Although patients with Chronic Obstructive Pulmonary Disease (COPD) who adhere to a pulmonary rehabilitation program are better able to manage their illness and experience a better health-related quality of life, pulmonary rehabilitation remains underused. This study aims to describe the experiences of patients who are in a pulmonary rehabilitation program, and explore the perceptions of both patients and health professionals about what improves effective pulmonary rehabilitation.A qualitative research design, including focus groups and individual interviews with 25 patients and 7 program health professionals, was used to obtain combined perspectives about the factors underpinning the COPD patient's reasons for participation in a rehabilitation program.Three themes were derived from the descriptive content analysis: (1) building confidence, (2) a perception of immediate tangible results, and (3) being ready and having access to the program.Qualitative findings from this study suggest that a patient's adherence to a COPD rehabilitation program can be improved by quickly building up the participant's confidence, promoting tangible results, and by timely recognizing and responding to the issues of readiness and access. Based on these findings, health care providers could develop strategies to better serve COPD patients who face multiple barriers to access and successfully complete a pulmonary rehabilitation program. Chronic obstructive pulmonary disease (COPD) is a major cause of disability and death in Canada and throughout the world. It was reported in 2012 to be the third leading cause of death in the world In response to the rising morbidity and mortality associated with this disease, a pulmonary rehabilitation program was developed to optimize the prevention and management of COPD Some studies investigated the adherence by COPD patients to PR programs. Brooks et al. A qualitative descriptive research design was used to obtain multiple perspectives about factors underpinning the reasons COPD patient participate in a rehabilitation program. Data were generated from four sources: (1) qualitative focus groups with COPD participants, (2) focus groups with program facilitators, (3) individual interviews with COPD participants.This study was approved by the research ethics boards of both the University and the Health Authority where this study was located. As per standard PR program protocol, PR staff members schedule an initial assessment session with each COPD patient referred to the program by a physician. At the end of the assessment session the PR staff member who conducted the session asked the patient if they would like to learn about a PR-related research study. If the patient was interested in learning more, the PR staff member referred them to research assistant. All participants were briefed by the researcher or research assistant regarding the research purpose, methods, and involvement required. Prior to participant enrollment, written consent was obtained. Health care professionals were purposively sampled through invitations to participate from a third party or flyers in accordance with procedures approved by the research ethics boards.The study included COPD participants (N = 25) from three different PR programs offered by two different hospitals and one community center in a large Canadian city. Here the eligibility criteria stipulated adults 40 years of age or older, diagnosed with COPD, referred by a health professional, having completed at least 75% of the PR program and being able to read and speak English. Patients with other organ dysfunction, skeletal muscular disorders, cancer, or who were unable to cooperate were excluded from the study. The other sample group consisted of program health professionals (N = 7) currently staffing PR programs at the three sites in the catchment area that included physiotherapists, respiratory therapists and registered nurses.Participants were recruited from three PR programs in the catchment area. All three programs were outpatient, multidisciplinary programs, each offering 24 or more consecutive sessions. Each session included both education and exercise training. The education sessions addressed the anatomy of the respiratory tract and the physiology of COPD, the effects of smoking, and also provided self-care skills. A multidisciplinary team consisting of a chest physician, nurse, physical therapist, and a dietician provided care and advice during each session. After completing the PR program no other structured and/or supervised home exercise programs were offered, but patients could choose to participate in a maintenance exercise program.Four to six weeks after the end of the program, an audiotaped focus group interview was conducted with the COPD PR participants from each of the three PR programs on site. To ensure richness of data, three participants were selected (one from each group) to be invited to take part in an individual interview. The selection criteria included being expressive and willing to share their experiences of living with COPD and attending a PR program. The interviews were conducted by telephone and audio-taped, and included an elaboration of the topics identified in the earlier focus group. The other focus group consisted of 7 professional PR staff, including three respiratory therapists, two physiotherapists and two registered nurses from among the three PR programs where focus groups were recorded.A total of 25 COPD patients across three sites participated in four focus groups and 7 health professionals participated in one group. All focus groups followed the procedure as outlined by Kreuger and Casey (2000) Transcribed data were coded using a thematic analysis approach Guba and Lincoln (2005) proposed that in qualitative inquiry, researchers pursue rigor by establishing the trustworthiness of the interpretations Twenty-five COPD patients (moderate to severe COPD without chronic respiratory failure) were enrolled. Diagnosis of COPD was made according to the International GOLD guidelines building confidence, perceiving immediate tangible results, readiness and access.Three themes were generated using the process outlined above. huge, with everything from filling out financial aid and disability forms, to dealing with loneliness, depression and anxiety.” As a result, some participants became progressively more isolated and depressed and less mobile. As one patient mentioned, “when I was finally diagnosed with COPD I didn't believe it, but since I had trouble breathing there had to be something wrong…I gave up golf and I stopped going fishing. In fact, I became a hermit and pretty much just sat in my den most of the day. ” Another patient stated “I've lost 50% of my lung capacity to this. I've got emphysema, asthma and bronchitis. My heart rate is way too high and my blood pressure is sky high, so I am just living from day to day.” PR staff noted that people who really need pulmonary rehabilitation are often physically limited and lack confidence in their ability to improve their quality of life.Being diagnosed with COPD was frightening for many participants. It made them feel vulnerable, concerned and undermined their confidence. Some participants had multiple co-morbidities complicating or delaying the diagnosis, while others knew that something was wrong but deferred seeking professional help. Their needs were described by a PR staff member as “I wasn't just short of breath, I was gasping for breath.” These patients expressed misgivings about the program and were unaware of the potential for a better quality of life with COPD. However PR staff also identified people who were highly motivated and had taken the initiative, including asking a physician for a referral. While some patients were less confident in their ability to improve their quality of life, some were more optimistic as shared by one patient who wanted to “learn everything that can help me”.Motivations for joining a PR program were mixed and affected the decision of the participant to register with a program and whether or not to complete it. Several patients were initially fearful or demoralized and were of the opinion that their disease was too far advanced to be able to benefit from rehabilitation–as one patient shared, “When I go out, I try not to walk too far. I know my limits, and it makes life easier.” Another participant shared, “Now I'm no longer so nervous. I know when I need to sit down and do my deep breathing exercise. Now that my friends know that there are things I can do to get my breath, they are more comfortable with, and that makes it easier for me”. There was a greater acceptance of the progressive nature of the disease: “If I can't change the illness then at least I can learn how to happily live with it.”Across this continuum participants reported that the knowledge and skills offered by the PR program helped them to realize that COPD was not a death sentence, but something that they could learn to manage effectively. An important outcome of the program was learning how to live with the limitations imposed by COPD. Participants spoke of regaining independence. As one patient mentioned, “You are with people who understand, because they are walking the same walk”. A patient spoke positively of group dynamics and co-learning, “because he had been in the program before, he was really informative with tidbits like how to live with an air conditioner.” PR staff paid close attention to relational approaches to teaching and learning and organized their classroom seats in circles, encouraging story-telling approaches, and built time for socializing into the schedule. In addition to providing social support, staff encouraged participants to make a concerted effort to build their confidence from the very beginning of the program by paying close attention in the first few classes, thereby creating pragmatic learning opportunities. As one staff member put it; “we consistently see that people can change and can make a difference. If we can get them to believe that, then that is helpful.”Key factors in committing to a program were the relationship and the group support fostered through the program as described by a patient, “A little hook to people to see some value in their daily life”.The PR programs varied in structure and length. Of the three programs, one used a six-week model with 2 sessions per week followed by an optional six-week maintenance program. The others used a one-month model with 3 sessions per week without an optional follow-up maintenance program. All programs included an assessment interview that as one RN stated was vital for offering ““…if we can give them something in that initial interview that they can see gaining some benefit from, then they're more inclined to come back. Sometimes it just means showing them how to correctly use their medications, or show them how to use pursed lip breathing when bending over to put on their shoes and socks….”in about ten minutes she taught me how to go upstairs and now I have no problem, none.” Or as another patient shared,Despite the difference in structure and intensity, participants across these 3 programs indicated that having positive results immediately was what gave them most of the motivation to continue. In particular, learning techniques for breathing and walking resulted in unexpected experiences of well-being, “th step of the stairs and so she came stand beside me while one of the instructors sat beside me. She had already told me how to breathe and I couldn't believe that I got up to the top and I wasn't winded at all. It was like I hadn't walked any stairs.I would be tired, crawling up the 10“If I hear of anybody that's got any type of COPD I say, well you should talk to your doctor about getting into that program–Cause it works”. The tangible change in people's mobility was seen as a simple but dramatic shift, but that it required expert input.Another patient stated, People weren't using their puffers because the doctor kind of glazed over why and how to use it. Having someone take the time to go through it step by step was well worth it to them”. Program participants responded well to measures illustrating “signs of progress.” In one clinic, oxygen levels were measured using pulse oximeters before and after activity sessions of walking or bicycling, followed by a five-minute rest break. Participants then assessed how oxygenated their blood was. They found these tracking methods interesting and motivating. In addition to pulse oximeters, others liked having large clocks visible so that they could keep track of their walking or cycling speeds to check on their progress or decline each week. The strategies put in place to highlight or enhance tangible and positive results were identified as strong factors that helped them to complete the program.Learning about pathophysiology, understanding the disease process and how the medications worked was also valued. One PR staff member observed, “a lackadaisical attitude.” PR staff conceded that patients “have to want to work at their own health; they have to be responsible for their own health.” Where a minority of patients was seen as not wanting to put in the required effort of doing regular exercises or “wanting a magic pill that was just going to fix them”, fears and concerns were identified as more significant barriers for the majority of the participants. As one woman stated, “When I get anxious, then I know that I can't breathe properly and can't get enough air. It is almost like you have to get bad enough to be able to realize that ‘oh I really need this’ before you use it”. Fear of exercise and shortness of breath, discomfort with the notion of going to “the gym”, and concerns of contracting germs when attending a hospital-based program were also identified as impeding participants' readiness to participate in or complete a PR program.Participants spoke of the need to be mentally and physically ready before attempting to successfully complete the program. For some this was their second or third time participating in a PR program because previously they were not able to commit themselves fully due to illness. Illnesses, such as colds, for COPD patients can take weeks to resolve and may undermine their readiness to attempt another program. Furthermore, some patients might not fully commit themselves because of what one staff member referred to as “they think it's beyond them”.One physiotherapist explained that many patients are hesitant to exercise because “OK, let's go and do some exercise, they would be horrified, not to even mention those that would be short of breath from just getting out of bed or their easy chair to go to the toilet or making themselves a drink. The thought of exercising I think is just beyond their comprehension.”I think that generally speaking, if you said to a group of 70 or 80 year olds….” they seem to think that [exercise] could be damaging their lungs and they don't want to get worse. They may not necessarily want to get better but they surely don't want to get worse.”Another factor is that some patients believe that having shortness of breath is detrimental to their lung capacity. As one RT shared, “When you have to pay for parking, which I think is six dollars an hour right now at the hospital, and when you come a little early to find a parking spot by the time you get out, it's like three hours and that is twice a week for 12 weeks, that gets to be costly”. One site used a sliding scale approach for program costs but transport was a key issue. For many, public transport was not a viable option because participants were often unable to walk to a bus stop and then up a hill as was required. PR staff also noted that people did not always know about the availability of transportation services for people with disabilities.There were also multiple access issues demonstrating that readiness was not only an individual choice but that it also had systemic components. Practical issues such as finances, parking, transportation and psychosocial support shaped how much people were able to participate. For example, one PR program included a second six-week program at an added cost of $40 which was prohibitive for some patients on a fixed income, especially when parking costs were high. As one staff member explained, “The results of this study revealed that successful adherence to PR programs among these Canadian patients with COPD was associated with building up the confidence of the participants, having them perceive immediate tangible results, and recognizing and responding to patient readiness and providing ready access.Attending pulmonary rehabilitation is a challenge for most COPD patients since most have shortness of breath and are activity intolerant. Most people will avoid any negative experiences of their symptoms and actively choose inactivity rather than exercise. This is especially the case for COPD patients who do not realize or understand that exercise helps to improve their health. Even when told that exercise will help, they may not believe it. Several studies have suggested that patients adhere to an intervention if they perceive that they will receive benefits from that intervention A key factor that encouraged patients to complete a program was confidence and group support. This finding reflects Bandura's Social Cognitive Theory (1986) which suggests that self-efficacy is an important factor for behavioral change Findings from this study about adherence to PR programs also align with the Transtheoretical Model (TTM) of change which assesses five stages of readiness including precontemplation, contemplation, preparation, action, and maintenance to change behaviour The PR participants and the staff made several recommendations to boost registration and get patients to complete the program by 1) Making a referral for PR earlier on in the illness trajectory; 2) introducing the PR option and explaining it to hospitalized patients; and 3) linking PR programs with existing community-based programs.While educational programs have been implemented to inform GP's about the availability of PR programs, there is, as one participant mentioned, “this ongoing occasional issue about a lack of referral and yet we know that they (GP's) see people with COPD.” In addition to making referrals earlier, PR staff also suggested that adequate planning was needed by the program coordinator to ensure proper funding, appropriate screening of the applicants, and to ensure adequate group sizes. Johnston et al. (2013) examined the barriers and the facilitators for being referred to a PR program for COPD patients in Australia A respiratory therapist in this study recommended using the term “lung attack” for notifying medical staff about a COPD patient with an exacerbation that required hospitalization. Then, similar to cardiac patients who are sent to cardiac rehabilitation, these COPD patients should then be considered for pulmonary rehabilitation.One of the three programs reviewed in this paper was linked with an existing Better Breathers Club and the YMCA. Anecdotally, PR staff found that community integration encourages patients to become more independent and less reliant on health professionals. Integration with community-based programs was seen as a means to sustain the life-style changes for patients who did not exercise before and needed continued group support beyond the four or six week PR program. Building up a patient's confidence allowed them to continue with their exercise program on their own, once the program was complete. It was seen as “preventative care” that would provide financial savings to the health care system in the long run. It was also suggested that patients should have the flexibility to be able to take the program over again if they were unable to continue a regular exercise practice on their own. Finally, staff recommended that an exercise maintenance program should be provided once or twice a year so that the long-term benefits to the patients could be tracked.As with all qualitative research, we are unable to generalize findings from this research since the sampling strategy is purposive rather than random. However, the findings can be used by clinicians to better understand perspectives of some COPD patients and PR health professionals. Readers may also recognize themes that represent situations in their contexts to inform their practice.Pulmonary rehabilitation is an important secondary prevention for individuals with COPD. In addition, patients with COPD who complete a PR program are reported to manage their illness well, and they enjoy a better health related quality of life


In 2006, funds were received to replicate Stanford’s Chronic Disease Self-Management Program (CDSMP) among eldercare providers in Honolulu. This case study, conducted 1 year after the close of the initial 3-year replication grant, explored factors for sustaining the delivery of CDSMP, with an aim to create guidelines for cultivating sustainability. Face-to-face semi-structured interviews were conducted with one representative from each of eight eldercare agencies, with the representative specified by the agency. Representatives discussed the presence and strength  of sustainability factors, including readiness, champions, technical assistance, perceived fit of CDSMP with their agency, CDSMP modifiability, perceived benefits of CDSMP, and other. Only three of the eight agencies (38%) were still offering CDSMP by the end of 2010. Agencies who sustained CDSMP rated higher on all sustainability factors compared to those that did not sustain the program. Additional factors identified by representatives as important were funding and ongoing access to pools of elders from which to recruit program participants. When replicating evidence-based programs, sustainability factors must be consciously nurtured. For example, readiness must be cultivated, multiple champions must be developed, agencies must be helped to modify the program to best fit their clientele, evaluation findings demonstrating program benefit should be shared, and linkages to funding may be needed. Demand for preventing, delaying the onset, and managing chronic diseases has escalated. Attention is being given to expanding replication of evidence-based health promotion programs, those proven to work, to address chronic disease . SeveralIn replicating an evidence-based program, organizations need adequate knowledge and skills in adapting the program to fit local circumstances while maintaining fidelity and evaluating the program to assure that it achieves the outcomes promised in the original research –8. Much These adaptation barriers also influence the long-term continuation of evidence-based programs, and more attention is being focused on ways to assure widespread availability of evidence-based programs –18. UsefAt the same time, researchers have summarized and advanced definitions of program sustainability, identified factors associated with sustainability, and developed conceptual frameworks to understand program sustainability , 20–22. Scheirer’s framework for program sustainability posits four phases of program adoption: (1) initiation; (2) implementation; (3) level of use ; and (4) sustainability  . Based oThe purpose of this study was to describe and determine the important factors that supported or hindered sustainability of the Stanford’s Chronic Disease Self-Management Program (CDSMP) among eldercare service providers in Hawai‘i. CDSMP was developed to empower people with various chronic diseases to take control of their health . ParticiThe implementation of CDSMP in Hawai‘i was supported by Hawai‘i Healthy Aging Partnership (HHAP), formed in 2003 to increase access to health promotion programs among Hawai‘i older adults with chronic conditions. HHAP members include professionals from government offices for aging and public health, elder care agencies, and the university. The process of CDSMP adaptation began in August 2006 when HHAP was awarded a 3-year grant from the Administration on Aging (AoA). HHAP members developed CDSMP implementation and evaluation plans, assessed readiness to implement CDSMP, and coordinated training for CDSMP leaders. Implementation in two of Hawai‘i’s four counties began in July 2007. It was expanded statewide in 2008 with funds from the National Council on Aging (NCOA). The sustainability phase began in 2009, when the original implementation funding ended. The purpose of this study, guided by Scheirer’s sustainability framework, was to better understand the process and factors associated with sustainability of CDSMP in Hawai‘i.Although CDSMP was implemented statewide, the findings reported here were gathered as a part of the Honolulu case study, which was conducted to understand the process of organizational change for CDSMP adoption. In the Honolulu case study, data from state and county government, community organizations, and older adults were examined to investigate “how” and “why” organizations in Honolulu adapted, implemented, and sustained CDSMP successfully or unsuccessfully . The HonFor the Honolulu case study, we identified three phases of the CDSMP adoption path. The first 6 months of 2007 was considered as the Initiation Phase, when HHAP began planning replication and training agency personnel in CDSMP delivery. The Delivery Phase ran from June 2007 to June 2009, during which time staff members from multiple agencies were trained and then delivered CDSMP to older adults and participated in ongoing fidelity monitoring and evaluation. The Sustainability Phase began in July 2009, when original funding ended. This paper reports on the Sustainability Phase of new-program adoption.The eight providers included multi-purpose social service organizations (designated as A and D), community health centers , a community college (designated as E), and a community meals program (designated as C). Four providers  had a closer relationship with the Honolulu County Area Agency on Aging than the other four , because they had been funded by the Honolulu County Area Agency on Aging for other programs. Five providers  were involved with HHAP during the statewide planning of CDSMP adoption, whereas three providers  joined HHAP when CDSMP training was held. Each provider chose the employee to be interviewed in this study.The investigators developed an interview guide that asked about the five sustainability factors identified by Scheirer : 1) cha cha1).Readiness refers to an individual’s and agency’s sense of preparedness to replicate the program. A champion is an agency employee who plays a key role in adapting, delivering, and/or sustaining CDSMP in the agency. Technical assistance refers to help employees could access when they had questions or encountered problems in CDSMP implementation and sustainment. Perceived fit of the program implies a similarity between the new intervention and the parent organization’s mission and culture. Program modifiability refers to the level of satisfaction that the agency has with the modifications that it can make to the evidence-based program  without jeopardizing the behavior-changing components of the program. Perceived benefits of the program include feelings of staff and clients  that the program is making a positive impact.These factors were identified by Scheirer , with thAlthough providers continue to offer CDSMP, data for this study of sustainability factors were collected in late 2010. At that time, the first author (MT) conducted face-to-face, semi-structured interviews with the eight community provider representatives in Honolulu. The interview questions were sent to the representatives ahead of the interview to help them prepare. All eight representatives provided a written consent. Interviews were held at the representatives’ offices and took about an hour. Six individuals allowed their interviews to be audio taped and, for two, hand notes were made. All interviews were transcribed into text files.a priori sustainability factors served to give examples of, expand on, and contextualize each factor, which was useful in understanding its ranking . Analysis of responses to the open-ended question about other possible factors required the two researchers to discern themes in the data and then code responses into themes. These were discussed in a meeting, and differences were resolved by re-reading the interview transcript together and having further discussion until consensus was reached. There were no major disagreements during the analysis process.Ratings of low, medium, or high were noted for each respondent for each sustainability factor. The discussion of each factor and the discussion of other possible factors were read independently by two researchers. For the most part, discussion of The progress of the eight providers who volunteered to replicate CDSMP in Honolulu is shown in Figure During the analysis process, it became clear that organizations that sustained CDSMP had more supports throughout the process than the organizations that were unable to sustain CDSMP. Table Thinking back to the Delivery Phase, providers described and rated their level of readiness to replicate CDSMP. The five providers (63%) who scored their organization as “high” had noted in their discussion of readiness that their staff had spent time learning about the concept of evidence-based programing prior to program adoption, felt well trained in CDSMP and data collection, were motivated to pilot CDSMP in their community, had identified potential CDSMP participants, had established policies and procedures related to CDSMP, and had purchased a CDSMP license. The three providers who scored medium or low remembered some uncertainty within their organization and perhaps some miscommunication with HHAP as to the costs associated with CDSMP licensing, the coordination of CDSMP workshops, and the need to participate in fidelity monitoring and evaluation.Respondents agreed that having champions was very important to sustainability, and the organizational representatives that reported high champion effectiveness were most likely to be from organizations that sustained CDSMP. The transcript-analysis process, however, distinguished three types of champions, including program champions, participant champions, and supervisor champions.Respondents defined a program champion as someone who had been trained to lead CDSMP, had a passion for it, was very committed, was able to promote it, and had the drive to expand it. Although all organizations had staff trained in CDSMP, not all could identify a program champion at the time of the interview, while some agencies reported as many as three program champions. The three sustained programs reported having more than one program champion at their organization.Both champions have been enthusiastic and … try to promote, try to get more funding, try to get more people, are involved … and they wish they were able to do more.”Interview findings suggested that the most successful program champions had relatively flexible schedules, which allowed them to offer CDSMP during or outside of work hours, and their job descriptions included CDSMP. They had strong skills in teamwork and took time to educate other branches of the organization in CDSMP to increase organizational buy-in. They advocated for other staff in the agency to attend CDSMP leader training. They networked with CDSMP leaders at other agencies, which helped them find a substitute or second workshop leader when needed. They also were seen as role models by program participants and provided support to CDSMP leaders at other organizations. As one provider noted: “We don’t have a champion because we had to take care of other things…Champion requires that one person constantly pushes CDSMP.” Sustained organizations reported that they would be able to continue to sustain the program as long as they had leaders and trainers on board. To facilitate this, HHAP continues to provide CDSMP leader trainings and encourage organizations to continuously send new staff or volunteers to training so that they could keep enough leaders within their organizations.The two providers who reported no program champion might have had a program champion initially, but this person changed jobs or became too busy to lead and advocate for CDSMP. One provider said: “A participant champion was described as someone who had graduated the CDSMP (attending four or more sessions out of six), realized benefits from the program, and was willing to share their story about CDSMP. By talking about the benefits they received, they helped to recruit other participants for the program. Many providers felt that the word-of-mouth strategy was the most effective approach to attract new participants.A supervisor champion was described as a manager who supported the delivery of CDSMP within the organization and supported the program champions in leading CDSMP sessions. Supervisor champions always sent an agency representative to the statewide HHAP meetings and saw CDSMP as a valuable service to offer agency clients. Interview analysis suggested that all sustained agencies had a supervisor champions. Respondents for the other four agencies felt that their supervisors were not strong champions. Two of them said that their supervisors oversaw a variety of projects and remained relatively uninvolved with CDSMP replication efforts. The other two providers reported that they did not get any support from their supervisors because their supervisors had unrealistic expectations of CDSMP, for example, that it would take less time than it did, would be more modifiable that it was, or would generate revenue. The discrepancy between the expectations of these supervisors and those of the staff trained in CDSMP discouraged staff from championing the program in their agencies.Five providers (63%) reported that CDSMP fit well with their organizational mission and goals. They valued the program’s concept of empowerment and its goal to help clients improve health and maintain independence through self-management. They also felt that their participants would appreciate the program’s motivational interviewing approach.Two providers rated program-organizational fit as medium. They felt that CDSMP fit their general mission – to improve the well-being of older adults – but not the type of service they provided, in this case meal delivery and college courses.our participants are not fluent English speakers … so it takes double the time to explain things …. We serve local food that they like or fit with their culture, they feel happy even though they work hard during the session. We also offer certificate of completion with leis.a little recognition for their hard work and they were very happy about it.” Providers who reported high program modifiability also spent time to develop local marketing tools that included pictures of local older adults and symbols that resonated with Hawai‘i’s cultures. The three providers who rated medium or low in program modifiability noted disappointment that the program materials were not available in the languages of their target groups  and that the program required two leaders to deliver each workshop. They also reported that the structured outline and scripted format of the workshop were too foreign for their clients.Five out of eight providers (63%) reported that the modifications of CDSMP by HHAP (with permission of Stanford) to fit Hawai‘i’s multicultural population helped them attract enrollees. This was done by including local examples and expressions of local culture in the curriculum . One proI see them really change and keep hearing their stories … We had a quite a few that really struggled with making action plans. Boy, when they get it, they get it and they got so excited, you know, the first time they come back, they were so proud that they got something accomplished. I just think … you know, to me, it’s really had a big impact on people’s lives.” They also saw benefits for their staff, many of whom had incorporated CDSMP tools  into their daily activities and had gained confidence in public speaking. One provider used some of the CDSMP tools for staff training. They also mentioned the benefit of receiving evaluation results from HHAP specific to their agency to share with supervisors and funders. Hearing good stories from their participants and seeing the positive evaluation data further boosted their confidence in replicating CDSMP. The two providers who were rating this factor as “medium” noted that some of the agency’s staff and clients were unable to grasp or apply CSDMP self-management strategies.One agency was not able to rate this factor because it dropped out prior to implementing CDSMP. Of the seven remaining providers, five rated CDSMP benefit to clients as “high” and perceived CDSMP was a good investment. They reported seeing improvements in the health of their clients and related success stories of participants who had lost weight, were exercising more, and/or were keeping better track of their health. One provider noted: “We are fortunate to have partners for CDSMP. I can call [Agency name], if I have questions. They also helped us and clarify things for us. One time, we did not have CDSMP books, and I called them … It was very helpful. “Some providers reported that the Stanford website and email listserv were useful and helped motivate them to continue offering CDSMP. The providers who rated technical assistance as medium indicated that they wanted more support to recruit participants and more clarification of program requirements.Six of the eight providers (63%) reported that the technical assistance that they received from HHAP was very useful. Technical assistance was provided through HHAP’s monthly meetings, from the evaluation team, and from Stanford. At monthly meetings, providers were able to exchange ideas on how to leverage resources, to recruit and retain participants and leaders, and to carry-out the evaluation protocol. Meeting attendance also helped providers to develop strong skills in working with other providers. These relationships were useful when they needed to find a substitute leader for a CDSMP session or borrow books and other program materials for a workshop. A provider said: “Interviewees were asked to identify other factors related to sustainability. Two were identified – having access to potential participants (four providers) and having access to additional funding (seven providers).once we went through all of the participants, then we did not have any more new participants … we do not have a large turnover in our clients, so we could not expand our numbers.” Provider B noted that their organization was established to serve a specific community. After all willing clients completed CDSMP, their organization had to consider the advantages and disadvantages to enrolling people from other communities. Provider A felt that the CDSMP was important enough to continue because it fit so well with their program. This provider’s solution was to conduct CDSMP workshop with a combination of participants who have done it before and any new participants that they could find.Because most of the providers were offering CDSMP to their existing clientele, they initially did not encounter problems finding participants. However, at some point they had provided CDSMP to all willing clientele. For the most part, agency clients were willing to participate in the program, and attendance was high , but “onin the long-term, always funding is needed, things cost money and staff time, plus money for licensing [and] when the new books come out … all of those things cost something.” Although most of the providers were able to access additional funding through the HHAP’s awarded grants, sustained organizations’ interviewees also wrote proposals to other funders to support CDSMP. They also used cost-saving strategies, such as holding workshops at no-cost sites and creating a library of workshop materials that could be loaned to (rather than purchased for or by) participants.Additional funding was also a critical factor to sustain CDSMP. One provider stated “Evidence-based health promotion programs are developed in research settings, and replicating them in real-world settings can be challenging , 5. ThisAs Scheirer  proposedReadiness can be cultivated by providing training about evidence-based programing, fidelity monitoring, and program evaluation, along with training in the intervention to be adopted . For nonExhausting potential clients can occur in agencies that work within small geographic areas, have a fixed number of clients that they are allowed to serve, and/or have low client turnover . This isThis study explored CDSMP sustainability among eight eldercare providers in one of Hawai‘i’s four counties, and only one representative from each organization was interviewed. Although organizations selected to be interviewed the individual most closely involved in CDSMP adaptation, the interviewee may not represent the whole organization.Also, because the interview asked about sustainability after initial funding ended, the results may have been compromised by inability to recall events, especially for those organizations that discontinued CDSMP, and by social desirability bias. Future examination of new-program sustainability would benefit from prospective study and inclusion of multiple representatives of an organization.Despite the limitations, this study was able to confirm the importance of the sustainability factors proposed by Scheirer , and addThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.This paper is included in the Research Topic, “Evidence-Based Programming for Older Adults.” This Research Topic received partial funding from multiple government and private organizations/agencies; however, the views, findings, and conclusions in these articles are those of the authors and do not necessarily represent the official position of these organizations/agencies. All papers published in the Research Topic received peer review from members of the Frontiers in Public Health  panel of Review Editors. Because this Research Topic represents work closely associated with a nationwide evidence-based movement in the US, many of the authors and/or Review Editors may have worked together previously in some fashion. Review Editors were purposively selected based on their expertise with evaluation and/or evidence-based programming for older adults. Review Editors were independent of named authors on any given article published in this volume.


Despite efforts expended over recent decades, there is a persistent gap between the production of scientific evidence and its use. This is mainly due to the difficulty of bringing such knowledge to health workers and decision-makers so that it can inform practices and decisions on a timely basis. One strategy for transferring knowledge to potential users, that is, gaining increasing legitimacy, is knowledge brokering (KB), effectiveness of which in certain conditions has been demonstrated through empirical research. However, little is known about how to implement such a strategy, especially in the African context. The KB program presented here is aimed specifically at narrowing the gap by making scientific knowledge available to users with the potential to improve health-related practices and decision making in Burkina Faso. The program involves Canadian and African researchers, a knowledge broker, health practitioners, and policy-makers. This article presents the collaborative development of the KB strategy and the evaluation of its implementation at year 1. The KB strategy was developed in stages, beginning with a scoping study to ensure the most recent studies were considered. Two one-day workshops were then conducted to explore the problem of low research use and to adapt the strategy to the Burkinabè context. Based on these workshops, the KB program was developed and brokers were recruited and trained. Evaluation of the program's implementation after the first year showed that: 1) the preparatory activities were greatly appreciated by participants, and most considered the content useful for their work; 2) the broker had carried out his role in accordance with the logic model; and 3) this role was seen as important by the participants targeted by the activities and outputs. Participants made suggestions for program improvements in subsequent years, stressing particularly the need to involve decision-makers at the central level. Calls are increasingly being issued for more use of research results by practitioners and decision-makers . Despitehttp://www.equitesante.org/; http://www.equiperenard.ca/). This research program is being conducted in one of the poorest countries in Africa, a continent that continues to have enormous health needs. For example, despite an encouraging reduction over recent years, the maternal mortality rate in Africa is 480 per 100,000 live births, as opposed to 14 per 100,000 in high-income countries; the discrepancy is about the same for mortality rates in children under 5 years of age   that target populations directly, as close as possible to where they live, and that are implemented with members of the community, whether formally organized or not. This first phase is intended to provide input into the development of a second phase at a broader national level.In January 2012, practitioners, decision-makers, and the research team met to describe the theory underpinning the interventions to be evaluated ; one French researcher from the Institut de recherche pour le développement (Institute of Research for Development); and four Burkinabè researchers from the University of Ouagadougou, the Institut de Recherche en Sciences de la Santé , and the Société d’Études et de Recherche en Santé Publique . Aside from the researchers, the program includes a knowledge broker; health professionals ; community-based organizations ; and local, regional, and national policy-makers .The gap between the production of scientific evidence and its use is due mainly to the difficulty of bringing research results to health workers and decision-makers at the local, regional, and national levels, where it could inform practices and decisions in a timely manner. Just because relevant information exists does not guarantee it will be used by health system decision-makers. They also need to see it as helpful in addressing a problem they are experiencing, and there need to be appropriate means by which they can access it , 7, 8. TEmploying knowledge brokers to facilitate the use of research results is increasingly recommended –25. ThiLow- and middle-income countries have even more difficulty using research-based knowledge because of often limited access to scientific databases. This difficulty may be compounded in French-speaking countries, where few decision-makers are able to read English and where health needs are often greater. West African countries have more difficulty using research results, both because of limited access and because decision-makers there perceive the scientific content as presenting only partial conclusions, often in a format they find difficult to understand, and they generally do not possess the tools needed to consolidate the various results –32. ThuFor all these reasons, implementing a KB project appeared to us to be a promising means of encouraging research use in a West African context , 30. To In this article we describe the first year of implementation of a KB program that has been in operation in the district of Kaya, in Burkina Faso, since January 2012 and is planned to span 4 years . With knThe KB program was developed in several stages. First we conducted a scoping study , consultn =12) and the local and regional levels in the Kaya region and district (n=13). The aim of these workshops was to explore the issue of low research use and to adapt the KB strategy to the Burkinabè context. At these workshops, a draft version of the KB policy brief served as the basis for discussion to illustrate what we were planning, and we were able to fine-tune the plan based on what stakeholders considered relevant. The KB program was then represented graphically in the form of a logic model for the intervention  from the national level  master's level training in either human and social sciences or public health; 2) at least 5 years of work experience in research or with researchers; 3) basic information technology competencies ; 4) familiarity with reference management software ; 5) excellent oral and written communication skills; and 6) ability to judge the quality of both quantitative and qualitative information. However, as there is no academic program to train knowledge brokers, we had to plan an intensive training program for this specific initiative. The knowledge broker works under the joint supervision of a senior consultant based in the capital and a researcher from the University of Montreal.In January 2012, during a 2-day planning session held in Kaya, the practitioners, decision-makers, and research team met again. The results of that workshop served to orient the content of the research program and to identify the knowledge needs of the practitioners in order to guide the knowledge brokers’ work. Those 2 days also provided an opportunity to identify any needs for which there was already evidence that the knowledge broker could transfer while waiting for the researchers to produce results on the interventions in place in the region. For example, some participants wanted the impacts of user fees exemptions for healthcare to be evaluated, whereas several studies had already been carried out elsewhere in the country and in Africa on this subject. In this case, rather than evaluating the interventions, the knowledge broker prepared a 20-page narrative review of the literature.Two Canadian experts trained several knowledge brokers in two 5-day sessions in January and May 2012 . Both heThe evaluation of the program's first year of implementation had three objectives: 1) to measure the reactions of knowledge brokers and researchers to the training activities; 2) to document KB activity implementation and output; and 3) to analyze the implementation processes.Participants’ reactions to the training activities were evaluated using a questionnaire administered at the end of each day of training. This questionnaire was adapted from an instrument previously validated in a Quebec (French-Canadian) context . It captKB activity implementation  was measn=19) in French to gather information on factors that facilitated or impeded the implementation of KB activities. The broker and a representative sample of 18 potential users were chosen according to a purposeful sampling strategy  and reports on activities . He also prepared more than 30 documents to disseminate the terms of reference of meetings, to list users’ high-priority questions, and to present various knowledge syntheses. Two deliberative workshops, both based on a literature synthesis and a policy brief, were organized to answer high-priority stakeholder questions , 45. TheMonitoring charts showed that some 50 different individuals participated in at least one KB activity . These individuals came from research institutes, various Ministry of Health agencies and local and regional authorities , local and international NGOs, and MHOs.There are very few references available on the implementation of KB strategies. This explains why, when the present program was implemented, no targets were set in terms of quantity of documents to be produced or contacts with stakeholders. Even though it took 5 months of preparation before the broker offered the first KB activity to users, we consider the results of this component of the evaluation to be satisfactory. When organizing an innovation in such a context, it is important to take the time to understand the issues well and to explain the details of the action to all the stakeholders. This was essential in our case, as not all the parties involved were familiar with the concept of KB. The results of this intervention could also serve as a point of reference for other KB projects in the future.The implementation analysis results were based on discussions with respondents around three main themes: 1) the usefulness of the knowledge transferred by the broker; 2) their assessment of the intervention's strengths and weaknesses; and 3) their opinions about how the program might be improved in subsequent years. The results presented in this section are also based on our observations of the broker's implementation, training, and coaching activities.All respondents had attended at least one formal broker-organized activity. Their opinions of the program were unanimously positive. While the decision-makers considered that research was useful and should be used in both practice and decision making, the respondents actually citing the most examples of the usefulness of knowledge transferred by the broker were from NGOs and MHOs: ‘Research has contributed to MHO development;  why people don't join, what is this related to? It helps in understanding why and in finding solutions’ (MHO respondent). Likewise, ‘this question [on models of health behaviour change] was formulated by NGOs but could also be used by government agencies, because awareness-raising activities are often carried out with no specific model, on the fly: models are needed to do things better’ (NGO respondent).To some MHO respondents and most of the decision-makers encountered, the program's objectives and the broker's role were still sometimes muddled. Some wanted the KB program to generate supplementary financial resources: ‘… if the program has the funds, take charge of paying their premiums [to the MHO]’ (MHO respondent). Others, however, understood clearly that this was not the intended role: ‘… they need to understand that this is what's being provided; people need to understand why there aren't any per diems, but that, in return, the broker works for them and gives them relevant new information’ (NGO respondent).The majority of MHO respondents were very enthusiastic about participating in these activities and saw the broker-led activities as being very useful. They offered many examples: ‘He gave us ways of increasing membership, he prompted us to develop an action plan, and he coached us through its implementation’ (MHO respondent). For most of them, participating in these activities led to concrete actions in the field, such as awareness-raising outings and mobilization of influential people in the community, that generated increased membership.Respondents noted a few of the program's limitations. Mainly, they thought there should be more meetings and more regular contacts with the broker in the field: ‘… ongoing contact, even if there isn't an upcoming workshop; we shouldn't wait for workshops to speak to people …’ (NGO respondent). A few participants in a workshop on health behavior models found this material more difficult to understand and suggested that the language level should sometimes be adjusted to avoid overly technical terminology.Respondents identified several strengths in the KB program. Several mentioned that the questions addressed during the activities met a need expressed by stakeholders. The broker's and speakers’ competencies were also affirmed: ‘Speakers and facilitators mastered their fields. In fact, they were able to lead the workshop without reading their papers, and to add comments and adjust [to the context]’ (decision-maker respondent). A few respondents noted the broker's versatility, which enabled him to obtain the information they needed. Lastly, another major strength was the fact that the participation level was high and sustained, even without per diems, which is an issue in Burkina Faso .Finally, several suggestions were made for improvements in subsequent years. One respondent pointed out the need to connect with decision-makers at the central level: ‘This has to go up to the central level, which hasn't yet happened, but there used to be relatively few products to disseminate. Now that there is more to present, we have to go there’ . Another challenge related to the issue of inadequate resources had to do with coaching from the broker; while participants recognized he was not there to provide financial support directly, they nevertheless hoped that ‘… the broker could support us in our search for funding’ (MHO respondent). Lastly, some mentioned the need to ensure the program's sustainability, adjust the level of language, and increase the broker's presence in the field.Despite the increasingly widespread use of brokers to create a bridge between the research and practice settings to promote the use of scientific knowledge, this role remains poorly defined –50. BroThe first section of this article described the different stages in the development of an intervention considered to be increasingly relevant in closing the gap between research, practices, and decision making. The implementation evaluation results showed that the preparatory activities, and in particular the training provided to knowledge brokers and researchers, were appreciated by participants, and that most of them considered that the content covered would be helpful in their work. Still, many would have liked more hours of training. A review of program activities and outputs also showed that, by the end of the first year, the broker had assumed his role in accordance with the logic model. Analysis of the interviews showed that this role was deemed important by the participants targeted by those activities and outputs.In this context where research use culture is still largely undeveloped, the coaching provided by the broker appears to us to be virtually indispensable. The broker's role cannot be limited only to transforming and disseminating information: it needs to include coaching that is responsive to change. We cannot yet, from the results of the evaluation of this first year of activity, draw any conclusions about the approach's efficacy in changing practitioner and decision-maker behavior. Nonetheless, this first stage in the process evaluation is promising: the intervention was appreciated and adapted to the context, and the results remind us of the extent to which evidence is poorly known and inaccessible. This, in turn, reinforces the relevance of the KB program.The program in Burkina Faso is a complex system made up of several activities aimed at a variety of interdependent actors  whose views about research are sometimes divergent. The West African context is another factor that adds to the complexity and must not be neglected when attempting to understand the program's functioning and effects. As such, a great deal of attention should be given to the context, the complexity, the nuances, and the interdependence of factors motivating behaviors. For example, in a country where decision making is highly centralized, any influence exerted to effect change should not be limited to the local arena, but should definitely also focus on the national level. For our project, this will involve determining how to disseminate knowledge more effectively to influence change at the national level. We believe it is important, before implementing any KB intervention, to analyze the decision-making context carefully. Likewise, in a country that receives a great deal of international aid for development, staff turnover is a major problem, as professionals change programs often and officials in various ministries have often been corrupted by NGOs and international aid agencies. It is therefore important to train as many brokers as possible and to maintain close ties with decision-makers.A comprehensive evaluation of the program is currently under way. Given the program's complexity, the evaluation is targeting several aspects. Our aim is not only to continue describing the activities undertaken and their impacts on the actors, but also to explain the effects obtained, while also studying the potential unintended effects. Thus, every component of the logic model will be evaluated to arrive at a complete, dynamic, and comprehensive understanding of the program.In the long run, the evaluation of the brokering program will provide knowledge on the broker's roles and responsibilities and on this strategy's effects on the use of research results to improve population health.Ethics certificates were obtained from the research ethics committees of the University of Montreal Hospital Research Centre (12.273) and the National Health Ethics Committee of Burkina Faso (2012-11-85).


Stingless bees are an important asset to assure plant biodiversity in many natural ecosystems, and fulfill the growing agricultural demand for pollination. However, across developing countries stingless beekeeping remains an essentially informal activity, technical knowledge is scarce, and management practices lack standardization. Here we profited from the large diversity of stingless beekeepers found in Brazil to assess the impact of particular management practices on productivity and economic revenues from the commercialization of stingless bee products. Our study represents the first large-scale effort aiming at optimizing stingless beekeeping for honey/colony production based on quantitative data. Survey data from 251 beekeepers scattered across 20 Brazilian States revealed the influence of specific management practices and other confounding factors over productivity and income indicators. Specifically, our results highlight the importance of teaching beekeepers how to inspect and feed their colonies, how to multiply them and keep track of genetic lineages, how to harvest and preserve the honey, how to use vinegar traps to control infestation by parasitic flies, and how to add value by labeling honey containers. Furthermore, beekeeping experience and the network of known beekeepers were found to be key factors influencing productivity and income. Our work provides clear guidelines to optimize stingless beekeeping and help transform the activity into a powerful tool for sustainable development. Beekeeping should be regarded as a prime tool to achieve sustainable development –5. KeepiApis genus) has become a major global business, the profitable use of stingless bees  has received much less attention [Although the commercial use of the honeybee , as well as the striking biological differences among species , 28. MorHere we profited from the large diversity of meliponiculture practices found in Brazil , 11, to A draft survey questionnaire was designed in 2012 in collaboration with several researchers and successful beekeepers from Brazil. The survey included questions on the species kept, the number of colonies, management techniques, and sales of bee products, among others, as well as an informed consent to participate in this study that was signed by all participants. As our study did not involve indigenous people, and does not disclose any personal information from its participants, we did not seek approval by an ethics committee. This initial questionnaire was tested across Rio Grande do Norte, a small Brazilian State with a rich tradition in meliponiculture . The anaSurvey data was collected during one year, between January 2013 and January 2014. Only data from beekeepers having at least one stingless bee colony at the moment of the interview were included in this study. Although respondents might have provided false or inaccurate answers in some cases, we have no reason to expect systematic response biases that could compromise our analyses. To minimize such potential biases, we carefully curated the data eliminating duplicated entries, contacting some beekeepers again to confirm certain answers, cross validating replies, and checking for outliers in each response. Four outlier observations were deleted because they were unrealistic, based on the other information provided and our current knowledge in meliponiculture  and repeated the whole model selection process. All statistical comparisons between two models were conducted using the same dataset. To avoid overfitting the data, care was taken not to construct models containing less than 15 observations per predictor. Once we identified the key predictor variables in each subset, we constructed a complete-cases dataset with these predictors and ran a similar model selection protocol to obtain a final model. Interaction effects were included in these final models to test whether they improved the models without interactions. Finally, we used the Akaike Information Criterion (AIC) to compare the best models with and without random intercepts, and in some cases with a random slope . The best models were validated by plotting residual vs. fitted values, residual vs. predictors, by looking at the distribution of residuals, by checking for multicollinearity, and by comparing observed data to simulations from the models. All analyses and graphs were implemented with R, version 3.1.0 [A model selection approach was used to relate production and income indicators to management practices and other confounding variables. Such an approach has gained substantial support in the natural sciences during the last decade, and is particularly well suited to analyze complex datasets, when several different competing hypotheses can be put forward , 39. Becon 3.1.0  , but the total number of stingless beekeepers in Brazil is estimated to be much higher (above 5000 according to the administrators of that group), as many live in remote rural areas without internet access and have never been registered by any agency. Nonetheless, we believe our data is suitable to model the relationships between management practices and production/income indicators. For instance, we did not find a strong dependency structure among predictors ., so ourBeekeepers can acquire new colonies either by collecting nests in the wild, by capturing new swarms using trap-nests , by buyiThe importance of supplementary feeding has been highlighted in many technical manuals , 29, 44,Honey conservation method was found to be a key predictor of the amount of honey sold and the beekeeper´s yearly earnings . It is wPhorid flies  constitute one of the most devastating pests of stingless bee colonies , 15, 50.Although the use of vinegar traps was not found to be among the factors explaining colony losses , the preEconomic gains from selling honey or colonies were determined by the total number of colonies kept. This is not surprising, given that more colonies imply more honey and more colonies are available to sell. However, the practice of labeling honey containers was found to affect this relationship in an unexpected way. For instance, the relationship between earnings and the number of colonies was much stronger among beekeepers labeling honey containers than among those that do not employ labels . This reOn the other hand, costs associated to keeping bees were found to be influenced by feeding frequency. Because the acquisition of sugar or honey for supplementary feeding implies input costs, our results could be explained by the fact that beekeepers feeding their bees more frequently need to buy more sugar or honey. Interestingly, we also found that this pattern was affected by the age of beekeepers. In general older beekeepers invested more into their bees, regardless how many colonies they kept and how frequently they feed them. Hence, older beekeepers seem to be more involved with managing their colonies, investing more money into things other than supplementary feeding, such as buying more colonies, building better boxes or improving the condition of their bee business.Selective bee breeding has had a tremendous impact on apiculture, resulting in healthier and more productive bees , 52. In Only a minority of the surveyed beekeepers sold honey (30%) or colonies (25%), a fact that illustrates that stingless beekeeping is still mainly a non-commercial practice. Motivating beekeepers to sell their products is essential to transform meliponiculture into a profitable activity. We found that the years of beekeeping experience and the number of known beekeepers are key determinants of whether beekeepers sell colonies or honey . Years kInterestingly, years of experience but not the network of known beekeepers was found to predict the number of colonies sold, the liters of honey sold, and whether beekeepers sold honey or not, suggesting that technical skills are the limiting factor determining sales. For instance, beekeepers that participated in a meliponiculture course were more likely to sell honey (in any amount). This explanation is further supported by the fact that demand for stingless bee products often exceeds supply , 16, so When asked to identify the main problem related to keeping stingless bees, more than half of all interviewees pointed at the current legislation and the lack of management skills . This isWe foresee an enormous potential in the stingless beekeeping industry. Once management practices are optimized and the activity is decriminalized, we expect that the market for stingless bee products will experience a significant expansion. Although stingless bee honey is frequently commercialized as medicine in developing countries like Brazil, Mexico and Bolivia, there seems to be a growing number of consumers that regard the product as a luxury item and pay much more for it than for conventional honeybee honey . MoreoveThe assessment of the status of wild stingless bee populations made by the interviewed beekeepers (92% believe there are now less wild bees than 50 years ago), supports recent reports on global bee declines , 59, 60.Our findings have important implications for the stingless beekeeping industry. We identified particular management practices, which could help many beekeepers produce and sell more honey and colonies and earn more money, thus making the activity more profitable. Specifically, our results highlight the importance of teaching beekeepers to inspect and feed their colonies, how to best multiply them and keep track of genetic lineages, how to best harvest and preserve the honey, how to use vinegar traps to control phorid fly infestations, and how to add value by branding their honey. Future experimental work could further test the patterns documented here. Our work also stresses out the importance of beekeeping experience, suggesting that future extension programs could profit from engaging more experienced beekeepers in the design and implementation of technical courses. Importantly, our results emphasize the key role of the network of known beekeepers as a source of colonies and technical knowledge. We believe that the creation or consolidation of local and state associations of stingless beekeepers could enhance such networks, facilitating communication between beekeepers, and unifying efforts to push forward the commercialization of stingless bee products. Our work underlines the need for more research devoted to optimize management practices, as well as more extension work to transfer the generated knowledge to beekeepers. Such efforts could help transform stingless beekeeping into a powerful tool to achieve sustainable development, helping low-income communities improve their living conditions, contributing to the conservation of wild bees and plants, and assuring crop pollination services.S1 Dataset Rscripts(RAR)Click here for additional data file.S1 Fig(TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.S1 Questionnaire(PDF)Click here for additional data file.S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.S3 Tabletot represents the total number of beekeepers providing an answer for each question , while Nreply represents the number of beekeepers in each reply category .N(PDF)Click here for additional data file.S4 TableAlthough beekeepers also reared other species, they were not included in this list since they were not registered as the main species kept.(PDF)Click here for additional data file.S5 Tablep < 0.05 (likelihood ratio tests).Estimates are provided for each level of the categorical predictors. Note that all predictors included in these models significantly increased the model´s likelihood at (PDF)Click here for additional data file.


On January 12, 2010, a devastating 7.0 magnitude earthquake struck the West Department of Haiti, killing more than 200,000 people and injuring or displacing many more. This disaster threatened continuity of HIV care and treatment services.This case study examined the effect of the devastating 2010 earthquake in Haiti on attrition from the HIV antiretroviral therapy (ART) program.The study triangulated retrospective data from existing sources, including: 1) individual-level longitudinal patient data from an electronic medical record for ART patients at two large public sector departmental hospitals differently affected by the earthquake; and 2) aggregate data on the volume of HIV-related services delivered at the two hospitals before and after the earthquake.The study compared ART attrition and service delivery in Jacmel, a site in the ‘very strong’ zone of earthquake impact, and in Jérémie, a site in the ‘light’ zone of earthquake impact. The analysis used time-to-event analysis methods for the individual-level patient data, and descriptive statistical methods for the aggregate service delivery data.p=0.03), and was lower in Jacmel vs. Jérémie both before  and after the earthquake . The number of new ART patient enrollments, new HIV patient registrations, and HIV clinical visits dropped notably in Jacmel immediately after the earthquake, but then rapidly rebounded. On average, there was no change in new ART enrollments per month after vs. before the earthquake at either site.Adjusted ART attrition risk was lower at the hospital in Jacmel after vs. before the earthquake (HR=0.51; These findings underscore the resilience of Haitian ART providers and patients, and contribute evidence that it is possible to maintain continuity of ART services even in the context of a complex humanitarian crisis. On January 12, 2010, a devastating 7.0 magnitude earthquake struck the West Department of Haiti, within 30 km of the capital, Port-au-Prince. Government officials estimated that 220,000–250,000 people were killed  and 425,000 (Grand Anse Department) respectively , as measured by the US Geological Service . The mayIn contrast, Hôpital St. Antoine in Jérémie is located >150 km from the earthquake epicenter, and is in the zone with direct effects of the earthquake falling in the ‘light’ category of the MMI . Still, Data for the case study come from the iSanté data system, the Haitian Ministry of Public Health and Population's (MSPP) electronic medical record system –18. The The outcome variable for the time-to-event analysis at the two hospitals was time in days from ART initiation to attrition, defined as the first incident of failure to return for pharmacy pick-up within 30 days of the expected ART refill date . While pCovariates for the time-to-event analysis at the two hospitals are represented in the conceptual model in For the case study, the Chi-square test of proportions, based on categorical versions of all covariates, was used to compare characteristics of patients enrolling on ART before vs. after the earthquake. Average rates of attrition per 100 person years both overall and by patient sub-groups were estimated. The numerator for the rate was number of cases of attrition, while the denominator was the total of time to attrition plus time on study see , expressThe study used existing, de-identified patient data from the iSanté data system. The study protocol was reviewed and approved by the University of Washington, the Haiti National Bioethics Committee, and the US Centers for Disease Control and Prevention.p<0.10 for the Chi-square test of heterogeneity across covariate categories), a result which was driven by differences over time in Jérémie. They were also somewhat less likely to have a baseline CD4 value of <100 cells/µl (p<0.10 for the Chi-square test of heterogeneity across covariate categories), a result driven by differences over time in Jacmel. They were more likely to use the ART regimen of zidovudine–lamivudine–efavirenz (AZT-3TC-EFV) as their starting regimen and to have a WHO stage IV symptom noted prior to ART initiation (p<0.01 for the Chi-square test of heterogeneity across covariate categories), results driven by similar differences over time at both sites. Finally, they were less likely to have no counseling sessions prior to ART initiation (p<0.01 for the Chi-square test of heterogeneity across covariate categories). Interestingly, the pattern on pre-ART counseling diverged by site; in Jacmel the proportion of patients with no counseling sessions fell from 52.7% before to 47.3% after the earthquake (p<0.001) while in Jérémie, the proportion climbed from 40.4% before to 57.2% after the earthquake (p<0.001).There were 1,012 patients in the time-to-event analysis newly enrolled on ART at the two hospitals, with 545 enrolled before the earthquake and 467 enrolled after. Patient characteristics are described in p=0.08). While there were 31 transfers observed in the study population, none were timely transfers which could explain the cases of ART attrition we observed. A total of 172 (17.0%) patients at the two hospitals met the definition for ART attrition for an overall ART attrition rate of 26.8 per 100 person-years (95% CI: 23.1–31.2 per 100 PY). Average ART attrition rates for each patient subgroup before vs. after the earthquake are displayed in p=0.03) (see p=0.29). Compared to patients in Jérémie, patients in Jacmel had a 45% lower risk of attrition before the earthquake  and a 65% lower risk after the earthquake , after adjustment for other factors. The interaction between site and earthquake timing was not significant (p=0.20). Apart from hospital site and temporal factors, location of patient residence was strongly associated with ART attrition risk. Patients living outside the commune where the hospital was located had a markedly elevated attrition risk compared to patients living in the same commune as the hospital , after controlling for all other factors. Results for the adjusted analysis were consistent when using other empirical ways of categorizing baseline CD4 and BMI covariates (results not shown).In the adjusted time-to-event analysis of ART attrition at the two hospitals (with adjustment for the measured factors shown in .03) see . Howeverp=0.05), while Jérémie showed no evidence of difference. In terms of the total number of HIV clinic visits per month, both sites showed significantly more visits per month on average after the earthquake .The volume of HIV-related services provided in Jacmel, the site closest to the quake, dropped steeply in the 2 months immediately following the earthquake, but then generally rebounded within the following months . There wIn Jacmel, the site closest to the earthquake, ART attrition improved following the earthquake after adjustment for patient clinical characteristics. Furthermore, adjusted ART attrition was significantly lower in Jacmel than in Jérémie both before and after the earthquake. At both sites, but especially in Jacmel, the number of new ART enrollments, new HIV patient registrations, and number of HIV clinical visits dropped dramatically in January 2010 immediately after the earthquake, but rebounded strongly thereafter. There were no prominent changes to the national ART program model during the 37-month study period, other than a change in 2010 in the national ART treatment guidelines which allowed for expanded use of the first-line regimen of zidovudine–lamivudine–efavirenz (AZT+3TC+EFV) among women of reproductive age. Given the extensive earthquake-related damage and disruption experienced in Jacmel, our findings of a more favorable trajectory of ART attrition in Jacmel and the less favorable trajectory in Jérémie after the earthquake were somewhat surprising.There are several possible explanations for the patterns we observed. In Jacmel after the earthquake, the quality of ART services could have improved, the site could have restricted ART enrollment to those who were likely to succeed on therapy, or patients could have changed in other ways such that they were more likely to remain in care and on treatment. Our findings support the first explanation. None of the key Haitian HIV care providers were killed, injured, or left the site as a result of the earthquake. Rather, there was an influx of materials and human resources to the site from non-governmental organizations such as the WHO, the United Nations Population Fund (UNFPA), Médecins Sans Frontiers, the Canadian Red Cross, and others. Near-term aid was focused on provision of surgery and trauma care services, stabilization of inpatient services, and restoration of outpatient services, including HIV care and treatment. Over the longer term, the enhanced external aid focused on strengthening health programs. The total number of HIV clinic visits steadily increased, and new ART enrollees were more likely to receive pre-ART counseling sessions in Jacmel. We found no evidence that new ART enrollments were restricted after the earthquake in such a way as to artificially boost ART retention. Patients who survived the life-threatening trauma of the earthquake and later enrolled on ART may have had a tendency to more highly prioritize health and health care, but this type of change is unobservable in our data. Our finding of minimal and highly transitory disruption to ART continuity in Jacmel is consistent with findings from the Walldorf et al. study . The favIn contrast, in Jérémie, the site farther from the quake, there was no new influx of external resources to the hospital after the earthquake. The population in and around Jérémie is disproportionately disadvantaged; in the surrounding Grand-Anse Department, fully half of the population is estimated to fall in the lowest quintile of wealth for Haiti  . OutlyinOur case study demonstrated disparities in ART program outcomes between the two facilities, despite adjustment for many socio-demographic and clinical characteristics. This type of disparity is consistent with findings of cross-sectional study of ART attrition among patients enrolled on ART in the year following the earthquake, which was carried out by Haiti's Ministry of Health National AIDS Program (PNLS) . This stOur case study contributes evidence that continuity of ART services is possible in settings of humanitarian crisis. As of 2006, the United Nations estimated 7–10% of people with HIV around the globe, representing over 1.7 million people, were affected by complex humanitarian emergencies, resulting from conflict, natural disasters or displacement , 26. SevIn contrast, our case study of ART services in Haiti following the 2010 earthquake is a counter-example demonstrating ART program continuity during an emergency situation. Other examples exist. An ART program serving internally displaced people in Northern Uganda reported higher ART adherence rates than those found in other parts of the country where conflict was absent . The proA strength of our case study was the availability of detailed person-level clinical data enabling adjustment for many of the factors that might have otherwise biased an analysis of ART attrition before vs. after the earthquake. A limitation is that the study included only two hospitals, and did not include any facilities from areas most violently affected by the earthquake. Despite this limitation, this case study offers a contribution to the literature on HIV service delivery in the context of natural disasters.The public health challenges presented by Haiti's devastating 2010 earthquake and subsequent cholera outbreak were profound. Despite this, we found no strong evidence of association between earthquake intensity and ART attrition patterns, based on a longitudinal comparison of two hospitals differently affected by the earthquake. That ART attrition improved at Hôpital St. Michel in Jacmel following the 2010 earthquake was an important accomplishment, reflecting the resilience of hospital staff and patients and the role of external aid in stabilizing the national ART program in the post-earthquake period.