Standard behavioral weight loss interventions often set uniform physical activity (PA) goals and promote PA self-monitoring; however, adherence remains a challenge, and recommendations may not accommodate all individuals. Identifying patterns of PA goal attainment and self-monitoring behavior will offer a deeper understanding of how individuals adhere to different types of commonly prescribed PA recommendations  and guide future recommendations for improved intervention effectiveness.This study examined weekly patterns of adherence to step-based and minute-based PA goals and self-monitoring behavior during a 6-month online behavioral weight loss intervention.Participants were prescribed weekly PA goals for steps  and minutes of MVPA (50-200 minutes/week) as part of a lifestyle program. Goals gradually increased during the initial 2 months, followed by 4 months of fixed goals. PA was self-reported daily on the study website. For each week, participants were categorized as adherent if they self-monitored their PA and met the program PA goal, suboptimally adherent if they self-monitored but did not meet the program goal, or nonadherent if they did not self-monitor. The probability of transitioning into a less adherent status was examined using multinomial logistic regression.Participants (N=212) were predominantly middle-aged females with obesity, and 67 (31.6%) self-identified as a racial/ethnic minority. Initially, 73 (34.4%) participants were categorized as adherent to step-based goals, with 110 [51.9%] suboptimally adherent and 29 [13.7%] nonadherent, and there was a high probability of either remaining suboptimally adherent from week to week or transitioning to a nonadherent status. However, 149 (70.3%) participants started out adherent to minute-based goals , with suboptimally adherent seen as the most variable status. During the graded goal phase, participants were more likely to transition to a less adherent status for minute-based goals  compared to step-based goals ; however, no differences were seen during the fixed goal phase .States of vulnerability to poor PA adherence can emerge rapidly and early in obesity treatment. There is a window of opportunity within the initial 2 months to bring more people toward adherent behavior, especially those who fail to meet the prescribed goals but engage in self-monitoring. Although this study describes the probability of adhering to step- and minute-based targets, it will be prudent to determine how individual characteristics and contextual states relate to these behavioral patterns, which can inform how best to adapt interventions.ClinicalTrials.gov NCT02688621; https://clinicaltrials.gov/ct2/show/NCT02688621 Adherence to physical activity (PA) is a pervasive challenge in behavioral weight control programs. Many individuals fail to achieve program recommendations and adopt a physically active lifestyle ,2. As a Ordinarily, all individuals receive the same programmatic goals, which gradually progress to targeted PA levels -7. RecomSelf-monitoring, a key element of lifestyle programs intended to promote behavioral awareness and fulfillment of recommendations ,13, servOthers have examined transitions in levels of adherence to dietary self-monitoring and found that individuals who partially self-monitor in 1 week have a greater chance of improving to full self-monitoring during the first 2 months of treatment, whereas after the first 2 months, partial self-monitoring in 1 week foreshadows discontinuation of self-monitoring . Using aExamination of weekly adherence to the different types of PA goals offers insight into goal operationalization, progression, and timing, since lifestyle programs tend to prescribe goals on a weekly basis. Therefore, this study aims to describe weekly patterns of adherence to (1) step-based goals and self-monitoring steps and (2) minute-based goals and self-monitoring minutes of MVPA, as well as examine whether weekly transitional patterns differ between step-based goals versus minute-based goals, across 6 months of an online, group-based behavioral weight control program.2; were at least 18 years of age with access to a smartphone, computer, and the internet; had no medical contraindications to moderate-intensity PA ; and demonstrated the capacity to monitor their PA using their smartphone or personal fitness tracker prior to randomization. The study was approved by the institutional review boards at both clinical sites, and written informed consent was obtained from all participants. The investigation included only the control group (N=212) to avoid the potential of financial incentives obscuring PA adherence patterns  that evaluated the impact of financial incentives on weight loss in a group-based behavioral weight control program delivered online . Brieflyerns see .All participants received a goal-oriented behavioral weight control program delivered online, which has been shown effective in previous studies ,19. WeekParticipants were instructed to use their personal fitness tracker or a smartphone app to track their total steps and minutes of planned exercise of at least a moderate-to-vigorous intensity and then record both their total steps and minutes of MVPA on the study website daily. In other words, participants were asked to report both metrics for each day of the study period, as opposed to reporting only 1 metric, even if they did not perform any PA on that day. Self-monitoring records were reviewed by the facilitator, who provided tailored feedback via email on a weekly basis with positive reinforcement of healthy lifestyle choices, constructive guidance promoting potential areas for change, and reminders of the program recommendations.The total number of steps and minutes of MVPA both were self-reported by participants daily on the study website. Weekly totals for steps and for minutes of MVPA were calculated by summing the daily reported values, with each week beginning on the day of the scheduled group session.Adherence to the program step goals (yes/no) and the MVPA minute goal (yes/no) was separately determined for each participant and for each week of the program based on the proportion of the program goal achieved. For example, a participant could be categorized as nonadherent to the step goal and adherent to the MVPA goal. For steps, the average daily step count for a given week was divided by that week’s program step goal and multiplied by 100%. For minutes of MVPA, the total minutes reported in a given week were divided by the program MVPA goal and multiplied by 100%. Proportions of ≥100% indicated that the corresponding goal was met (yes), and proportions of <100% indicated that the goal was unmet (no). A value of 0 was assumed for missing and implausible entries, including daily step counts of <1000 or >30,000 ,22 and >Adherence to self-monitoring of steps (yes/no) and minutes of MVPA (yes/no) was based on whether an entry was submitted and calculated separately for each type of PA goal . For steps, a participant was considered to have self-monitored (yes) in a given week if ≥1 record of any step count was submitted, including a value of 0. Likewise, a participant was considered to have self-monitored minutes of MVPA (yes) for a given week if ≥1 record of any number of minutes, including 0, was submitted. If no entry was submitted for the corresponding PA goal on any of the 7 days, the participant was considered nonadherent to self-monitoring (no) for that week. The approach described here is consistent with previous work, which categorized a participant as adherent if ≥1 record of any value of exercise minutes was submitted for a given week and nonadherent if no records were submitted .adherence to PA goal and adherence to PA self-monitoring were used to categorize participants into 3 mutually exclusive categories each week for step-based goals and separately for minute-based goals. Participants were categorized as (1) adherent if they met the goal and self-monitored, (2) suboptimally adherent if they did not meet the goal but did self-monitor, and (3) nonadherent if they did not self-monitor  [The variables -monitor . It was nactive) , which anactive) . CategorDescriptive analyses were conducted to characterize the sample and determine frequencies for the number of participants meeting PA goals and self-monitoring their PA each week. Marginal proportions of weekly PA adherence categories were separately tabulated for each type of PA recommendation (steps and minutes of MVPA) beginning at week 3 and continuing through the end of the 6-month period. The weekly transition probabilities of adherence status were then independently summarized for step- and minute-based goals using separate models for the graded PA goal phase (weeks 3-8), fixed PA goal phase (weeks 9-24), and across all time points (weeks 3-24). Models were conditioned on the probability of maintaining the same adherence status from the preceding week or transitioning to another status within each type of goal prescription.P<.05.The likelihood of having an adherent, suboptimally adherent, or nonadherent status over time was examined for step- and minute-based goals, separately, using multinomial logistic regression for correlated data. The odds of having a less adherent status were modeled for each type of PA recommendation during the graded PA goal phase, fixed PA goal phase, and across all time points. Comparisons were then made between models for step- versus minute-based goals on the odds of transitioning into a less adherent status. All analyses were performed using SAS 9.4 , and the level of statistical significance was set at 2. The majority  were female, and approximately one-third  self-identified as a racial/ethnic minority. Most participants had at least a college degree  and were employed full-time . Retention was 81.1% (n=172) at the 6-month assessment visit.All participants randomized to the control group (N=212) in the larger RCT  were incOn average, of the 212 participants, 144 (67.7%) self-monitored their steps on ≥1 day/week during the 6-month period and 27 (12.4%) met the prescribed steps goal each week. Approximately one-third  of the participants started out adherent to the 7000-daily-step goal in week 3 . Rates dComparable to daily steps, 143 (67.4%) participants self-monitored their total minutes of MVPA on ≥1 day per week over the 6-month period ; howeverThe weekly transitional probabilities of adherence to prescribed PA goals and PA self-monitoring across successive weeks of the behavioral weight control program are summarized for steps and minutes of MVPA in During the initial 8 weeks, as the goals progressed from 7000 to 10,000 daily steps, the probability that a participant would remain adherent was 29%, while the probability of transitioning from adherent to suboptimally adherent was 67% , as well as for minute-based goals .Analyses examining adherence status over time indicated that participants were significantly more likely to be in a less adherent category relative to adherent as the program progressed . Thus, pFor steps, participants were 1.24 times more likely to be less adherent, relative to being adherent, each week during the graded goal phase, 1.07 times more likely to shift to a less adherent status during the fixed goal phase, and 1.09 times more likely to be in a less adherent category each week across the 6-month period. For minutes of MVPA, participants were 1.39 and 1.06 times more likely to be in a less adherent category each week during the graded and fixed goal phases, respectively, and 1.11 times more likely to shift to a less adherent category each week over the entire 6 months.P=.004). In other words, participants were more likely to become less adherent from week to week with respect to minute-based goals compared to step-based goals during weeks 3-8. No significant difference was seen in the propensity to be adherent between step- and minute-based goals during the fixed goal phase (P=.65). Although a trend was noted between models for steps and minutes of MVPA in the odds of being in a less adherent category when examining the full 6-month period (P=.07), the difference was not statistically significant.When steps and minutes of MVPA were compared during the graded PA goal phase, participants were significantly more likely to regress to a less adherent category the following week when examining minutes of MVPA relative to considering steps (To the best of our knowledge, this study is the first to describe the stability of adherence to weekly self-monitoring and attainment of PA goals prescribed in terms of daily steps and weekly minutes of MVPA during an online behavioral weight control program. Few participants met the initial step-based goals and subsequently either remained in a nonadherent or a suboptimally adherent status from one week to the next or transitioned from a suboptimally adherent to a nonadherent status over time. Conversely, most participants started out adherent to the minute-based goals but demonstrated greater variability between adherence statuses from week to week than was seen for step-based goals. Thus, participants with overweight and obesity enrolled in a behavioral weight control program were unlikely to achieve even the lowest step-based goals or to catch up with the goals as the step target progressively increased but had a greater chance of meeting the minute-based goals, particularly early in treatment.The weekly transitional probabilities identified in this study underscore the initial 2 months of a lifestyle program as a formative period that contributes to an individual’s chances of future PA adherence. Participants who met the earliest recommendations were most likely to be adherent at 6 months relative to those who started out suboptimally adherent or nonadherent. Intriguingly, the likelihood of long-term adherence increased 2-fold if a participant remained adherent through the graded goal phase. Our findings substantiate previous studies that demonstrate that the first 2 months of program initiation serve as a critical juncture associated with better long-term program adherence, weight loss, and health-related outcomes ,27-30. FFew participants achieved stability in adherent behavior, which is of concern. Indeed, nonadherence was the most consistent status and was increasingly more likely over time, regardless of the type of PA goal. Some adults with overweight may prefer monitoring minute-based activity rather than step counts ; howeverSuboptimally adherent behavior appeared to be the most vulnerable to transitions, particularly with respect to minute-based goals. It is striking that participants had the best chances of shifting from suboptimally adherent to fully adherent behavior during the graded goal phase, yet the likelihood of becoming nonadherent outweighed becoming adherent after 2 months. A similar pattern with weekly dietary self-monitoring was previously reported where individuals who demonstrated suboptimal adherence to dietary self-monitoring had the greatest potential for transitioning to adherent behavior during the first 2 months of a lifestyle program but not after that time . It is pTo capitalize on the early weeks of program initiation and move more individuals toward adherent behavior, reevaluating how PA recommendations are structured for behavioral weight control is warranted. It is apparent that providing everyone with the same incremental, linear progression of PA goals does not accommodate the dynamic process of lifestyle change for each individual. From a clinical perspective, it is imperative to appreciate that the continuation of conventional treatment likely will not help vulnerable subgroups transition to adherent behavior. Instead, it may be important to provide tailored goals that adapt based on the individual’s recent PA, thus providing more realistic, attainable PA targets ,41-43.Although this study took the formative step of describing behavioral patterns, more work is needed to identify precisely how best to adapt treatment to capitalize on these patterns and enhance outcomes. There are likely other factors, such as cognitive, affective, and motivational components, influencing whether individuals are adherent to PA, and these should be explored to guide treatment tailoring -48. For This research advances our understanding of the effects of different types of PA goals commonly prescribed in behavioral weight control interventions on goal attainment combined with self-monitoring among a large sample of adults with overweight and obesity. However, findings should be considered with the following limitations in mind. First, participants were predominantly women with obesity, and results may not generalize to other populations. Next, the influence of exercise history or the level of activity when entering the study on adherence patterns could not be determined. If program goal attainment differs between individuals who are inactive at study entry compared to those who are already engaging in some PA at baseline, recommendations may be tailored based on baseline activity levels. Although the goals offered in the program are similar to those provided by other behavioral weight control programs ,7, patteThis study begins to identify key transition points in the behavior change process as it relates to PA adherence for step- and minute-based goals in a behavioral weight loss program and provides a useful framework for detecting responsiveness to program recommendations. Moreover, it may assist in shaping more effective PA recommendations in lifestyle programs, particularly during the early period of program initiation. The initial 2 months provide a window of opportunity to assist people in transitioning to adherent behavior, especially those who fail to meet the PA goals but engage in self-monitoring. As a result, researchers and clinicians should consider PA self-monitoring and goal attainment concurrently as an indication of an individual’s adherence status. Emphasis should be placed on strategies that help people start and reach the 2-month mark with consistent self-monitoring and attainment of PA recommendations, since this appears to be a formative period for continued adherence. Future research should investigate how these transitional patterns in PA adherence status are influenced by individual characteristics and contextual factors, as well as how they relate to weight loss and other health-related outcomes, to inform optimization of treatment recommendations.


This study examines the extent to which collaborative governance thinking is realized in a government-funded sport policy program. Our main argument is that this conversion requires the analysis and interpretation of meso-governance and related networks. In the analysis of meso-level sports policy governance networks, we apply social network analysis and theme interviews. The empirical analysis conducted in this study involves the network-based structure of the Finnish Schools on the Move (FSM) program, which was implemented in Finland from 2009 to 2018. Our research questions are as follows: (1) How have the nature and network structure of the program changed throughout the implementation of the program? (2) How is the collaborative governance thinking reflected in the design and implementation of the FSM program? This study shows that the network is the most significant intermediary structure at the policy and organizational levels. Particularly, it was important in the start-up phase of the program, when the main task of the network was to bring together different actors and to generate a common vision. By the end of the program’s funding, the structure of the network became centralized, with decreasing density. However, the analysis shows that collaborative governance thinking is mainly reflected in implementation, rather than in the genuine joint planning of activities. The government’s sport policy in Finland has traditionally been pursued through rigid top-down regulatory and budgetary control. However, in the member states of the European Union, program- and project-based thinking has strengthened over the last 20 years, as both EU and national funding have been channeled down to regional and local government through the program structure.In recent years, alongside program-based policy models, network-like approaches and coordination mechanisms have also emerged. This has been the result of an increase in the interdependence and complexity of the governance system. Self-organized and broadly inclusive approaches to management are a natural response to this increasing complexity . ComplexHowever, there seems to be a shared understanding of the basic principles of governance that cuts across trends in different governance. First, governance emphasizes the importance of networks ,7. In a Governance reforms are a type of perpetual-motion machine used to develop solutions to various problems in public policy. Over time, these will create new public policy problems that require resolutions of a different method ,10. The Collaborative governance (CG) and its practices have been seen as a response to a situation, whereby it is necessary to implement policy actions together with cross-sectoral actors and practices . In thisThe basis for collaborative governance is determined by the starting conditions . Power relations, asymmetries, and epistemic tensions limit opportunities for action and affect incentives and constraints. The skills and abilities of different groups of actors are of great importance for the type of operating conditions under which they need to achieve their goals. The actual collaboration takes place in an interactive systemic space . NetworkComplexity leadership is a key tool for controlling system dynamics. Ultimately, the action will not be of great importance unless it produces results and genuine change in the environment. Complexity leadership theory (CLT) is also acknowledged in the conceptual framework. It is developed in an organizational context, and emphasizes that the adaptive space of leadership is created when informal and formal types of knowledge unite . This isIn the field of sport governance research, CG may be an integrative framework to identify relevant questions for new research directions in sport governance . For exaAs a CG research agenda, three relevant research themes have been pointed out: power and structure, leadership and motivation, and decision making . ThematiLater, the term “collective board leadership” was used to describe the leadership style that might be best suited to collaborative governance. Board-to-board relationships were researched to generate key strategic leadership and progress initiatives within and across a network of affiliated bodies, such as in a federated model, in which several independent organizations constitute a network-based system . HoweverWhen summarizing studies concerning CG in sport, two main conclusions are relevant. First, the previous studies relate to sport more than to physical activity, which means that the role and structure of sport organizations and sport systems are more relevant than in our current study, whereby the focus is on a state-controlled program aiming to increase the physical activity of children and adolescents. As a consequence, the logic of actors in the program’s networks are mainly connected to current sport policy action, focusing on the public sector’s school environment and physical activity. The network they constitute is established due to the need to govern the program, not to sustain a  system. However, these different premises are not in conflict when looking at the possibilities, which have been explored as a research agenda for CG and its theoretical base. Therefore, this study complements the research agenda framed by the CG theory, from a new perspective focusing on a sport policy program based on network practices. To be specific, the analysis of the network of actors in the FSM program provides new insight into collaborative governance. through the application of the network analysis of the structural characteristics of the FSM network.As for the societal impact of the study, this article presents possibilities for increasing the strategy of the network governance by analyzing the CG practices that the actors have produced in the FSM program. As a result, it provides tools to develop public governance related to sport. Belonging to, acting in, and working in networks necessitates more understanding of these networks as a contributor to public sector effectiveness and forms of governance. There is also a methodological contribution, in combining social network analysis (SNA) and qualitative themed interviews. This solution is rarely used in sport social sciences ,25,26, dThis research study relied on the use of a mixed methods approach. The collection and analysis of the data were based on methodological triangulation, an approach in which more than one method is used to collect and analyze data. This is not only a way to assure the validity of the research, but also a means of capturing multiple dimensions of the phenomenon being researched . In termIn a policy session carried out in 2009, the Finnish government took a stand on promoting good conditions for physical activity among children and adolescents. In their statement, the government defined the actions needed to ensure that the targets of the government program would be met. One of these actions was Finnish Schools on the Move, with its goals emphasizing the need to increase pupils’ physical activity in comprehensive schools. In practice, this meant establishing a day-to-day operating culture involving physical activity in schools, rather than only increasing the quantity of physical education classes .The program was launched as a project, and in spring 2010, during the pilot phase, funding was granted to 21 municipal projects involving 45 schools. The funding that was allocated was nearly 450,000 euros. The project funding for municipalities came from lottery funds, and the municipalities could allocate the funding freely to their chosen school setting, in line with the main project goal. This municipality-specific funding model is still in use today.In the pilot phase, from 2010 to 2012, the project’s focus was on increasing the overall PA, which in this model meant a blend of sport, physical games, play, and outdoor recreation activities. As the project became a national program in 2013, the content and goals increasingly highlighted other concepts, such as making school days and learning more enjoyable. However, the 2015 government program included an item that was especially significant for the progress of the program: the government’s key project on new learning environments and digital materials for comprehensive schools included a procedure for reaching the target of ‘one hour of physical activity per day’ .By late 2018, 90% of Finland’s comprehensive schools had registered as participants in the FSM program, which corresponds to a total of 2136 schools. Of the more than 300 municipalities in Finland, 93% took part in the program, including more than half a million basic education pupils, representing 92% of pupils at this level . RegistrFrom its inception, the program has been based on networked co-operation at the administrative level and in stakeholder groups . This waA social network is a set of socially relevant nodes, connected by one or more relations. Nodes, or network members, are the units connected by the relations, and it is the patterns among these that are under study. These units are most commonly people or organizations, but any units that can be connected to other units may be studied as nodes . For thin = 14). All of these groups were established and named by the state. The total number of separate organizations represented in the groups was 58. The inclusion criteria were membership in a project, working group, or committee. These memberships have been referred to as events. In network analysis, two-mode data are frequently encountered in the form of affiliation data: information is collected on a set of groups or events that a set of actors are involved with. The data matrix typically has actors for rows, and groups or events for columns. A given data value X = 1 if actor i is associated with group/event j and X = 0 otherwise. From this matrix, we computed actor-by-actor matrices by counting the number of groups/events that each pair of actors have in common. The result is a “co-occurrence” or “co-membership” matrix that is then analyzed as ordinary  network data. Alternatively, one can compute an event-by-event matrix, that counts the number of actors attending both events for every pair of events, yielding a measure of the overlap of attendance between the events. The data for SNA were collected from the sport policy memos and the FSM program’s documents, which consisted of archival data. This type of data is more useful than questionnaires, for example, when the aim is to explain structures in certain social networks . The netThe data analysis was performed with two-mode analysis in the UCINET network analysis software . The namThe degree of centrality explicitly describes the number of links that a given actor or event has. In the case of this study, the degree is the number of links to events. Hence, the degree of centrality is used to measure the activity or direct influence of a certain actor . Actors n = 4), and the Finnish Schools on the Move Office (n = 1) between October and December 2018. The interviewees were key informants on the issues related to the governance model of the FSM program. As stated, a key informant is an expert source of information [Thematic interviews were conducted with government officials that were representing the Division for Sport of the Ministry of Education and Culture  or the Finnish Schools on the Move Office (FSM office).The same thematic questionnaire was sent to every interviewee before the interview by e-mail. All interviews were recorded, conducted, and analyzed in Finnish, as the natural language of the informants and researchers. The selected text examples were translated into English when writing the results section. The total duration of the interviews conducted was 5 hours, which produced 22 pages of transcribed text . The average duration of an interview was 60 min, with a range from 50 to 77 min. The interviews were conducted in the offices of the informants. Two broad areas provided the thematic structure for the interview framework: (1) the network-based governance model within the state administration and (2) the design and implementation of the program. As an example, the detailed questions were: How is the network-based FSM program organized in the Ministry of Education and Culture? In what terms could network leadership be developed in the FSM program?The material was analyzed in three phases by one researcher using theory-based content analysis . In the In both periods (2009–2014 and 2015–2018), public sector organizations were found to have the most affiliations with the FSM program’s network. In the first period, the share of affiliations was 55% and in the second period it was 58.3%. The share of third sector organizations’ affiliations decreased between the first period (37.7%) and the second (32.6%). The share of the FSM office’s affiliations increased slightly, from 7.3% to 8.7%. In the second period, one organization from the private sector obtained one affiliation with the thematic sub-group (0.5%).The number of events increased from 3 to 12, and the number of actors increased from 22 to 38 . In addiIn both periods, the minimum number of affiliations per actor was one. The maximum number of affiliations per actor increased from three to nine. In addition, the share of affiliations of those actors who had three or more affiliations increased to 76% in the second period. The share of actors in this group also increased from 32% to 42%.At the same time, the share of actors with the maximum degree of centrality decreased from 31.8% to 2.6%. In the second period, there was only one actor, the FSM office, with the highest degree of centrality (0.750), which was the most central actor in the network structure. Overall, the structure of the network was more centralized in the second period than it was in the first.However, when classifying actors based on societal sectors and administrative positions while only considering the number of actors between the periods, the share of municipalities as local administrative actors increased remarkably . In the The share of municipalities as local administration representatives increased in the second period, and the aim of the program was local level school-based operations. Nonetheless, only two municipalities had representatives in the program’s management group (advisory board). However, the main affiliations of the municipalities were linked to events that were focused on the thematic planning of the program, such as equality, accessibility, and learning environments. It seems that the role of local actors was practical, not managerial, from the viewpoint of the program’s management practices at the national level.The interviews revealed that the collaborative governance arrangements and thinking occurred in relation to the following themes: path dependencies and power resource (a)symmetries (baseline/starting conditions), strategy/strategic planning, and trust and shared understanding (interaction patterns and systems dynamics). In addition, forms of complexity leadership and institutional design were found .When the FSM program was in its planning phase (baseline), the solution for establishing the program and the FSM office as part of the National Agency for Education was self-evident, while the focus of the FSM program was the school environment. Therefore, the way that the state used its structure and power resource practices while building the program’s governance model was not asymmetric but symmetric.In addition, the chosen model could be seen as part of the reforms of the sport system that began at the same time as the FSM´s pilot phase, in the early 2010s ,43. ThroFrom the viewpoint of implementation (interaction patterns and the dynamics of the system), the main goal was to gain a shared understanding of the creation of a new network-based governance model coalescing around the FSM program. In addition, an important element was to have a vision of the coordination and program planning and what it entails—i.e., strategic planning was carried out. However, the basis of the implementation and networking was trust, which was built together with commitment, shared understanding, and strategic practices. While the FSM office acted as a coordinator of the program, trust building was mainly in the hands of the office and its actors. Thus, the office can be said to be a trust builder, which was working strategically to find network brokers to enable the program.The empirical analysis of the FSM program shows that collaborative governance thinking mainly occurs in the way that institutional design determines opportunities for the FSM program´s network, at the systemic level. In the FSM program, the chosen governance model inside the state administration gives credibility to the FSM office and legitimizes its position inside the program´s network. Accordingly, it seems that the FSM office’s external positioning and location influenced not only the legitimacy of the FSM office but also that of said office’s employees for the coordination of networks. These findings strengthen our earlier remarks underlining the importance of legitimacy as a key element of successful networking .In a broader sense, the location of the FSM office was part of this implementation of multilevel governance—also called complexity leadership—which is the element at the core of collaborative governance for controlling systemic dynamics. However, as a single actor, the FSM office could not function as the coordinator of the program. It requires other organs and levels of governance to achieve its full capacity as a coordinator . In the Second, the role of the MEC’s Division for Sport was important in coordinating the many differently oriented ministries. However, the division of roles between the Division for Sport and the FSM office was at the heart of the governance model. At the same time, this division opened a door to the operational logic of traditional public administration, in which hierarchies form the foundation for policy actions by using these hierarchies and bureaucracy as the major building blocks. This combination was indeed seen in the governance model of the FSM program, where the coordination of the program included the role of a trust builder and informal relationships handled by the FSM office, while MEC´s Division for Sport were in charge of the funding and formal leadership of the program. Our findings strengthen earlier research findings, in which trust was found to be an important feature of successful collaborating practice in sport-related networks ,43,46.The SNA showed that despite the extension of the network in the second period, the structure of the network became centralized, and formal power resources were increasingly placed in the hands of the MEC and FSM office. The latter was important when the aim was to enable someone to coordinate the program. However, from the viewpoint of the implementation and idea of CG, actors from different sectors (private and third) or representatives of local-level administrators were missing when we observed those actors in the nexus of the network. In other words, the state kept the power resources in its own hands, and the complexity leadership was extended mainly to other ministries and public authorities rather than to the executors of the program, i.e., municipalities, which played the role of innovators in different sub-groups. Therefore, we can conclude that the CG practices reflected the state administration well, including the FSM office, but the complexity of the leadership arrangements did not actualize in the wider sense, where self-organizing and emergent events were relevant .Every study has its limitations, and in this current one we would like to point out the scientific generalization of the results, and the utilized mixed method analysis. As we considered the FSM program as a case, it is obvious that the interpretations based on data cannot be widely generalized without some re-contextualization . For exaA key shortcoming of this study is the lack of reliable outcome and effectiveness data. In this study, networks or collaborative arrangements could not be used to explain the results and impacts of the program. This would require a completely different research design—for example, applying a randomized controlled trial design (RCT) for a comparison of the results and impacts of physical activity programs in purely top-down cases and those of the participatory models. Thus, this is recommended as a topic for further research, particularly since systematic monitoring and evaluation data were collected from the FSM program.This study shows that networks are the most significant intermediary structures at the policy and organizational levels. They have been particularly important in the start-up phase of programs, when the main task of the network has been to bring together different actors, and to generate a common vision. However, the analysis shows that collaborative governance thinking is mainly reflected in the implementation, rather than the genuine co-creation of activities. This is related to the instrumental nature and the strong concerns of cooperation and network-based activities, which primarily aim to obtain funding rather than to achieve the consolidation and dissemination of results.As a practical policy recommendation, it could be suggested that sport policy programs should be prepared through joint planning, co-design, and generating wider involvement. In this case, regional and local executive structures and networks would be likely to survive longer after the end of funding. The current program and funding model encourages sub-optimization and the instrumental development of operations. Solving complex social, environmental, economic, and political challenges is a collective endeavor. These challenges are often multi-dimensional and decentralized. Often, they emerge or change very rapidly, particularly when the environment is unpredictable. In an environment such as this, a sustainable impact on physical activity programs can be achieved only by social innovations that are based on local needs and designed by local actors for the local users.Finally, when observing the results from a practical perspective, more effort should be devoted to thinking strategically about the particular types of models used for network coordination before one starts to implement the instruments directed at the network-based policy goals. This research has indicated that this is possible. However, a shared understanding of central actors is needed, in order to carry out the strategic work as well as implement it into daily practice.


To evaluate the cost-effectiveness of biologics and methotrexate (MTX) for rheumatoid arthritis (RA) using the number needed to treat (NNT) concept and total actual health care cost.This study included 121 RA patients with newly prescribed biologics and/or MTX between 2012 and 2017. The NNT was calculated based on the 24 week remission rate of Disease Activity Score in 28 joints using erythrocyte sedimentation rate (DAS28-ESR) and Clinical Disease Activity Index (CDAI).Remission rates were 76.4% for DAS28-ESR and 45.4% for CDAI in the biologics group and 63.6% and 24.2%, respectively, in the MTX group. The NNT was calculated as 6.4 and 4.2 in the biologics group and 34.2 and 35.2 in the MTX group, respectively. Mean total actual health care costs were 1,044,066 JPY (9835 US$)/24 weeks per treated patient in the biologics group and 75,860 JPY (715 US$)/24 weeks in the MTX group. Although the effectiveness of biologics was superior to MTX from the standpoint of NNT, the mean total health care cost and mean cost per NNT were much higher in the biologics group.Cost-effectiveness is clearly higher for MTX than biologics from the standpoint of mean total health care cost per adjusted NNT under the Japanese health insurance system. Biologic disease-modifying anti-rheumatic drugs (bDMARDs) have recently become widely used for patients with rheumatoid arthritis (RA). Although more expensive, they are reported to have higher effectiveness than other disease-modifying anti-rheumatic drugs (DMARDs), including methotrexate (MTX) –4. BecauThe number needed to treat (NNT) is an indicator that represents the effectiveness of therapeutic drugs , 7. It iAlthough the NNT is not itself a pharmacoeconomic indicator, some studies have reported the cost-effectiveness of bDMARDs for RA treatment from the standpoint of NNT and the relevant costs per NNT. Batticciotto et al.  reportedThe aims of this study were to evaluate the cost-effectiveness of bDMARDs and MTX in patients with RA, using NNT, in addition, the total actual costs were investigated and compared between bDMARDs and MTX.The study flowchart is shown in Fig. College of Rheumatology (ACR) classification criteria for RA  and/or tThis study was conducted with approval from Ethics Committee . Written informed consent to participate and publish the material was obtained from all patients included in the study.As previously mentioned, NNT is not itself a pharmacoeconomic indicator but is an indicator of the effectiveness of therapeutic drug or treatment intervention. It is an index for determining the number of patients who need to be treated in order for one patient to achieve a clinical goal when a new drug or treatment intervention is introduced. Thus, the lower the NNT, the better the effectiveness of a drug or treatment intervention. In this study, we set remission on DAS28-ESR or CDAI at 24 weeks as the clinical goal. NNT is calculated as a reciprocal number of the absolute risk reduction (ARR). The ARR refers to the difference in the remission rate between the therapeutic group (bDMARDs group or MTX group) and the control group.In this study, patients’ background including disease duration, Steinbrocker stage and class , and ratFor each patient, the actual total health care costs between the first visit and 24 weeks after the introduction of the therapeutic drugs, including the consultation fee, laboratory test fee, prescription fee, and cost of bDMARDs, were calculated as shown in the medical receipt and then averaged and compared between the groups. All patients underwent blood examination and chest radiography or computed tomography as screening tests immediately before the introduction of the bDMARDs or MTX. Therefore, the total actual costs in this study included the costs of these screening tests.The aim of this study was to compare cost-effectiveness of bDMARDs with MTX. As previously mentioned, because bDMARDs are remarkably more expensive than MTX, simple comparison of total health care cost of bDMARDs with MTX is inadequate. Therefore, we investigated mean cost per NNT as an indicator of cost-effectiveness of bDMARDs and MTX. Mean cost per NNT represents the costs required for a single patient to achieve remission. In other words, it was calculated by multiplying the total actual health care costs by the NNT. The costs needed to treat adverse drug reactions or complications such as bacterial pneumonia or liver dysfunction were excluded from the amount in the medical receipt, in line with previous studies , 9.When two or more health care technologies are being compared for pharmacoeconomic purposes, international guidelines recommend the use of a suitable time horizon to delineate all the main differences expressed in terms of both outcomes and treatment costs . The cosStatistical analyses, except logistic regression analysis, were performed using BellCurve for Excel . Logistic regression analysis was performed using EZR on R Commander version 1.31 . Kruskal–Wallis test was used to compare demographic data of the bDMARDs, MTX and control groups. Student’ t-test was used to compare changes in disease activity between the bDMARDs and MTX groups. Logistic regression analysis was applied to calculate the adjusted OR of the bDMARDs and MTX groups. p < 0.05 was considered statistically significant.The demographic and baseline clinical data of the bDMARDs, MTX, and control groups are shown in Table In the bDMARDs group, TCZ was used in 20 patients, golimumab (GLM) in 16, etanercept (ETN) in 13, and other bDMARDs in 6 patients  achieved remission according to DAS28-ESR while 25 patients (45.4%) achieved remission according to CDAI. The corresponding rates were 63.6% and 24.2% in the MTX group and 60.7% and 21.4% in the control group , and in the MTX group from 3.75 at baseline to 2.29 at 24 weeks (p < 0.001). There were significant differences in CDAI between baseline and 24 weeks in either the bDMARDs or the MTX group /24 weeks per treated patient in the bDMARDs group and 75,860 JPY (715 ± 155 US$)/24 weeks in the MTX group (US$ 1 = 106.16 JPY in February 2018). Two patients developed adverse drug reactions: ETN was interrupted for 3 weeks in 1 patient due to bacterial pneumonia, and the other patient in the MTX group needed 2 blood analyses due to liver dysfunction. The costs to treat these adverse reactions were excluded from this study, in line with previous study protocols [The mean total actual health care costs were more than tenfold higher in the bDMARDs group than in the MTX group. Furthermore, the mean cost per NNT in the bDMARDs group was 2.6-fold higher than in the MTX group based on DAS28-ESR or 1.6-fold higher based on CDAI. Although TCZ and ETN showed the lower mean costs per NNT, there was no significant difference in the mean cost per NNT between the biologic agents.Through logistic regression analysis using DAS28-ESR remission rate as an objective variable, the OR of the bDMARDs group compared with the control group was 2.38 , whereas that of the MTX group was 1.61 (95% CI 0.98–3.02). On the other hand, logistic regression analysis using CDAI remission rate as an objective variable revealed ORs of 3.24 (95% CI 1.31–8.01) in the bDMARDs group and 1.72 (95% CI 0.87–3.37) in the MTX group (Table Using the adjusted remission rate in the bDMARDs and MTX groups, the adjusted NNT was calculated as 5.71 based on DAS28-ESR and 3.86 based on CDAI in the bDMARDs group and 9.52 and 9.62, respectively, in the MTX group. The adjusted NNT was lower in the bDMARDs group than in the MTX group based on both DAS28-ESR and CDAI. However, the mean costs per adjusted NNT based on both DAS28-ESR and CDAI were lower in the MTX group than in the bDMARDs group Table .In this study, the NNTs of bDMARDs in patients with RA were 5- to eightfold lower than those of MTX. However, the mean total actual health care costs were much higher in the bDMARDs group than in the MTX group. Mean costs per NNT based on both DAS28-ESR and CDAI were higher in the bDMARDs group than in the MTX group. This means that although the effectiveness of bDMARDs was much better than that of MTX, the cost-effectiveness of MTX was superior to that of bDMARDs from the standpoint of NNT and total actual health care cost.Some economic measures can be used to assess the cost-effectiveness of drugs, such as the incremental cost effectiveness ratio, quality-adjusted life-years, and NNT. As mentioned earlier, NNT is not itself a true economic indicator of cost-effectiveness, but an indicator to assess the effectiveness of therapeutic drugs. However, because NNT is easy to understand and calculate, it is used to assess the cost-related effectiveness of drugs. Several studies have examined the cost-effectiveness of bDMARDs in RA using NNT. Batticciotto et al.  investigAlthough simple comparison is difficult because each country has own health insurance system, several studies have reported the cost-effectiveness of bDMARDs in the treatment of RA. Hyon et al.  comparedSyngle et al.  noted thThe adjusted NNT of bDMARDs was superior to that of MTX based on both DAS28-ESR and CDAI, which means that the effectiveness of bDMARDs was superior to that of MTX when patients’ backgrounds were adjusted to exclude bias. On the other hand, the costs per adjusted NNT in the bDMARDs group were eightfold higher than those of the MTX group based on DAS28-ESR and fivefold higher based on CDAI. Given that the total health care cost of the bDMARDs group was more than tenfold higher than that of the MTX group, the difference in the mean costs per adjusted NNT between the bDMARDs and MTX groups was smaller than in the mean costs per non-adjusted NNT. However, the mean cost per adjusted NNT of MTX were still superior to those of bDMARDs.The results of this study indicate that although the effectiveness of bDMARDs was better than that of MTX, the cost-effectiveness of MTX was superior in terms of the adjusted NNT and the total costs under Japanese health insurance. Therefore, considering the costs of therapeutic drugs, we recommend MTX for first-line appropriate use in patients with RA who have no complication such as chronic kidney disease, interstitial pneumonia, or liver dysfunction that prevent the use of MTX. If the treatment target is not achieved with MTX, bDMARDs should be added immediately from the economic viewpoint, similar to the EULAR recommendations on the management of RA .There are some limitations to this study. First, the placebo group should be set as controls in this type of study, however, it was difficult to assign some patients to truly placebo group because this study based on real-world clinical setting, therefore the patients who administered csDMARDs without bDMARDs or MTX was set as the control group in this study. Second, due to the small number of patients involved in this single center study, bias might exist in terms of medication selection. Particularly in the bDMARDs group, two or three specific agents were frequently used as the first bDMARDs. Especially, GLM is used for relatively higher aged patients in our hospital, in addition, 11 out of 16 patients administered with 100 mg of GLM, so the mean total health care costs in the patients who administered GLM was much higher than the other patients. Third, bio-similar of bDMARDs was not used in our hospital during the observational period in this study. The difference of total health care cost between MTX and bDMARDs will be smaller if bio-similar of bDMARDs is used because the price of bio-similar of bDMARDs are much lower than original bDMARDs. Regarding to oral medicines, the patients receive the prescript oral drugs from out-of-hospital pharmacies in principle in Japan, and pharmacies can decide whether to prescribe original or generic drugs. We did not know that the patients were prescribed original or generic drug from out-of-hospital pharmacy from the medical system of our hospital. Therefore, we calculated the costs of oral medicines assuming the prescribed drugs are all original drugs. Fourth, because the initial purpose of this study was to compare remission rates at 24 weeks between the bDMARDs and MTX groups, we excluded patients who switched medications within 24 weeks due to an adverse drug reaction or who did not need to change the former medication, which might have led to a higher remission rate than in previous studies. Finally, this study evaluated only the disease activities using DAS28-ESR and CDAI 24 weeks after the introduction of therapeutic drugs. Further investigation is required including the spacing or tapering of bDMARD, or the evaluation of joint destruction to compare between the MTX and bDMARDs groups.Despite these limitations, we believe that this study is unique and clinically relevant. To our knowledge, no earlier studies have reported on the cost-effectiveness of bDMARDs versus MTX in patients with RA from the standpoint of NNT and total health care costs in the real-world clinical setting.In conclusion, the NNT of bDMARDs in patients with RA, which is used as an indicator of the effectiveness of therapeutic drugs, was superior to that of MTX. However, the mean total actual health care costs were much higher in the bDMARDs group than in the MTX group. In addition, the mean costs per adjusted NNT based on both DAS28-ESR and CDAI were higher in the bDMARDs group than in the MTX group, suggesting that the cost-effectiveness of MTX is superior to that of bDMARDs from the standpoint of mean total actual health care costs per adjusted NNT under Japanese health insurance system.


Individuals with serious mental illnesses experience deaths related to smoking at a higher prevalence than individuals without a psychotic-spectrum disorders. Traditional smoking cessation programs are often not effective among individuals with chronic mental disorders. Little is known about how to implement a tobacco cessation treatment program for this at-risk population within a community health center. The current study used qualitative methods to examine the factors that may enhance or impede the delivery of a novel tobacco cessation treatment for smokers with a psychotic-spectrum disorder diagnosis in an integrated care community health center.Using a case study design, we conducted 22 semi-structured interviews with primary care providers, mental health providers, addiction counselors, case managers, intake specialists, schedulers, pharmacists, and administrative staff employed at the organization. Interviews were transcribed and themes were identified through a rich coding process.We identified environmental factors, organizational factors, provider factors and patient factors which describe the potential factors that may enhance or impede the implementation of a smoking cessation program at the integrated care community health center. Most notably, we identified that community mental health centers looking to implement a smoking cessation program for individuals with chronic mental health disorders should ensure the incentives for providers to participate align with the program’s objectives. Additionally, organizations should invest in educating providers to address stigma related to smoking cessation and nicotine use.The findings of our study provide valuable insight for administrators to consider when implementing a smoking cessation program in an integrated care community health center. Our findings provide public health practitioners with potential considerations that should be discussed when designing and implementing a smoking cessation program for individuals with chronic mental disorders.The online version contains supplementary material available at 10.1186/s13033-022-00517-y. Compared to the general population, individuals with psychotic-spectrum disorders, such as schizophrenia and mood disorders with psychotic features, die approximately 15–20 years earlier than the general population . About tDeficits in cognitive functioning are the most frequently experienced mental health symptoms for individuals with psychotic-spectrum disorders, and the elevated rates of smoking in this population may stem , in partDrawing on these results, we developed a 12-week combination therapy that included traditional pharmacological treatment for smoking cessation  and a modified version of MCR [metacognitive remediation to quit (MCR-Q)] that is designed to promote development of skills and strategies to address specific real-world situations related to quitting smoking. In an open trial of MCR-Q, individuals with psychotic-spectrum disorders who smoke experienced reductions in nicotine dependency over the course of the intervention that were sustained six weeks after the completion of treatment .feasibility of implementing a tobacco dependence treatment program into integrated community health centers, which focus simultaneously on treatment of mental health, chemical dependency, and primary care, as well as provide employment and homelessness services. In addition, community health centers receive funding from multiple agencies and state and federal programming, making the management of such organizations complex. The little information that is available comes from facilities that specifically treat veterans [For an effective smoking cessation program to have an impact, it must be easily incorporated into clinical practice. Barriers and facilitators to implementing tobacco dependence treatment in mental health and substance use treatment programs have been reported –25; howeveterans , 25, whoOur public health system in the United States relies significantly on community health centers to provide primary care and mental health services to some of the most vulnerable populations in our society. More research exploring the implementation and feasibility of clinical care programs on our vulnerable populations will provide managers and administrators with guidance to facilitate the appropriate treatments for their clients. The purpose of this study was to explore the feasibility of implementing our combination tobacco cessation treatment for smokers with a psychotic disorder diagnosis in an integrated care community health center setting. Using a qualitative case study design approach, we interviewed employees in an integrated care community health center and identified potential barriers and facilitators to implementing the novel MCR-Q program into clinical care. The findings provide valuable insight for managers and administrators regarding the implementation of a smoking cessation program in an integrated care community health center.We used a case study design to explore the feasibility of implementing of our combination tobacco cessation treatment for smokers with a psychotic disorder diagnosis in an integrated care community health center setting. A case study design was chosen because it lends itself to understanding and capturing how interventions are implemented on the ground and explaining the complexities of a phenomenon in everyday contexts.The MCR-Q intervention was implemented at a community healthcare organization serving four counties in central Ohio. In Ohio, 20.5% of adults smoke, which is above the national average of 16.1, making smoking cessation an important public health initiative for community leaders and policy makers . This paThe organization supports smoking cessation and felt strongly that their clients would benefit from evidence-based tobacco cessation programs that are effective among individuals who experience severe mental health disorders, which were prevalent among their client population. Prior to the study, primary care providers counseled smokers to quit and wrote prescriptions for cessation pharmacotherapy when appropriate. Additional services had been a struggle to adopt within the organization, as the current financial model made other counseling services and support groups unfeasible. Lastly, the organization had recently adopted a tobacco-free policy that included employees committing to be tobacco free. Employees who used tobacco were offered tobacco cessation programs through the organization’s insurance plan.The foundation of the smoking cessation program is MCR, but it was tailored to promote quitting smoking (MCR-Q). Across the 12-session intervention, individuals participate in therapist-delivered metacognitive skills development exercises designed to facilitate improved knowledge and regulation of skills applied during completion of activities requiring the use of working memory, sustained attention, and behavioral disinhibition—three cognitive domains repeatedly linked to tobacco use . MoreoveThe current interview sub-study was approved by the Institutional Review Board of the Ohio Department of Health. Interviews were conducted by one investigator THH using a face-to-face format at the organization’s office where the cessation program was offered. To minimize the burden on participants, interviews lasted approximately 30 min and participants received a $20 gift card. We developed a semi-structured interview guide , worked with clients who may utilize tobacco cessation services , or were in administrative positions that could provide insight into the organization’s ability to implement the program and manage the patient processes . Additionally, two weeks after the initial recruitment email was sent, the lead qualitative investigator followed up the intervention therapy leadership team and showed the team a list of titles of participants which had participated or were scheduled to participate. Together, the group brainstormed additional individuals from the organization who had not yet responded to the first recruitment e-mail, and we sent an additional recruitment email directly to this list of individuals. This ensured we had adequately sampled participants who could address the complexity related to the clinical and administrative needs related to implementing the MCR-Q program in the organization. Questions related to the program were asked, including resources available, barriers, financial impact, training of staff, and staff attitudes towards a new tobacco cessation program.We conducted interviews prior to the start and at the end of the MCR-Q program. A total of 22 interviews were conducted and were deemed appropriate because the study had reached saturation . The finPrior to analyzing the data, a team of three students transcribed the interviews. After each student transcribed an interview, a different student reviewed the transcript and audio file for inaccuracies using a protocol developed by the first author.As suggested by Creswell , the anareimbursement mechanisms, organizational issues, provider behaviors, and client concerns. Within these, we identified 8 sub-themes. Table Through our analyses, we identified 4 themes: This theme describes issues related to being able to receive reimbursement for components of the MCR-Q program. Participants stated that the organization’s ability to implement a program was based on whether they could receive reimbursement for MCR-Q, and the specific components involved. This was described by participants as both a potential facilitator or barrier to implementing the MCR-Q program. As an FQHC, the organization relies primarily on Medicaid and Health Resources and Services Administration (HRSA) funding mechanisms which have specific billing requirements. Activities which can be billed for are easier to adopt into practice in the organization. Activities which are not able to be billed for are a struggle to adopt into practice in the organization. At the time of the interviews, the research team was able to confirm that the activities of the program would meet the requirements of the tobacco cessation programs for these reimbursement mechanisms. HRSA provides funding for the primary care center within the comprehensive care clinic. Medicaid reimburses for the addiction and behavioral health services offered at the comprehensive care clinic. When evaluating the feasibility of the MCR-Q program, the ability to be reimbursed is a significant consideration that participants described.aligning the human resource incentive programs with MCR-Q and multi-disciplinary provider teams are included in this theme.This theme describes issues related to how the organization operates that are important to consider when evaluating the feasibility of the MCR-Q program. Two sub-themes, Sub-Theme 1: aligning the human resource incentive programs with MCR-Q describes the importance of the MCR-Q program being included in the organization’s employee work incentive program. Participants explained that the organization utilizes productivity hours as the basis for salary and compensation for many employees. Employees must track productivity hours for services they provide to clients. For example, when a therapist spends one hour leading a group therapy session, they receive one productivity hour. Each staff member has a goal for monthly productivity hours, and upon meeting each monthly goal, they receive additional compensation. Employees would need to be able to receive productivity hours for their efforts related to the MCR-Q therapy program for the program to be successful at their organization. Some participants stated that if employees could not receive productivity hours for the MCR-Q program, then the program would most likely not be successful.Sub-Theme 2, multi-disciplinary provider teams describes how the organization has multi-disciplinary teams which are comprised of primary care, mental health, and addiction services providers which is an amenable structure for the MCR-Q program and the multi-disciplinary clinicians needed to implement such a program. There was a consensus among participants that the new program would not require any new hiring within the organization. Additionally, within this theme, some participants noted that some of the teams had prior experience offering tobacco cessation programs which may have incorporated some of the techniques of the program.buy-in/attitudes of providers and team members, provider prescribing behaviors, and lack of time.This theme describes issues regarding provider behavior, and how that behavior may impact the implementation of a new tobacco cessation program. Providers refer to anyone in the organization who offer a service to a client, such as social workers, primary care providers , pharmacists, psychiatrists, case managers, and counselors. There are three sub-themes in this theme: Sub-theme 1: buy-in/attitudes of providers and team members describes the role of the providers’ and other team members’ personal perceptions and attitudes toward tobacco cessation and the importance of providing tobacco cessation during a clinic visit. The study site used inter-professional teams comprised of social workers, primary care providers (MDs and NPs), pharmacists, psychiatrists, case managers, and counselors, and each team member needs to be aligned with the broader patient care goals and care needs. The new MCR-Q program has the potential to impact how some of these individuals provide care; for example, the psychiatrist may need to adjust their current clinical treatment plans or be aware that a client could be more irritable while trying to quit smoking and adjust expectations accordingly. This may subsequently require more time from a provider or a team member and make the patient more demanding during one-on-one treatment sessions or other services provided by someone on the interprofessional team. During our interviews, participants made note that the program would need to address this issue if it were to be successful. For example, team members suggested that despite their strong relationship with their clients, this intervention would require the cooperation of multiple team members and the belief from all team members that tobacco cessation was important.Sub-theme 2: provider prescribing behaviors describes how the new tobacco cessation program would require providers who are responsible for managing the pharmacological components of a client’s treatment to potentially be open to changing the medications they prescribe. Participants indicated that the medications needed as part of the MCR-Q  program may interact with the current prescriptions used to manage the patients’ psychotic-spectrum disorders. Providers, specifically those with a role in medication management, may have to make these changes if an individual’s current medications have interactions with the medications included in the MCQ-R program. Participants described how a vital part of the program being successful will fall on the willingness and ability of prescribing providers to adjust medications, if necessary, due to a person quitting smoking, taking cessation pharmacotherapy, or experiencing an adverse event to a cessation medication [dication . There wSub-theme 3: lack of time describes how participants stated that a barrier to successful implementation of the tobacco cessation program was a lack of time during their day to devote to adopting the program and incorporating it into their interactions with clients. Participants stated that this would be “one more thing” for them to do, within a long list of job tasks. Participants described being open to the treatment, since quitting smoking was an important issue for their clients, but also expressed difficulty in understanding how they would be able to continue to do what they are already doing while adding another task to their list of responsibilities.competing client needs and priorities, and motivation to quit smoking.Client themes describe perceived issues related to the client population that would impact the implementation of a new tobacco cessation program. Two sub-themes emerged as a part of this theme: Sub-theme 1: competing client needs and priorities describes how there are competing health and social needs of individuals with psychotic-spectrum disorders who may be seeking tobacco cessation treatment. Study participants expressed that due to the complex health and social needs of their clients, it may not be feasible to address tobacco cessation during client interactions. Many of the clients who receive care at this organization deal with homelessness, food insecurity, legal issues, or have other issues, which they consider higher priority. Additionally, the clients targeted in the MCR-Q intervention often have a co-diagnosis that creates complex health needs. Two participants referenced the “Maslow’s hierarchy of needs” with regard to the program and suggested that tobacco cessation may be lower on the hierarchy. For example, a provider explained that when a client comes to a visit and shares that they have recently lost their home and during that process they lost their medications, that visit is spent helping the client find a place to live and helping them get re-fills on their medications. These needs make it difficult to prioritize tobacco cessation activities.Sub- theme 2: motivation to quit smoking describes how clients targeted for the MCR-Q treatment may not be interested in quitting smoking and this may make it difficult to recruit individuals to the treatment program. Participants explained that the organization would need to encourage and support clients and educate them about the program to improve the motivation to quit using tobacco products among this client population. Some reasons clients may not be interested include that many enjoy smoking or relate tobacco use to positive symptom management outcomes, which specifically should be addressed when considering how to get clients to consider the MCR-Q program.reimbursement mechanisms, organizational issues, provider behaviors, and client concerns, which provide insight for leaders planning to implement the MCR-Q program. Our findings are consistent with implementation science studies which have found that patients, providers, organizations, and the payer environment play a vital role when implementing a new evidence-based practice into care [This study is responsive to critical gaps in the implementation of tobacco cessation for people with psychotic-spectrum disorders—the need for an effective tobacco cessation program, and the need for evidence to support the implementation of such programs within community health centers. Translating what is learned from research into real world settings is far more complex and challenging than it appears . Integranto care .Our study found that staff perceive reimbursement mechanisms as being an important factor to consider when evaluating the feasibility of implementing an MCR-Q program. Federal and state policy makers determine HRSA and state Medicaid reimbursement policies, which are responsible for determining the services within the MCR-Q program for which community mental health centers could bill. It is common for community mental health centers to rely on two major revenue sources: HRSA reimbursement for the organization’s FQHC activities and Medicaid for mental health and substance abuse services. The MCQ-R program would require a primary care clinician, psychiatrist, or mental health nurse practitioner to prescribe cessation pharmacotherapy, provide medication management, and troubleshoot with clients who may need medication adjustments as a result of either quitting smoking or side effects of the cessation pharmacotherapy. This finding suggests that integrated community health clinics have a strong need for any tobacco cessation programs to work within the already existing reimbursement mechanisms. This would be a key matter for all organizations considering the MCQ-R program.Next, we identified two themes which we considered to describe organizational issues that should be evaluated as part of understanding the feasibility of the MCR-Q- program. The bulk of tobacco cessation programs are implemented at primary care offices, substance abuse treatment centers, and mental health clinics. Our study was the first to examine the feasibility of implementing a combination tobacco cessation therapy in a comprehensive community care clinic which offers integrated mental health, substance abuse treatment, and primary care under a single organizational entity. We found that staff at our organization believed that their organization’s multidisciplinary approach to patient care was an added benefit and made their organization a good fit for the MCR-Q program, which incorporates pharmacological with behavioral health interventions into a single treatment.We also found that participants perceive a struggle to get buy-in from providers, while other employees perceive providers to be very supportive. These findings are consistent with previous studies which have identified a multitude of barriers to the provision of tobacco cessation programs among clinicians working with underserved communities . During competing client needs and priorities they must manage. This finding is consistent with previous research which has identified that providers in community mental health centers believe tobacco cessation services are not a priority for their clients [Our study identified that providers may struggle to implement a tobacco cessation program due to the  clients . Yet, pr clients . When coOur findings provide valuable insight into the implementation of new clinical programs in community mental health centers. The successful implementation of evidence-based practices in community mental health settings is based on a multitude of implementation domains, such as leadership, workforce, workflow, and reinforcement, and the ratio of barriers and facilitators within an organization . OrganizOur first limitation is that we only conducted interviews with staff at one study site. This meant that there was a limited sample of individuals who met the criteria to be included in our purposeful sampling approach. Given the limited potential pool of participants, this may have influenced the amount of variability in our participants’ responses. In addition, participants were all employed by the community mental health clinic, which may bias their responses to the interview questions. However, they were assured that their responses were anonymous, that all results would be reported in aggregate, that the organization’s leadership would not know they had participated in the study, and that participation would not affect their employment. Lastly, we did not systematically collect information on participants’ smoking status or tobacco use history, though some participants voluntarily shared this as part of their responses. We acknowledge that individuals’ tobacco use may have impacted their responses to questions regarding the implementation of a tobacco cessation program, and we do not know the extent to which results are indicative of personal factors related to tobacco use.Overall, this study provides insight into factors that community mental health administrators and leaders should consider when planning to implement a tobacco cessation treatment targeted at clients with serious mental health disorders. When considering our findings, leaders of community health centers and mental health clinics may want to ensure that, in addition to the tobacco cessation services, the organization engages providers in education and training regarding their attitudes toward tobacco cessation, meets regularly with interdisciplinary team leaders to ensure all elements of the organization’s incentive structures are aligned to support success of the program, and ensures that the organization is supporting team members’ commitment to such a service.Additional file 1. An evaluation of the feasibility of implementing a novel tobacco dependence treatment program for high-risk individuals into clinical practice within a community mental health center.