We conducted a prospective evaluation of the “Rapid Scale-Up” (RSU) program in Burkina Faso, focusing on the integrated community case management (iCCM) component of the program. We used a quasi-experimental design in which nine RSU districts were compared with seven districts without the program. The evaluation included documentation of program implementation, assessments of implementation and quality of care, baseline and endline coverage surveys, and estimation of mortality changes using the Lives Saved Tool. Although the program trained large numbers of community health workers, there were implementation shortcomings related to training, supervision, and drug stockouts. The quality of care provided to sick children was poor, and utilization of community health workers was low. Changes in intervention coverage were comparable in RSU and comparison areas. Estimated under-five mortality declined by 6.2%  in the RSU area and 4.2%  in the comparison area. The RSU did not result in coverage increases or mortality reductions in Burkina Faso, but we cannot draw conclusions about the effectiveness of the iCCM strategy, given implementation shortcomings. The evaluation results highlight the need for greater attention to implementation of iCCM programs. Over the course of the previous decade, there has been rapid and increasing investment in community case management (CCM) at country and global levels, prompted in part by the issuance of several World Health Organization (WHO)/United Nations Children's Fund (UNICEF) joint statements promoting CCM as a way to reduce mortality in children under five and increase equity.5From 2008 to 2010, the Catalytic Initiative funded “proof of concept” evaluations in three countries  to show that proven interventions could be scaled up rapidly to reduce maternal, newborn, and child mortality. In each country, the Ministry of Health (MoH), together with a UN agency, planned and implemented a “Rapid Scale-Up” (RSU) of high-impact interventions that was evaluated prospectively by Johns Hopkins University together with in-country research partners.Burkina Faso, which is ranked 181st of 187 countries on the Human Development Index,This article, focusing on the RSU in Burkina Faso, is one of three reports of full prospective evaluations of the implementation of the RSU. The objectives of the evaluation in Burkina Faso were to assess whether the program objectivesThe RSU in Burkina Faso was implemented in nine health districts comprising the Nord and Centre-Nord regions of the country (The RSU in Burkina Faso included both community and facility components.The ASBCs who were responsible for the community-based component of the RSU were part of an existing cadre of lay volunteers in Burkina Faso.13The facility component of the RSU used project funds to support activities such as integrated management of childhood illness (IMCI); emergency obstetric and newborn care; emergency triage and treatment training for clinicians; and acquisition of commodities, such as delivery tables and bag and mask kits for hospitals, which were expected to reduce maternal, newborn, and under-five mortality.Because the program districts were not randomly selected, the evaluation design was restricted to a quasi-experimental approach with both pre-post and difference in differences analyses. The evaluation was guided by the common evaluation framework . We then identified 61,652 combinations of 7 districts from the pool of 25 candidate districts that satisfied our matching criteria. Of these, one set of seven districts was selected at random.15A set of seven health districts was matched to the nine intervention districts using the following approach. The Independent Evaluation Team limited the pool of potential comparison districts to 25 districts, on the basis of ecological and cultural similarities to the project area. We defined matching criteria for six demographic and health systems indicators  using systematic random sampling, of which 385 were found and agreed to participate. Data collectors interviewed each participating ASBC and inspected their drug kit and register. ASBC supervisors at the local health facility were also interviewed. Data collectors then observed up to two sick child consultations (for children aged 2–59 months) for each ASBC and recorded their observations in a questionnaire. They then conducted an exit interview with the caregiver accompanying the child. Finally, the sick children were reexamined by study team members who were experienced IMCI-trained clinicians, and the gold standard diagnoses and treatments for the child were recorded. Data were collected on Samsung Galaxy 2 and 3 smartphones  using Pendragon Forms software .25An assessment of the quality of care provided to sick children in health facilities was conducted in 2011 in the project districts. This assessment was funded and carried out separately by WHO in collaboration with the Institut pour la Recherche en Sciences de la Santé without involvement from the Independent Evaluation Team. The methods of this assessment were consistent with the WHO guidelines for quality of care assessments at health facilities,Household coverage surveys were conducted in August 2010 to January 2011 (baseline) and November 2013 to March 2014 (endline) in both program and comparison areas. These surveys collected data on coverage of MNCH interventions, as well as on water, sanitation, and hygiene indicators.For both surveys, two-stage cluster sampling was used, stratified by district. In each district, rural census enumeration areas (EAs) were sampled with probability proportional to size, with data on EA size provided by INSD based on the 2006 national census.The baseline survey sampled 2,000 households in each of the districts implementing pneumonia CCM, and 1,000 households in each of the remaining districts, for a total of 18,000 households. The endline survey sampled 3,000 households in each of the districts implementing pneumonia CCM, and 840 households in each of the remaining districts, for a total of 17,760 households. We oversampled in the districts implementing pneumonia CCM to provide sufficient power to detect the effect of this intervention on careseeking and treatment of pneumonia in these two districts relative to the comparison districts. These samples sizes were selected to provide 80% power to detect a difference of differences of 10–15 percentage points (pp) or better in intervention coverage levels between program and comparison areas. With these sample sizes, the evaluation also had 80% power to detect a difference in differences of at least 15 pp in pneumonia treatment coverage levels between the two districts implementing pneumonia CCM and the comparison districts.Baseline data were collected on paper questionnaires, which were checked in the field. Questionnaires were double-entered using CSPro 4.0Analysis of iCCM implementation and quality of care data was conducted in Stata versions 12 and 13.30We calculated point estimates and 95% confidence intervals (CIs) using standard indicators where possible. Indicators were calculated for the RSU area as a whole, for districts without pneumonia CCM, and for districts with pneumonia CCM. For utilization, we had incomplete register data as only 70% of ASBCs could produce a register, and ASBC self-reports of the number of sick children seen were contradictory. We therefore calculated a range of possible utilization rates from these different data sources. We multiplied the mean number of sick children treated per ASBC per month based on register data by 12 months and by the estimated number of ASBCs providing iCCM services and divided the result by the estimated number of under-fives in the program areaWe used the implementation and quality of care results to inform our interpretation of the data on changes in intervention coverage and mortality.We used standard coverage indicator definitions from the Multiple Indicator Cluster Surveys and the Commission on Information and Accountability in Women's and Children's Health.For each coverage indicator, the percentage point change in coverage from baseline to endline was calculated by subtracting the baseline coverage value from the endline coverage value and calculating the 95% CI for the difference.The differences in differences analysis compared changes in intervention coverage in RSU areas and comparison areas. For indicators of careseeking for children with suspected pneumonia, and treatment of suspected pneumonia with antibiotics, we compared coverage changes in comparison areas to coverage changes in the two RSU districts implementing CCM for pneumonia. This analysis does not require that coverage levels in intervention and comparison areas be the same at baseline, but assumes that the RSU program is the only factor that could lead to changes in coverage in the RSU area. As we were evaluating the effectiveness of the RSU approach relative to the status quo, we also assumed that there were no major programs with the potential to affect MNCH intervention coverage in comparison areas. These assumptions are examined in the section on contextual factors.The difference in differences in intervention coverage between program and comparison areas from baseline to endline was calculated by first computing the point estimates and standard errors for coverage indicators at baseline and endline in RSU and comparison areas, as described above. We then computed the point estimate and 95% CI for the linear combination of these indicators, subtracting the coverage change from baseline to endline in the comparison area from the coverage change from baseline to endline in the RSU area. We made no adjustments for multiple comparisons.We estimated changes in mortality using LiST.We used LiST to produce four models of mortality change  from 2010 to 2013. Demographic data for each district were taken from the MoH's annual statistical handbook,At present, there is no agreed-upon approach for computing uncertainty bounds around LiST mortality estimates because of challenges in determining the extent to which errors and biases in the many different inputs are correlated. However, we conducted a sensitivity analysis by producing two additional projections, one using the upper bounds of the 95% CIs around the LiST intervention effectiveness estimates and one using the lower bounds. This produced a range of possible mortality reductions, which we report in the results. A similar approach was used by Bhutta and othersEthical approval for the evaluation was obtained from the Johns Hopkins Bloomberg School of Public Health Institutional Review Board (IRB) (IRB2590 and IRB3909) and from the Burkina Faso National Ethics Committee for Health Research (DELIBERATION No. 2009-67 and DELIBERATION No. 2012-10-69).The evaluation sponsor had no role in the design of the evaluation; in the collection, analysis, or interpretation of data; in the writing of the report; or in the decision to submit the article for publication.Supplemental Web Annex 1, Table 2.1. There were no significant differences between the RSU and comparison districts at baseline, except that coverage of oral rehydration solution (ORS) for diarrhea was significantly higher in RSU districts relative to comparison districts.Baseline values for key variables for each arm of the evaluation are shown in Initial program implementation appeared strong, with 3,399 ASBCs trained in 2010 , increasing to 4,012 by 2013 . In addition, 99% of ASBCs providing iCCM services in 2013 reported receiving an initial drug kit . HoweverWith respect to ongoing implementation, we observed that in 2013, only 64% of ASBCs having received iCCM training reported providing iCCM services in the previous 12 months. Further, only 38% of ASBCs providing iCCM services had been supervised in the past 3 months and only 9% had a fully stocked drug kit. A frequent problem in health facilities was the absence of IMCI-trained personnel: During the health facility assessment, only 62% of health facilities had at least one IMCI-trained health worker in the facility on the day of the assessment. Further, only 18% of health facilities had all essential oral medications in stock on the day of the visit.We observed poor quality of care for sick children in both health facilities and the community  and 3. ABased on data from ASBC registers (which were available for 70% of ASBCs), mean utilization was two sick children/ASBC/month. Based on ASBC self-reports of utilization, the median time since the ASBC's last sick child consultation was 1 week, and mean utilization was 12 sick children/ASBC/month. Assuming 4,012 ASBCs in 2013, of which 64% were providing iCCM services and 572,238 under-fives,Supplemental Web Annex 2 ). Careseeking for fever from health facilities decreased by 9.7 pp (95% CI: −14.1 to −5.2) from baseline to endline, while careseeking from ASBCs increased by 2.6 pp (95% CI: 0.7–4.6). Careseeking for suspected pneumonia from ASBCs increased from 5.5 to 10.2%, a 4.6 pp increase (95% CI: −3.0 to 12.3), but the CIs were very wide. We saw little change in careseeking for diarrhea.We observed shifts in the coverage of careseeking for fever and the sources from which care was sought . With the exception of ITN ownership, these coverage increases were relatively small (< 10 pp) and similar in magnitude to coverage increases in comparison areas. Coverage of key iCCM interventions, including antimalarials for fever, antibiotics for pneumonia, and ORS for diarrhea, decreased in program and comparison districts. We did observe a small but statistically significant increase in the treatment of diarrhea with zinc in the program area (from 4.0% [95% CI: 2.8–5.8] to 8.3% [95% CI: 6.2–11.0]) but not in the comparison area. Only two RSU targets for intervention coverage were achieved   . For fouSupplemental Web Annex 2).The difference in differences analysis showed relatively small differences of differences between RSU and comparison areas (< 10 pp), with the exception of intermittent preventive treatment of malaria in pregnancy (IPTp) , and antibiotics for pneumonia (14.2 pp [95% CI: −1.7 to 30.1]), all of which increased more (or decreased less) in RSU areas than in comparison areas  versus 4.2% (range: 3.6–6.0%) in comparison areas  from 2010 to 2013 .Most of the estimated mortality reduction in both program and comparison areas was attributable to household ownership of ITNs. Increases in the coverage of this intervention accounted for 71% of the mortality reduction in program areas and 63% in comparison areas . We observed significantly greater in-migration in comparison districts relative to program districts from 2010 to 2013 . Access to health facilities, as reported by the MoH,A quantitative description of key contextual variables is shown in Supplemental Web Annex 4, Table 2.4).22In-depth interviews with district health personnel in program and comparison areas revealed similar trends in contextual factors that could have had an impact on MNCH over the program period. All districts reported poor harvests in 2011, but improved harvests and food security in 2012 and 2013. Gold mining activity and migration due to that activity was also a concern of health authorities across the program and comparison areas. Industrial gold mines are located in Kongoussi, Boulsa, and Ouahigouya districts in the program area and in Tenkodogo district in the comparison area, and smaller-scale “artisanal” gold mining is ongoing throughout the country, with the exception of the central region. Regional data on the number of gold mining sites in each region (province and district level data were not available) from 2010 to 2012 shows reductions in the overall number of gold mining sites in RSU regions during this period, but no overall change in the number of gold mining sites in regions containing comparison districts . No other major programs likely to have affected MNCH coverage indicators were identified in program or comparison areas.This full prospective evaluation of the effectiveness of the RSU program in Burkina Faso included in-depth assessments of program implementation, quality of care, utilization, and intervention coverage changes, as well as modeled changes in mortality. We found important shortcomings in each of these areas and were unable to attribute any change in under-five, maternal, or neonatal mortality to the program. In this section, we discuss these findings and their implications as responses to a series of questions.Although initial iCCM implementation appeared to be strong, with over 3,000 ASBCs trained in 2010–2011, there were important shortcomings in both initial and ongoing implementation. In terms of the initial training, there were quality concerns including the use of nurses trained months before on iCCM to deliver the training, the failure to adapt training materials for illiterate ASBCs, the relatively large size of some training groups, and the lack of clinical practice for half of ASBCs. Thus, we would not expect this training to produce community workers able to provide high-quality care for sick children. In addition, in 2013, only 64% of the ASBCs who received initial iCCM training were providing iCCM services, suggesting an inefficient approach to training and deployment of ASBCs.Ongoing iCCM implementation suffered from difficulties including infrequent supervision and lack of observation of case management during supervision. In addition, drug stockouts at the ASBC level were very common. Provision of clinical IMCI services suffered from some of the same difficulties, notably widespread stockouts of essential drugs and the fact that many first-level facilities did not have an IMCI-trained clinician present.The implementation difficulties for both iCCM and clinical IMCI would be expected to lead to unsatisfactory quality of care for sick children, and this is what the evaluation found. All aspects of case management were poor at facility and community levels, with the exception of malaria case management in health facilities, which was quite good. Because the facility-level assessment was conducted in 2011, it is possible that facility-based care improved in program areas in 2012–2013. The community-based assessment, however, was conducted in 2013 and thus is a good representation of the quality of care provided by ASBCs at the end of the program.Both quality of health services and utilization of these services must be high to produce population-level changes in coverage and mortality. We found that at community level, in addition to poor quality of care, utilization of ASBCs was very low. Low levels of utilization were likely attributable to the practice of charging for drugs, the fact that careseeking from facilities for sick children was relatively high at baseline, and the lack of a strong strategy to generate demand for iCCM. Given implementation challenges, poor quality of care at facility and community levels, and low utilization of ASBCs, there was no clear way for the RSU program to achieve significant changes in population-level coverage of interventions for sick children, and therefore few pathways to reducing under-five mortality, which was the program's overall objective.Of the interventions targeted by the RSU program, there were only three for which coverage increased significantly more in the program area than in the comparison area: one antenatal (IPTp), one postnatal (postpartum vitamin A), and one for sick children (zinc treatment of diarrhea). Most program interventions, including zinc for diarrhea, saw only small coverage increases or even decreases from 2010 to 2013.Because we modeled mortality change in program and comparison areas using LiST, a model in which mortality change is driven by intervention coverage change, it is not surprising that we saw small and similar levels of mortality reduction in both program and comparison areas. Without uncertainty bounds, we cannot determine whether the mortality reductions in program and comparison areas  were significantly different. However, we note that these reductions are qualitatively similar, that the sensitivity analysis produced overlapping ranges of possible mortality reductions in RSU and comparison areas, and that the reductions are very far from the 25% under-five mortality reduction targeted by the program.Much of the estimated mortality reduction from LiST was attributable to increases in ITN coverage in program and comparison areas. Increases in ITN coverage were similar in program and comparison areas and were likely largely attributable to the Global Fund-supported ITN distribution campaigns. Although the RSU used program funds to pay for some of the ITNs distributed in the program areas, it seems likely that if these funds had not been available, an alternative source would have been found. Thus, our modeled mortality reductions are partially attributable to the Global Fund's activities.We did not observe major differences in contextual factors between program and comparison areas that could have confounded the association (or lack thereof) between the program and intervention coverage. This does not exclude the possibility of unmeasured confounding, which is always a risk, particularly in nonrandomized evaluations. However, we believe that our findings with regard to intermediate factors  sufficiently explain the coverage and mortality results. We note, however, that contextual factors, and particularly gold mining, may have acted as effect modifiers, in that they may have led to some attrition and dissatisfaction of ASBCs who may have seen gold mining as a more profitable occupation than community health work.12Based on the results of this evaluation, we cannot draw conclusions regarding whether iCCM as a strategy “works” in Burkina Faso, as the implementation of the strategy was flawed, perhaps because of pressure to implement quickly. Evaluators in other settings have also noted that attempts to rapidly scale up a complex intervention such as IMCI resulted in poor implementation and no impact.A second lesson is the importance of the cadre delivering the program. Burkina Faso used an existing cadre of community health workers (ASBCs) to implement iCCM, and while their long-standing ties with their communities may have been an asset in program implementation, their low level of education and volunteer status may have impeded program success. Commendably, the MoH and partners have developed a new policy on ASBCsA final lesson is the importance of taking into account drug supply systems and demand generation in the design of an iCCM program. Widespread stockouts at community level made it difficult for ASBCs to provide adequate case management, and the low level of utilization of ASBCs likely limited the impact of the iCCM program. In addition, stockouts were not systematically monitored by the program and therefore were not identified as a problem until the Independent Evaluation Team's survey of ASBCs in 2013.The findings regarding utilization and careseeking point to the need for programs to develop, before implementation, a clear strategy regarding the population to be targeted by a particular program, and regarding how to increase demand in the target population. An equity analysis to assess the types of households that sought care from different sources is underway and will be published separately. This analysis may provide the basis for recommendations on how to reach those sick children who are taken neither to a health facility nor to an ASBC.Supplemental Web Annex 5, Tables 1.15 and 2.5), suggests that this difference should have favored the program . In addition, we would expect the seasonal effect to be similar in both intervention and comparison areas. However, we cannot exclude the possibility that this seasonal difference in baseline and endline surveys affected our difference in differences analysis.This evaluation had a number of limitations. Due to delays in inviting the evaluation team to Burkina Faso and initial funding delays, the baseline survey was conducted in 2010, although some health facility activities had started in 2009. While this should not affect our assessment of the impact of iCCM, it means that we may not have captured the full effect of facility-based activities. There were also timing issues with respect to the endline survey: Because the transfer of funds for the survey was delayed by the primary grantee, the endline was conducted in a slightly different season than the baseline (November–March versus August–January). A previous study on seasonal differences in careseeking in Burkina Faso,The evaluation included one round of facility-level quality of care assessments and one round of community-level implementation and quality of care assessments. To better capture changes in program implementation and quality of care, it would have been preferable to conduct two rounds of assessments and to conduct the facility assessments in both program and comparison areas. An economic assessment was also planned as a part of the original design, but could not be completed because the facility quality of care assessment was conducted only in the program areas, and there was therefore no basis for cost comparisons.This evaluation focused primarily on assessing whether the program achieved its targets, which were formulated in terms of intervention coverage and under-five mortality. We did not conduct an in-depth assessment of policy inputs and effects of the program, although we tried to document these as we learned about them through meetings with implementing partners.One of the RSU program indicators was the proportion of children with suspected pneumonia who received antibiotics. Validation studies published in 2013Finally, this evaluation used a nonrandomized design by necessity, as the program districts had already been selected by the time the evaluation team was invited to Burkina Faso and randomization was not an option. We instead used a group-matched design and found that our program and comparison areas were very similar at baseline. We also attempted to measure contextual factors to account for potential confounding. However, unmeasured confounding cannot be ruled out with this type of design.Although the RSU did result in a number of policy changes at program outset and later on in response to evaluation findings, implementation of the RSU program itself and in particular the iCCM component was not strong enough to achieve population-level changes in coverage or mortality. Encouragingly, the Burkina Faso MoH and partners have indicated that they will incorporate evaluation findings in future MNCH programming. These results should not be interpreted as evidence that iCCM cannot result in coverage or mortality changes, but rather that it did not result in changes in this setting given weak implementation, poor quality of care, and low utilization. It is notable, however, that very few settings have been able to implement CCM at scale with strong enough intensity and quality to achieve mortality and coverage impacts.Supplemental Datas.


Falls are the leading cause of injury death in older adults and present a significant public health problem and a major burden to healthcare. Although there is sufficient evidence from randomized controlled trials to indicate that exercise can prevent falls in older people, few effective, evidence-based fall prevention programs exist in community practice. Thus, there is a pressing need to translate and disseminate evidence-based exercise programs to community providers that serve older adults at increased risk of falling. The current study addresses this public health need by disseminating the evidence-based Tai Ji Quan: Moving for Better Balance (TJQMBB) program through community senior centers.The study uses a single-group design in which the TJQMBB program is being delivered to community-dwelling older adults through collaboration with senior centers in selected counties in Oregon, USA, for 48 weeks, followed by a 24-week post-intervention follow-up. Study process and outcome measures will be evaluated in accordance with the components of the RE-AIM framework that focus on Reach, Effectiveness, Adoption, Implementation and Maintenance.This study will determine whether the evidence-based TJQMBB fall prevention program can be disseminated through a broad spectrum of community-based senior centers that often cater to low-income, underserved community-dwelling older adults at risk of falling. If shown to be both practically implementable and sustainable, the TJQMBB program will provide an effective, potentially low-cost, easy-to-implement intervention that could be used by public health practitioners and community-based organizations to address the problem of falls among older adults.NCT01854931ClinicalTrials.gov Identifier:  There is little debate about falls in older adults being a significant public health issue ,2. It isAmong various exercise programs that focus on increasing lower-extremity muscle strength and improving balance ,13, Tai The overarching objective of this study is to disseminate the evidence-based Tai Ji Quan: Moving for Better Balance (TJQMBB) program -20 throu1. Adoption – to examine the proportion of community senior centers that agree to adopt TJQMBB.2. Reach – to examine the proportion and representativeness of the older adults who participate in the TJQMBB program.3. Maintenance – to evaluate, upon completion of TJQMBB, the levels of sustained use of the program within the senior centers delivering the TJQMBB program and sustained participation in Tai Ji Quan exercises by participating individual older adults.4. Implementation – to determine the degree to which the various TJQMBB program elements are delivered as intended.5. Effectiveness – to examine the degree to which fall incidence is reduced and physical performance measures are improved.A secondary aim of the study is to conduct a preliminary cost-effectiveness analysis of the TJQMBB program.Within the RE-AIM framework , which iThe dissemination area for this project is four counties in the state of Oregon, USA: Clackamas, Lane, Multnomah and Washington. The total population of these counties in 2012 was 2,045,327, of which 259,747 were persons 65 years old and over (per U.S. Census estimates), which accounted for 45% of the older adult population in the state. Per CDC data, these four counties ranked highest in Oregon in terms of the number of unintentional falls between 2004 and 2010 in individuals aged 65 and older, with the average annual  fall fatality crude rate  being 85.8 in Clackamas, 73.2 in Lane, 89.9 in Multnomah, and 74.9 in Washington, compared with the national rate of 47.8 per 100,000 . Within i.e., local Area Agencies on Aging, county and state Senior & Disability Services, Oregon Recreation & Park Association), approximately 50 senior centers within the study area were potential candidates for our study.In line with our pilot work , the proi.e., can walk with or without an assistive device), (b) without severe mental deficits, as determined by Mini-Mental State Evaluation (≥ 19) [Community-dwelling adults aged 65 and over living within the defined study area are the target population because this age cohort (a) is most at risk of falling ,6,24 andn (≥ 19) , (c) ablEligible senior centers are initially contacted by research staff to solicit or confirm their interest in participating in this dissemination project. At the point of contact, a full description of the TJQMBB program is discussed with the center manager, program coordinator, or supervisor. When a center expresses interest in participating, a logistical plan that covers program/class promotion and set-up, size of the class, recruitment of participants, and class start-up date and scheduling is made jointly between the project staff and the participating center.On the basis of available classroom sizes at the center, a maximum number of class enrollments is determined in consultation with staff at the participating center. The TJQMBB program advertisement and promotion is primarily done in collaboration with the participating center using sources such as monthly or quarterly newsletters, center websites, in-house flyers and class sign-up sheets, and word of mouth.Prospective participants who respond to the promotion and/or sign up for the class at each center are contacted by telephone by the research staff to initiate a phone screening for initial eligibility. This is followed by an in-office visit where a full description of the program is given, consent forms are obtained, and study baseline measures are collected.The TJQMBB program implemented was developed on the basis of early trials ,26, modiPer program protocol, each session begins with warm-up exercises (5 to 10 minutes) based on Tai Ji Quan movements, followed by the teaching and practice of core movements and subroutines that involve single forms and mini therapeutic movements (40 to 45 minutes), and ending with a simple set of breathing exercises (3 to 5 minutes). The core training protocol, which involves a set of simple but functional Tai Ji Quan-based actions, focuses on stimulating and integrating musculoskeletal and sensory systems via self-initiated movements such as weight shifting from foot to foot, unilateral weight-bearing, trunk rotation/flexion, ankle sways, and coordinated eye-head-hand movements, executed with integrated cognitive tasks . The goaA copy of a DVD with selected forms/movements of the program is distributed to all participants 4 to 6 weeks into the program. Participants are encouraged to use the material for additional home practice.All instructors are chosen from local communities. In an effort to make the program more easily disseminable and generalizable, special efforts are made to recruit individuals who have little or no background in Tai Ji Quan or who currently work at participating centers giving instruction in other exercise modalities.The first author trains all instructors via a two-day workshop at the Oregon Research Institute, using the training materials already developed. The training protocol includes a discussion of the theoretical underpinnings that were used to develop the program, findings from the efficacy trials and dissemination studies, detailed information and hands-on drills with the forms, variations of forms and routine exercises, mini therapeutic movements, and discussion of implementation- and teaching-related issues. Instructor training emphasizes consistency of delivery to ensure generalizability across different implementation centers. After instructors begin teaching, brief refresher training sessions are provided on a monthly basis.e.g., meal services, education, physical activity); number of rooms devoted to physical activity; average class attendance across programs offered; and number of full- and part-time staff. Information on participants includes demographic and health characteristics, including age, gender, marital status, living situation, education, family income, race/ethnicity, existing medical conditions, use of medication, body weight, and body height. In addition, information regarding types of services received and frequency of visits to the service providers is also collected.General information that describes the social demographics of participating centers and their older adult clients is collected at baseline. Information on participating centers includes: types and number of services provided (http://www.re-aim.org/) as described below.Each component is operationalized per our study aim and assessed per procedures outlined by the RE-AIM developers  by the total number of centers approached within the dissemination geographic area (denominator). We document and report in detail on the following components: (a) total number of centers approached within the study area, (b) total number of centers that express interest in participating, (c) total number of centers that decline to participate (and reasons for declining), (d) total number of centers not responding to program promotion, (e) total number of centers participating, and (f) characteristics of participating centers. As part of the evaluation, the representativeness of participating centers will be determined by comparing them with the overall service characteristics of all senior centers in Oregon.Reach is defined as the absolute number, proportion and representativeness of the older adults who participate in the TJQMBB program. This indicator will be assessed by first calculating the participation rate, using the number of eligible people qualified per study criteria and enrolled (numerator) divided by the total number of older adults who respond to the program promotion (denominator). In addition, we will also evaluate Reach by using the total number of older adults who attend regular activities at the participating centers as a denominator, which gives us a population index on the Reach component. In assessing the representativeness of our study population, we will compare information on demographics and health status of those who participated with those who met our recruitment criteria but who eventually, for any reason, declined to participate.i.e., continuing vs. not continuing) and with respect to time (length of practice sessions) and frequency (number of sessions per week).Maintenance is defined as the level of continued adoption of the TJQMBB program at the participating senior centers and sustained participation in Tai Ji Quan practice among the study participants after the completion of the 48-week active class implementation. At the center level, we will determine the number of participating centers that either continue offering the class or plan to adopt it in the future. At the individual participant level, we continue to collect data during the 24-week post-intervention follow-up with regard to participant Tai Ji Quan exercise status , integration , and actual practice time (40 to 45 minutes spent on core movements). The first author or an experienced peer instructor conducts in-class fidelity checks at least every two months.Implementation is defined as the degree to which instructors deliver the various intervention elements as intended. In this regard, measures of fidelity from our previous studies of this program are used ,19. Spece.g., water bottles, DVDs).As part of the evaluation for our secondary study aim, the implementation component will include documenting project implementation costs. Specifically, direct costs associated with implementation of the intervention will be documented, including (a) participant recruitment costs , (b) instructor liability insurance costs, (c) instructor salary costs, (d) classroom rental costs in the local community, (e) cost of the initial two-day training and refresher courses for instructors, as well as in-class fidelity checks, and (f) other expenses related to program promotion and supplies  Timed Up & Go test , (b) MulClass attendance is recorded for each participant at each class session and evaluated monthly by research staff. The attendance data will be tallied at the end of the class intervention across all participating centers to derive an average class attendance for the study.i.e., participants are nested within centers) can result. To account for potential clustering effects, outcome data will be analyzed with sampling weights and a clustering variable (PSU) that allows correction of the correlation between participants within centers and standard errors of estimates.Descriptive statistics will be presented for all outcome measures. The fall incidence rate will be determined as the number of falls that occurred during the intervention period divided by the total follow-up time in months (person-months of follow-up). Paired t-tests are planned to examine change in functional outcomes of participants from baseline to program termination at 48 weeks. Because senior centers are the primary sampling unit (PSU) in this study, a clustering data structure .TJQMBB: Tai Ji Quan: moving for better balance.The authors have no competing interests to declare.FL and PH obtained funding for this study and contributed to the design of the study and writing of this manuscript. Both authors have read and approved the final manuscript.


Escherichia coli lab strains K-12 GM4792 Lac+ and GM4792 Lac- carry opposite lactose markers, which are useful for distinguishing evolved lines as they produce different colored colonies. The two closely related strains are chosen as ancestors for our ongoing studies of experimental evolution. Here, we describe the genome sequences, annotation, and features of GM4792 Lac+ and GM4792 Lac-. GM4792 Lac+ has a 4,622,342-bp long chromosome with 4,061 protein-coding genes and 83 RNA genes. Similarly, the genome of GM4792 Lac- consists of a 4,621,656-bp chromosome containing 4,043 protein-coding genes and 74 RNA genes. Genome comparison analysis reveals that the differences between GM4792 Lac+ and GM4792 Lac- are minimal and limited to only the targeted lac region. Moreover, a previous study on competitive experimentation indicates the two strains are identical or nearly identical in survivability except for lactose utilization in a nitrogen-limited environment. Therefore, at both a genetic and a phenotypic level, GM4792 Lac+ and GM4792 Lac-, with opposite neutral markers, are ideal systems for future experimental evolution studies.The online version of this article (doi:10.1186/s40793-015-0114-x) contains supplementary material, which is available to authorized users. The monoclonal GM4792 Lac- colonies were grown in LB liquid medium, collected by centrifugation, and washed with the culture solution. Then, approximately 109 cells were plated on Davis minimal media [+ strain was obtained with the ability to metabolize lactose. The genome of each strain is a single circular chromosome with knockout plasmids; so, genetic variants between them could arise only from de novo mutations. Like most strains of E. coli [E. coli“var. communis” [E. coli K-12 GM4792 are shown in Table GM4792 is a strain of  lactose . This laommunis” . As prevommunis” , 26. StrE. coli have been thoroughly studied. This is described in detail by Scheutz and Strockbine [E. coli, GM4792 has a single peptidoglycan layer within the periplasm, consisting of D-glutamic acid, D-alanine, mesodiaminopimelic acid, N-acetyglucosamine and N-acetylmuramic acid linked to the tetrapeptide L-alanine. The cells stain Gram-negative and contain an outer membrane, with a lipopolysaccharide layer containing lipid A, the core region of the phosphorylated nonrepeating oligosaccharides and the O-antigen polymer [As a model organism, the molecular structure and chemical composition of the cell wall of rockbine . Similar polymer , 26.E. coli lab strains K-12 GM4792 Lac+ and GM4792 Lac- were selected for genome sequencing for subsequent use in experimental evolution studies. The genomes were sequenced in the year 2012. The genome project is deposited at the Genome OnLine Database [CP011342 and CP011343. A summary of the project information is shown in Table The two closely related Database  and the - strain. A single Lac+ clone was obtained after the Lac- strain had been incubated for 4 days under selection conditions for lactose metabolism. Strains stored at –40 °C were thawed at room temperature. Each strain was streaked on LB solid medium with an inoculation needle and incubated for 24 h at 37 °C. Distinctive monoclonal colonies grew, and a single colony was selected and inoculated into 5 ml LB liquid medium and grown at 37 °C with shaking for 24 h. Total genomic DNA was extracted using the TIANamp Bacteria DNA Kit , according to the manufacturer’s instructions. Additional RNaseA  was added, following the manufacturer’s instruction. The quality and quantity of the genomic DNA was evaluated using agarose gel electrophoresis and the λ-Hind III digest DNA Marker . For each sample, approximately 3 μg DNA with a concentration of 100 ng/μl was obtained.After receiving the laboratory strain GM4792 from M. G. Marinus, a single clone was randomly selected as a LacWhole-genome sequencing was performed using the Illumina HiSeq 2000 by generating paired-end and mate-pair libraries with an average insert size of 180 bp, 380 bp, 2 kbp and 6 kbp. The length of reads for each library was 100 bp. Duplicate paired reads were filtered out from each library with FastUniq v1.1 , and reade novo annotation was performed on both those regions with imperfectly transferred annotations and the insertions with respect to the stain MG1655. tRNA and rRNA were identified using tRNAscan-SE v1.3.1 [As the GM4792 strains are very closed to the strain MG1655, the annotations of GM4792 strains were firstly transferred from MG1655 using RATT . And theE v1.3.1  and RNAmE v1.3.1 , respectE v1.3.1 . CDSs weE v1.3.1 , InterPrE v1.3.1 , TIGRFAME v1.3.1 , Pfam [4E v1.3.1 , and COGE v1.3.1  databaseE v1.3.1  and SignE v1.3.1 , respectE v1.3.1 . TranscrE v1.3.1 . Gene onE v1.3.1  and BlasE v1.3.1  and KAASE v1.3.1 . The com+ genome contains a 4,622,342 bp long chromosome with 50.81 % G + C content. GM4792 Lac- genome has one circular chromosome of 4,621,656 bp with a G + C content of 50.80 %. Totally 4,144 genes were predicted for GM4792 Lac+, including 4,061 protein-coding genes and 83 RNA genes (tRNA and rRNA). Similarly, GM4792 Lac- is composed of 4,117 genes . The majority of protein-coding genes, for both GM4792 Lac+ and GM4792 Lac-, were assigned a putative function  and the remaining genes were annotated as hypothetical proteins. The properties and statistics of the two GM4792 strains are summarized in Tables Escherichia albertii KF1 was included as outgroup. Totally, 45 genomes including 44 Escherichia coli K-12 strains were analyzed  [+ and GM4792 Lac- are a good system for studies of population evolution and adaption.Phenotypic analysis revealed that the lactose marker was neutral under the conditions used in our studies of experimental evolution of nterval) . TherefoE. coli lab strains K-12 GM4792 Lac+ and GM4792 Lac-, which lay a solid foundation for future variant analysis of evolved lines at the genome scale in evolutionary experiments. A whole-genome comparison of GM4792 Lac+ and GM4792 Lac- reveals that the extent of genome-wide differences between GM4792 Lac+ and GM4792 Lac- are not significant and are isolated to the loci related to the utilization of lactose. Only two significant variants have been detected. One is a synonymous SNP, and the other is 1-bp deletion that is responsible for lactose utilization in GM4792 Lac+. Moreover, phenotypic analysis also showed that GM4792 Lac+ and GM4792 Lac- are nearly identical regarding survivability, except for lactose utilization, in a nitrogen-limited environment. All of the results indicate that GM4792 Lac+ and GM4792 Lac- with neutral markers are ideal systems for future experimental evolution studies.This study presents two closely related genomes,


Objective. To investigate the efficacy of using “Instagram application” with a “home-exercise program” as a motivational stimulus in improving physical activity (PA) adherence levels among female college students. Methods. Fifty-eight female undergraduate students with the mean age 20.3 ± 0.96 years participated. Participants were divided into two groups: intervention and the control group; both the groups received an exercise program and the intervention group was additionally motivated by “Instagram.” Adherence to PA was measured by using an adherence sheet. The Exercise Motivation Inventory (EMI-2) was used to assess the motivational factors. Results. The most frequent motivational factors were extrinsic as assessed using the EMI-2. “Positive health” was the most frequent factor mentioned of the two types with 47% of the sample. The intervention group adhered with 17% more to the activity program compared to the control group. Moreover, 72% of the participants in the intervention and control groups found the activity program flexible enough to be performed at home; they agreed about its effectiveness on adherence (53%). Conclusions. The use of Instagram with the home exercise program as a motivational modality could be attractive and effective to reinforce adherence and maintain an appropriate PA level.  Adherence to physical activity (PA) leads to improvements in physical function and quality of life . The adhAdherence to PA must be improved in order to improve health prospects. The adherence to the PA has been found to be extremely low in the Saudi population, particularly among young females . This poMotivation for PA could be defined as the intrinsic and extrinsic factors that stimulate desire and energy in people to be continually interested and committed to the initiation and the maintenance of a PA program or any type of exercise . IntrinsThe present study aimed primarily to investigate the efficacy of using social media “Instagram application” with a “home exercise program” as a motivational stimulus in improving PA adherence levels among Saudi female college students and secondarily to measure the motivational factors that influences their engagement or continued participation in an exercise program.Fifty-eight undergraduate female students from the College of Applied Medical Sciences (CAMS), King Saud University, Riyadh, participated in this quasi-experimental study. Self-selection sampling method was used. The selected sample was mostly newcomers to exercise and the time of study was in the second semester of the academic year and the designed program started before the middle of the semester at the period of first midterm exams. They were assigned into two groups in a nonrandomized way. The inclusion criteria were as follows: the participants should have online social network (Instagram) accounts, female students in the age range from 18 to 25 years. The participants were excluded if they are pregnant and had any medical problems. The purpose and procedure of the study and the activity program were explained and demonstrated to each participant. Each participant who agreed to participate signed written informed consent approved by the institutional ethics committee.2. Each participant asked to respond to the Exercise Motivation Inventory-2 (EMI-2) questionnaire [https://www.youtube.com/watch?v=fcN37TxBE_s) was played which consisted of 37 minutes of cardio workout. This workout was lower to moderate intensity and is made for the beginners. The participants were divided into two groups the intervention group (Instagram group) and the control group. The intervention group had an online social network (Instagram) accounts; however, control group had no such account. An email was sent to all of the participants about the date for returning the adherence sheet and only the intervention group received the study account in Instagram and was required to follow it. A variety of techniques were used in Instagram to improve motivation for adherence to PA. First, a small number of pictures were posted to educate the participants about the benefits of PA such as benefits of exercise on bone density, back pain, stress, and mood. Secondly, Instagram was used as an alarm, to remind them to do the exercise sessions at each week. They asked to post their own pictures of adherence sheet when they complete the session in order to motivate other participants to do the exercise. In addition, they received the exercise program video link (can be accessed on YouTube https://www.youtube.com/watch?v=fcN37TxBE_s); this was an exercise video from Fitness Blender Cardio Workout at Home, which was a 37-minute, Fat Burning Cardio Workout, 3 in difficulty. It focused mainly on the lower body and was also generally for all the body. It consists of a warmup, workout, and a cool down at the end of the video. This activity is designed to be performed at home without any need for any exercise equipment or registration in a gym and this type of activity was moderate intensity physical activity, 150 minutes per week according to the 2008 Physical Activity Guidelines for Americans [Anthropometric parameters including body weight, height, and body mass index (BMI) were measured. The participants wore simple clothing and had no footwear. Height was measured using a fixed stadiometer (resolution of 0.5 cm). The weight was measured with Beurer glass diagnostic scale (resolution of 0.1 kg). The BMI was estimated using the formula: weight (kg)/height (m)ionnaire , 16. Theionnaire . In addimericans . After tt-test was chosen to compare adherence between the two independent groups (intervention and control groups). Descriptive statistics for the motivational factors and the flexibility and effectiveness of the program were employed to analyze the data. A level of significance was taken P < 0.05.The Statistical Package for the Social Sciences (SPSS) program “version 22” and Microsoft Office Excel 2007 were used in the statistical analysis. The unpaired P = 0.04). Fifty-eight students completed the EMI-2 survey, and 47 of 58 were included in the intervention and control groups to test the efficacy of intervention. Eleven participants did not submit their adherence sheet (attrition rate 19%). The primary aim of this study was to investigate the efficacy of using social media “Instagram application” with a “home exercise program” as a motivational stimulus in improving PA adherence level. It has been hypothesized that motivation by using “social media” in combination with an “Organized Activity Program” would increase adherence to regular PA. Previous studies suggested that the use of electronic media to improve motivation had an effect in improving adherence among participants –14.In the present study, participants from the intervention group performed more than eight sessions compared to control group who performed 2-3 sessions only; this might be referred to the motivation caused by Instagram in the intervention group. These findings were consistent with those observed in the previous study , who repFrom the above discussion it follows that adherence is a subjective characteristic that all people have in different levels and it is affected by many social and personal factors that must be considered in any situation . TherefoParticipants were asked to perform exercise sessions as they feel and want to get benefits of PA, so they could continue in any type of regular PA. Adherence to certain exercise programs is predicted by using of motivation in the program, and it is an effective way to encourage a person to participate in the activity . In the Moreover, investigating the flexibility and effectiveness of the designed home exercise program to improve adherence to PA was an objective of the current study. The participants' opinions about the motivation for PA with the designed program were mostly positive in comparison to their adherence to the program which was slightly negative. This may indicate that the program was effective in a motivational way to encourage participation in the activity program but for adherence it was insufficient. Some reasons for nonadherence to the exercise program were given by the participants and the three most important were “academic stress, not enough time,” and “the program is hard to perform” and “not motivated by the program” was also mentioned. In the previous study, the lack of time was one of the commonly reported reasons for nonadherence . Anothern = 60) and some of the study findings may have been affected by this. In addition, sample was selected based on self-selection technique instead of probability sampling, which could affect the results. For future research, it is recommended that further investigation in this field needs to be undertaken in different colleges on the campus as well as at various universities, and with a sample which includes people with different levels of education, and increased duration of intervention to test adherence to PA program more accurately. Home based exercise is a good motivational way to participate in physical exercise, but it was found insufficient for exercise adherence. Thus more effective modifications to this type of motivation may well improve adherence. Health providers and trainers at the health centers should activate the use of social network sites to provide guidance, instruction, and motivation to the people to maintain regular PA in order to gain a healthy lifestyle.The present study had some potential limitations. The sample size was small due to the short duration of study time. If the study had included multiple colleges on the campus, diverse findings might have emerged. The study required to receive adherence sheets about the activity program from all included participants. This being said, there were 11 participants of 58 who did not return the sheets and there were 2 participants excluded from the study which resulted in a 23% attrition rate from the recruited sample (The adherence to PA among female college students was poor. The use of Instagram with the home exercise program as a motivational modality could be attractive and effective to reinforce adherence and maintain appropriate PA levels among these populations.


In order to manage with the burden of mental health problems in the world we need to develop cost-effective and safe preventive interventions. Education about resilience to support the ability to cope with life challenges in general, may be a useful strategy. We consider the concepts of Theory of Mind and Mentalization to be relevant in this context. In this paper we describe a simple modular intervention program based on these concepts which can be tailored to specific needs and situations in individual therapy as well as group levels. The program has shown promising results in pilot studies and is now tested in controlled trials in settings such as schools and educational institutions, adults diagnosed with ADHD, and children in care. There is an increasing awareness that the burden of mental health problems in the world cannot be addressed by therapeutic interventions alone . AlongsiOne promising approach is structured mental health education. A number of meta-analyses suggests that mental health education has positive effects on perceived health and behavior in a wide range of settings , such asResilience is defined as successful adaptation to adversity, including successful recovery from adverse life events and sustainability in relation to life challenges, individually and on group- and community-levels .The term Mentalization refers to the skills involved in understanding mental states, not only in others but also one’s own mental states as well as their connections with behavior. This is central in mutual understanding of relationships, self-control, motivation, and flexible understanding of what is going on in the world around. Theory of Mind is thus an integrated part of mentalization .A compromised ability to mentalize is considered as a core neuropsychological deficit in autism spectrum disorders  and bordThe psychological research about mentalization is supported by neuro-imaging studies demonstrating frontal and temporal functional changes . MentaliBased on these findings we have developed a modular mentalization-based intervention program that we call ‘the Resilience Program’ in which a social field education model is combined with a self-directed web-based approach. The aim of this article is to describe the Resilience Program briefly and present preliminary results and ongoing studies.The Resilience Program is a flexible web-based modular mental health education program that can be used in general mental health promotion as well as in supporting people with mental health problems independent of character and complexity. The program can be used in any organizational context  and can be integrated with any daily routines and in combination with other interventions, with low or high intensity. Hitherto our pilot experiences clearly indicate that following a brief period of training the program can be used by any professional and by lay persons, including parents, and students.1 contains all information and a number of presentations about the Program, which consists of knowledge about resilience, mentalization and self-control, social learning theory, cognitive training, and neuroscience. This knowledge is transformed into a coherent yet simple, easy to understand set of presentations combining daily language texts, pictures, and short films.The Resilience Program websiteIt is possible to use the Resilience Program as a completely self-directed program. However, the program is most often introduced to target groups in short lectures and courses followed by discussions, group work, and follow-up supervision. Whenever possible we use a social field model of delivery, for instance a whole school intervention approach including both teachers and parents. Afterward teachers and parents use whichever program modules they find relevant to their setting, in talks and education with their children (down to the age of 6–7 years) and adolescents. The program is thus organized as free-standing modules that can be combined for individual purposes. It is clear from the material what is applicable for children and adolescents and what is useful for the adults around them.For illustrative purposes, we present two examples from the Resilience Program (copied directly from the program website) describing in daily language and metaphors what is going on in the brain and our minds in mentalizing and non-mentalizing states.The Story of the House of Thoughts is a metaphor for the core idea about mentalizing and non-mentalizing states. It is read aloud by parent, teacher, or instructor. Children can then eventually write or draw their own personal version of the story – their own house.In some way, we may say that our thoughts live inside our heads. Imagine that your thoughts live in a house with many rooms where you can wander around and discover them. When you discover thoughts, you are using the world’s finest tool – your attention, which is a kind of spotlight. When you throw light on a thought, you spot it and discover it. Thereafter you can shift your attention and discover another thought.The House of Thoughts has plenty of rooms – a number of exciting thoughts may live in one room, perhaps some sad or angry thoughts live in another room and various happy thoughts live in a third room.From The House of Thoughts, your thoughts can call you if they want to be discovered. This may be really exciting and good, but could be irritating too – especially if the thoughts are annoying and keep knocking all the time, trying to take charge over your attention. In the case where you have sad, anxious, or angry thoughts that take charge and force you into their room all the time, you might end up believing there are no exciting or happy thoughts to be found anywhere and that is not much fun.… Yet this is not the case at all. All the happy and exciting thoughts are just waiting in other rooms in the House of Thoughts, waiting for you to discover them with your attention. Maybe there are even tools to be found in one room that could be used to fix some other thoughts in another room in the house. There may also be thoughts in a room that need to be left in peace, so they will not disturb you too much. If you often go to explore The House of Thoughts with your attention, then it becomes easier to be in charge of your thoughts.Figure 1 and the italic text below the figure):The section about the Thinking Brain and the Alarm Center explains the neurobiology behind mentalizing in simple terms  of course increase the risk of over-sensitizing the alarm center. Unfortunate micro-events can, by chance, also create permanent over-sensitivity in the alarm system . The most frequent cause of imbalance in the alarm center is insecurity in everyday life for example within family, in school or at work, and stress at a level that overloads the working memory and causes loss of overview.Other people’s thoughts are invisible. That is why we sometimes misunderstand another person and believes that he or she does not want any good for us. Such thoughts can trigger the alarm center. If the other person is in an alarm state as well, we have two alarmed brains fighting each other and/or fleeing from each other.Fortunately, the brain can be trained to become resilient instead of becoming vulnerable. When the thinking brain and the alarm center face appropriate challenges, neither to big nor too small, the thinking brain is able to control the alarm center, so it is not triggered without reason. The brain’s working memory is trainable too, thus making it easier to cope with life.The Resilience Program has been developed in 2005–2007 inspired by mentalization research, cognitive, and neuroscience and social learning theory. The program was pilot tested in the Municipality of Aarhus in Denmark in 2008–2010 . The pri2 on the sub-site ‘about us.’In 2013 we began to investigate the efficacy and efficiency of the program, using the intervention methods described above, in four controlled studies: a school study involving 60 schools and a youth education study involving 16 educational institutions; a study with 9,000 looked after children; and a study with 8,000 young people with ADHD. Data collection will start in late 2015 and be repeated in the following years. Results will be presented in 2016–2018. Trial protocols can be seen at the program websiteThe Resilience Program is currently implemented locally in five European countries and is also being tested in studies with various other methodologies by independent researchers.In order to illustrate the potential use of the Resilience Program, we here present 3 years follow up results from an exploratory pilot study in spring 2011 using the first version of the Resilience Program in a low-income city area in Denmark.Ninety percentage of the population in the target area of the study is immigrants from Middle East countries. In the area, there are several social clubs for adolescents. In 2009–2011, one of the clubs was challenged by increasingly severe disruptive behavior among the adolescents, for reasons which the managers of the clubs were not able to clearly identify. For that reason the managers asked for this intervention. At the time of intervention in spring 2011, 130 adolescents were registered members of the club.The staff in the Municipality of Aarhus are regularly offered post-graduate education. In the period 2009–2011, the staff in the trial club in the area had two other post-graduate courses, one about coaching, and one about body relaxation.Because of encouraging findings from the pilot trial described here, the managers implemented the same program and training in a neighbor club in the area in the late 2012. The neighbor club did not receive the other mentioned post-graduate courses. Data before and after intervention from this neighbor club is included in the study.All staff members received a 3-days Resilience Program course with follow-up supervision for 3 months. The staff introduced the adolescents to the program. A sub-group among the adolescents received a more intensive education (45 min × 6).The results in the social club study are based on the following data:• The frequency of incidents where staff members use physical force in high-risk conflicts in order to protect persons from physically damaging themselves or other persons. We have incident data from the trial club and the neighbor club in the period 2009–2014.• Staff sick leave. This is standard administrative data in the organization. We have data from all clubs in the municipality from 2008 to 2014.•presently consider their post-graduate courses from 2011: the coach course, the body relax course and the Resilience Program course. They were also asked if they specifically use Resilience Program modules in direct talks and education with adolescent in their present daily work in the club. Questionnaire data. In spring 2014 the staff in the trial club and the neighbor club filled out a questionnaire asking them to evaluate how meaningful  they Figure 2 and Table 1.The yearly force incidence rate in the trial club was nearly halved after the intervention , while this rate remained low and stable in a neighboring club. Compared with the neighboring club, the rate in the trial club was four times higher before the trial and reduced to two times higher after trial . See also In the neighboring club, the intervention was introduced in March 2012, giving no changes in yearly force incidence rate after intervention .Table 2. Compared to all other clubs, the trial club had more sick leave days before the trial and had fewer sick leave days after the trial, with a statistical significant difference of 3.0 days (95% CI 1.8 to 4.2) before trial and of -3.4 days (95% CI -4.3 to -2.6) after trial.The average yearly sick leave days was significant reduced in all clubs in the municipality in 2008–2014, but the reduction in the trial club was larger than that of all other clubs (12.0 vs. 5.5 days) and that of a neighbor club (12.0 vs. 8.3 days). See Table 3, the response rate to the questions is generally high although varying. In both clubs the coach education and the Resilience Program course is rated higher than the body relaxation course. The Resilience Program is still used by a large majority of the staff in both clubs in communication with the adolescents.As can be seen from Because the scores are not normal distributed, we used Kruskal–Wallis test to check the differences in the distributions of scores between different programs or clubs.p < 0.05 and p < 0.01, respectively), while there was no difference between RP and coaching (p = 0.66). The same is true for neighbor club .Among trial club, both RP and coaching had a higher score than body relaxation (p > 0.10).If we compare the same program between trial club and neighbor club, there is no difference for any program  and/or a positive effect of the intervention. Because this is not a controlled trial, we cannot determine which of the hypotheses is most likely to be true.Despite the positive evaluation and use of the Resilience Program in the neighbor social club 1 year later in spring 2012, this has not affected the force incident rate in that club. This may indicate that the RP program in the form it was delivered was not effective in relation to this outcome in that club. Another hypothesis may be that the force incident frequency in that club is as low as can be, considering the challenges children and young people and families in this low income area face in their lives. Maybe a further decrease cannot be expected. However, it is also important to notice that the development in the frequency of high risk conflicts leading to incidents of using force in 2009–2010 was very different in the trial club and the neighbor club so one should be cautious in the interpretation of the data since the two clubs in this respect cannot be considered comparable.The exploratory pilot study results suggest that the Resilience Program may be promising and that randomzied testing of the program is justified. The program is easy to understand, even for disadvantaged children and adolescents. The results indicate that the program may contribute to building a safe mental environment for disadvantaged adolescents and the staff around them in social youth clubs.The ongoing randomized trials will show if the Resilience Program is efficient as a completely self-directed online program as well as a group-based education and training program used within organizational contexts such as schools and educational institutions.May be this type of low cost brief intervention programs focused on education can contribute to the solution of societal mental health problem challenges.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.


Inadequate program design and lack of access to evidence-based programs are major barriers to the management of chronic diseases such as arthritis, particularly for African Americans. This study evaluates the effectiveness of the Arthritis Foundation’s Walk With Ease Program (WWE) in a subsample of African Americans who were part of a larger study that established evidence of the program’s efficacy.t tests were conducted to examine group differences  in arthritis-related symptoms at baseline, and paired sample t tests were conducted to examine differences over time  in symptoms. Satisfaction was examined by descriptive statistics.Participants were African Americans (N = 117) with self-reported arthritis who chose to participate in either a self-directed (n = 68) or group (n = 49) 6-week WWE program. Arthritis-related symptoms  were assessed at baseline, 6 weeks, and 1 year. Independent samples P < .001, P = .008; respectively). After the 6-week intervention, participants reported a decrease in pain (P < .001), fatigue (P = .002), and stiffness (P < .001). At 1 year, the decrease in pain (P = .04) and stiffness (P = .002) remained constant. Overall, participants were satisfied with both program formats.Younger, more educated individuals chose the self-directed format (The individualized and group formats of the WWE program improved arthritis-related pain, fatigue, and stiffness in African Americans. Culturally appealing arthritis interventions ultimately may increase the use of existing arthritis interventions. Arthritis, the leading cause of disability in the United States, affects almost 50 million Americans  and contEvidence-based arthritis interventions  are effective in reducing arthritis-related symptoms such as pain, fatigue, and stiffness and are a useful treatment option for people with arthritis –13. HoweSpecifically, our study is focused on a subset of the parent study population that was used to establish evidence of effectiveness for WWE in general . To dateThe Arthritis Foundation’s WWE program, currently offered in 2 formats , is a community-based 6-week program for adults with arthritis. The program focuses on setting goals, developing action plans, identifying motivational strategies, and building one’s confidence to increase physical activity as a way to minimize arthritis-related symptoms. Participants in the self-directed program are provided with the WWE workbook as a guide to navigate the 6-week program on their own. Participants in the instructor-led group program attend a class that meets 3 times a week for 1 hour, taught by lay leaders who have received a certification after attending a 1-day Arthritis Foundation Leader Training course.Participants in the parent study included 462 community-dwelling adults recruited from senior centers, aging councils, public health departments, medical centers, rheumatology clinics, fitness/wellness centers, retirement communities, colleges and universities, churches, a service sorority, recreation centers, and various employers across urban and rural North Carolina counties . EligiblThe parent study was initially performed at 33 community sites throughout North Carolina, 20 of which had participants who reported being African American. Sites included senior centers, churches, community/health wellness centers, employers, and departments or councils on aging. To protect the privacy of participants where only 1 or 2 participants signed up, we do not provide detailed information by site. At baseline, each participant who provided written informed consent completed a self-report survey (on paper or computer-based), and a series of performance-based tests administered by a trained research team member was included in the study. Six-week follow-up assessments were conducted at each of the community sites, where participants completed the same initial tests and survey and a written satisfaction survey comprising closed and open-ended questions about their experience. One year after completion, participants were mailed surveys assessing their self-reported outcomes only, to evaluate long-term effects of the program. For the purposes of this study, we focus on self-report survey data only. All procedures for the parent study were approved by the University of North Carolina, Chapel Hill Biomedical Institutional Review Board, and by the Institutional Review Board of George Washington University for the substudy.Demographics. Demographic information included race, age, education, sex, body mass index (BMI), health status, and comorbid conditions. Race was assessed by asking participants, “What is your race/ethnicity?” Age was measured as a continuous variable by using participant self-reported date of birth and later stratified into 3 categories . Education was assessed on the basis of the response to “What is the highest degree or level of school you have completed?” Responses were later dichotomized (having a high school education or less and having more than a high school education). BMI (kg/m2) was a continuous measure that was calculated by using self-reported height and weight and later dichotomized as less than 30 kg/m2 or 30 kg/m2 or more. Health status was assessed by asking participants to rate their health in general as excellent, good, fair, or poor  (es (VAS) ,21. VAS es (VAS) . ParticiSatisfaction. Participants in both self-directed and group delivery formats were surveyed about their overall satisfaction with WWE. The survey assessed satisfaction and acceptability of information, tools, workbook, program presentation, value, or benefit. The survey questions were formatted differently depending on the type of program ; however, answers were standardized for comparison of overall satisfaction. For example, in the group format, participants were asked: “Overall, to what extent are you satisfied with this program? .” In the self-directed format, participants were asked, “Overall opinion of WWE program: I was satisfied with my experience doing the Walk With Ease program .” Although the self-directed and group satisfaction survey results cannot be quantitatively compared, they are described in this study.To gauge the sensitivity of the statistical analyses used in this study, a power analysis was conducted on one of the main variables, pain, which was measured using the VAS. We found a minimal detectable difference (MDD) of 6.9 units with 80% power . This difference approaches the recommended VAS pain MDD range of 7 to 37 units and detects smaller differences as baseline pain scores decrease –25.t tests and χ2 tests. Pearson correlations were conducted to assess if any of the demographic factors served as covariates when comparing the 2 program delivery formats.All analyses were conducted using SAS version 9.2. Descriptive statistics for demographic and outcome variables  were calculated separately for both the self-directed and group walking formats to provide a summary of the sample distribution at baseline. Differences in delivery formats were examined by using t test. Following the standard set forth in the parent study  at 6 weeks and at 1 year (independently) with baseline scores using a paired nt study , effect study . No significant differences were found in average number of comorbidities. However, a large number of participants in each format reported having high blood pressure  and diabetes  at baseline (data not shown). No significant group differences were found for BMI, health status, pain, fatigue, or stiffness.Significant differences were found in the age and education level of people selecting the self-directed versus the group format . IndividP = .04) and stiffness  from baseline to 1 year  . Particio 1 year . We founOf the 71% of African American participants (n = 48) who completed the satisfaction survey after participating in the self-directed format at 6-week follow-up, 92% (n = 44) agreed or strongly agreed that they were satisfied with the overall WWE program (data not shown). In surveying the group format participants at 1-year follow-up, data were collected anonymously; therefore, satisfaction specifically for African Americans could not be determined. However, overall, participants enrolled in the group format were indeed satisfied. Of the 109 group participants who completed follow-up surveys in the original study, 100% reported that they would recommend the WWE program to a friend. Nearly all of the group format participants also reported that their instructors kept them interested in the program at a fairly or very well level (99%), that they were satisfied with the way the instructor presented the topics (100%), and that the program fulfilled their expectations (99%).This study evaluated the effectiveness of WWE in African Americans with arthritis, who are disadvantaged in the impact and prevalence of the most common symptoms associated with arthritis ,5. ResulWWE not only reduced arthritis-related symptoms but was also perceived as acceptable by African American participants. Specifically, most participants in the self-directed program reported being satisfied and having completed the program with lessons learned. Because differences in demographics were negligible by program format, it is plausible that African Americans’ overall satisfaction with the self-directed format is similar to their overall satisfaction with the group format. Previous research has found that African Americans with arthritis respond favorably to programs beneficial for their condition that could be delivered to them independently or in a group setting . TherefoFindings from this study have implications specifically for African Americans. Having a physical activity program that minimizes disease-related symptoms and is deemed acceptable among this target population provides a foundation for future research. Not only do African Americans have worse arthritis outcomes than other races/ethnicities ,6, they Our study has limitations. Although our study was adequately powered to detect the recommended MDD for our primary outcomes , the small sample size prevented additional analyses that could determine differences in symptoms according to delivery format. However, the findings still provide novel information about the effectiveness of WWE among African Americans. Using 2 different surveys and following 2 different methodologies may have limited our ability to determine any differences in satisfaction according to format. Because we used participant self-report to measure arthritis symptoms, responses may have been biased due to social desirability. However, the scale used for this study has been used in similar research as a valid measure for pain, fatigue, and stiffness. In addition, future research examining the effectiveness of a behavioral arthritis intervention should include a control group to provide stronger evidence that the effects found are due to participation in the intervention. Notably, this sample of African Americans was highly educated, predominantly female, and reportedly in good health. Demographics of this type limit the external validity of our findings. Lastly, a mixed-method  design may have been a stronger methodological approach for assessing satisfaction and acceptability.Despite these limitations, our study provides practical lessons. For example, we used targeted strategies  in an effort to overcome barriers to recruiting and retaining African Americans. Recruitment efforts resulted in 25% of the WWE parent study population being African American ; this peFrom a public health perspective, a community-based walking program for African Americans with arthritis has the potential to increase the currently limited culturally sensitive self-management opportunities now offered . Our fin


Caring for a person with dementia has profound physical, psychological, social and financial impacts on the carer, while morbidity in carers has detrimental effects on outcomes in people with dementia. A 10-day hospital-based residential carer training program (BMJ 299(6712):1375–1379, 1989) delayed residential care placement, delayed mortality, reduced carer’s psychological morbidity and lowered care costs. This study aims to evaluate the effects of a similar program adapted for use with residential respite.This is a single-arm longitudinal study conducted at a residential aged care facility involving 100 people with dementia and their primary carers. In a 7-day residential program, carers will attend intensive training sessions while the people with dementia are engaged in daily activities. Data will be collected at the start of the residential program (baseline), at 6 months (post 1) and at 12 months (post 2) after completion of the program. The primary outcome is carer psychological distress. Secondary outcomes include carer burden, carer quality of life and time to residential care placement.This study will provide evidence on the effectiveness of the program in reducing carer distress and burden as well as delaying institutionalisation of the person with dementia, which may have important implications for policy. Approximately 70% of people with dementia in Australia live in the community and most of them receive some informal care AIHW . InformaCarer burden refers to the carer’s perception of the extent to which their physical, psychological, social and financial status has been affected as a result of care provision   have been shown to be associated with carer burden  with the main purpose of providing the family carer with respite and support. The use of residential respite care has steadily increased in Australia, but take up rates remain low, with only 32% of eligible people with dementia accessing residential respite care services within 12 months of gaining approval AIHW . There aGoing to Stay at Home program, which is adapted from the Prince Henry Hospital program for use with residential respite.The principal aim of this study is to evaluate, in an open single-arm trial, the effects of the carer psychological distress will be reduced at 6- and 12-month follow-up compared to baseline,carer burden will be reduced at 6- and 12-month follow-up compared to baseline,there will be no increase in BPSD in the person with dementia, anda minimum of 60% of carers will have the person with dementia still living at home at 12-month follow-up.It is hypothesised that:A single-arm longitudinal design will be used. Data will be collected at three time points: at the start of the residential program (baseline), at 6 months (post 1) and at 12 months (post 2) after completion of the program.The study will be conducted in an eight-bedroom cottage at an RACF in southern Sydney, Australia.Going to Stay at Home program at the RACF will be invited to participate in this evaluation study. Participants of the GTSAH program will be recruited through the community care division of the RACF, aged care assessment teams, carer groups and hospitals, and will then be clustered into groups of four to six person with dementia-carer dyads according to their demographic characteristics.People with dementia and their primary carers enrolled in the Inclusion criteria for people with dementia:confirmed diagnosis of dementialiving at home with a primary carerable to understand and communicate in Englishinformed consent (self and/or proxy) and verbal assent to participateExclusion criterion for people with dementia:no written consent and/or verbal assent to participateInclusion criteria for carers:able to understand and communicate in Englishinformed consent, and where appropriate, consent for the person with dementia to participateExclusion criterion for carers:no written consent to participateThe 7-day residential program will begin on a Sunday and finish on a Saturday  will be discussed in this session. Other issues such as driving, legal and financial matters, as well as Advance Care Planning will also be explored.Re-roling. This session will explore the issues pertaining to the changes in roles and responsibilities between the person with dementia and the carer. Practical problem solving skills will be taught to help carers encourage the person with dementia to allow the carer to take over some of the tasks while maintaining his/her dignity and to develop the carer’s confidence in taking over these roles.Reminiscence and reality orientation. Carers will be provided with information on techniques of reminiscence (e.g. use of a life history book), environmental reality orientation (e.g. use of signs or clocks) and validation to enable the person with dementia to maintain connection with their environment as well as improve the communication between the carer and the person with dementia.Communication. Information on receptive and expressive dysphasia that the person with dementia may experience and how these may affect communication will be provided, and then carers will have the opportunity to learn communication strategies to enhance understanding.Assertion. Carers will be provided with an understanding of assertive, non-assertive and aggressive behaviours, a “carer’s bill of rights” and strategies to cope with criticisms to ensure that they are heard and understood and their personal rights are maintained.Therapeutic use of activities. Activities that may be meaningful and enjoyable to the person with dementia will be identified in this session and carers will be provided with knowledge of activity analysis that enables them to break down familiar tasks into component steps and to modify or eliminate steps that prevent the person with dementia from completing them.Work simplification, organisation and safety in the home. Problem solving skills of prioritising, simplifying and using outside assistance will be explored to help carers achieve a balance of work, leisure and rest in their daily life. Tools to identify risks within the home environment will be provided and safety measures to minimise the risk to the person with dementia will be discussed.Nursing skills. Clinical issues associated with dementia such as incontinence, medication, mobility, personal care and acute illness will be covered and carers will receive hands-on experience in using clinical care equipment that can be used to aid care practices.Fitness. Information about the benefits of exercise for both the person with dementia and the carer will be provided, and a daily exercise routine will be established.Nutrition. Changes in diet, food intake and nutritional needs of the person with dementia will be examined, and carers will be provided with practical skills to enhance intake as well as improve the eating experience.Caring for self. This session will provide carers with the opportunity to identify their need for support and they will be taught a variety of relaxation and stress management techniques.Using community services. Information about the types of support services available in the community as well as how to contact and access these services will be provided.There will be 14 intensive psychoeducation sessions for carers. These sessions will be delivered in an informal structure, with didactic segments, group work, modelling and role play. The sessions cover the following topics:The program for people with dementia will include activities that focus on sensory stimulation, environmental orientation, brain training, physical activity, reminiscence, self-expression, creativity, social interactions and relaxation. Outings may be arranged depending on personal preferences. A large variety of activities will be arranged to cater to different personal preferences and individual needs. The people with dementia will also be provided with the opportunity to discuss changes in their memory and their brain on a physiological level depending on their ability and willingness to receive the information.Global cognitive function of people with dementia will be assessed at baseline by RACF staff using the Mini Mental State Examination (MMSE)      : The Instrumental Activities of Daily Living Scale (IADL) (Lawton and Brody Activities of daily living (ADL): The Physical Self-Maintenance Scale (PSMS)      difference at a significance level of 0.05 (two-sided), assuming a medium within-subject correlation (ρ = 0.5) between pre- and post-intervention measures.t-test at a significance level of 0.05 (two-sided). To control for covariates  linear mixed models will be used.The difference in outcome measures before and after intervention will be examined using a paired Patterns of missing data will be examined to identify potential biases. Where applicable, missing items will be handled as suggested in the literature for that particular instrument.This study has been approved by the Human Research Ethics Committee, University of New South Wales, Sydney, Australia . Written consent will be obtained from all participating people with dementia and their primary carers. In the case where the person with dementia is deemed unable to provide informed consent, a responsible person will provide written consent and verbal assent will be obtained from the person with dementia.Going to Stay at Home is a 7-day residential carer training program, which was adapted for use in residential aged care settings from a successful hospital-based residential carer training program. The present study aims to evaluate the effects of this program. Outcomes for carers and people with dementia will be measured using standardised instruments. In addition, qualitative analyses of interview and focus group data will be carried out to determine which components of the program carers found most effective and the impact of the program on practices within the residential aged care facility. This evaluation study will provide evidence for whether the program is effective in reducing carer psychological distress and burden as well as delaying institutionalisation of the person with dementia, which may have important implications for policy.