and 66°E and latitudes between 21° and 31°N was considered during the dataset compilation. The dataset was mainly compiled from the following bulletins and publications: Ambraseys and Melville , the IntFocal-mechanism solutions for the surroundings of the UAE (between 47° and 66°E longitude and 21° to 31°N latitude) were mainly obtained from the following published sources and bulletins: the Global Centroid Moment Tensor (GCMT) catalog , the Zurhttps://doi.org/10.1016/j.jseaes.2019.104063 [The related article has been published in the Journal of Asian Earth Sciences under the title “A State-Of-The-Art Seismic Source Model for the United Arab Emirates”.


The roles of ergosterol in the regulation of membrane fluidity and structure, as well its role as a target for the activity of antifungals, have been known for decades. Two recent studies, however, demonstrated that ergosterol is an immunologically active lipid that induces pyroptosis and that virtually all steps of its biosynthetic process are potential drug targets. The roles of ergosterol in the regulation of membrane fluidity and structure, as well its role as a target for the activity of antifungals, have been known for decades. Two recent studies, however, demonstrated that ergosterol is an immunologically active lipid that induces pyroptosis and that virtually all steps of its biosynthetic process are potential drug targets. In combination, those two reports strongly indicate that the biological relevance of ergosterol is broader than the current literature suggests. Ergosterol, a 5,7-diene oxysterol, is the most abundant sterol in fungal cell membranes, where it regulates permeability and fluidity . BecauseAspergillus fumigatus, Paracoccidioides brasiliensis, or Candida albicans have suggested that organ damage, increased fungal dissemination, and reduced host survival might be related to pyroptosis  that induces inflammasome activation and a nonfilamentous strain (S288c) that does not, they identified a set of genes involved in ergosterol and membrane homeostasis as candidates to participate in the induction of pyroptosis-related macrophage lysis. Several genes required for macrophage lysis were also required for filamentation , the ERG1 gene , and the ERG2 gene . The potential of the 22 remaining genes required for ergosterol biosynthesis as antifungal targets remains to be explored. Most genes required for ergosterol synthesis are essential, which imposes difficulties with respect to the characterization of antifungal targets. In this scenario of great complexity, Bhattacharya and colleagues  had an effect on the activities of all stress agents, while overexpression of all 25 genes had an effect on the activity of at least one agent  (Overexpression or viable deletion of ergosterol biosynthesis genes differently impacted the susceptibility of osterol) . In partThe surface of fungal cells has been long recognized as a static molecular complex with exclusive structural functions. This classic view changed radically during recent decades after the demonstration that surface polysaccharides with well-described structural roles, including glucans, chitin, and mannan, were identified as key regulators of immunological activity (reviewed in reference


The 2008 Wenchuan earthquake caused significant economic losses and degradation of regional ecosystems, including the terrestrial vegetation. Since the vegetation root system can enhance the soil’s anti-erosion capacity and therefore mitigate the occurrence of slope instabilities, it is beneficial to study the spatial and temporal evolution of vegetation for a long-term assessment of co-seismic secondary disasters. The Mianyuan River Basin, an uninhabited area passing through an active fault located in the earthquake-affected region, was selected as the study area. The Normal Difference Vegetation Index (NDVI) was calculated using remote sensing images from 1994 to 2017 to analyze the process of vegetation growth, loss, fluctuation and recovery. Statistical results suggest that the area in the middle and lower reaches, near the river network, and with a slope of 30 to 40 degrees were variable regions, showing more significant vegetation destruction during the earthquake and faster repair after the seismic event. Besides, vegetation near the fault was damaged more severely after the earthquake, but the active fault did not play an essential role in the vegetation recovery period. In the Mianyuan River Basin, vegetation experienced a volatility period (5 plus or minus one year) before entering the recovery period. In 8 to 9 years after the earthquake, the surficial vegetation could recover to the state before the earthquake. The notorious fault has nurtured some of the most catastrophic earthquakes in human history, including the Wenchuan earthquake on May 12, 2008  studied the variation of vegetation cover in the Longmenshan area and concluded that vegetation recovery was faster at higher altitudes13. Lu et al. (2010) presented the relationship between several spatial characteristics and vegetation loss9. Liu et al. (2017) interpreted the remote sensing images of the entire Wenchuan earthquake-affected area to get vegetation recovery rate in 2016 and estimated the time for complete vegetation recovery14. It is over ten years after the catastrophic Wenchuan earthquake as of today. Examination of the vegetation recovery in a specific time period can be insufficient to understand the recovery of the ecosystem. Therefore, the spatial and temporal evolution of vegetation in the earthquake-stricken areas is scrutinized in this study.With the rapid development of space platforms and digital imagery, rational interpretation of remote sensing data can thus facilitate efficient natural-hazard investigation and managementVegetation loss and the frequency of secondary disasters have an interactive relationship. It is possible that the vegetation loss after the earthquake aggravated the frequency of secondary disasters, resulting in continuous damage to the vegetation and then forming a vicious circle. It is also possible that vegetation may also recover relatively quickly and the frequency of secondary disasters reduced gradually, and thus forming a virtuous cycle of ecological restoration in earthquake-affected areas. To better understand the dynamic process of post-earthquake vegetation evolution, areas with less human activity rather than the whole earthquake-affected areas should be used as the study area.In this study, the Normal Different Vegetation Index (NDVI) was used to illustrate the surficial vegetation coverage condition in an uninhabited area affected by the 2008 Wenchuan earthquake. Remote sensing imageries and Geographic Information System (GIS) were used to calculate the NDVI before and after the Wenchuan earthquake. After that, we demonstrated a relatively balance in the fluctuation of vegetation before the earthquake and vegetation loss and recovery after the earthquake in detail. Meanwhile, the effects of topographic characteristics and distance from the river network on vegetation were also studied. Besides, the temporal and spatial evolution of vegetation loss and natural recovery in the earthquake-affected area were discussed, and the key time points of volatility and recovery periods were indicated.15. Human factors such as construction and reclamation have negligible effects on the natural ecological environment in the basin, and it is thus selected as the study area17. Figure 16. The outcrops within the basin show the Sinian, Cambrian, Silurian, Devonian, Carboniferous, Permian and Triassic rocks, which are covered by loose Quaternary materials. The area of the Mianyuan River Basin is about 401 km2 with the highest elevation about 4,417 m and the lowest about 697 m18. The Yingxiu-Beichuan fracture (mid-fracture) of the Wenchuan earthquake goes through the middle part of the Mianyuan River Basin. The southwest mountainous area has a subtropical monsoon climate, with hot and rainy summers and less moderate precipitation in winter. The annual rainfall is between 1,500 to 1,700 mm and mainly concentrated in July-September18. Figure http://westdc.westgis.ac.cn)19. As shown in Fig. The Mianyuan River basin Fig.  is an unhttp://www.gscloud.cn/). The elevation value of DEM was from 307 to 6132 meters. (3) Scientific reports, papers and maps related to landslides, vegetation and fault distribution in the Wenchuan earthquake-affected areas. In addition, the method used in this research, as shown in Fig. http://www.gscloud.cn/, Free Access for use) and ArcGIS 10.4 (https://www.esri.com/) was used to create the images.In this study, three different datasets were used: 1) Pre-earthquake and post-earthquake satellite image data  were subtracted to get the vegetation changes in the earthquake-affected area. Meanwhile, effects of topographic characteristics on vegetation loss and recovery were discussed. Other characteristic parameters (such as the distance from the river) which may directly or indirectly affect the revolution of vegetation were discussed as well. After that, temporal and spatial evolution of vegetation under the influence of external factors in the earthquake-affected area and the key time points of volatility and recovery periods were demonstrated.24. Thus, the vegetation coverage in the earthquake-affected area is subject to dynamic changes. Figure The combination of the Wenchuan earthquake in 2008 and other exogenic factors  made the studied mountainous area highly vulnerable to landslide hazards, disturbing vast area of vegetationVegetation in the earthquake-affected areas was also subject to slow natural recovery after the Wenchuan earthquake. The NDVI distribution maps before and after the shock in the Mianyuan River Basin were calculated by the Landsat 7-ETM+satellite images. The NDVI values calculated by Landsat 5 and Landsat 7 were not analogous because of the use of different sensors. As shown in Fig. Figure The surficial vegetation coverage in earthquake-affected areas has been described above. From Figs. The main factors affecting vegetation recovery include three aspects: environmental factors , soil nutrient factors  and topographical factors . The Mianyuan River Basin is an uninhabited area, and thus the environmental factors and soil nutrient factors cannot be comprehensively measured. Therefore, this study mainly focuses on the impact of topographic factors on vegetation changes. After the earthquake, the loss of vegetation near the fault was more serious Fig. . The larSlope gradient is a key topographic factor that affects vegetation changes. Figure Aspect is another topographical feature that affects vegetation growth. Differences in conditions such as lighting lead to differences in vegetation growth rates. Figure The details of the NDVI change were obtained by subtracting the NDVI distribution data for several years The catastrophic Wenchuan earthquake caused surficial vegetation coverage in the mountainous areas to drop drastically. After the disturbance, the ecological equilibrium of the earthquake-affected zone fluctuated for a period. As shown in Fig. After the volatility period, the surficial vegetation coverage in mountainous areas restored to the pre-earthquake state after several years of growth. Although the recovered surficial vegetation coverage cannot be exactly the same as that in the previous time, it can restore to quite a similar state. As shown in Fig. The ecosystem of nature is always in a state of volatility. Before the Wenchuan earthquake, the self-repairing process of the environment can moderate the ecological damage caused by small fluctuations immediately. However, after the disturbance of the strong earthquake, the ecological self-repair cannot rejuvenate the damaged environment immediately, and it will undergo a long-term evolution instead to restore the normal ecological fluctuation pattern before the earthquake. As shown in Fig. The catastrophic Wenchuan earthquake caused great disturbances to the ecology of the Longmenshan fault area and caused long-term effects on the environment. Remote sensing images were used to calculate surficial vegetation coverage in the earthquake-affected areas and the following conclusions can be drawn as follows: (1) Before the earthquake, vegetation in the lower reaches and near river networks grew better than that in other regions. (2) In the short period after the earthquake, the vegetation damage near the fault area and the river network is more serious than other areas. However, the areas with high surficial vegetation coverage were less disturbed by the earthquake. (3) The slopes at 30 to 40 degrees are more susceptible to earthquake disturbances but are easier to repair. (4) The vegetation near the fault is disturbed by the earthquake, but the vegetation restoration is independent of the fault. (5) The Wenchuan earthquake had a terrible impact on the vegetation in the southwestern mountainous areas of China. Ecological damage and repair in earthquake-affected areas underwent a volatility period of approximately 5 plus or minus 1 year. (6) In the 8–9 years after the earthquake, the mountain vegetation has basically recovered to the state before the earthquake.


Older adults value community living and prefer to “age in place”, which increased the need for long-term care to be provided at home. Recently, a capitated option for Medicaid beneficiaries, managed long-term services and supports (MLTSS), has become popular. This evaluation research study investigated 1) the effectiveness of attendant care services to avoid long-term institutionalization of older adults when provided as part of an MLTSS program, and 2) the effect of the type of attendant care services on long-term institutionalization. Using enrollment and claims data of 491 community-dwelling older adults enrolled in an MLTSS program for at least six months, multivariate regression models analyzed the association between long-stay nursing facility (LSNF) admissions and the use of attendant care services. Findings confirmed the hypothesis that those receiving attendant care services are less likely to have LSNF admissions and that as the dosage increases, the odds of LSNF decreased. The type of attendant care services also influenced the results. Participants who used only self-directed AC services were 93% less likely to have an LSNF admission than those receiving no AC services, and 23.5% less likely to have this outcome than those who only received agency attendant care services. In addition, the use of other home and community-based services are also significantly associated with LSNF admissions. These findings have important research and practical implications at the program and policy level, as MLTSS programs spread across the country and aim to “rebalance” the LTSS system.


This two-step study evaluated the cost-effectiveness of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for presurgery staging of non-small cell lung cancer (NSCLC) in France .Step 1 consisted of a high-benchmark EBUS-TBNA–training program in participating hospital centers. Step 2 was a prospective, national, multicenter study on patients with confirmed or suspected NSCLC and an indication for mediastinal staging with at least one lymph node > 1 cm in diameter. Patients with negative or uninformative EBUS-TBNA and positron-emission tomography-positive or -negative nodes, respectively, underwent either mediastinoscopy or surgery. Direct costs related to final diagnosis of node status were prospectively recorded.Sixteen of 22 participating centers were certified by the EBUS-TBNA–training program and enrolled 163 patients in Step 2. EBUS-TBNA was informative for 149 (91%) patients  and uninformative for 14 (9%). Mediastinoscopy was avoided for 80% of the patients. With a 52% malignant-node rate, EBUS-TBNA positive- and negative-predictive values, respectively, were 100% and 90%. EBUS-TBNA was cost-effective, with expected savings of €1,450 per patient, and would have remained cost-effective even if all EBUS-TBNAs had been performed under general anesthesia or the cost of the procedure had been 30% higher .After EBUS-TBNA training and certification of participating centers, the results of this prospective multicenter study confirmed EBUS-TBNA cost-effectiveness for NSCLC staging. Mediastinoscopy has traditionally been considered the gold standard for biopsying lymph nodes of patients with suspected or confirmed lung cancer. However, mediastinoscopy requires general anesthesia, provides access to only the paratracheal and anterior subcarinal lymph nodes, and often requires hospitalization. Rare but potentially severe complications of mediastinoscopy include cord palsy, innominate vein damage and even death .The advent of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), during the early 1990s in Japan, radically changed the guidelines for lung-cancer mediastinal node staging. Today, EBUS-TBNA has been shown to facilitate biopsy of Mountain and Dressler classification  lymph-noFew “real-world” studies have explicitly evaluated the role and cost implications of EBUS-TBNA in patients with mediastinal lymphadenopathy and suspected or confirmed malignancy –12. In 2In study Step 1, all participating centers received an EBUS system  and dedicated puncture kits sufficient for 40 procedures free-of-charge, provided that they accepted prospective evaluation of all subsequent procedures. All the investigators underwent 2 days of high-benchmark training to learn the EBUS-TBNA procedure and were certified for study Step 2 if, during a 6-month period, at least nine of their 10 consecutive procedures were informative (tissue biopsies containing lymphocytes or tumor cells in at least one station). Several investigators could be certified in each center.All consecutive eligible patients were informed of the protocol, gave their signed informed consent to participate and were enrolled in a central database before the procedure. The main inclusion criteria were suspected or confirmed lung cancer, suspicious mediastinal lymph node(s), and the use of EBUS-TBNA as the initial diagnostic procedure for node assessment.The procedure was done according to local practices: some centers used brief general anesthesia with day hospitalization, others did it on an outpatient basis with intravenous sedation  and some centers mixed the two practices. The system’s linear echoendoscope was always used, and all hilar and mediastinal lymph nodes were systematically assessed. Under ultrasound guidance, mediastinal and/or hilar lymph nodes were punctured with a 22-gauge needle and suction was applied. Tissue samples were transferred to glass slides and air-dried or directly expelled into a liquid fixative for cell-block processing. Any tissue cores were placed in formalin. The lymph-node stations and numbers sampled, and the number of passes per node were left to the investigator’s discretion. Biopsies were evaluated on-site in some centers. The pathologists were provided with clinical information, reflecting routine clinical practice. An informative biopsy was defined as containing lymphoid tissue or tumor cells.Centers with a least one certified investigator were allowed to participate in Step 2, which consisted of a multicenter single-arm prospective trial designed to assess EBUS-TBNA cost-effectiveness in a real-world setting. The inclusion criteria for this step were suspected or confirmed non-small–cell lung cancer (NSCLC) with suspected mediastinal lymph-node involvement, eligibility for surgery with curative intent, adequate fitness for EBUS-TBNA and surgery, and no evidence of metastatic disease. The exclusion criteria were previous lung-cancer treatment, concurrent malignancy, uncorrected coagulopathy and unsuitability for surgical staging. In each center, between March 2009 and June 2011, consecutive patients with mediastinal lymphadenopathy and suspected or confirmed lung cancer were invited to participate in the trial. All recruited patients underwent EBUS-TBNA. Tolerance was assessed using a visual analogue scale. EBUS-TBNA complications were recorded. In each center, patient-management decisions following the EBUS-TBNA results were decided by a multidisciplinary team that included radiologists, pulmonologists, oncologists, thoracic surgeons and pathologists. If EBUS-TBNA did not yield a diagnosis retained by the multidisciplinary team, the patient underwent cervical mediastinoscopy under general anesthesia via an incision above the suprasternal notch, with sampling of lymph-node stations 2, 4 and 7.Step-2 primary endpoints were the percentages of patients spared mediastinoscopy and EBUS-TBNA impact on healthcare costs, compared to systematic mediastinoscopy as the first diagnostic procedure.The economic analysis, limited to direct costs, adopted the perspective of the French healthcare system. The cost of the EBUS-TBNA strategy , depending on their type and distribution. The accuracies of EBUS-TBNA and mediastinoscopy were calculated, in terms of their sensitivity and negative-predictive value, for the entire population and the subgroups with positive- or negative positron-emission tomography (PET) scans. The design, running, analysis and reporting of this study conformed to the Standard of Reporting Diagnostic Accuracy Guidelines . The NorTwenty-two centers  volunteered for study Step 1 and were included in the training program. Three centers did not include patients during the first 6 months and their participation was stopped. The other 19 centers included 231 patients . Most patients were men (77%), mean age was 61±11.4 (range 37–86) years, and 78% of the patients were smokers or ex-smokers. At inclusion, 100% and 53% of the patients, respectively, had had computed-tomography (CT) and PET scans. The mean number of CT-detected pathological lymph nodes was 2.2 per patient. EBUS-TBNA was performed under general anesthesia, conscious sedation or local single midazolam injection, respectively, in 75%, 9% and 16% of the patients. The EBUS-TBNA procedure took a median of 47 minutes. Patient-rated tolerability was rated good, medium or poor, respectively, for 90%, 10% and 0.4% of them. A pathologist was present during the procedure in five centers. Seventy-six percent (387/508) of lymph nodes identified as pathological by imaging were biopsied, with a median of three punctures per node; a median of 2 (range 1–4) nodes were punctured per procedure, and the mean size of the sampled nodes was 1.5±0.4 cm. Stations 7 and 4R were biopsied significantly more often . SamplinAt the end of Step 1, three centers had not achieved the target of nine informative out of 10 consecutive procedures. These three centers had no previous experience with EBUS-TBNA. A central cytology review confirmed that their failures reflected the TBNA technique and not cytological processing. The operators’ previous experience was significantly associated with the time taken to reach the 9/10 target. The 13 investigators who reached the target had performed 33.3±31 procedures before the training program, compared to 5.3±4.3 procedures for those who failed to reach the target. After Step 1, 16 centers and 20 investigators were approved to participate in Step 2.During Step 2, the 16 participating centers included 163 patients with suspected or confirmed lung cancer and a theoretical indication for staging mediastinoscopy . Almost EBUS-TBNA histological examinations found tumor cells in 75 patients, normal node cells in 74 and were uninformative for 14 . Among tThe respective total costs of the mediastinoscopy and EBUS-TBNA strategies were €370,330 and €138,600 . EBUS-TBThis multicenter study led to EBUS-TBNA equipment to being installed in 22 hospitals and enabled us to evaluate the procedure in the real world setting. A medical-economic evaluation was also conducted in the setting of the French healthcare system.One original feature of this study was the use of a high-benchmark training program with a simple and explicit target, namely nine informative out of 10 consecutive procedures, leading to the certification of 20 operators. The operators’ learning curves were significantly associated with their prior experience with EBUS-TBNA, as observed previously , 16–18. The average number of 2.8 punctures per node herein was in keeping with current recommendations ; it is wOne advantage of this study is its pragmatic approach, in near real-life conditions. The centers were free to adopt their regular practices regarding the type of anesthesia, the presence of an on-site pathologist and an outpatient setting. No association was found between any of these variables and the success of the procedure.The clinical value of the EBUS-TBNA strategy was assessed during study Step 2. We found that EBUS-TBNA avoided mediastinoscopy for 80% of the patients, a rate similar to the 87% obtained in a prospective study conducted in the UK, in the same context . SimilarThe cost-minimization approach was considered most appropriate for this study, as the same final diagnosis, treatment and outcomes would have been reached, regardless of whether the diagnosis was based on initial EBUS-TBNA or mediastinoscopy. We found that EBUS-TBNA was cost-effective, with expected savings of €1,450 per patient, and that it would have remained largely dominant even if all the procedures had been performed under general anesthesia. These results are in keeping with published economic analyses , 26. OneThis study took place in high-volume tertiary centers following a high-benchmark training program in which EBUS-TBNA was performed by experienced physicians assisted by experienced pathologists. As a result, the EBUS-TBNA sensitivity obtained herein and the number of mediastinoscopies avoided might not be immediately reproducible in other centers.In summary, EBUS-TBNA is a safe, highly sensitive and cost-saving procedure for the diagnosis and staging of NSCLCs. In France, EBUS-TBNA is now firmly established in NSCLC-management algorithms.


This presentation covers the steps to achieve accreditation of a gerontology program as well as the costs and benefits of accreditation. The overall timeline for a typical accreditation process is presented as well as the organization of required standards. Advance planning and a close review of Accreditation for Gerontology Education Council standards will allow time for a program to comply and document compliance with standards. Communication and cooperation within an institution are needed for a program to successfully seek accreditation. Key individuals and important conversations will be identified to assist those who are considering accreditation for their gerontology program.