SD = 1.0) recruited from two schools in Chile and two schools in Colombia. Qualitative and quantitative methods were applied for data collection and analyses. Although the levels of acceptance were moderate to high across all variables, adherence was lower than expected. The participants deemed important for an intervention of this type offered a higher level of interaction with team members through internet-based and face-to-face activities. Post-intervention outcomes show a reduction in depressive and anxious symptoms in adolescents in Chile, while there were no significant changes in the level of symptomatology in adolescents in Colombia. The women used the program more than the men. Results show the need to improve the intervention by increasing its levels of customization and developing strategies to achieve better adherence. The contradictory results of the program in Chile and Colombia suggest the importance of other variables beyond the content of the intervention, such as the setting or context of the intervention.The rapid internet penetration in Latin American countries has made it possible to implement digital mental health interventions. “Cuida tu Ánimo” (Take Care of Your Mood) is an internet-based program for the prevention and early intervention of depression in adolescents. A pilot study was conducted in Chile and Colombia to study the feasibility and acceptability of the program and estimate its effects. There were 199 participants (53.3% women; mean age = 14.8 years,  Depression in adolescents is a worldwide challenge that entails huge individual and social costs . DepressEpidemiological studies show that depression is common among adolescents, with up to a 25% lifetime prevalence before adulthood . In an eDespite the existence of effective treatments for depression, there is evidence for low rates of help seeking among adolescents . When asInterventions aimed at reducing the burden of depression have become a priority public health need. These interventions face great complexity due to the multiple variables associated with depressive symptoms, the high costs of treatment, and the specific characteristics of this problem in adolescence . This stg = 0.23 immediately after the intervention and g = 0.11 at 12-month follow-up). In addition, universal programs have worse outcomes than indicated prevention programs [Growing evidence suggests that targeted prevention and early intervention programs in adolescent depression produce larger effect sizes than universal programs in improving psychological wellbeing or preventing mental disorders . Studiesprograms .In Santiago (Chile), a universal preventive intervention investigated in a sample of 2512 secondary students from 22 schools failed to demonstrate its efficacy in reducing depressive symptoms . The autIn recent years, numerous internet-based interventions have been developed worldwide and have proven to be useful and effective ,19,20,21In Latin American countries, such as Colombia and Chile, developing and testing these types of interventions is critical given the high prevalence of depression ,25. In aMore evidence should be generated on interventions designed specifically for adolescents to minimize the impact of risk factors and promote healthy lifestyles at this stage of development. The internet offers the opportunity to provide this type of intervention given its high penetration in the daily lives of adolescents ,28. The Internet-based interventions developed for a school setting could provide greater flexibility, as there is no need to be physically present during the intervention, and it is easy to provide tailored support according to individual needs. However, a major limitation of digital programs is the high dropout rate ,36. A syThe objective of this study was to evaluate the feasibility and acceptability and estimate the effects of an internet-based program for the prevention and early intervention of adolescent depression in high school students implemented in Santiago (Chile) and Medellín (Colombia).A pilot study was conducted with adolescents in Chile and Colombia to study the feasibility and acceptability of the “Cuida tu Ánimo” (CTA) (Take Care of Your Mood) program and estimate its effects. A mixed methodology  was applied for data collection and analysis.Four schools (two schools in each country) were invited to participate. In Chile, the choice of schools was for convenience since there was previous contact with them. In Colombia, the schools were suggested by the Municipal Secretariat for Education. In Chile, they were subsidized private schools, and in Colombia, they were public schools. Only schools with a school psychologist or school counselor were eligible to participate, and the school’s principal had to consent to participation. Before inclusion in the study, participants had to provide written informed consent. For students younger than 18 years old, informed consent from their parents or primary caregivers was required. In the schools, a face-to-face induction to the program was provided to introduce CTA and provide information about the usage and access to the intervention. In order to use the program, participants had to register on the web platform.A total of 517 adolescents (271 from Chile and 246 from Colombia) in grades 8 to 11 in Chile and 6 to 10 in Colombia were invited to participate. The final sample consisted of 199 participants  from Chile and 53 (26.6%) from Colombia).www.cuidatuanimo.org, accessed on 7 September 2021). The program was developed based on the experience and results of previous studies by the research team, which were conducted in another setting [CTA is an internet-based program for the prevention and early intervention of adolescent depression .Psycho-educational information (Learn): The program offered information on depression , healthy lifestyle habits, emotion regulation, social support networks, and cognitive-behavioral techniques .Mood monitoring and feedback (How did you feel?): This component included (a) mood monitoring: every two weeks, participants received an e-mail with a link to an online questionnaire ) ; (b) indForums: The program offered a space for peer interaction moderated by a mental health professional on general mental health topics .Individual chat or phone call: An individualized support space was offered, accompanied by a program professional. Teenagers were able to book a 45-min appointment with a psychologist. Adolescents were able to access this component at any time during the program, and when they reported moderate or severe symptoms during monitoring, they were encouraged to request this component in the feedback message.News blog: There was a regularly updated blog with news and general information on mental health and related topics. Participants were able to comment on and discuss the contents.Emergency: This section provided adolescents with a crisis plan and general information for dealing with acute crises .Contact: Teenagers were able to contact program professionals at any time via e-mail.The CTA program included the following components:The primary outcome measure was depressive symptomatology, measured with the PHQ-9 . The PHQIn addition, anxious symptoms were assessed as a secondary outcome given their strong association and comorbidity with depressive symptomatology . AnxiousHealth-related quality of life (HRQoL) was measured with the KIDSCREEN-27 questionnaire , which iThe Self-Stigma of Depression Scale (SSDS)  was usedAssessments for all measures took place at baseline and after 6 months.The usability of the intervention was evaluated considering the number of clicks on the page and the use of modules.Adherence to the monitoring was defined by the research team as a minimum of one-third of completed monitoring assessments (five responses).Students who actively used the program were surveyed about their acceptance of the program and their satisfaction with the support that CTA offered to them. Acceptance was evaluated through 7 questions with a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). Higher scores indicate more satisfaction with the program. Good satisfaction with the program was defined as a score of 3 or 4. A question on overall satisfaction with the program was asked on a scale of 1 to 10. A higher score indicates more satisfaction with the program. In addition, the students answered two open-ended questions about positive aspects of the program and recommendations for improvement.n = 2) and Colombia (n = 2) to explore the adolescents’ expectations, their user experience, and their evaluation of the program’s content and accessibility as well as to obtain suggestions to improve the program.Finally, four focus groups were held in Chile . Then, a multivariate logistic regression model was developed using this binary variable as the main outcome. Finally, a descriptive content analysis was conducted of the central themes reported by the adolescents in the open-ended questions on positive aspects of the program and recommendations for improvement as well as in the focus groups.Descriptive analyses of socio-demographic and baseline outcome variables were carried out. In addition, differences in outcome variables between the baseline and six-month assessment were calculated using All procedures were approved by the Ethics Review Boards of both Universities participating in this study. Ethical approval was obtained from the Ethics Committee of Human Research of the Faculty of Medicine of the Universidad de Chile (Chile) and the Institutional Ethics Committee of Human Research of the Universidad CES (Colombia).Adolescents with severe depressive symptoms and/or suicide risk at the baseline assessment were referred to face-to-face evaluation with their parents or primary caregivers in coordination with a school psychologist to determine the need for referral to face-to-face treatment.SD = 1.0, range: 13–18; mean years of schooling = 9.1, SD = 0.8) recruited from four schools in Colombia and Chile. A total of 517 adolescents were invited to participate. A different recruitment rate was observed depending on the country. Of the adolescents invited, 52.3% accepted in Chile and 21.5% in Colombia. The final sample of this pilot study included 199 participants  and 7.2 (SD = 4.8) at the post-intervention assessment after six months .The PHQ-9 score at baseline was 8.9 (x months . The PHQSD = 2.9) monitoring assessments. Almost half of the participants  did not respond to any monitoring assessments, 17% (n = 34) responded to only one, and 7% (n = 13) responded to seven or more monitoring assessments. Only 15% of the participants (n = 29) made an expected use of the program, i.e., they responded to at least one-third of the monitoring assessments (five responses).Participants received a total of 16 e-mails each asking them to complete the mood monitoring. Participants answered on average 1.8 (SD = 9.4), with a maximum of 55 clicks. This level of use was similar in both countries. The sex of the participant was the principal predictor of high website usage . Being a woman increased the probability of being placed in the 75% percentile or above of webpage usage by almost three times (OR = 2.9). Impairment—at either baseline or six months—was not associated with the intensity of website usage.Concerning the use of the CTA website, participants clicked on the platform six times on average  activated the alarm at least once, indicating the possibility of suicidal thoughts throughout the intervention. These participants were contacted through the school coordinator to offer them the possibility of scheduling an individual chat or phone session with a therapist. However, only five  utilized that counseling appointment. One adolescent in Chile was referred to face-to-face care with his parents.SD = 2.1) (score range: 1–10). Most participants were satisfied with the program (82.5%) and would recommend it to another adolescent (77.7%). A total of 60.8% of the participants considered the program useful, and 67.6% stated that it met their expectations. Regarding technical aspects and their usage of the website, 69.9% of the participants rated it as entertaining, while 86.1% stated that it was easy to use and comfortable. Likewise, 62.1% of the participants believed that they learned new things.A total of 103 participants (51.8%) answered the acceptability and satisfaction questionnaire. The overall rating of the program was 7.1 , utilization rates were low overall. These results are in line with studies that challenge the assumption that adolescents prefer internet-based interventions . CorrespA study on the feasibility and acceptability of a monitoring program for patients in treatment for depression conducted in Chile showed similar results: participants showed a high level of acceptance of the program and considered it a source of support and benefit but used it substantially less than expected . This isThe present study also shows that female adolescents made greater use of the program. The sex of the participants was the main predictor of website use. This result is consistent with research showing a gender difference in the use of digital interventions, with women being more receptive to behavior change strategies .In addition to the factors mentioned above, the opportunity to have individual chat or phone sessions was considered useful even if the participants did not use this resource much. In this regard, perceived staff interest and concern for users emerges as one of the main factors associated with satisfaction. Several studies have argued that regular contact may give people a feeling of “social connection” . In otheConcerning suggestions for improving the program, the adolescents consider it essential to improve the attractiveness and design of the website. In this regard, the key aspects of the “Persuasive Systems Design Model” (PSDM) could be incorporated into the CTA program to improve adolescent use, adherence, and satisfaction . Many ofIn addition to improving the attractiveness and persuasiveness of the content of the website, the adolescents consider it necessary for them to be involved in the design of the intervention to encourage participation. The results of the focus groups pose the challenge of incorporating internet-based program activities that reflect greater proximity to adolescents and are more playful in nature. The adolescents also consider it important to have a higher level of presence and interaction with team members and other peers through the internet, engage in more face-to-face activities, and receive relatable information and stories. This type of strategy could offer adolescents a space of greater trust and closeness, as has been reported in other studies .With regard to technical recommendations, participants mentioned that e-mails are not an adequate way to contact them. This requires developers to use contact methods that are more familiar to young people and to prepare programs for migration to new types of networks and technologies that are being introduced while maintaining information security and privacy. Given the rapid penetration of smartphones in Latin America and elsewhere, the integration of app-based interventions may offer the potential to provide more widely distributed mental health care .In order to test the efficacy of the intervention and investigate the specific subgroups of adolescents who are most likely to use and benefit from the CTA program, a randomized controlled trial (RCT) needs to be conducted.Overall, this pilot study showed moderate to high levels of acceptance; however, adherence was lower than expected. This suggests that it is necessary to not only improve the intervention but also to increase its level of personalization so that students have an experience of greater identification and closeness so that users can take ownership of it and benefit to a greater extent.The program could be implemented in a variety of contexts, which opens up the possibility of thinking about interventions with a broader scope. This type of experience makes it possible to evaluate the feasibility of overcoming cultural differences and implementing interventions at the Latin American level, taking advantage of the shared language. However, the contradictory results of the program in Chile and Colombia suggest the importance of other variables beyond the content of the intervention, such as the setting or context of the intervention.In conditions of greater psychosocial adversity, it is recommended that: (a) the professionals implementing the intervention work directly in the institution to increase the familiarity and intensity of the process, (b) articulate the intervention with other institutional projects and activities, and (c) increase awareness campaigns on mental health and stigma.This pilot study conducted in two schools in Santiago, Chile, and two schools in Medellín, Colombia, showed high levels of acceptance of an internet-based program—“Cuida tu Ánimo” (CTA) (Take Care of Your Mood)—for the prevention and early intervention of depression in adolescence. However, our findings showed the need to improve the intervention by increasing its levels of customization, developing strategies to achieve better adherence, and considering the setting or context of the intervention. Furthermore, this feasibility study should be followed by an RCT to study the efficacy of CTA.


Cardiovascular diseases (CVDs) are health problems that demonstrate high death and prevalence rates, and exhibit large health inequalities across different socio-economic status. Although interest in community-based participatory research (CBPR) is increasing because of the efforts to improve health equity, not enough literature review has been conducted on CBPR-based CVD management programs. The objective of this scoping review is to identify the key elements that should be considered when developing CBPR-based CVD management programs, and explore the effects of CBPR-based CVD management programs.This study will use the databases of PubMed, Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) including grey literature. The criteria for selecting literature will be research that was published in or after 2000, applied CBPR, and either developed or implemented CVD management programs. No limit will be placed on the research design or method. Data extraction will be conducted independently by two researchers, and in the case of data mismatch, a consensus will be reached through discussion. The extracted data will be combined through narrative synthesis.This scoping review will identify specific methods in the development and implementation process of CBPR-based CVD management programs, as well as the characteristics of the programs that were shown to be effective. Therefore, it will be able to provide specific guidelines to researchers, government agencies, and local organizations to design and implement participatory health promotion programs related to CVDs.Open Science Framework 10.17605/OSF.IO/ZW2UYThe online version contains supplementary material available at 10.1186/s13643-021-01804-4. Cardiovascular diseases (CVDs) are one of the leading causes of death according to the World Health Organization and are believed to be responsible for 18 million deaths worldwide every year . Higher The CBPR is a community-based participatory research approach that involves a community’s members, leaders, and academic researchers as equal participants . In thisThe community capacity is known to be a mediating factor that decreases the gap between the health status and socio-economic status. Health promotion programs based on CBPR are grounded in this mechanism and aim to build community capacity through mediating variables like social networks, support, and social capital, thereby reducing health disparities and improving overall health status. Specifically, they emphasize the importance of addressing social determinants of health, which are defined as factors related to the social environment in which an individual is born, grows up, and lives, to reduce CVD risk factors and health inequalities arising from CVDs . The AmeMany previous reviews of CBPR in the health and medical sector are focused on specific ethnic groups such as Hispanics, African-Americans, Asian-Americans, and immigrants , 15, or The purpose of this scoping review is to identify the key elements that should be considered when developing CBPR-based CVD management programs and to explore the contents and outcome of the CBPR-based CVD management program.This scoping review was designed based on the scoping review methodology developed by Arksey and O’Malley  and reviWhat are the key elements that should be considered in the development process of a CBPR-based CVD management program? Focusing on establishing partnerships, applying CBPR principles, and using of field activistsA.How was the program structured and what were the outcomes?B.What were evaluated in the qualitative studies and how were the outcomes?What are the contents and outcome of the CBPR-based CVD management program?The research questions were divided into two streams through a preliminary investigation on the relevant literature. The first is the CBPR-based CVD management program development “process” and the second is about the “outcome” after application of the program. The 'outcome' is subdivided into quantitative and qualitative aspects.This study will use the databases of PubMed, Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). ProQuest Dissertation and Theses, and Open Grey will be searched for grey literature. We established the search strategies by examining in the abstracts and full texts of previous studies related to this study. The search terms “cardiovascular disease,” “vascul* disease,” and “CVD” for the target population were combined using the Boolean operator “or.” The search terms “community- based participatory research,” “participatory action research,” “CBPR,” “PAR,” “community engagement,” “community involvement,” and “civic engagement,” for the intervention were combined using the Boolean operator “or.” The Boolean operator “and” was used to further combine search results for intervention and target population. For a more comprehensive search, we searched all search terms in Medical Subject Headings, title, and abstract fields. The search strategies were presented in the Additional file In order to elicit answers for the research questions of this scoping review, we have determined the selection criteria for this review as shown in Table The studies retrieved using the search terms presented in the search strategy will be reviewed according to the study selection criteria. Two researchers will review the titles and abstracts of the studies independently and the studies that do not meet the criteria will be excluded under the agreement of the both researchers. If it is difficult to select the literature based on the abstract, the full text of the study will be reviewed to determine its selection. In the case where the two researchers disagree on the selection, the study will be selected after a consensus is reached through sufficient discussion between them. If a consensus cannot be reached, the study will be selected after discussion with a third researcher.The two researchers will extract data independently and compare their results. The data will be extracted using the standardized form in Tables The result of research question 1 — key elements for development of CVD management program based on CBPR — will be extracted using conceptual model that is taken from the CBPR quality assessment tool developed by Viswanathan et al.  and reviThe results of research question 2A — program structure and outcome — will be presented as the program content and measurement before and after the program. To this end, we will review the methods and the results of the selected research. The selected studies are expected to not only use various research designs, but also use several indicators such as health status, knowledge, and satisfaction. Therefore, we will describe pre-post changes to the indicators but not present summarized values. The outcome synthesis of research question 2B — program evaluation through qualitative method — will be described narratively.The quality of CBPR for the selected studies will be assessed. The quality of CBPR will be assessed using tools developed by Viswanathan et al.  and reviTo achieve the objective of this review to identify the key elements of the CBPR-based CVD management program and to assess the effectiveness of the program, we will take consultation from relevant experts on how appropriate the results of the review are. Specifically, we will organize a focus group of researchers or activists who have participated in CBPR, and we will conduct a focus group interview to confirm if the results from this review adequately reflect the needs or experiences of them.The objective of this scoping review is to examine the literature on CBPR-based CVD management programs, and thereby identify the key elements that should be considered when developing a CBPR-based CVD management program and assess the programs’ effects. This study will be the first scoping review on CBPR-based CVD management programs. As communities are units that not only share geographic boundaries but also identity, it is important to consider the unique environment and context . By examAdditional file 1:. Appendix. Search Strategies by the Electronic Database


Physical activity rates in cancer survivors continue to be low despite the known benefits and availability of evidence-based programs. LIVESTRONG at the Y is a national community-based physical activity program offered cost-free to cancer survivors, though is underutilized. We explored perceptions and experiences of staff and participating survivors to better understand program awareness, referrals and participation.n = 16), instructors (n = 4)] and survivors (n = 8) from 8 United States YMCAs took part in 30-min semi-structured phone interviews between March–May 2019. Interviews were digitally recorded, transcribed, and evaluated using a thematic analysis approach.LIVESTRONG at the Y program staff [directors (Program staff themes included: 1) Program awareness should be further developed for both the general public and medical providers; 2) Strong relationships with medical providers increased program referrals; 3) Electronic referral systems between providers and LIVESTRONG would help to streamline the referral process; and 4) Bi-directional communication between program staff and medical providers is key to providing patient progress updates. Survivor themes included: 1) Survivors trust their medical team and the information they provide about physical activity; 2) Providers need to incorporate an action plan and referrals for survivors to be active once treatments are completed; and 3) Personal experiences of those who participated in LIVESTRONG resonate with survivors and increase participation.LIVESTRONG staff reported the need for an integrated electronic referral system and bi-directional communication with providers about participant progress. Survivors want physical activity education, electronic referrals and follow-up from their healthcare team, coupled with peer support from other survivors. Cancer care provider knowledge and electronic referrals during and after treatment may expedite and increase participation in this community-based program. Among cancer survivors, regular physical activity may prevent cancer recurrence and lead to improvements in quality of life, fatigue, fitness, body composition, mood, self-esteem and physical function , 2. The P < .05), quality of life and fitness for survivors [LIVESTRONG at the Y is a national, community-based program that addresses financial and access barriers to survivor physical activity. Any person with a past cancer diagnosis, over the age of 18 years and medically cleared to perform physical activity is eligible to join. It is a cost-free evidence-based physical activity program shown to be safe and effective at increasing activity levels  and in high household income areas (n = 9) to ensure a representative sample by location. Emails were sent to 25 directors, across 15 US states. Of the 25 emails sent, 2 were undeliverable, thus out of 23 delivered emails, 16 program directors (69.6%) completed the study. Due to the location of the research team’s site, a greater sample of directors in Massachusetts (n = 7) were chosen based on prior relationships and potential sites for future work. Once a program director completed an interview, they were provided with a recruitment email from the study team to pass on to program instructors and/or cancer survivors who took part in the program. Interested instructors and survivors contacted the study team via telephone or email to perform a phone screening and subsequent interview if eligible. The lead researcher and interviewer (JF) were trained in conducting qualitative interviews. This study was approved by the Institutional Review Board at the University of Massachusetts Medical School.To ensure a variety of perspectives were captured, we conducted a qualitative study of LIVESTRONG at the Y Program Directors, instructors, and recent program graduates using 30-min semi-structured interviews between March and May 2019. Specific inclusion criteria included: 1) current LIVESTRONG at the Y Program Director or in a position of program leadership/supervisory role, 2) current LIVESTRONG at the Y Instructor, and 3) recent (within 3-years) graduate of LIVESTRONG at the Y. Participants were recruited in collaboration with YMCA-USA leadership, a group responsible for overseeing implementation of all the YMCA’s chronic disease prevention programs. YMCA-USA leaders sent all program directors an email of support regarding this study with contact information for our research team. The research team was granted access to the master list of program directors contact information. In prior work, we identified sites located in both low and high household income areas based on a median of $47,300 . Using tThis study was guided by the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) Framework , and sem. We used thematic analysis to identify, code, analyze and report themes within the data [All interviews were digitally recorded and transcribed verbatim, with any personal information deleted to preserve anonymitythe data . Data wethe data . Transcrn = 16) were female and had worked with the YMCA for a mean of 4.75 (2.34) years (see Table n = 4) of survivors heard about LIVESTRONG at the Y from their cancer care provider, 25% (n = 2) from family/friends and 25% (n = 2) from a cancer support group.Overall, 28 people participated in the interviews including 8 former program participants and 20 program staff. Of the program staff, 16 were program directors responsible for overseeing the programs recruitment and enrollment. The 4 program instructors were primarily involved in session programming and session planning, though also contributed to the recruitment and enrollment efforts. Program staff were from 8 states . Eighty percent  Program awareness should be further developed for both the general public and medical providers; 2) Strong relationships with medical providers increased program referrals; 3) Electronic referral systems between providers and LIVESTRONG would help to streamline the referral process; and 4) Bi-directional communication between program staff and medical providers is key to providing patient progress updates. Sample illustrative quotes are presented with each theme below:“The biggest thing, too, that’s lacking is really our promotion of the program. So, I know it seems like – of course people know about LIVESTRONG, but I’m here, and I see it, and I’m part of the Y. But anyone I ask outside of here from one of the different state – my friend moved to Texas. Her husband got cancer. She had no idea what LIVESTRONG was. So is it just ‘cause they don’t go to the Y, they don’t know about the Y?”Most program directors and instructors reported the need for more general public awareness about the LIVESTRONG at the Y, especially for those who are not members of a YMCA. One program director noted:An instructor concurred:“I think a lot of it is just building that awareness that the program exists, because there are plenty of people that could take advantage of it in our area within the seven counties that we serve, but the word really isn’t out there, and I think that’s what I need to do.”“So we send them  the information, and then a lot of it is people that are still in treatment go back and talk to their oncologists how great this program has been for them, and then the oncologist sees that and really starts speaking toward it. So we have a lot of support in that sense as well.”Many program directors and instructors reported that they had relationships with some medical providers in their area to help facilitate referrals. These included a number of providers, including oncology, primary care, and nurse navigators. One staff member noted:“We work with some nurse navigators, and actually it’s been kinda nice, because the nurse navigator that sends us the most referrals has went through our program as well. So she’s a huge advocate for our program. We have an oncologist in the area that is a huge advocate for our program as well and tells all of her patients about it. And then a cancer service center in the area puts our information and our class list, upcoming class list, in their newsletter every month. So, that’s been helpful as well.”Another program director agreed:“it’s word of mouth, doctors, the ones that we do have that connection with our program. We have a signature event in November at our hospital – and those’re a lotta the oncology doctors. So they’ll do referrals, but it’s not all doctors definitely know about it.”A few program directors spoke to their efforts to educate providers, including educational sessions and visiting sites/sessions to view what participants do in the program.“I’ve talked to nurse navigators, and I asked, “Why don’t you push or program?” Come and see what it is I want you to push for your patients. If you wanna go through the entire intake process, I will take you through that so that you know what they can expect. If you wanna see a class who’s running, come and play with us. Bring some tennis shoes. Come work out with us. Come watch us from the doorway, whatever it is you wanna do, talk to our participants, anything.”Another program director concurred:“If we could do doctor referrals online... There’s just a link for them to go do all this, that’s – saves a lotta time on our end.”“I know we’ve even looked into a system which connects doctors and patients to different programs, depending on their condition, what outcome they’re looking for and their location. So, we haven’t really progressed as far as how we can apply it. But the intention is to find some way using technology to make this process easier and really value the time that we have.”“I think maybe the patient portal would be awesome or, a mass e-mail from the hospital –I’ve noticed is if it comes from their medical staff … they are more likely to try it, to sign up for it.”Several instructors and program directors reported that using an electronic referral system would save time and provide ease for providers to refer patients to programs:“Having an electronic referral system, where I could get a little popup window that somebody’s been referred through a secure network, here’s a medical release and the contact information. If I get medical releases without any sort of information about a patient … I really value that intake to see if this is the right fit for them at that time.”One program director noted the importance of being able to include personalized feedback on the patient’s status into the referral form.“Some of them (doctor’s) are starting to send an actual medical referral over to us saying that they told somebody that they need to be in this program. … I know some other Y’s actually did that in an electronic referral system. Their doctors or their cancer center made them a referral option, and they send referrals that way to them.”One program director reported hearing of others using an electronic referral system for providers to directly refer patients to the program:… thinking about some kind of platform, too, that really allowed a provider to see what their patient is doing, kinda almost in real time, some kind of electronic system so that it doesn’t have to be this fax and call and things of that nature...”“Program directors reported wanting to provide feedback to providers in real-time, using an electronic platform in an ideal referral scenario:“… we also give them (oncologists) a feedback report as well. We created a generalized feedback report, which says, “Your patient, date of birth, enrolled or completed in X program on this date,” or, “Program was unable to participate. Participant dropped out,” … so that the oncologist or the physician or whoever knows where the patient ended up and have that feedback report from us”.Some program directors reported having success using a system to provide feedback to their participants’ providers:“… one of the things that we incorporated that was really beneficial … when our referrals started to take off is we created a report pre- and post-assessment of the fitness-assessment data. And we faxed it to the doctors with the participants’ permission. That’s when we really started to see doctors referring.”Another program director suggested increased communication led to greater referrals:For survivors interviews, 3 themes emerged: 1) Survivors trust their medical team and the information they provide about physical activity; 2) Providers need to incorporate an action plan and referrals for survivors to be active once treatments are completed; and 3) Personal experiences of those who participated in LIVESTRONG at the Y resonate with survivors and increase participation. Sample illustrative quotes are presented with each theme below:“Well, certainly hearing from it from my medical team that everybody – I assume everybody pays close attention to their medical team, especially when you get a diagnosis of cancer. It’s serious. So you listen to ‘em. You pay attention to them.”Half of the survivors interviewed heard about the program through a medical provider. Many credited their medical team and providers for decisions made throughout their treatment. They emphasized how important their providers were and the magnitude of the information they would relay to them:“I believe that people, docs, nurses, PCAs in the clinic should be made aware of it, maybe even a little seminar or something, “Hey, this is available to your patients. Please, when you’re speaking to them, mention it to them. Give ‘em a brochure.” It’s a matter of getting the word to people. Some of your people in cancer treatments got enough on their mind to think about some other thing, but if somebody presented to them, then certainly that’s gonna help”.Another survivor noted providers are best-suited to make referrals:“It might’ve been helpful to have been handed something from either the doctor, the oncologist, or the hospital shrink they made me go talk to. – I spent a lotta time online.. a lot of the cancer links bring you to the LIVESTRONG organization. And nowhere did I see something (about LIVESTRONG at the Y) … ..It must be overwhelming to people to be told, “We’ve gotten rid of the cancer, but it might come back, but now you need to get yourself in shape,” and not really understand what that all involves, the life changes that that all involves.”Survivors who didn’t hear about it from their medical provider felt that it would’ve been helpful to get a referral from them:“I can only speak for myself from a transplant standpoint … the doctor, the PCA, the nurse, somebody from pharmacy, they come into your room to get you ready to leave and go home. Well, it’s part of that whole discharge process. Shouldn’t that be in there about LIVESTRONG?”Most survivors reported wanting to hear about programs available to them when they completed their treatment. They mentioned the timing of after completing treatment or after a transplant as being the opportune time for medical providers to intervene.“… it was an exit appointment almost, not quite an exit interview, but I think about it similarly like a survivor, “Here’s your next steps after you’ve gone through surgery …. This is offered to you.” So at (name) clinic it was a nurse, and then it was – at my local cancer center – I believe she’s also a nurse, but it was a survivorship appointment, where we reviewed my diagnosis and the treatment that I had, and moving forward, what’re my next steps, and then also here’s a program that’s offered for you.”Another survivor concurred about their last appointment at their clinic:“I think probably primary care would be the best and that’s a person that you probably pretty much would trust or at least give credence to it and know if the next time you see them they’re gonna ask you, “Did you do that? Did you think about there’s gonna be a follow-up?” whereas, that oncologist, they’re not gonna follow up on that.(Name) clinic goes through this. It’s sort of a perfunctory final visit, and I have to tell you – it was so unimpressive. I can’t even tell you what they covered, but it was this long interview. I don’t know what was the purpose. I think it was for collecting data, not for really helping people … and it was boring and useless.”One participant noted that she would like it to come from her primary care doctor, as her final visit with her oncologist was not helpful.“I would think that if there was some sort of contact made through your medical group … When you’re at the point when you begin to say, “How am I gonna recover from this? How am I gonna get back to normal physically?” is when it would be helpful to have someone have a routine call to say, “We have this available.” … I guess that you’d have to do it through your doc, because how would the Y know that you were a candidate?”They also wanted to know from their provider if they were physical ready and able to complete a program like LIVESTRONG, not knowing exactly what it entailed.“The thing that would’ve made it easier was what we would do and what the program was – how it was structured and if I was physically ready for it. I think that was my big unknown. And then after the first meeting or session, I guess, all of my fears were put completely at ease. It was like, we’re gonna help you do what you can do in this way. So that was really helpful, but I was definitely curious before we started. What are we getting into here, and will I be able to do it?”Another survivor concurred about how it would’ve been easier to be referred to LIVESTONG:“they (LIVESTRONG) always send out at the beginning of the year, “Hey, here’s our schedule. If you know anybody with cancer” – and I have referred some people to the program.”Several participants reported being able to refer other people they knew who had cancer to the program would be helpful as it was to them.“I would say that if you have all the materials and all of those things, with all the technology right now, I can forward that information to that person, because I’ve been there. Even if all those information are there, I think there is such a thing about speaking personally to that person, telling your experience, and it makes a lotta difference, right?.”Some survivors noted that hearing personal experiences from other survivors would be helpful in understanding what the program consisted of and how it could relate to them.“… but it’s the specific nature of LIVESTRONG. If that is described to people, I think it has a much greater chance of success than just in general describing it as a “get back and get fit” program. The fact that it covers every single possible way that a body could move and get back and fit and that you get to try it all, that’s the Number 1 thing about that program that makes it really the success that it is or the success for me that it was.”Survivors notes the description of the program would be helpful when being referred:This study was the first to examine perceptions and experiences of recruitment and referrals to a community-based physical activity program for cancer survivors from staff and participant perspectives. Twenty LIVESTRONG at the Y staff and 8 survivors completing the program participated in semi-structured interviews exploring their experiences with program referrals. Both staff and survivors described low levels of awareness of LIVESTRONG at the Y across multiple levels; knowledge and awareness were perceived as low among the oncology teams, the broader medical care teams and the greater lay community. Many staff reported rigorous outreach to providers through in-services, emails, flyers, phone calls and session visits. However, both staff and survivors noted the preferred method of referrals from and communication with providers was through an electronic referral system. Survivors also made note of the importance of identifying with other survivors in order to increase participation in the program.Program directors discussed many ways in which they attempted outreach and education to providers, though felt it was difficult to communicate with them. Consistent with our findings, prior studies showed a lack of effective ways to communicate physical activity education and awareness to cancer care providers , 16. HowMost survivors preferred to hear from someone on their oncology team, though one survivor preferred to hear from her primary care physician due to the continued follow-up care she would receive from them. Many of LIVESTRONG at the Y staff reported strong relationships with oncologists and those in the oncology clinic as compared to primary care physicians. Transition of care between oncology and primary care has been a longstanding gap in care . Cancer Though we found medical providers to be the top and preferred referral source, many participants (and program staff) mentioned the importance of relating to those who had completed the program. Peer support may provide emotional, informational and appraisal support to others and has been shown to be beneficial during weight management, alcohol and smoking cessation programs , 25. SpeThere are several limitations to this study. Snowball sampling for instructors and program graduates may have led to unbalanced demographic characteristics of the population. However, since we only used snowball sampling to reach instructors and survivors participating in the program, we were still able to reach a more diverse population of YMCA Associations overall. Due to this approach, we also do not have access to the number of emails sent out to potential instructors and survivors and are unable to calculate the response rate for these two groups. This approach may also lead to selection bias. It is possible that those who had good/better experiences with the program (staff and participants) were more likely to respond, thus limiting participant representativeness. As previously noted, more than half of our participants were from Massachusetts and responses may differ between states based on state guidelines, steering committees, and action plans. We also only interviewed a small portion of survivors who took part in the program. Which may limit our generalizability. To generalize our data, we used a representative sample of both high and low household YMCA areas, though future trials should assess variations in participant responses by household income status. Future research will seek information from those who were made aware of the program but did not participate, or those who were never made aware of the program. We interviewed a large sample of program staff, though concluded our instructor interviews after six to prioritize reaching program directors, as they had more control over the recruitment/referral process.As the number of cancer survivors continues to grow, efforts must be made to address reported patient, clinical and community-based program barriers to increasing survivor’s physical activity. A systematic surveillance, education, referral and follow-up pattern integrated into clinical workflow of oncology, in coordination with primary care, may increase the number of survivors referred to evidence-based programs. This may be augmented by the support of peer cancer survivor champions or advocates during the referral process. As stated by Courneya and colleagues, it is critical to design approaches to translate physical activity in cancer survivorship into “real world settings” using dissemination and implementation research . These a


In 2012, VA Central Iowa developed a novel program known as the Behavioral Recovery Outreach (BRO) Team to address unmet needs of our aging Veteran population with complex medical, psychological, neurocognitive and behavioral concerns. BRO Teams provide evidence-informed treatments in inpatient VA settings, and transitional care/support post-discharge to ensure successful placement and stability in the community. We will discuss how implementation science informed the expansion of this model from a local pilot to a nationally disseminated program. We will explore the challenges of ensuring program fidelity while fostering innovation and adaptation. Given the challenges of national dissemination, we will highlight the predicted and unforeseen aspects of program evaluation and policy implications. Finally, we will discuss the impacts of the COVID-19 pandemic on delivery of care methods and community-based interactions, as well as how this program has improved the lives and quality of care for this high-risk Veteran population.


The community health worker (CHW) asthma home-visiting model developed by Public Health-Seattle & King County (PHSKC) is an evidence-based approach proven to improve health outcomes and quality of life. In addition, it has been shown to be an effective and culturally appropriate approach to helping people with asthma understand the environmental and behavioral causes of uncontrolled asthma, while acquiring the skills they need to control their asthma. This paper describes the development and implementation of training curricula for CHWs and supervisors in the asthma home visiting program. To facilitate dissemination, this program took advantage of the current healthcare landscape in Washington State resulting from Centers for Medicare & Medicaid Services (CMS) approval of the 1115 Medicaid Waiver project. Key aspects of the training program development included: (1) Engagement: forming a Community Advisory Board with multiple stakeholders to help prioritize training content; (2) Curriculum Development: building the training on evidence-based home-visit protocols previously developed at PHSKC; (3) Implementation of the training program; (4) Evaluation of the training; and (5) Adaptation of the training based on lessons learned. We describe key factors in the training program's improvement including the use of a community-based participatory approach to engage stakeholders at multiple phases of the project and ensure regional adaption; combining in-person and online modules for delivery; and holding learning collaboratives for post-training and technical support. We also outline our training program evaluation plan and the planned evaluation of the home visit program which the trainees will deliver, both of which follow the RE-AIM framework. However, because the COVID-19 pandemic has curtailed training activities and prohibited the trainees from implementation of these CHW home visit practices, our evaluation is currently incomplete. Therefore, this case study provides insight into the adaptation of the training program, but not the delivery of the home visit program, the outcomes of which remain to be seen. Asthma is a chronic condition that impacts the lives of ~1 in 12 Americans and over 24 million people in the United States . In WashMany of the drivers of asthma morbidity are factors related to low socioeconomic status, such as transportation, language, and financial barriers; poor access to primary health care services; and environmental exposures to allergens and irritants including second-hand smoke , 8–13. MThese multicomponent home visit interventions for asthma led by CHWs have been shown to reduce morbidity from asthma and result in cost savings to the overall health care system –16. MultPublic Health-Seattle & King County (PHSKC), the health department of the most populous county in Washington State, has prioritized reduction of asthma health disparities using a CHW-led intervention model. The CHW program at PHSKC has many years of experience in development and implementation of CHW-led public health programs for asthma, including five research studies spanning from 2004 to 2015 , 18–21. This success motivated us to scale up the CHW asthma home visit model used by PHSKC to other communities throughout Washington State. Historically, there has been no sustainable funding source for such a project. However, the recent initiation of the $1.5 billion 1115 Medicaid Waiver project in Washington created an opportunity . The WaiThe project described here is hosted by PHSKC with four primary implementation partners within western Washington: three ACHs  and one Federally Qualified Health Center , a safety-net provider with clinics in nine counties in Western Washington . These pWe sought to train the CHWs connected to these regional hubs on the delivery of the evidence-based asthma home visiting program. However, we realized that our CHW program had 25 years of development and infrastructure that may contribute to positive results not easily replicable by other programs. In order to boost regional program effectiveness and sustainability, we decided to develop a program manager/supervisor training as well. This training would be built on the principles of best practices in creating supportive and sustainable CHW programs –26.The development and implementation of our training program followed five phases: (1) Engagement: we establish our community advisory board, partnership, and infrastructure for decision-making to support throughout the project. (2) Curriculum Development: we develop our training curriculum. (3) Implementation: we host our first trainings. (4) Evaluation: we measure and assess how the trainings were received. (5) Adaptation: we iterate phases 2, 3, and 4 applying improvements based on learnings from the implementation and evaluation stages. This manuscript is intended to present the proposal, design, and development of a training program, following many years of research and development of the program. At the time of submitting this manuscript, we are between phases 4 and 5. Therefore, we present some initial  outcomes and our plan for the Adaptation phase. This work was funded by the Patient-Centered Outcomes Research Institute (PCORI).Our work approaches community, program development, and research based on the principals of community based participatory research (CBPR) . Using tOur initial step was to convene a Community Advisory Board (CAB) consisting of key stakeholders who would provide guidance and increase local engagement. The CAB included representatives from our priority patient populations, CHW and supervisor teams, Washington State's Department of Health CHW program, local managed care organizations and Medicaid, a Federally Qualified Health Center, PHSKC, and three additional regional ACHs. Three CHWs from PHSKC served as lead educational consultants, and a University of Washington research group specializing in producing online, interactive medical training resources provided expertise. The CAB was representative of both new stakeholders as well as partners who were involved in our recent PCORI-funded randomized trial. This was intentional so that the diversity of experiences and expertise from our partners would enable adaptation within local contexts and provide a feedback loop regarding implementation challenges and opportunities. Authentic engagement, clear communication, and shared leadership with patients and other stakeholders in all project phases was considered critical to the project's success.We held regular monthly CAB meetings during which we created working groups for different tasks, and encouraged active participation toward four primary goals: (1) improve the scope and design of the training program to meet the needs of the various project partners; (2) develop, tailor, and deliver the support structures needed by the CHWs, program supervisors and organizations implementing the model; (3) provide input on the design of the evaluation of the training program, and (4) engage stakeholder end-users and funders to determine opportunities for continued spread. Participation in CAB meetings ranged from 20 to 30 in attendance, beginning in March 2020 and continuing to the present.Participation in the CAB was compensated with an annual stipend offered to our four project partner agencies through funds from our PCORI grant. The amount was calculated based on the anticipated staff time and resources, and use of the stipend was not restricted. In addition, we developed several additional entry points for engagement that were fully compensated. Each site was encouraged to identify at least one CHW, one program manager, and one person with asthma from their region to sit on the CAB. We also budgeted for interviewing program recipients in each region to provide feedback on the program aspects they experienced, compensating them for their time.After assembling the CAB, we conducted an in-depth examination of the existing evidence-based CHW asthma educational and environmental protocols at PHSKC and resources on CHW supervision to create a comprehensive foundation on which to build the new curriculum. We strategized with the CAB to narrow down the protocols to those most relevant and useful, and to identify gaps in information. The resulting protocols were then modified into a format appropriate for an in-person 2-day training for CHWs. Selected content was converted into a multi-media interactive online tutorial for asthma-focused CHWs by our partners at the University of Washington.In order to assist the integration of CHWs into their teams and to increase the sustainability of the project, we also designed a training specifically for CHW supervisors. We used the same strategy described above to develop a curriculum for a 2-day training for CHW supervisors.During the monthly meetings of the CAB, we worked together on the above curriculum development tasks and solicited feedback on the materials developed. The CAB provided invaluable feedback regarding potential implementation challenges and opportunities for continued dissemination of this model. For example, one of our primary partners noted that their CHWs primarily work with asthma patients who also are experiencing homelessness. Based on that feedback we incorporated information in our trainings on how CHWs can be innovative when it comes to delivering the asthma intervention protocols in situations where traditional housing or indoor shelter is not an option.chw.uwimtr.org), to be followed by an in-person training, covering the topics listed in The application of a community-based collaborative approach paired with an adult learner-centered curriculum development process resulted in a training tailored to support CHWs focused on asthma and their supervisors. This process yielded a collection of online tutorials intended for independent, self-paced study , but no data regarding the home visit intervention. The evaluation will continue when in-person asthma CHW activities are allowed to resume.In January and February of 2020, we delivered two in-person CHW trainings and two in-person CHW supervisor trainings, rather than the planned four trainings for each group (one for each ACH region). Our initial plan to hold separate trainings in each ACH region was modified once we discovered established venues that were convenient to multiple regions, allowing us to consolidate to two locations. A total of 60 individuals attended a training. This initial cohort of trainees were representative of over 12 different organizations including health departments, local neighborhood groups, community-based organizations, and managed care organizations. The training was provided in Spanish and English as planned.77% of CHWs (24 out of 31) were extremely clear about the takeaway points.91% of supervisors (32 out of 35) were extremely clear about the takeaway points.74% of CHWs (23 out of 31) thought the presentation of information was extremely clear.89% of supervisors (32 out of 36) thought the presentation of information was extremely clear.71% of CHWs (22 out of 31) were rated their confidence 8 or higher for their ability to apply what they learned at work .91% of supervisors (31 our 34) rated their confidence 8 or higher for their ability to apply what they learned at work Initial results from surveys of training participants showed the following:Interviews revealed that overall, there was a positive experience with major elements of the training such as food, environment, location, built confidence, facilitation, activities, interactivity and engagement, and room set-up and rotation. When speaking about the facilitation, one participant stated, “I think any time you have a training that's gonna be 16 hours over two days and there's a lot of material to cover, the facilitation makes or breaks the training. And they were just so personable and open, and asked pertinent questions and waited for the replies that needed to come out. I didn't feel pressured in any way to perform or not perform. I think the facilitators make or break any training, and they were exceptional.”CHWs especially felt that the motivational interviewing, visual aids/diagrams, role playing practice and the background was helpful. One CHW stated, “What will help me are the handouts that they gave us on ‘What is asthma?' and ‘How do we breathe?' [and] on why it's important to have controlled asthma and the importance of what the inhalers do. The actual visual diagrams I think will help clients understand ‘Oh yes, this is important', since they'll be able to see how it affects them when they are having an asthma attack, what actually is happening inside their lungs.”Several areas for improvement of the training program were identified. For example, feedback from the CHW training showed the desire for a refresher course online, funding for supplies, instruction on topics beyond asthma, and avoiding repetition of the online module content. Supervisors suggested slowing the pace of the training, providing tools that can also be applied to other chronic conditions, and spending more time on best practices for supportive supervision. One supervisor also suggested including a half-day overlap with CHWs to share learnings.This report has outlined the development of a training program to teach CHWs and CHW supervisors how to deliver an asthma home visit intervention built on an evidence-based, cost-effective model in Washington State. The scale-up of this approach took advantage of the state Medicaid Waiver program, which is likely to accelerate its integration into the health care system and improve its sustainability over time. Our use of a Community Advisory Board from the very early stages of the project enabled us to identify opportunities for adaptation of the proposed training to the settings in which it would be delivered, and offered invaluable feedback on what was and was not working. Following the trainings, the monthly Learning Collaboratives allowed ongoing engagement and review of skills, which is also expected to improve effectiveness and sustainability. The iterative nature of the curriculum design allows for continual improvement of the program over time. While not all states are participants in a Medicaid Waiver project, the other community-based participatory methods described here may still be applicable for other organizations seeking to scale up CHW home visit models across different settings in their state.Throughout the implementation of this project, we learned several lessons which will help to improve future iterations of the program. Firstly, changing conditions during the pandemic reinforced the importance of flexibility and willingness to adapt program implementation to the setting. Since the COVID-19 pandemic started in our region very shortly after our in-person trainings, many trainees were unable to go back to their communities in person and immediately apply their new asthma education skills. As the pandemic continues and some attention shifts back toward non-COVID-19 health concerns, we are encouraging our trainees to begin conducting virtual asthma visits as a way to resume providing this service. We are also developing ways for trainees to refresh these asthma skills remotely. Another invaluable lesson was the tremendous utility of soliciting feedback from both the community and CHW participants early on and frequently. This provided the insight we needed into the needs of each individual community, such as a focus on managing asthma during housing instability, or the importance of obtaining funding for program supplies. Recognizing the challenging and complex environments the trainees were working in was essential to adapting the training appropriately.Our program has a number of limitations which are important to consider. Firstly, the training capitalized on the Washington Medicaid Waiver project. While any state can apply for permission to pursue similar projects through the Centers for Medicare and Medicaid Services, they do not currently exist in every state, which limits the generalizability of our program design. Additionally, our program is funded by an outside source (PCORI). In accordance with PCORI values, we have done our best to avoid direct compensation for program aspects that would require coverage by an employer or the health system to be sustainable. However, we have offered compensation for the CAB and the training program staff, and the training and materials are offered free of charge, which raises concerns for sustainability. The Learning Collaboratives are also dependent on this funding as it provides for program staff. Because of this, our team has been exploring avenues of more sustainable funding, including the potential for Medicaid reimbursement of material costs and CHW time, but this issue has not yet been resolved.Despite these limitations, our case study has shown that a community-based approach to curriculum development and improvement can produce a training program that is adaptable, engaging, and valuable to participants and has the potential to produce CHWs competent to deliver high-quality, effective home visit interventions for asthma. The coronavirus pandemic has limited the ability of our trainees to implement their training, but our program is adapting with the creation of protocols for virtual visits. The next steps include evaluation of the effectiveness of our trainees' services, and further refinement of the training program design. Through this community-based, adaptive approach, we hope to harness the proven effectiveness of CHW-led home visits to address asthma in a way that is culturally acceptable and cost-effective, and addresses some of the root causes of asthma-related disparities.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by University of Washington Institutional Review Board. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.JS, BW, and CK contributed to the conception and design of the program and evaluation plan. NE, JS, KB, and CK implemented the program. NE wrote the first draft of the manuscript. NE, MC, KB, and CK wrote sections of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This study on the gross anatomy of the West African giraffe's hind limb was aimed at investigating the unique morphological features and number of bones making up this region of the skeleton. Two (2) adults obtained as carcasses at different times after postmortem examination were prepared to extract the bones via cold water maceration for use in the study. The appearance of the ossa coxarum and its features presented similarities to that of the horse. However, differences were evident in the convex cranial border of the ilium, small less prominent coxal tuber, and wider interval between the opposite sacral tuber and an oval obturator foramen. Common features reported in most species such as the gluteal line and psoas tubercle were absent. The long femur presented proximally; the greater trochanter connected obliquely via the trochanteric crest to the lesser trochanter. The supracondyloid fossa, obliquely directed medial condyle, and trochlea with two unequal ridges were presented distally. The fibula was absent while the tibia was typical of ruminant presentation with one popliteal line and no muscular lines on its caudal surface. The five (5) tarsals were arranged three proximally and two distally. One (1) metatarsal (3rd and 4th fused) presented two condyles that anchor two (2) digits with 3 phalanges and 3 sesamoid bones each. The total number of bones making up the hind limb was accounted to be 45. In conclusion, this study has provided a baseline data for further biological, archeological, and comparative anatomical studies. Giraffa camelopardalis), the tallest living terrestrial mammal and largest ruminant, is a representative of the Graffidae family of the order Artiodactyla consisting of one species having multiple subspecies [The West African giraffe  carcasses weighing 1,070 kg and 812 kg were obtained after postmortem from the Department of Veterinary Pathology, University of Ilorin at different periods of time. This small sample size is permitted and quite understandable given that giraffe carcasses are not commonly available for scientific research. They were transported to the Veterinary Anatomy gross laboratory, University of Ilorin, Nigeria, for bone preparation as museum specimens. They were carefully defleshed using sharp knife and scalpel blades. The skin was removed, and muscles teased out, leaving the bones with minimal soft tissue attachment before being transferred to a large container of cold water enough to submerge the bones at room temperature. The container was covered airtight and placed away from the sun throughout the period of maceration with regular change of water. After completion, the bones were recovered after draining, and sun dried. Photographs of recovered bones were taken individually. They were also articulated using glue, noting the bones that constituted the pes of the hind limb.Two  West African giraffe (The hind limb comprised of bones of the hip (ossa coxarum), thigh (femur), leg (tibia and fibula), and pes . They exhibited general and peculiar features similar to and different from the bovids and equids. The average number of bones of the hind limb was found to be 45 as shown in ilium presented a wing cranially and a body caudally that extended to form the cranial part of the acetabulum. The wing presented two surfaces  with a convex cranial border, concave medial, and lateral borders. It formed the sacral and coxal tubers at its medial and lateral angles, respectively. The dorsolateral surface was smooth while the ventral surface presented an inner auricular area (for sacrum articulation) and an outer quadrilateral area. On the ventral surface of the body cranial to the acetabulum, it presents a fossa  of the tarsal bones were similar to the those reported in other ruminants . The shaGiraffa camelopardalis peralta) presented the numerical and morphological information on bones of this animal skeleton highlighting specific features, similarities, and differences from other ruminant and domesticated animals.This study on the gross anatomy of the hind limb of the West African giraffe (


More and more people survive cancer, but the disease and its treatment often lead to impairment. Multidisciplinary ambulatory oncological rehabilitation (OR) programs have thus been developed. SW!SS REHA, the organization of major Swiss rehabilitation clinics, has defined ambulatory OR quality criteria for its members (about 50% of the Swiss rehabilitation capacity). However, SW!SS REHA criteria are not fully implemented and/or interpreted differently by different specialties or in different linguistic regions in Switzerland. The aim of our study was to carry out an online survey of existing outpatient programs to define quality criteria for an ideal OR program in Switzerland.A mixed methods approach was used for the survey—qualitative and quantitative. The qualitative part consisted of a guided discussion with OR experts and the quantitative part of an online survey. The quantitative part comprised the development and evaluation of an online questionnaire. It served to record the opinions of OR centers in Switzerland on the desired situation of outpatient rehabilitation.Eighteen OR centers and 71 (49.7% response rate) OR actors participated in the online survey. The survey results indicate that some of the SW!SS REHA quality and performance criteria only partially match with the desired OR criteria for Switzerland. Key disparities occur particularly in the program design and structure and specifically around how many interventions are required to constitute an OR program, the extent of standardization versus individualization of the program, i.e., how many and which modules in a program should be obligatory, and finally the duration and intensity of the program. The online survey did not generate any statistical evidence that OR requirements vary significantly between different linguistic regions and among different specialties.Cancer patients are heterogeneous with respect to cancer type, prognosis, and disability level, such that a standard program cannot be uniformly applied. Therefore, a flexible program is required with few mandatory modules and additional individual modules to achieve the threshold number of modules that would constitute a multidisciplinary OR program. Intensity and frequency of OR needs to consider the health state of the participants. The results indicate a need to modify some of the existing SW!SS REHA criteria to ensure that more patients can gain access and benefit form evidence-based OR interventions. Furthermore, the survey provides important findings so that the existing OR offer can be improved with the goal that OR centers will be able to be quality certified in the future.The online version contains supplementary material available at 10.1007/s00520-020-05913-z. More and more people in Switzerland are diagnosed with cancer due to increasing life expectancy, but thanks to improved early detection and better treatment options, more and more people are surviving a cancer diagnosis. For 2015, the number of cancer survivors in Switzerland was estimated at 317,000 and are continuously increasing , Australhttp://www.swiss-reha.com/). It has previously defined ambulatory oncological rehabilitation (OR) quality criteria for its members. However, it has been observed that the SW!SS REHA criteria are not fully implemented and/or interpreted differently by different specialties or in different linguistic regions in Switzerland . The aim of this project was therefore to establish the basis for the desired outpatient OR program from the providers’ point of view and, if necessary, for recommendations for adjustments to the SW!SS REHA criteria.In Switzerland, cancer-specific rehabilitation programs have mainly taken place in an in-hospital setting. Because of the increasing number of cancer patients, changing patient wishes and changes in financial conditions, the number of centers offering oncological rehabilitation in an outpatient setting in Switzerland has steadily increased over recent years. However, these programs are inconsistent in their design and often poorly coordinated. SW!SS REHA is an organization of major Swiss rehabilitation clinics, covering about 50% of the Swiss rehabilitation capacity of any medical specialty  and a guided discussion among Swiss outpatient OR providers  aiming aMost of the questions were closed with both single choice and multiple-choice answers appendix . As neceIn a first phase, the questionnaire was reviewed by members of the project team and tested. The revised version of the survey was tested once again. The German version was then translated into French and Italian and the translated questionnaires were cross-checked with respect to language.n = 145). The invitees of the online survey included oncologists, internists, physiotherapists, exercise/sports therapists, nutritionists, psycho-oncologists, social counselors, complementary medicine specialists, nurses, pain therapists, pastoral care, somatic therapists, and OR coordinators. The survey was conducted in April 2019 using “Survey Monkey ®.”All 18 ambulatory OR centers operating in March 2019 in Switzerland were invited to participate. All OR centers provided a list of employees, which were invited by e-mail to participate in the online survey , a guided discussion [8] and the different perspectives of the OR centers and actors, it was decided to analyze the results of the online survey with three language region variables  and by three professional groups. These included the two largest participating groups consisting of physiotherapists and oncologists as well as a third mixed group of all the other participating specialists.Data were analyzed using MS Excel. A descriptive statistical analysis of the survey results was conducted. As the questions in the questionnaire were frequently of a single choice nature and the variables to analyze were categorical, the chi-squared test was used to test for differences between subgroups of the study population. No test was conducted if multiple replies per question were possible.From the 145 individually identified OR professionals, 71 (49.0%) responded. Among the responders to the survey Table , there wOf the participants, 91.4% stated a medical doctor should lead the OR Table . FurtherThere is no clear consensus regarding the length of experience necessary to lead the management of the OR. 60.9% of physiotherapists and 48.5% of oncologists considered at least 1 year of experience is necessary. Only one quarter of respondents considered that a full 2 years of experience are necessary. According to the free text answers, it was considered that after 1 year of experience, a certain understanding of OR has been achieved and adequate knowledge acquired to be able to lead the service.The information flow for the OR team coordination should be supported ideally through an electronic patient dossier (43.7%). To the question, how often a rehabilitation team discussion should take place, the most frequently given response was once a month (45.1%).Regarding generic screening instruments to measure the need for rehabilitation, there was no dominant instrument and the preferences were split between Functional Capacity Assessment (EFL) and/or Edmonton Symptom Assessment Score (ESAS) and/or WHO Disability Assessment Schedule (WHODAS) II and/or Eastern Cooperative Oncology Group (ECOG)/Karnofsky or adapted ECOG, and/or distress thermometer Table . From thThe view on the value of specialty specific instruments for measuring progress and goal achievement across all specialist groups was three quarters in favor (77.5%). Among the three specialty groups, the value of specialty specific instruments was perceived differently Table . WhereasThe preferences were split between a fully individualized modular program or a combination of partly standardized (core modules) and partly individualized according to specific needs Table . These rThe core modules that were considered by most participants to belong to a standardized program were physiotherapy (66%) and exercise and sports therapy (76%). In the cases of nutritional counseling and psychotherapy/psycho-oncology, approximately half of the respondents considered these modules as part of a standardized program. The remaining modules were considered by the majority to be elective and based on individual need. These included social counseling and support, complementary medicine, occupational therapy, sexual counseling, creative therapy (painting and music therapy), speech and swallowing therapy, and pastoral care. There were no apparent deviations in any of the answers to these questions from the respondents according to their specialty or language region.The quantity of ambulatory rehabilitation that a patient can cope with during the oncological treatment was quantified in the questionnaire during and after the acute phases of treatment. For patients who have ongoing acute treatment, the median number of modules was two per week corresponding to a median duration of rehabilitation of 120 min per week. Following completion of the acute treatment, the median number of rehabilitation modules that can be completed increased from two to four modules per week with a total duration of OR which increased overall from 120 to 180 min. The median of 4 was consistent across all specialties and language regions apart from the oncologists where the median was 3.The desired total length in weeks of the ambulatory physiotherapy was investigated in the survey for both an individual modular program and for a standardized program. For both an individual modular program and for a standardized program the median length was recorded at 12 weeks. This was strongly supported and consistent for all specialties and language regions.The definition of an interdisciplinary ambulatory program and the minimal number of modules to fulfill the definition was surveyed. Overall, for an ambulatory program to be considered interdisciplinary, the median number of modules on offer should be at least four, with the patient completing at least 3 modules during their OR program.Overall, there was no clearly preferred system among the different specialties Table .Table 6FThe pattern of responses was quite similar across the three language reasons. The only apparent outlier was in the French-speaking region, where the flat rate billing model was preferred by more than half of this group.The survey checked on the need for certification of the OR program. Almost all respondents (94.2%) were in favor of a certification of the ambulatory program for oncology; reasons being recognition by patients and stakeholders, guarantee of quality of the program, and delivery of a standardized program, but also improved program financing and reimbursement.The objectives of rehabilitation are the improvement of functional limitations and improvement of activities in everyday life, in the world of work and in participation. To support these objectives, SW!SS REHA has defined quality and performance criteria to govern the set up and deployment of multidisciplinary OR programs and interventions in Switzerland , 11.In contrast to cardiac rehabilitation where the patients are more homogeneous, cancer patients are heterogeneous and a standard program cannot so easily be uniformly applied . TherefoNational evidence–based cancer rehabilitation guidelines in the Netherlands are considered the most advanced . They caThe duration of the OR is not fixed in the SW!SS REHA criteria. According to survey participants, the program should last on average 12 weeks, independent of the type of program and whether it is an individual modular or a standard program. Based on the information that could be gathered from the international literature research with data available for eight of the 15 countries , outpatiAmong the program prerequisites in the SW!SS REHA criteria are a minimum of 10 treatment units per week per patient. Regarding the frequency of rehabilitation interventions (or sessions) per week, a high degree of variation between countries was identified. Nevertheless, the average intensity seemed to be around 2 to 4 sessions/interventions per week –18, lendAnother area of divergence between the SW!SS REHA criteria and the survey results concerns the leadership and organization of the multidisciplinary OR program. From the guided discussion , it was The SW!SS REHA criteria stipulate that a coordinating function is mandatory but do not specify which specialty should be accountable for ensuring the patient coordination in the program. The Swiss survey results indicate a strong preference for a rehabilitation team. Moreover, the role of the coordinating function should be clarified in the SW!SS REHA criteria. The coordinator should be someone from the multi-professional rehabilitation team, with clear responsibility and triage and decision-making processes. According to the international literature review , there iFinancing of OR programs is not addressed in the SW!SS REHA criteria. During the guided discussion, guaranteed financing was identified as a conducive factor for the successful implementation of an OR program, although there was no clear consensus on whether one financing model would be more conducive to a successful OR program than another one. For this reason, the most frequent models were tested for approval in the survey. This showed that of the three main options, including individual fee for service billing, flat rate billing, or combination of both, there was no clear difference in favor of one model. For those advocating a combination of flat fee for core modules with a fee for service approach for additional models, flat rate billing was foreseen for the physiotherapy and exercise/sports therapy interventions, inclusive of coverage of the cost of coordinating all additional elective modules, as coordination time and costs for the OR program also need to be financed.Certification is currently not possible for the centers offering OR programs, because they cannot currently completely fulfill all the SW!SS REHA criteria. According to the survey, 75% of respondents consider certification as advantageous. The international literature research did not reveal any certification as such in the fifteen countries investigated. What could be observed was that some countries seemed to have quality standards for their programs. In Luxembourg , 19, aftThe Swiss national study on interdisciplinary ambulatory OR provides a thorough basis to design an evidence-based ambulatory OR program building upon and where necessary adapting the SW!SS REHA guidelines with the relevant actors. The online survey confirms that many of the SW!SS REHA quality and performance criteria fit with the actual or desired OR programs in Switzerland. Other criteria might need to be added, adapted or removed.The guided discussion had indicated that there may be important differences in the approach to OR among the different language regions or specialists . The resThe overall response rate was 49% and was lower in some groups such as the centers in F-CH or in the mixed group of specialists “other.” It would be valuable to follow-up with a sample of non-responders, to investigate the underlying reasons behind their non-response. In the context of the above non-responder results, this could give valuable insights as to what extent non-responding members of the “other” group, e.g., nurses, occupational therapists, and social councilors, feel concerned resp. do not feel concerned by the subject of multidisciplinary ambulatory oncological rehabilitation programs and how they could be better integrated into OR programs.The international literature review has indicated that the level of evidence supporting multidisciplinary ambulatory OR is modest . There iFor clarity of focus, our survey focused on the two main phases of rehabilitation, namely ongoing acute oncological treatment phase or after completion of the acute phase. In practice, there are several phases of OR covering pretreatment rehabilitation, rehabilitation during cancer therapies, between cancer therapies, after cancer therapies and both a curative and non-curative approach. Additionally, acute oncological treatments could be further differentiated, including chemotherapy, immunotherapy, targeted oral therapies, radiotherapy, and surgeries of varying intensity with either extensive neoadjuvant radio-chemotherapy or just simple adjuvant hormone therapies. The fuller set of indications or settings should ideally be investigated with further research.ESAS, Edmonton Symptom Assessment Scale; WHODAS, WHO Disability Assessment Schedule; ECOG, Eastern Cooperative Oncology Group Performance Status; HADS, the Hospital Anxiety and Depression Scale; NRS, Numerical Rating ScaleESM 1(PDF 491 kb)


This study presents (1) a case of an injury to an unbelted passenger and (2) the possibilities of proving the occurrence of injuries to traffic accident participants. We demonstrate the case of an injury to a passenger who failed to fasten her seat belt, and question whether her injuries would have been equally serious if she had fastened her seat belt. Theoretical bases and methods for the interdisciplinary procedure of medical examiners using the PC Fortis program and technical analysts of traffic accidents using the PC Crash program are presented. Furthermore, individual practical steps are documented, the result showing that the injuries to the passenger would have occurred, but, to a minimum extent, i.e., 6.9% of the original injuries, which would have not exceeded the legal limit for damage to health. In answering serious legal questions from investigators and courts, contemporary medicine has new possibilities for systemic interdisciplinary cooperation between forensic physicians and technical experts through a new method of injury quantification and localization, namely the FORTIS system developed by the Department of Forensic Medicine at the Faculty of Medicine of P. J. Safarik University.The system responds to how to use a great deal of new information on the nature and extent of physical parameters resulting from the movement and contacts of a vehicle and participants in an accident, provided by simulation programs. Consequently, this gives new possibilities for taking evidence for investigations and legal assessments, which have not been possible so far. For instance, the exact specification of the extent of injury caused by a traffic accident due to changed circumstances can also include finding the difference in the degree of injury in a belted passenger compared to an unbelted one. From this point of view, this article provides information on the latest methods for proving the injuries of participants in traffic accidents.Technical experts in road transport perform technical analyses of accidents in which participants are injured to clarify the course of an accident and make the cause of occurrence clear.As every traffic accident is a combination of individual and unique physical parameters and phenomena, it is indisputable that injuries represent an individual and unique reflection of the physical violence affecting the participants in a traffic accident. Until now, a technical expert in road transport has had extremely limited possibilities to use the information on the extent and manner of injuries in a traffic accident participant, when dealing with the course of a traffic accident, even after using advanced simulation programs. The reason is that such information cannot be explicitly interpreted from a technical point of view to be used for the accident analysis itself . MoreoveIn practice, however, there are cases where, to assess the degree of fault, it is necessary to determine the biomechanical response, which represents the extent of injuries, that could have occurred if some circumstances of the accident had been different. Probably, the most common case when such an assessment is required is a case of an unbelted passenger  where it is necessary to prove the extent of injuries the person in question would have suffered if he/she had fastened the seat belt and had been wearing it during the accident.This is also the case of the presented injuries to the unbelted passenger caused by a drunk driver, which was processed at the request of the court, and which represents practical possibilities of how to use FORTIS medical system by doctors together with the simulation program used by technical experts. Improved methods of proving should become part of the transport policy in the European Union, and these should have a positive effect on driver discipline on European roads .The FORTIS forensic system, which allows to parametrize individual injuries, and to locate the places of action of contact forces resulting in the occurrence of detected injuries (using the PC Fortis program), was used to deal with the case. This way, the extent of violence and the affected location on the body of an injured person for each injury are defined. Defined injuries may be technically assessed regarding the contacts in the accident simulation, while the extent of the injuries may be detected using the outputs of the PC Crash simulation program . Thus, tThe traffic accident occurred in the residential area, at a crossing, with poor visibility. Based on the inspection of the accident site, an investigator prepared the plan of the traffic accident site – The supporting documents also included the photo documentation of the accident site, which shows the situation after the accident, the extent of damage to the vehicles, and other facts identified during the inspection of the accident site  3]..3].Afterwards, a calculation of the vehicle collision was performed in the PC Crash simulation program, and a technically acceptable result was achieved: at the time of collision, the Sedan (1) was moving at a speed of 11.0 km/h, and the brake was used; the Pick-Up (2) was moving at a speed of 36.0 km/h. The calculation of the vehicle collision is demonstrated in During the collision, the passenger in the Pick-up suffered the following injuries: dislocation of the left hip joint with a fracture of the left femoral head and a fracture of the posterior edge of the acetabulum, fracture of the nasal bones, and left knee contusion.The localization of the contact places and parametrization of the injuries using the PC Fortis program was performed by a medical examiner. The FORTIS score of the detected injuries of 4.3 Fortis point (FP) is shown in A technical expert performed this movement using a multi-body system on the PC Crash program. The figure of the calculated movement of an unbelted and belted passenger dummy is shown in The movement parameters of the passenger’s body and its selected parts were read from the PC Crash simulation program, which allows showing the results of the calculations also in the form of diagrams . These cThe value of 100 G exceeds the general injury limit (40–80 G) . The selThe examples of the comparison of physical parameters: acceleration in the left hip joint in the direction of the x-axis  and contThe final values of the calculations were then presented to a medical examiner who, after considering all facts, prepared the parametrization and localization of estimated injuries to the passenger provided her seat belt had been fastened during the collision. Her FORTIS score would have been 0.3 Fortis points .Medically defined extent and manner of injuries may help reconstruct a more detailed course of a traffic accident. These may also be very useful control values and, as described in the present article, could allow for an accurate, highly qualified estimate of potential injuries under different conditions concerning the detected circumstances of the injuries , throughThe authors believe that the presented methodology has considerable potential for further research not only for the investigation of traffic accidents but also for investigating other types of accidents and violent crimes against life and body by the police. It is also important to acquaint investigators and judges with the possibilities of new interdisciplinary procedures and outcomes, which should increase legal certainty for each participant in a traffic accident or a victim of crime . In thisThe authors declare that there is no conflict of interest.No special ethics approval is needed. However, the information was shared to the ethics committee from the Faculty of Medicine, P. J. Safarik University in Kosice, Slovak Republic. This manuscript does not mention or cover any use specific or personal data concerning animals or humans or tissues.NB was involved in participation and performance of medical procedures, JM, AV participated in evaluation of diagnoses, simulation in PC Crash, technical assessment, and description of cases. AO, BS conducted text processing and finalization. The authors read and approved the final manuscript.